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Further fracture displacement
21%
196/941
Posterior column involvement
3%
32/941
Epidural hemorrhage
63%
593/941
Traumatic spinal cord injury
10%
92/941
Injury to posterior longitudinal ligament
2%
20/941
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This 49-year-old male presents to the emergency department with a cervical spine fracture in the setting of an ankylosed spine. The most likely cause for the patient's delayed deterioration is epidural hemorrhage (Answer 3).Spinal trauma in those with ankylosing spondylitis (AS) is a common occurrence, secondary to a rigid, compromised spinal column unable to withstand what would typically be normal stress loads. Because of this, AS patients accrue a risk for spinal fractures that is four times greater than the general populace. The sequelae of greatest concern is epidural hemorrhage, which has the propensity to cause permanent neurologic effects if not addressed emergently and has been found to occur in up to 15% of patients following their fracture. Because of this, serial examinations and advanced imaging in the form of MRI are required prior to operative fixation, which includes a long fusion construct (three levels above and below the fracture).Courvoisier et al. performed a prospective study examining the transient breath-holding sign (TBHS), which is defined as a sensation of “breath arrest” at the time of the accident, as a possible clinical predictor for thoracolumbar trauma in pediatric patients (n=198). Overall, the authors found the sensitivity and specificities of the TBHS to be 92% and 83%, respectively, while the positive predictive value was 83% and the negative predictive value was 91%. The authors concluded the sign may be of clinical value when attempting to clear the axial spinal following a traumatic event in pediatric patients.Reinhold et al. provided a review of the literature summarizing current diagnostic modalities, treatments, and, ultimately, recommendations for cervical and thoracolumbar spinal injuries in the ankylosed spine. Diagnosis and treatment are broken down into patients with and without radiographic evidence of axial spondyloarthritis. The authors note an increasing incidence of unstable spinal trauma in AS patients secondary to the aging populations and recommend a whole spine CT scan or MRI for diagnosing the injury before highlighting combined anterior and posterior fixation as the ideal treatment in cervical spine injuries and posterior fusion with or without cementation in thoracolumbar injuries.Phan et al. performed a systematic review and meta-analysis of 12 studies (n=279) examining percutaneous versus open pedicle screw fixation for the treatment of thoracolumbar fractures. Percutaneous fixation was found to lead to shorter operating times, shorter hospital stays, lower rates of infections, and lower levels of pain, while not compromising screw positioning or any other post-operative radiographic parameters. The authors recommend giving strong consideration to the percutaneous method of fixation for thoracolumbar injuries.Figures A, B, and C represent coronal, sagittal, and axial cuts of a three-column cervical spine fracture in a patient with ankylosing spondylitis.Incorrect Answers:Answer 1: In theory, the fracture should not have displaced any further after being immobilized. Answer 2: While posterior column involvement is present, this would not be the cause for delayed deterioration.Answer 4: Traumatic spinal cord injury most commonly manifests from the time of injury.Answer 5: Although the posterior longitudinal ligament may be involved, the structure would not be responsible for the delayed deterioration.
3.7
(3)
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