ReviewManagement of spinal fractures in patients with ankylosing spondylitis
Introduction
Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that primarily involves the vertebral column and the sacroiliac joints [6]. The disease has a characteristic caudal to rostral progression and overtime alters the strength and biomechanical properties of the spine through extensive remodeling involving ligamentous ossifications, vertebral joint fusion, osteoporosis and kyphosis. These changes lead to a brittle spine that is more susceptible to fractures affecting the three spinal columns thus resulting in spinal cord injury (SCI). AS is a chronic disease that typically starts before the age of 30, it has a slow but steady progression [13]. Typically spinal fractures occur mostly in patients with advanced age and therefore have inherently a poor outcome. Treatment of spinal fractures in AS is controversial. While older studies have deemed non-surgical management safer due to the high morbidity and mortality associated with operative management, more recent studies have demonstrated much better outcomes in patients treated surgically. In this review paper, we present the factors that lead to increased risk of spinal fractures in AS patients; we also discuss the management options of these fractures. We look particularly at injuries of the craniovertebral junction, the subaxial cervical spine and the thoracolumbar spine. We finally discuss strategies in place to prevent spinal fractures in AS patients.
Section snippets
Epidemiology
AS affects between 0.5 and 14 per 100,000 new people every year. Its overall prevalence is estimated to be between 0.1% and 1.4% [5]. Males are affected twice as often as females and in general tend to have more pronounced symptoms [13]. Some authors have argued that the prevalence of the disease is roughly equal in both genders, and that milder forms of the disease in women has led to underreporting of the condition in females and therefore to an exaggeration of the estimation of male
Diagnosis
The diagnosis of AS is based on clinical and radiographic factors initially proposed in 1984 by van der Linden et al. as a modification to the original New York Diagnostic Criteria (Table 1) [27], [45]. The modified New York criteria have a higher sensitivity and specificity; however, they may not be helpful for early diagnosis of AS and involvement of the sacroiliac joint remains the sine qua non for definite diagnosis.
Central to the diagnosis of AS are the presence of sacroiliitis and
Pathological changes in AS
From a pathologic standpoint, AS is characterized by inflammation and new bone formation. Inflammation, mainly involves ligamentous insertion points throughout the axial skeleton, this is known as enthesopathy. This process promotes ossification of the affected ligaments. Ossification also involves the intervertebral discs, the endplates and the apophyseal structures. Extensive ossification leads to the formation of syndesmophytes, which span the ossified nucleus pulposus at each level.
Management of craniovertebral junction injuries
Atlantooccipital subluxation is one of the most dreadful complications of AS. It was first described in 1933 by Stammers and Frazer [44]. They reported the case of a 30 year-old man with AS who developed pyramidal signs and sensory changes as a result of forward dislocation of the atlas on the axis. The neurological symptoms resolved after the head was extended and a plaster cast was applied. Since then, most reports detailing the presentation and treatment of CVJ disease in ankylosing
Management of subaxial spine injuries
Management of subaxial spinal injuries in AS patients is particularly challenging view the associated high rates of mortality and morbidity. In these patients, even a low-velocity accident can result in serious neurological injury and in one-third of cases, cervical fractures in patients with AS result in fatality [42]. The incidence of vertebral fractures following accidents in AS patients increases yearly following onset of the disease. Forty-five years after the diagnosis, this risk is 1.3%
Management of thoracolumbar spine injuries
Thoracolumbar spine fractures are also more common in AS patients. Fractures in the ankylosed thoracolumbar spine are particularly unstable when compared with those in the normal spine due to increased moment of the forces across the fractures sites by the same rigid long lever arms mechanism described above [39]. The rate of neurologic complications following thoracic and lumbar fractures is also higher in AS patients with more than 50% of patients developing post-injury neurologic deficits
Prevention of SCI in AS
SCI injury resulting from spinal fracture in AS is common as stated above. This can occur as a result of injury at the time of their accident or can develop iatrogenically. Iatrogenic SCI may occur as a result of inappropriate mobilization from an unrecognized fracture. Additionally due to the unstable nature of these fractures can occur from positioning for surgical treatment of a recognized fracture. This latter point is especially true if a posterior instrumentation is undertaken prior to
Conclusion
Spinal fractures in AS patients have potentially devastating complications. Treatment of these fractures has progressively shifted from conservative to operative management, mostly guided by improvements in operative tools and techniques. These have turned surgery into a safe and most likely beneficial approach to these injuries. Unfortunately, while viewing the rarity of these cases there is still no high level evidence to guide the management of these fractures and current data are based on
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