Good outcomes of percutaneous fixation of spinal fractures in ankylosing spinal disorders

doi:10.1016/j.injury.2014.03.020

Injury

Volume 45, Issue 10, October 2014, Pages 1534-1538

https://doi.org/10.1016/j.injury.2014.03.020 Get rights and content

Abstract

Introduction

The ankylosed spine is prone to trauma even with after application of force at low energy levels. Multi-level vertebral bony fusions produce long lever arms, susceptible to fracture, with an increased risk of neurological injury. Additional problems result from delayed presentation and osteoporosis. These patients are also often at high risk of complications, making conventional open spinal surgery less appealing. We present the outcomes of percutaneous fixation and its advantages in this high risk group of patients.

Methods

A retrospective review of a series of 10 patients with a diagnosis of either ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis (DISH). All patients had sustained a spinal fracture between January 2009 and January 2013 and underwent percutaneous fixation using Medtronic longitude system (Minneapolis, USA) with Polyaxial screws. All were followed up with outcomes, complications and functional scores (Oswestry Disability Index (ODI) and Pain Visual Analogue scores (VAS).

Results

The mean patient age was 68. There was a delayed presentation in seven patients, of which two presented with neurological compromise. The neurological deficit did not change with surgery and there were no neurological complications as a result of surgery. The mean length of stay was 24 days, with no direct surgical complications. The mean drop in haemoglobin level was 2.1, with three patients requiring a blood transfusion. The patients were followed up to a mean of 22 months, with a mean ODI of 16 and pain VAS of 1.1. At the time of follow up, two patients had died with no loss to follow up.

Discussion

Even minor trauma can result in fracture in the ankylosed spine, requiring a high index of suspicion from the physician. The risks of missing such a fracture are significant neurological injury. The biomechanics of the spine are significantly altered, and treatment is demanding. We propose that minimally invasive spinal surgery can achieve good outcomes, low complication rates and high rates of satisfaction.

Introduction

The ankylosed spine is prone to trauma even after application of force at low energy levels [1]. It has also been shown that ankylosing spondylitis (AS) is associated with a fourfold increased fracture risk [2]. The disease has a prevalence of 0.1–1.4%, typically affecting males and manifesting between the ages of 20–30 [3]. Multi-level vertebral bony fusions produce long lever arms, creating an environment in which fractures can occur in settings of low energy trauma. With this, there is also an increased risk of neurological injury in the presence of fractures, and one should exercise due diligence in the initial assessment and subsequent handling and treatment of this cohort of patients. Patients with AS have a risk of spinal cord injury 11.4 times greater than the general population [4].

Diffuse idiopathic skeletal hyperostosis is a non-inflammatory disease, whereby the spinal longitudinal ligaments and entheses become ossified over time, resulting in decreased mobility of the affected segment [5]. The diagnosis can be made when flowing ossification of the anterior longitudinal ligament is present on spine radiographs over at least four consecutive levels [6]. It is suggested that the biomechanical behaviour of AS and DISH are very similar, both susceptible to spinal fractures secondary to low energy trauma [7]. These conditions are associated with osteoporosis as a result of chronic inflammation and disuse atrophy [8]. Another problem is the often delayed presentation of spinal fractures in the ankylosed spine, due either to physician misdiagnosis or late patient presentation. The delayed diagnosis can often result from a combination of an inexperienced physician reviewing the radiographs in combination with the seemingly trivial mechanism of injury. Thoracic spine radiographs are also notoriously difficult to interpret due to the superimposed structures. These issues make the treatment of these injuries challenging.

This study presents a series of patients with ankylosed spines, who have presented with a spinal fracture to our unit. All patients were treated with percutaneous fixation via a posterior approach. We present the results, with special attention paid to outcomes and complications.

Section snippets

Methods

This was a retrospective review of a series of 10 patients with a diagnosis of either ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis (DISH). All patients had sustained a spinal fracture between January 2009 and January 2013 and presented to Brighton & Sussex University Hospital. Data was collected using Bluespier Hospital Patient Tracking (Bluespier International, Worcestershire) and details obtained from the medical records and operation notes. Images were available to be

Results

There were a total of 10 patients in the study. All patients except one, had low energy trauma as the mechanism of injury, i.e. fall from a standing height, or fall off a chair. In two patients, ankylosing spondylosis was made as a new diagnosis. There was a delayed presentation in seven patients. In some cases this was due to late patient presentation, but in others it was a missed diagnosis. Of significance, two patients with a missed spinal fracture subsequently re-presented with significant

Discussion

Ankylosing spondylitis is often picked up late, either as a result of late patient presentation or unsuspected and undiagnosed injury. From our experience, this can have devastating results for the patient, in terms of subsequent neurological injury and morbidity. The spinal fractures can often result from trivial injuries, requiring a high index of suspicion. Due to long lever arms created by multiple fused segments, this created a high strain environment at the fracture site, making it

Conclusions

Conflict of interest

We, the authors have no financial and personal relationships with other people or organisations to disclose that could inappropriately influence or bias our work.

References (14)

J. Braun et al.
Ankylosing spondylitis
Lancet
(2007)
Y.P. Charles et al.
Fracture in ankylosing spondylitis after minor trauma: radiological pitfalls and treatment by Percutaneous instrumentation. A case report
Orthop Traumatol Surg Res
(2013)
T. Hunter et al.
Ankylosed spines are prone to fracture
Can Fam Physician
(1995)
J.A. Finkelstein et al.
Occult vertebral fractures in ankylosing spondylitis
Spinal Cord
(1999)
M. Mathews et al.
Treatment of spinal fractures in ankylosing Spondylitis
Orthopaedics
(2013)
T.A. Belanger et al.
Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations
J Am Acad Orthop Surg
(2001)
D. Resnick et al.
Diffuse idiopathic skeletal hyperostosis (DISH): Forestier's disease with extraspinal manifestations
Radiology
(1975)

There are more references available in the full text version of this article.

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Less invasive spine surgery (LISS) has become well-established for thoracolumbar burst fractures without neurological deficits. However, notable controversy persists regarding the adequacy of LISS for more unstable AO type B and C injuries, as it does not allow for formal open fusion.
In this cross-sectional survey experienced spine surgeons of the Dutch Spine Society were invited to participate (56 participants). They were asked to indicate the most appropriate treatment for AO type B1, B2 (L1: A1 and L1: A3), B3 and C (L1: A4) injuries at level Th12-L1. Taking into account: age, AO N0-N1, or polytrauma. Specific agreement between participants was obtained applying Variation Ratio (VR).
A significant level of overall agreement was observed for AO type-B1 injuries with 73.8% of participants opting for percutaneous short-segment fixation (VR 0.775). For AO type-B3 injuries, 79.4% of participants favored percutaneous long-segment fixation (VR 0.794). for AO type-B2 injuries, there was less overall agreement (VR 0.571–0.657). Nonetheless, when considering all AO type-B injuries combined, percutaneous fixation emerged as the most preferred treatment option with substantial agreement (VR 0.871–0.923). Conversely, for AO type-C injuries, there was less agreement among the participants (VI 0.411), 26.5% of them chose additional open spinal fusion.
For all AO type-B injuries there was substantial agreement to treat these fractures with percutaneous techniques. For AO type-C injuries, the survey results do not support a consensus. Nevertheless, the responses raise important questions about the necessity of spinal fusion for such injuries.
First intention vertebroplasty in fractures within an ankylosed thoracolumbar spinal segment
2021, Diagnostic and Interventional Imaging
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However, further studies are needed to evaluate the potential role of TBA as an indicator of PVC outcomes. Surgical staged osteosynthesis remains the standard treatment of vertebral fractures located within a rigid spine segment with excellent primary consolidation rates (up to 100%) [11,12,42–44]. However, these procedures require long-lasting prone position under general anesthesia.
To evaluate the outcome of percutaneous vertebral cementoplasty (PVC) as the first-line treatment for traumatic thoracolumbar fractures within an ankylosed spinal segment.
Thirty-one patients (15 men, 16 women; mean age: 79.2 ± 11 [SD] years; age range: 66–95 years) with thoracolumbar fractures within an ankylosed spine segment without neurological impairment treated with PVC were retrospectively evaluated. All patients were controlled at six weeks and one year after PVC. Ankylosing conditions, fractures sites and types, radiological consolidation, spinal complications were assessed. Anterior/posterior vertebral height ratios were measured before and after PVC. Postoperative pain relief and treatment success (radiological fracture consolidation) rates were considered.
The 31 patients had a total of 39 fractures (19 stable [49%], 20 unstable [51%]) treated with PVC. Primary success rate of PVC (initial fracture consolidation without complication) was 61% (19/31). Seven patients (7/31; 23%) exhibited new fractures, and the secondary success rate of PVC (global fracture consolidation one year after repeat PVC) was 87% (34/39). Global consolidation rates of unstable fractures were 85% (17/20) of treated levels. Pain score was null in 84% patients (26/31) one year after PVC. There were no significant differences between pre-PVC (0.62 ± 0.18 [SD]; range: 0.22–0.88) and post-PVC (0.60 ± 0.18 [SD]; range: 0.35–0.88) vertebral height ratios (P = 0.94).
PVC conveys a high overall success rate and effectively controls pain in patients with vertebral fractures within ankylosed spine segments.
Minimally Invasive Percutaneous Modified Iliac Screw Placement Using Intraoperative Navigation: A Technical Note
2021, World Neurosurgery
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Krüger et al.23 showed satisfying results with only 1.8 reconstructed vertebral segments on average above and below the fracture. Nevertheless, Yeoh et al.24 recommended that 3 levels on either side of the injured vertebra needed to be fixed. In this case, we decided to place the instrumentation 3 levels above and 1 level below the fracture with additional modified iliac screw augmentation below the injured vertebra.
The modified iliac screw fixation technique was proposed to be an interesting alternative option for spinopelvic fixation. In this study, we describe a new minimally invasive technique for percutaneous placement of modified iliac screws.
A 64-year-old man with ankylosing spondylitis suffered from a 3-column fracture at the L5 vertebra without any neurologic deficit. We performed percutaneous pedicle screw fixation from L2 to S1 with additional modified iliac screws augmentation using an intraoperative navigation. We inserted both S1 pedicle screw and modified iliac screw within a stab incision on each side of the patient's back without using rod connector.
The patient's severe low back pain subsided on the day following the operation. There was no clinical low back pain at 2-week follow-up. The 1-year follow-up x-ray showed that the fracture was healed successfully without signs of screw loosening or breakage.
The modified iliac screws can be placed safely via percutaneous approach with an intraoperative image guidance. By using this new technique, surgeons can easily adjust the screw head to align with S1 pedicle screw via the same small incision. The rod connectors are not necessary for this technique. This method also prevents the acute angle that can develop between the screw head and shaft of the screw, which is typically found in S2 alar-iliac screw technique.
Diffuse idiopathic skeletal hyperostosis: Etiology and clinical relevance
2020, Best Practice and Research: Clinical Rheumatology
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Compared with percutaneous pedicle screw fixation techniques, open stabilization is associated with more complications, longer hospital stay, more blood loss, and a higher mortality rate in several small retrospective studies [94,95]. Percutaneous pedicle screw-based fixation techniques are therefore the favored method for thoracolumbar B3 or C type fractures without neurological deficit [96–98]. Physicians’ awareness regarding implications of spinal ankylosis is essential for the adequate diagnosis and treatment of patients with a fractured ankylosed spine.
Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic bone-forming condition characterized by the presence of at least three bony bridges at the anterolateral spine. The aim of this review was to address the present state of pathophysiological knowledge, the clinical relevance, and diagnosis of DISH. The pathogenesis of DISH is currently unknown. The presence of DISH has been associated with older age, male sex, obesity, hypertension, atherosclerosis, and diabetes mellitus. Because the new bone forms mainly at entheseal sites, local fibroblasts, chondrocytes, collagen fibers, and calcified matrix are probably influenced by genetic, vascular, metabolic, and mechanical factors. Diagnosing the presence of DISH is of clinical importance, because the risk of a spinal fracture increases and associations with the metabolic syndrome, coronary and aortic disease, and respiratory effects are strong. Unravelling the pathogenesis of DISH can impact the field of regenerative medicine and bone tissue regeneration.
Ankylosing Spinal Disease—Diagnosis and Treatment of Spine Fractures
2019, World Neurosurgery
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Some have advocated long-segment posterior fixation with instrumentation of ≥3 levels above and below the thoracic or lumbar injury.16 Finally, reports of percutaneous and hybrid techniques have been increasing.33-35 We observed a relatively low (12.2%) mortality during the hospital stay compared with the reported data (8%–60%).8,16,21,27,31
In patients with ankylosing spinal disease, including ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, even low-impact trauma can lead to complex injuries. The injuries seem to be highly unstable and associated with greater mortality rates compared with the general spine trauma population.
We reviewed the medical records of a consecutive series of 41 patients (34 men, 7 women) with ankylosing spinal disease and unstable traumatic spine injuries who were admitted to our department from 2007 to 2016.
The mean patient age was 73.4 ± 12.7 years. Of the 41 patients, 24 (58.5%) had ankylosing spondylitis and 17 (41.5%) had diffuse idiopathic skeletal hyperostosis. Low-velocity accidents were documented in 38 patients (92.7%). The most frequent injuries were type B spine fractures (61.0%). Accompanying spinal epidural hematoma was detected using magnetic resonance imaging in 12 patients (29.3%) but was not found by radiography or computed tomography. Of the 41 patients, 24 (58.5%) presented with American Spinal Injury Association impairment scale (AIS) grade E, 6 (14.6%) with grade D, and 8 (19.6%) with grade C or worse. All the patients had undergone internal fixation. All but 1 (97.6%) had received posterior fixation. In 25 (61%), a combined approach was performed. Five patients died of early complications. Of the 36 discharged patients, 11 died during the follow-up period and 1 was lost to follow-up. The surviving 24 patients had a median follow-up of 733 ± 576 days; 21 had AIS grade E, 2 had AIS grade D, and 1 had AIS grade C.
A thorough diagnostic evaluation with multislice computed tomography and magnetic resonance imaging can reveal injuries that would remain undetected on conventional radiographs. A combined approach or posterior-only fixation seems safe.
Percutaneous surgery for thoraco-lumbar fractures in ankylosing spondylitis: Study of 31 patients
2017, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
Our findings support these previous results by showing that percutaneous internal fixation reliably ensures healing of thoraco-lumbar fractures in patients with AS. Minimally invasive surgery is associated with better functional recovery during the early post-operative period [20–23]. A meta-analysis by McAnany et al. [24] found no difference in clinical or radiological outcomes between open and percutaneous surgery.
The risk of vertebral fracture is increased 4-fold in patients with ankylosing spondylitis (AS). Diagnostic challenges and the vulnerability associated with AS combine to generate high morbidity and mortality rates. The objective of this study was to assess the outcome of percutaneous thoraco-lumbar fracture surgery in patients with AS, in terms of quality of life, fracture healing, and complications.
Percutaneous surgery used to treat thoraco-lumbar fractures in patients with AS reliably provides fracture healing, preserves self-sufficiency, and minimises post-operative complications.
Two centres included 31 patients with AS who were managed by percutaneous surgery for thoraco-lumbar fractures in 2013–2015. The data were reviewed retrospectively, although admission data were collected prospectively. Clinical outcomes were assessed by comparing the values at baseline and last follow-up of three variables: the Parker score, the visual analogue scale (VAS) pain score, and the EuroQol five dimensions (EQ-5D) quality-of-life score. Computed tomography was performed 1 year after surgery to evaluate bone healing, screw position, and implant loosening. Intra- and post-operative complications were recorded.
The 31 patients had a mean age at surgery of 75.1 years, a mean follow-up of 35.6 months, and a minimum follow-up of 12 months. Three patients died during follow-up. Mean hospital stay duration was 6 days. Cemented screw fixation was used in 18 patients. At last follow-up, all patients had recovered their self-sufficiency; the mean Parker score was 7.14, compared to 6.73 at baseline, the mean VAS pain score was 1.8, and the mean EQ-5D score decrease versus baseline was 0.07 (P = 0.02). Bone healing was consistently achieved. Loosening of an uncemented pedicle screw was noted in 1 patient. Of the 228 screws implanted, 6 (2.6%) were improperly positioned, including 1 within the spinal canal in a patient free of neurological manifestations. Asymptomatic cement leakage was noted in 2 patients.
Percutaneous fixation of thoraco-lumbar fractures in patients with AS is a reliable method that produces a high healing rate and allows prompt patient mobilisation with preservation of self-sufficiency. The post-operative complication rate is low.
IV, retrospective observational study.

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Good outcomes of percutaneous fixation of spinal fractures in ankylosing spinal disorders

Abstract

Introduction

Methods

Results

Discussion

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Conflict of interest

Lancet

Orthop Traumatol Surg Res

Ankylosed spines are prone to fracture

Can Fam Physician

Occult vertebral fractures in ankylosing spondylitis

Spinal Cord

Treatment of spinal fractures in ankylosing Spondylitis

Orthopaedics

Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations

J Am Acad Orthop Surg

Diffuse idiopathic skeletal hyperostosis (DISH): Forestier's disease with extraspinal manifestations

Radiology