Injury Extra 40 (2009) 242–245

Case report

Concomitant cervical and thoracic spinal fractures in ankylosing spondylitis:A case report and review of literature

Fahim Anwar *, Ahmad Al Khayer, M. Fraser, D.B. Allan

Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, 1345 Govan, Glasgow G51 4TF, United Kingdom

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Injury Extra

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A R T I C L E I N F O

Article history:

Accepted 23 June 2009

1. Introduction

Ankylosing spondylitis is an autoimmune spondyloarthopathythat primarily affects the spine and the sacroiliac joints.Inflammatory low back pain, a feature of the early disease, isthe defining clinical criteria for ankylosing spondylitis.19 Thecourse of the disease is highly variable ranging from episodes oftransient acute back pain to more chronic back pain. Painfulepisode and remissions are characteristics in almost everyindividual. As the disease progresses, the spine movementsgradually becomes reduced and the spine becomes completelystiff and flexed. Spinal fusion my eventually develop. This leavesthe patients prone to spinal fractures from minor injury,particularly in the cervical spine. Fractures can extend throughall three columns, leading to significant instability and neurolo-gical injury. Early stage ankylosing spondylitis is often misdiag-nosed as common mechanical back pain. This delays the start ofearly treatment in the course of the disease. Although there is noknown cure for the disease, recent developments in the diseasemodifying agents may improve its prognosis. Management of thespinal fractures in ankylosed spine is difficult and challengingbecause of the altered biomechanics.

2. Case report

A 74-year-old man presented to the Accidents and Emer-gency department following a fall from the third step of a ladder(1 m height), onto his back. He had a long standing past medicalhistory of ankylosing spondylitis along with neck and back pain.Initially, he experienced altered sensations (pins and needles)down both arms with increased pain intensity in his neck

* Corresponding author at: 9 Rowan Court, Cambuslang, Glasgow G72 7FX,

United Kingdom. Tel.: +44 7932833480.

E-mail address: fanwar@nhs.net (F. Anwar).

1572-3461/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.

doi:10.1016/j.injury.2009.06.169

and back. He was immediately able to stand up and walk, andthe parasthesia resolved within 20 min. On examination in theAccidents and Emergency department, he had no apparentneurological deficit but had tenderness in his cervical andthoracic spine. X-ray at this stage showed fusion of the cervicalspine with no obvious fracture. The patient was dischargedhome without a hard collar and allowed to mobilise. Threedays later he presented to his General Practioner (GP) withdysphagia and altered sensations down both arms, increasedpain intensity both in his lower back and on neck extension. Hereported minor weakness in his upper limbs and therefore wasreferred to the Accidents and Emergency department. Examina-tion in the hospital revealed grade 4/5 power on the MedicalResearch Council (MRC) scale in shoulder abductors andadductors, with grade 3/5 for all other upper limbs musclegroups. Normal power 5/5 was observed in the all lower limbsmuscle groups. A computed tomography (CT) scan, at this stage,diagnosed fractures of the C6/7 vertebral bodies and C6 laminafracture. CT scan of the thoracic spine showed fracture of the T11pedicle along with 5 mm anterior translation of T11 over T12. Areferral was made to the tertiary Spinal Injuries Unit.

Examination on admission to the Spinal Injury Unit confirmedthe above findings and revealed normal pin prick and soft touchsensation of all four limbs along with normal tone and reflexes andnormal down going planters. This gave the patient an AmericanSpinal Injuries Association (ASIA) impairment scale rating ofIncomplete D, Central Cord Syndrome. MRI of the whole spineshowed a small amount of retrolithesis of C7, causing impinge-ment of the cord at this level. Epidural haematoma was notedposterior to the C6 vertebral body and also at T10/T11 level. Anormal signal throughout the cord suggested no significant cordcompression (Fig. 1).

The cervical fracture was treated conservatively. The thoracicfracture was found to be unstable and therefore was managedwith posterior thoraco-lumbar fixation using pedicle screws andtitanium rods (Fig. 2). Post-operatively the patient was fitted witha cervical, thoracic and lumbar custom made brace (Fig. 3). Thebrace aimed to provide a rigid external immobilisation for boththe cervical and the thoracic fractures in order to facilitatehealing.

The patient made a good recovery with satisfactory progress inupper limb strength on discharge. He was independent in allactivities of daily living, was mobilising independently with thebrace and his pain was well controlled.

Fig. 1. (a) T2 weighted image of cervical spine showing a fracture at C6/C7 along

with reterolithiasis of C7 causing impingement of the cord at that level. (b) T2

weighted image of thoracolumbar spine showing a fracture at T11/T12 inter-

vertebral disc, slight epidural haematoma noted that level.

Fig. 2. AP thoracolumbar spine showing posterior instrumented fusion using

pedicle screws and titanium rods.

Fig. 3. Custom made brace used to support cervical and thoracic fracture.

F. Anwar et al. / Injury Extra 40 (2009) 242–245 243

3. Discussion

Ankylosing spondylitis is a chronic arthropathy which occurs in1.6% of the population worldwide.1 The aetiology of the disease isunknown. There is a strong predisposition to both genetic andfamilial factors. About 90–95% of patients with ankylosingspondylitis are positive for the human leucocyte tissue antigenHLA-B27. Loss of lateral spinal flexion and the sacroiliac jointtenderness are the earliest clinical signs. The ability to flex thelower back can be assessed by Schober’s test. The test was firstdescribed by Dr Paul Schober (German Physician) in 1937.17 Theexaminer marks the level of 5th lumbar vertebrae while the patientis standing. A mark is then made 10 cm above and 5 cm below the

level of 5th lumbar vertebrae. The patient is then asked to touch histoes by bending forward. In a normal person the distance betweenthese two marks should increase from 15 to 22 cm. In ankylosingspondylitis, due to restricted spine flexion, the distance betweenthese two marks in <7 cm.

Early in the disease the sacroiliac joint and the thoracolumbarinvolvement are most common features. Involvement of thecervical spine is later in the disease; almost 75% of patients willdevelop the cervical spine disease as a late manifestation.6 Mostcommon presenting symptoms of the disease are low back paineven at rest, early morning stiffness and positive family history ofankylosing spondylitis. Involvement of the thoracic spine and therib cage leads to restricted chest expansion, whereas involvementof the cervical spine causes restricted neck and head movements.Later in the disease the entire spine becomes completely rigid withloss of spinal curvatures and movements. Peripheral jointinvolvement may occur in chronic disease.

F. Anwar et al. / Injury Extra 40 (2009) 242–245244

The early signs of ankylosing spondylitis on conventionalradiographs are narrow sacroiliac joint space, subchondral bonyerosions on the iliac side followed by late signs of sclerosis, bonyproliferation and fusion of the sacroiliac joint. Early plain X-raychanges in the spine are small erosions at the corners of thevertebral bodies, sclerosis, squaring of the vertebral bodies,calcification of the disc material, and ossification of the para-vertebral connective tissue. Complete fusion of the vertebralbodies occurs as a late manifestation and produces characteristicbamboo spine appearance on the radiographs.15

Fractures of the spine following trivial trauma are very commonin the ankylosing spondylitis. The incidence of spinal fractures inankylosing spondylitis is 3.5–4 times than the normal population.3

Rigidity of the spine, kyphosis and osteoporosis leads to abnormalvertebral biomechanics. The most common site for the spinalfractures is the cervical spine followed by the thoracic and lumbarspine. The rigid and immobile spine is not able to resist even smallforces and tends to fracture easily with minimal trauma. Almost75% of the fractures occur in the cervical spine.12 Forcedhyperextension of the spine is the most common mechanism forfracturing the ankylosed spine.11,7 Long standing spine pain inpatients with ankylosing spondylitis will make the diagnosis ofspinal fractures very challenging. These patients are usually underevaluated after a minor trauma leading to missed vertebralfractures and more seriously spinal cord damage. Therefore highindex of suspicion of spinal fracture after minor trauma along withappropriate imaging are essential to diagnose these injuries earlyand to prevent the possible neurological complications associatedwith them.

Initial plain radiographs may, at times, fail to show the fracturebecause of patient positioning, abnormal spinal curvature andartefacts created by ossified ligaments especially if the fracture isin the posterior elements of the spine.5 Persistent pain at theinjured site must dictate further radiological investigations.Computed topography scans, especially high resolution or multi-slice, are helpful in these cases to demonstrate an occult fracture.5

MRI scans can be used as an additional tool to access any possiblespinal cord damage, ligamentous and other soft tissue injuries.Isotope bone scans are unreliable as a diagnostic tool in the earlystages of injury; they only become positive between 3 and 10 daysfollowing acute injury.9

There are no treatment guidelines for spinal fractures inankylosing spondylitis. Technically a fracture through the anky-losed and fixed spine always extends through the anterior andposterior elements and therefore very unstable. Secondarycomplications like cord damage, dislocations, extradural haema-toma and disc herniation can make the existing neurologicaldamage worse if these fractures are not treated appropriately.12

Controversies exist between conservative and operativemanagement of spinal fractures in ankylosing spondylitis.Prolonged bed rest is recommended mostly in order to avoidthe mortality and morbidity associated with operative treatmentin these patients. The risk of poor outcome with surgery alsoincreases with age.2 In cases of cervical fractures, if thedisplacement is minimal and there is no neural involvement,immobilisation of the cervical spine in an effective cervical bracefor 6–8 weeks is deemed to be sufficient. The patients can bemobilised as soon as they are fitted with the brace. Unstablecervical fractures are treated with skeletal traction for 3 weeksfollowed by cervical brace until the spine is stable.4 With stablethoracic and lumber fractures early mobilisation in a thoraco-lumbar brace is advocated. The main difficulty in conservativetreatment is maintaining the fracture reduction.20 In order toprevent secondary neurological complications early operativefixation of the fracture is advocated by many authors.10,18 Theadvantages of definitive fracture fixation are excellent deformity

correction, immediate stability, direct and indirect decompres-sion of the spinal canal, excellent maintenance of correction, earlymobilisation and prevention of secondary complications like lossof reduction and deterioration in the neurology.14 The disadvan-tages of surgical intervention are post-operative complications,particularly respiratory, poor outcome and increased mortality.16

Co-morbidities associated with ankylosing spondylitis alsoincrease the incidence of post-operative complications. The riskof multiple spine fractures also increases after spinal instrumen-tations in patients with ankylosing spondylitis. This is due to thefact that the junction of the spinal instrumentation device withthe non-instrumented spine acts as a potential stress point thatmay fracture with minor injury.16 Our patient had both cervicaland thoracic fracture. The cervical fracture was stable and treatedconservatively. The thoracic fracture, being unstable, was treatedwith posterior instrumented spinal fixation. Early mobilisation ofour patient was encouraged with the help of a custom made(cervical, thoracic and lumbar brace) supporting both his thoracicand cervical spine (Fig. 3).

Fractures at two levels are very rare. We identified only 3 casesof concomitant cervical and thoracic spine fractures in ankylosingspondylitis in the medical literature.4,8,13 They were associatedwith significant cord damage and were very difficult to manage.We believe that two level fractures are rare in ankylosingspondylitis because the rigid ankylosed spine normally fracturesalong an ossified disc space like a chalk stick. It is therefore difficultfor the stiff spine to give way at two places rather than one toabnormal biomechanical forces.

4. Conclusion

Spinal fractures in ankylosing spondylitis patients arecommon and can be overlooked because of chronic pain. Thesefractures can extend across the three spinal columns andeventually be very unstable leading to severe neurological injury.It is therefore important to fully investigate a patient with thisdisease who presents with pain, with or without neurologicaldeficit, following minor trauma. This case also demonstrates thefact that fractures in ankylosed patients may occur at multiplelevels. All efforts should be made to exclude occult fractures atother levels.

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