Management of spine fractures in ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis: a challenge.

OBJECTIVE Ankylosing spinal disorders (ASDs) such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are complex diseases regarding diagnostics, treatment, and patient outcome, especially in trauma. Originating from rigid biomechanics and low bone quality in considerably comorbid patients, serious spinal injury requires thorough and immediate imaging and is frequently missed. The aim of this study was to evaluate patient characteristics as well as procedures in patients with ASD in order to identify the major particularities of treatment. METHODS A total of 60 patients aged 78.5 ± 8.9 years were retrospectively included. Preoperative imaging as well as surgical treatment procedures and postoperative patient outcome were analyzed, including 30-day readmissions. RESULTS CT imaging of the entire spine was performed within 24 hours after the initial trauma in 73.3% of patients. A delay in diagnostics (> 24 hours) occurred in 41.7% of patients transferred from primary care centers. At admission, 25.0% of patients had fracture-related neurological deficits (American Spinal Injury Association [ASIA] grades A and B in 4 patients, and ASIA grades C and D in 11 patients). A spinal epidural hematoma was found in 21.2% of patients and was symptomatic in 72.7% of those patients. Of the patients with fracture-related neurological deficits, 93.3% were operated on within 48 hours from symptom onset. One patient (1.7%) developed neurological deficits from diagnosis to surgery. Postoperatively, 18.3% of patients had surgical complications, and 76.7% of patients developed further medical issues, with pneumonia (38.3%), pulmonary decompensation (25.0%), and cardiac decompensation (20.0%) being the leading causes. The 30-day mortality rate was high at 10.0%. CONCLUSIONS Treatment of patients with ASDs is complex. While surgical outcome is usually good, the multimorbid nature of these patients results in a high rate of major medical complications. If an ankylosing disease is suspected, MRI of the entire spine is mandatory. Upon diagnosis, treatment should be performed in centers capable of managing all aspects of the regular complications these patients will develop.

[1]  T. Schildhauer,et al.  Factors Associated With Major Complications and Mortality During Hospitalization in Patients With Ankylosing Spondylitis Undergoing Surgical Management for a Spine Fracture , 2021, Global spine journal.

[2]  Tetsuro Ohba,et al.  Risk factors for delayed diagnosis of spinal fracture associated with diffuse idiopathic skeletal hyperostosis: A nationwide multiinstitution survey. , 2020, Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association.

[3]  R. Molinari,et al.  An Analysis of Patient and Fracture Characteristics and Clinical Outcomes in Patients With Hyperostotic Spine Fractures , 2019, Global spine journal.

[4]  A. Disch,et al.  Spine Fractures in Ankylosing Diseases: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) , 2018, Global spine journal.

[5]  A. Mesfin,et al.  Surgical management of spinal fractures in ankylosing spondylitis. , 2018, Journal of spine surgery.

[6]  J. Schwab,et al.  Spinal cord injury after traumatic spine fracture in patients with ankylosing spinal disorders. , 2017, Journal of neurosurgery. Spine.

[7]  M. Yaszemski,et al.  Perioperative complications in open versus percutaneous treatment of spinal fractures in patients with an ankylosed spine , 2016, Journal of Clinical Neuroscience.

[8]  D. Gelb,et al.  A Comparison of Open and Percutaneous Techniques in the Operative Fixation of Spinal Fractures Associated with Ankylosing Spinal Disorders , 2016, International Journal of Spine Surgery.

[9]  F. Shen,et al.  Spinal Fractures in Patients With Ankylosing Spondylitis: Etiology, Diagnosis, and Management , 2016, The Journal of the American Academy of Orthopaedic Surgeons.

[10]  P. Lechler,et al.  Percutaneous dorsal instrumentation for thoracolumbar extension-distraction fractures in patients with ankylosing spinal disorders: a case series. , 2014, The spine journal : official journal of the North American Spine Society.

[11]  Z. Ozmen,et al.  Pulmonary involvement in ankylosing spondylitis assessed by multidetector computed tomography , 2014, Polish journal of radiology.

[12]  D. Buskila,et al.  Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms , 2013, Nature Reviews Rheumatology.

[13]  A. Deodhar,et al.  Osteoporosis and vertebral fractures in ankylosing spondylitis , 2007, Current opinion in rheumatology.

[14]  M. Vives,et al.  Management of Acute Spinal Fractures in Ankylosing Spondylitis , 2011, ISRN rheumatology.

[15]  J. Braun,et al.  [Development of morbidity and mortality in patients with spondyloarthritis]. , 2011, Zeitschrift fur Rheumatologie.

[16]  E. Barrett-Connor,et al.  Diffuse idiopathic skeletal hyperostosis (DISH): relation to vertebral fractures and bone density , 2010, Osteoporosis International.

[17]  T. lee-chiong,et al.  Pulmonary manifestations of ankylosing spondylitis. , 2010, Clinics in chest medicine.

[18]  J. Chapman,et al.  Spine Fractures in Patients With Ankylosing Spinal Disorders , 2010, Spine.

[19]  P. Schneider,et al.  Acute Cervical Fractures in Ankylosing Spondylitis: An Opportunity to Correct Preexisting Deformity , 2010, Spine.

[20]  F. Oner,et al.  Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications , 2009, European Spine Journal.

[21]  Y. Robinson,et al.  [Fatal complex fracture of the cervical spine in a patient with ankylosing spondylitis after a fall from a racing bicycle]. , 2007, Sportverletzung Sportschaden : Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin.

[22]  C. Argenson,et al.  [Ankylosed spine fractures with spondylitis or diffuse idiopathic skeletal hyperostosis: diagnosis and complications]. , 2004, Revue de chirurgie orthopedique et reparatrice de l'appareil moteur.

[23]  H. Alaranta,et al.  Traumatic spinal cord injury as a complication to ankylosing spondylitis. An extended report. , 2002, Clinical and experimental rheumatology.

[24]  C. Kiss,et al.  Risk factors for diffuse idiopathic skeletal hyperostosis: a case-control study. , 2002, Rheumatology.

[25]  S E Barton,et al.  Do patients with ankylosing spondylitis have poorer balance than normal subjects? , 2000, Rheumatology.

[26]  H K Genant,et al.  Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. , 1999, Archives of internal medicine.