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Spinal Fractures Complicating Ankylosing Spondylitis.

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75 1
A Long-Term Followup Study
Twenty-two spinal fractures in 20 patients with
chronic ankylosing spondylitis are reported. Nineteen
fractures occurred in the cervical region. Fourteen of
the fractures were caused by minor falls, 3 by falls down
steps, 4 by motor vehicle accidents, and 1 by cardiopulmonary resuscitation. Long-term followup (mean 3.2
years) of 9 fractures diagnosed early and managed
conservatively showed bony union of all fractures. No
patient deteriorated neurologically and 3 patients made
maor recovery. Long-term followup is also reported on
6 patients in whom the diagnosis was delayed. The
difficulties in diagnosis and management are discussed.
We have now enlarged our experience to 22
spinal fractures in 20 patients with chronic ankylosing
spondylitis. The purpose of this study is first, to
determine whether the statements we made previously
still hold true for a large series of patients from one
center. Second, since we have conducted a clinical
and radiographic followup of these patients, we are
now able to report on the natural history of these
fractures and the long-term results of conservative
In 1978 we reported 8 patients with chronic
ankylosing spondylitis complicated by spinal fracture
and we reviewed 56 patients previously reported in the
English language literature (1). The experience from
these small series gathered from a number of centers
suggested that the ankylosed cervical region was the
most common site of fracture, that minor trauma was
the most common cause of the fracture, and that
radiographic visualization of the fracture site may be
The clinical records of all patients with ankylosing
spondylitis complicated by spinal fractures, admitted to the
Health Sciences Centre or St. Boniface General Hospital,
Winnipeg between 1965 and 1982, were reviewed. Clinical
and radiographic followup was then obtained.
For the purpose of assessing the natural history of
these fractures and the results of conservative management,
the patients were divided into 2 groups. Group I consisted of
patients in whom the diagnosis of spinal fracture was made
immediately and conservative management instituted.
Group I1 consisted of patients in whom the diagnosis of
spinal fracture was delayed.
Presented in part at the 45th Annual Scientific Meeting of
the American Rheumatism Association, Boston, Massachusetts,
June 1981.
From The University of Manitoba, Winnipeg, Canada.
Thomas Hunter, MB, BS, FRCP(C): Associate Professor of
Medicine and Director, University of Manitoba Rheumatic Disease
Unit; Hyman 1. C. D u b , MD, FRCP(C): Associate Professor of
Medicine and Director, Spinal Cord Injury Unit, University of
Address reprint requests to Dr. Thomas Hunter, University
of Manitoba, Rheumatic Disease Unit, Health Science Centre,
Room RR149, 800 Sherbrook Street, Winnipeg, Manitoba, R3A
1M4, Canada.
Submitted for publication March 17, 1981; accepted in
revised form February 4, 1983.
Arthritis and Rheumatism, Vol. 26, No. 6 (June 1983)
Twenty patients with ankylosing spondylitis
had suffered fractures of the ankylosed spine. All the
patients were male. The clinical data, including nature
of the trauma, level and type of bony and neurologic
injury, management, and results of long-term followup, are listed in Table 1 for Group I and Table 2 for
Group 11. Two patients had suffered a second cervical
fracture during the period of followup, and the details
of these fractures are included.
Table 1. Clinical features of I5 spinal fractures diagnosed at time of injury*
Patient Age AS (years)
Cause of
Bone lesion
Fell 6 steps
Minor fall
C4-5 fracturedislocation (unstable)
Minor fall
Body C6 (stable)
Minor fall
Body and posterior elements C7
Minor fall
C5-6 (unstable)
Fell 20 steps
Minor fall
Minor fall
C6 posterior arch
C5-6 fracture
Not visualized
Minor fall
Cardiac resus.
Minor fall
Minor fall
C6-7 fracturedislocation (unstable)
C6-7 fracturedislocation (unstable)
C6-7 fracturedislocation (unstable)
T9-10 fracturedislocation (unstable)
C5-6 fracturedislocation (unstable)
C7-TI fracturedislocation (unstable)
C6-C7 fracturedislocation (unstable)
Body and posterior elements
C5-C6 (unstable)
* AS = ankylosing spondylitis; I = incomplete spinal cord lesion; ACCS
accident; C = complete spinal cord lesion.
t First fracture.
S Second fracture in same patient.
Cervical trac- 2.5 years
tion 12
Cervical trac3 years
tion 6
weeks; collar 6 weeks
Cervical collar 2.5 years
16 weeks
Postural re6.5 years
duction 7
weeks; Taylor brace 5
Cervical trac- 1.2 years
tion 16
Minerva plas- 7.5 years
ter 6 weeks;
collar 6
Bed rest and
2 years
collar 6
weeks; collar for further 2
Bed rest and
3 years
collar 3
weeks; collar 11 weeks
Cervical traction
Bed rest; collar
Bed rest; cervical collar
Cervical traction
Clinical and
Union 16 weeks
Major recovery
Union 12 weeks; No change
died (pulmonary embolus)
Union 16 weeks
Major recovery
Union 12 weeks
No change
Union 16 weeks; No change
died (septicemia, renal amyloidosis)
Union 12 weeks Major recovery
Partial union 8
weeks; complete union
0.5 years
N o change
Union 12 weeks
No change
Lost to followup
Lost to followup
Died 3rd day
Died 2nd day
Died 5th day
Cervical collar
Bed rest; cervical collar
4 months Union 12 weeks
Bed rest; cervical collar
7 weeks
Partial union
acute cervical central cord syndrome; MVA
No change
N o change
No change
N o change
Major recovery
motor vehicle
Table 2.
Clinical features of 7 spinal fractures with a delay in diagnosis*
Duration Cause of
Patient Age AS (years) fracture
Bone lesion
Cord lesion
Minor fall Cervical fracture None
diagnosed by
Minor fall C W 7 fracture- None
dislocation (unstable)
Delay in diagno- 10.5 years
sis 5 years
Delay in diagnosis 3 weeks;
cervical collar
C6 root lesion; Delay in diagnoMinor fall Fracture body
sis 3 weeks;
bilateral T4
and posterior
root lesions
collar & bed
elements, C7
rest 4 weeks;
collar 2 weeks
Delay in diagnoMinor fall L5-S I fracture
sis 1 year;
(pseudoarthrobed rest;
Knight spinal
Delay in diagnoMinor fall T9-Tl0 pseuNone
sis 4 weeks;
bed rest 6
Delay in diagnoMVA
C W 7 fracture- C8 (1)
dislocation (un- ACCS
sis 4 weeks;
collar 8 weeks
Delay in diagnoFell 5
C W 7 fracture
sis I week;
4 poster collar
and bed rest
* AS = ankylosing spondylitis; MVA
t First fracture.
6.5 years
2.5 years
5 years
Clinical and
followup findings
Union 5 years
No change
No change
Early union 3
weeks; complete union 0.5
Clinical union 6 Complete recovery
weeks; radiograph union at
6 weeks
at 5 years
Developed L5
root lesion
6 months
after injury
6 months Pseudoarthrosis
at 6 months
No change
3 months Union 12 weeks
2 weeks
motor vehicle accident; I = incomplete spinal cord lesion; ACCS = acute cervical central cord
Group I consisted of 15 spinal fractures in 14
patients, in whom the diagnosis of spinal fracture was
made immediately and conservative management instituted. The mean age was 59.3 years (range 45-76
years). The mean duration of ankylosing spondylitis
was 30.9 years (range 20-47 years).
Nine of the 15 fractures were due to minor falls
to the floor. Two were caused by falls down stairs.
Three were due to motor vehicle accidents, and 1 was
due to a hyperextension injury of the cervical spine
which occurred in the patient’s home while attempts
were being made to resuscitate him following a cardiac
arrest. Fourteen of the 15 fractures occurred in the
cervical region and 1 in the thoracic region. Thirteen
fractures were unstable by clinical or radiographic
examination. Six of the fractures caused complete
spinal cord lesions. Four produced incomplete lesions
of the acute cervical central cord syndrome type. Five
fractures caused no associated neurologic deficit.
Three patients died within 5 days of their injury.
The cause of death was pneumonia and pulmonary
congestion in 2 patients and septicemia complicated by
bradycardia and cardiac arrest in 1 patient. Two
patients with cervical fractures were returned to the
care of their referring physicians, and we were unable
to locate them for long-term followup.
We were able to obtain long-term clinical and
radiographic information on 9 patients in group I. The
mean duration of followup was 3.2 years (range 4
months-7.5 years). Of the 8 cervical fractures, 2 were
treated with cervical traction in a position of cervical
flexion for 12 and 16 weeks, 1 was treated with
cervical traction for 6 weeks and then mobilized in a
cervical collar for 6 weeks, and the remaining 5
patients were treated with bed rest and a cervical
collar for a mean of 12.5 weeks (range 8-16 weeks).
The patient with a T9-10 fracture-dislocation was
treated with bed rest and postural reduction for 7
weeks and then mobilized in a Taylor brace for 5
Followup of all 9 spinal fractures revealed clinical and radiographic union at a mean of 13 weeks
Figure 1. Tornogram of T9-10 pseudoarthrosis, showing fracture
extending through anterior spinal ligament and posterior elements
(patient 16).
(range 8-16 weeks). Long-term radiographic followup
showed that none of the patients had developed a
pseudoarthrosis. Neurologic followup revealed that
none of the patients had suffered further neurologic
deficit following the institution of conservative management. There was no neurologic recovery in the 3
patients with immediate and complete spinal cord
lesions. However, all 3 patients with incomplete lesions of the acute cervical central cord syndrome type
made major recovery, regaining normal motor power
in the lower limbs and control of bowel and bladder
function. At long-term followup their only functional
neurologic deficit was some residual weakness of the
During the long-term followup period, 2 patients died. One died 14 months after a spinal fracture
associated with a complete C4 spinal cord lesion.
Death was due to amyloidosis causing chronic renal
failure, which was further complicated by septicemia.
The second patient died due to a massive pulmonary
embolus 3 years after a spinal fracture which caused
complete quadriplegia below C6.
Group I1 consisted of 7 patients in whom the
mean delay from the time of spinal fracture to diagnosis by a physician was 47 weeks (range I week-5
years). The delay in diagnosis was due to failure of 6 of
the patients to report to a physician following minor
spinal trauma. The mean age of the 7 patients was 55.8
years (range 45-65 years), and the mean duration of
ankylosing spondylitis was 27 years (range 20-35
years). The spinal fractures were due to minor falls in 5
patients, a fall down 5 steps in 1 patient, and a motor
vehicle accident in 1 patient. Five fractures occurred
in the cervical region, 1 in the thoracic region, and 1 at
the lumbosacral junction. All of the fractures were
judged by clinical or radiographic examination to be
unstable. A fracture was unstable clinically if there
was a history of movement at the fracture site. A
fracture was judged to be unstable on radiographic
grounds if dislocation was present or if the fracture
extended from the anterior longitudinal ligament
through to involve the posterior elements.
On presentation to a physician, 3 patients had
cervical fractures that had not caused neurologic damage. Two of these fractures had healed spontaneously.
One patient with a cervical fracture had developed a
right C6 root lesion and bilateral T4 root lesions. One
patient with a C6-C7 fracture-dislocation had developed an incomplete quadriplegia below C8 during the 4
weeks following his injury. The 2 patients with fractures of the lower thoracic region and lumbosacral
junction had both developed a pseudoarthrosis at the
fracture site (Figure 1).
Long-term followup of 6 patients over a mean
period of 4.2 years (range 3 months-10.5 years) revealed that 3 patients with cervical fractures had
undergone complete clinical and radiographic union
and had no neurologic deficit. One of these patients
had suffered a second cervical fracture with no neurologic deficit, and the followup of this fracture is
documented as patient 7B in group I.
The fourth patient with a cervical fracture, who
presented with an incomplete quadriplegia below C8,
was immobilized in a cervical collar for 8 weeks. At 12
weeks after injury, bony union had occurred together
with major neurologic recovery. The 2 patients who
developed pseudoarthroses at the lower thoracic and
lumbosacral region continued to have some local tenderness and pain on movement after 6 months and 5
years of followup, respectively. The patient with the
lower thoracic pseudoarthrosis has not developed any
neurologic deficit. However, the patient with a pseudoarthrosis at the lumbosacral junction presented 1
year after the spinal fracture with pain, decreased
sensation, and muscle wasting in the distribution of the
left L5 nerve root. At laminectomy the left L5 root was
found to be bound down, encircled, and inseparable
from nonspecific chronic granulation tissue.
Further study was undertaken of the 12 patients
who suffered spinal fractures due to minor falls. Three
of these patients had been knocked to the ground. The
other 9 patients had suffered spinal fractures by losing
their balance and falling to the floor from a standing
position. Information on the degree of hip involvement
was available in 7 of these patients. Three patients had
normal hips. Two patients had marked restriction of
hip movement, and 2 had complete bony ankylosis of
both hips.
One patient with complete ankylosis of both
hips refused hip arthroplasty, despite suffering cervical fracture on 2 separate occasions. In view of his
history of numerous falls despite the use of axillary
crutches, we arranged for the staff of the Rehabilitation Engineering Department to fit him with a stable
walking frame (Figure 2). This device consists of
axillary crutches fitted to a walking frame on wheels.
The patient straps himself into the frame, uses a swingthrough gait, and is able to control his speed by the use
of hand brakes. The patient has used this device for 2
years and has suffered no further falls.
It is recognized that the ankylosed spine of a
patient with chronic ankylosing spondylitis is more
prone to fracture than the normal spine (1). The
fracture most commonly occurs in the cervical region,
as illustrated by our series in which 19 of 22 fractures
occurred in the cervical region.
The trauma which causes the fracture is often
minor. Fourteen of the 22 fractures resulted from
minor falls. This includes 2 patients who suffered
cervical fracture on 2 separate occasions. In 4 patients
the minor fall could be attributed to partial or complete
ankylosis of the hips.
The minor nature of the spinal trauma leads to
problems in diagnosis. In 6 of our patients in whom the
diagnosis of spinal fracture was delayed, the delay in
diagnosis was due to a failure of the patients to
recognize the significance of a minor fall and an
increase in spinal pain, to which they had become
accustomed. In fact 1 of these patients, having suffered a cervical fracture following a fall down 5 steps,
went duck hunting for 6 days before reporting to his
When the patient presents to a physician who is
unfamiliar with this problem, the diagnosis of spinal
fracture may not be considered, or it may be dismissed
too readily when radiographs fail to demonstrate a
spinal fracture. The difficulty in radiographic visual-
Figure 2. Patient 7, with ankylosed hips, who suffered 2 spinal
fractures from minor falls. The patient was fitted with a special
walking frame to provide stability.
ization of these fractures is illustrated in our series by
1 patient with clinical instability of the spinal fracture,
which could not be demonstrated radiographically.
Tomography was needed to visualize the fracture site
in a second patient.
The difficulties in radiographic visualization are
best illustrated by a recent report of 4 patients in
whom there was a delay in diagnosis in the emergency
room, with the subsequent development of spinal cord
damage (2). All 4 of these spinal fractures occurred in
the lower cervical region, which is the most difficult
area to visualize radiographically in the normal spine.
Radiographic visualization of this area in patients with
chronic ankylosing spondylitis is made more difficult
by the spinal kyphosis, which causes more of the
cervical spine to be obscured by the clavicles and
scapulae. Immobility of the glenohumeral joint will
also prevent the positioning necessary to take “swimmer’s views” of the C7-T1 region of the spine.
Figure 3. Radionuclide bone scan of midcervical fracture 10 days
after injury, showing increased uptake at the fracture site.
We have found tomography of the spine to be of
benefit in some patients. In addition, further confirmation may be achieved by the use of the radionuclide
bone scan. We have no experience with the use of the
bone scan immediately after injury, and we do not
believe this could be used in the acute situation to
definitely exclude a fracture. Figure 3 shows the
findings on bone scan of a midcervical fracture 10 days
after injury. This fracture was difficult to visualize
radiographically, even with tomography. The value of
a bone scan is clearer in patients with a chronic
pseudoarthrosis, in whom the scan can greatly facilitate the localization of the lesion (3-5).
The ankylosed spine fractures like a long bone,
and if the fracture is through and through involving the
posterior elements of the spine, it is grossly unstable
due to the loss of ligamentous support (1,2,6). It is
essential that this be borne in mind during the initial
handling of the patient and during the period of fracture healing.
In the present paper we have reported the
results of management of these fractures by conservative or nonoperative techniques. However, in many
centers a surgical approach is taken, with a view to
early stabilization of the fracture site and/or decompression of the spinal cord. The controversy regarding
surgical versus conservative management during the
acute stage after spinal cord injury has been thoroughly discussed in recent reviews (7-9). The value of
routine laminectomy in the treatment of human spinal
cord injury is unproven (7-9). There is evidence to
suggest that laminectomy may increase the spinal
instability, aggravate the neurologic lesion, and increase the mortality in patients with spinal cord injury
associated with fractures of the spine (2,7,10). There
has never been a controlled trial to evaluate the benefit
of surgical decompression procedures versus conservative management after human spinal cord injury.
A recent laboratory report has documented the
value of decompression for defined spinal cord forces
of varying magnitude in the rat (11). Unfortunately,
the results cannot be directly extrapolated to human
spinal cord injury, and further work is necessary to
clarify indications and contraindications for surgery in
The University of Manitoba Spinal Cord Injury
Unit has emphasized the conservative approach to the
management of spinal fractures and spinal cord injuries (12). This includes cervical traction or posture
techniques to achieve early reduction of a fracturedislocation, correction and maintenance of alignment,
and immobilization until bony union has occurred. We
have found it to be a successful form of management of
fractures of the ankylosed spine in patients with chronic ankylosing spondylitis (Figure 4).
When cervical traction is applied to patients
with ankylosing spondylitis, it is important to take into
account the increased thoracic and cervical kyphosis,
and it may be necessary to apply traction in a neutral
or flexed position rather than slight extension as one
would with a normal spine. Traction must also avoid
excessive separation at the fracture site with consequent traction of the spinal cord and risk of further
neurologic deterioration. Improved posture following
conservative management of cervical fractures in ankylosing spondylitis patients has been reported (6,13).
However, since none of our patients had a severe
disabling kyphotic deformity, no attempt was made to
take advantage of the fracture in order to correct the
cervical kyphosis.
The importance of careful immobilization cannot be stressed too highly. Two previously reported
patients died while being turned (2,14). This emphasizes the importance of careful immobilization, especially during turning. This is accomplished in our
Spinal Cord Injuries Unit by the use of the StokeMandeville automatic turning bed. This bed allows
utilization of postural reduction techniques for thorac-
Figure 4. Lateral radiographs of patient 5 showing: A , fracture-dislocation at C4-C5, B, reduction of fracture-dislocation
immediately following cervical traction, and C, solid union of fracture at 4 months after injury.
ic and lumbar fractures, and the traction unit allows
safe turning of cervical fracture patients by one person
( 15,16).
To compare the results of conservative versus
surgical management of cervical fractures in patients
with chronic ankylosing spondylitis, we have reviewed
39 previously reported patients, in whom details of
management and final bony and neurologic outcome
were available (6,13,14,17-3 1).
Twenty-six patients described in the literature
were managed conservatively with cervical traction
and/or cervical collar. Three of these patients had
unstable fractures and complete quadriplegia. One of
the 3 did not achieve complete radiologic bony union
at 1-year followup, but remained complication-free
with no evidence of redislocation. One patient died of
a cardiorespiratory arrest 4 days after injury. The
other patient died of a cardiorespiratory arrest on the
second day while being turned, and the autopsy findings included a large cervical epidural hematoma and
Ten patients had an unstable fracture and incomplete quadriplegia. The fracture healed in 6 patients, with major neurologic improvement occurring
in 4. One patient deteriorated neurologically and underwent laminectomy , with subsequent neurologic improvement. Three patients died, 2 of cardiorespiratory
complications and 1 of epidural hemorrhage.
Eleven patients had unstable fractures with no
spinal cord damage and were managed conservatively.
The fracture healed without complication in all 11
patients. None of the patients developed neurologic
deficit during the period of conservative management.
All fractures demonstrated clinical and radiologic
union within 8 to 12 weeks after injury.
Two patients had stable fractures associated
with incomplete quadriplegia. The fractures healed in
both patients. One patient improved neurologically
and the other remained unchanged.
Thirteen of the 39 cases were managed surgically (14,18-22,24,26). Laminectomy was performed in 9
patients, and laminectomy and fusion in 3 patients.
One patient had posterior fusion and bone graft. Three
of these patients had unstable fractures and complete
quadriplegia. The fracture healed with no neurologic
change in 1 patient. The other 2 patients died, 1 of
pneumonia and the other of epidural hemorrhage.
Nine patients managed surgically had unstable fractures with incomplete quadriplegia. The fractures
healed in 7 patients. Two patients were neurologically
improved, 4 unchanged, and 1 worse. Of the 2 remaining patients, 1 died of a cardiorespiratory arrest and
the other patient suffered a redislocation of the fracture site following laminectomy. The fracture was
reduced and immobilized by cervical traction in bed,
and solid union eventually occurred.
One patient with a stable fracture and incomplete quadriplegia without neurologic deterioration
had a laminectomy 3 days post-injury. He remained
neurologically unchanged postoperatively and died 2
weeks later of pneumonia.
Because the patients from the literature are not
a controlled group and were not managed in a standardized way, a direct comparison between conservative and initial surgical management cannot be made.
Though our unit has used a conservative approach to
the management of spinal fractures, we would support
the use of laminectomy for a patient with progression
of a neurologic lesion, and spinal fusion for fractures
which could not be stabilized by conservative means.
The experience from the literature highlights
several important complications of spinal fractures in
patients with ankylosing spondylitis. In 9 of 54 patients, there was evidence of spinal epidural hematoma. This is in contrast to the absence of clinically
significant epidural hemorrhage in a recent review of
292 fractures of the normal cervical spine (2). It would
appear that bleeding from the perivertebral or epidural
veins and from the fractured cancellous bone, leading
to further neurologic damage, is a particular hazard in
fractures of the ankylosed spine (2,22). The second
major complication common to both forms of management is cardiorespiratory instability and respiratory
infection, leading to a high mortality rate. Third, the
danger of hyperextending the cervical spine during
intubation or cardiac resuscitation cannot be overemphasized. Finally, tracheal intubation is more difficult
in these patients, as illustrated by a previously reported patient who required tracheostomy because of
tracheal hemorrhage at the time of intubation (14).
The management of spinal fracture is costly,
especially if it is complicated by spinal cord injury. It
is therefore important to attempt to reduce the duration of hospitalization.
There is some evidence in the literature that the
use of halo traction and body cast or vest may shorten
the period of bed rest and hospitalization (25). However, of 13 previously reported patients, 2 patients
redislocated at the fracture site (21,25,26,28,30). Great
care must therefore be taken if this form of management is used initially. Frequent neurologic and radiologic evaluation is important to ensure the early detection of redislocation at the fracture site. Despite these
concerns, halo traction and body cast may allow for
early mobilization and thereby avoid the physical and
psychologic problems associated with prolonged bed
rest, provided they can be fitted correctly. Their use
may also speed up the rehabilitation program and
thereby reduce the length of hospital stay.
The final decision on conservative versus surgical management of a spinal fracture in a patient with
chronic ankylosing spondylitis must rest with the
experience and expertise of the local spinal cord injury
team. Whether surgical or conservative, the management should include careful reduction and immobilization of unstable fracture-dislocations, as well as close
watch for neurologic deterioration due to change in
alignment or epidural hemorrhage. An attempt must be
made to avoid cardiorespiratory complications. This
includes frequent turning, assisted coughing, and frequent chest radiography and blood gas analysis.
Because of the increased risk of spinal fracture
in patients with ankylosed spines, we have tended to
alert the patient to this possible complication. If even
minor spinal trauma occurs, the condition should be
managed as a spinal fracture with potentially serious
neurologic complications, until this diagnosis has been
We wish to thank the staff of the Section of Special
Devices, Rehabilitation Engineering Department at the
Health Sciences Centre for designing and providing the
walking frame, Dr. Ian Chalmers for his helpful comments,
and Mrs. Debbie Murray for secretarial assistance.
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spina, ankylosis, complicating, fractured, spondylitis
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