146

KISEP Case Reports J Korean Neurosurg Soc 26 146-151, 1997

An Occult Fracture in a Ankylosing Spondylitis Patient

Chang Myong Choi, M.D., Ji Ho Yang, M.D., Il Woo Lee, M.D.,
Chul Ku Jung, M.D., Joon Ki Kang, M.D.
Department of Neurosurgery, Taejeon St Marys Hospital,Catholic University Medical College,
Taejeon, Korea

= Abstract =

KEY WORDS


Case Report

A 61-year-old male fell off a 3-m high roof landing on
his head and back. The patient was first treated at a local
clinic before transfer to our hospital. In the emergency room
he was stuporous and irritable. Neurological examination
revealed no motor weakness. Cervical spine X-ray showed
hyperlordotic curvature and bamboo spine without fracture.
Brain CT scan showed hemorrhagic hyperdense lesions in
the right frontal region, the cerebellar vermis and the fourth
ventricle Fig. 1 . Respiration was controlled with intubation
and the man was restrained due to uncooperative irritable
behavior. The patient was treated conservatively with a
course of bed rest, hypertonic solutions, anticonvulsants,
and analgesics. He regained the consciousness alert and his
general condition was improved over next three weeks. He
then, suddenly became paraplegic during wheel-chair am-
bulation with assistance by his family members.
Examination Paraplegia with trace movement to painful
stimuli was observed. No pain or temperature sense below
the T12 dermatome were evident. Anal and bulobocavernous
reflexes were also lost.
Neuroradiology Review of T-L spine radiographs de-
monstrated a supspicious transverse linear fracture through
the disc and juxta-end plate region between the T11 and
T12 vertebrae with typical findings of ankylosing spondylitis
Fig. 2 . An MRI scan revealed posterior compression of
spinal cord by a bony spicule at the T12 level with signal
change in marrow Fig. 3 .
Operation The patient underwent small laminectomy
and posterior spinal fusion with a rod system. There was a
transverse fracture line extending posteriorly to the laminae
and spinous process. A bony spicule was impinging upon
the dura which exhibited bluish discoloration and swelling.
A small amount of epidural hematoma was found. There was
calcification involving apophyseal joints with interspinous
ligaments and ligamenta flava resulting in ossification of
the spaces between the dorsal arches. The small bony spicule
impining upon the dura was removed. A spinal fusion was
performed with rods on two segments above and three
segments below the lesion using sublaminar hooks and
wires. The hook entry site was made by use of an air drill
Fig. 4 .
Postoperative Course The patient was nursed on a conve-
ntional hospital bed and turned by log rolling. No significant
improvement was observed in the immediate postoperative
course. Neurologic symptoms improved gradually and the





Chang Myong Choi Ji Ho Yang Il Woo Lee Chul Ku Jung Joon Ki Kang
26 1 1997 147


Fig. 1. CT scan obtained on admission shows hemorrage in the right frontal region, cerebellar vermis, and the fourth ventricle.
Fig. 2. Retrospective examination of films on admission showing suspicious transverse linear fracture line through the ossified
disc space and juxta-end plate region between the T11 and T12 vertebrae of bamboo spine.





An Occult Fracture in a Ankylosing Spondylitis Patient
26 1 1997 148

Fig. 3. CT and MRI examinations taken after paraplegia. Computerized tomography section through the T12 pedicle shows
disruption of the posterior arch. MRI scan demonstrates marrow change and a bony spicule impinging upon cord with
increased signal intensity in the T12 area.
Fig. 4. Postoperative radiograph The fractured spine was fused, two levels above and three levels below the lesion, by a rod
system with sublaminar hooks and wires.





Chang Myong Choi Ji Ho Yang Il Woo Lee Chul Ku Jung Joon Ki Kang
26 1 1997 149

patient could walk without assistance approximately 3 months
after the operation. After two years , the independent activities
of daily living ADL were possible, but the patient com-
plained of paresthesia and radiculopathy in both legs.

Discussion

Ankylosing spondylitis Marie-Strmpel arthritis results
in development of a rigid spinal column bamboo or poker
sign , often severly deformed by exaggerated thoracic
kyphosis and cervical lordosis
25)30)
. The ankylosed spine of
a patient with chronic ankylosing spondylitis is more prone
to fracture than the normal spine
15)
. Since most afflicted
patients remain physically active, the risk of injury causing
fracture and spinal contusion is significant
13)14)23)31)
. The
trauma which causes the fracture is often minor. Fourteen
of 22 fractures resulted from minor falls in the series of
Thomas et al
27)
.
The pathology of ankylosing spondylitis has been des-
cribed in detail elsewhere
8)
. Although diarthrodial extremities
and spinal joints are frequently involved, the proliferative
process which results in spinal ankylosis predominently
affects ligamentous attachments and intervertebral discs.
Chondroidal metaplasia is followed by calcification and
ossification involving the apophyseal joints, as well as the
anulus fibrosus, and the anterior, but not always the posterior,
longitudinal ligaments
9)
. Interspinous ligament and ligam-
entum flavum involvement is not unusual, resulting in
ossification of the spaces between the doral arches. Apo-
physeal joint involvement begins with erosive changes that
progress to cartilage destruction, joint narrowing, and ank-
ylosis. Serial biopsies have demonstrated that inflammatory
synovial proliferation generates a thickened vascularized
fibrous layer which is thought to disrupt adjacent cartilage
and bone
9)11)
. P.R. Weintstein et al found 13 of the 20
fractures and destructive vertebral lesions to be located in
the intervertebral discs
21)
. This finding suggests a selective
vulnerability of ossified discs to traumatic stress. Disc ossi-
fication may be incomplete, with fibrous and cartilaginous
tissue persisting centrally and posteriorly, creating a weaker
structure than the adjacent vertebral bodies. Such transdiscal
fractures may be more difficult to visualize radiographically
than fracture lines passing through the bodies or ppedicles.
Mostoften the posterior elements are fused and fracture
lines extend posteriorly to the lamina and spinous process
31)
.
Ankylosis of the spine results in biochemical alterations
that predispose the patient to serious spinal injury. Alth-
ough the degree of precipitating trauma may be small, the
ensuing damage to the spine and spinal cord may be exten-
sive
12)
. Fractures through the cervical spine in ankylosing
spondylitis have been well documented in the literature,
usually occurring through the ossified disc space or ver-
tebral body and extending posteriorly through the posterior
elements
3)19)20)31)
. The existence of similar fractures in the
thoracic and lumbar spine has not been emphasized as clearly,
probably because of confusion with inflammatory changes
as well as the lack of serious neurologic impairment. Lower
thoracic fractures are also quite unstable, and even minor
mechanical stresses may cause dangerous dislocation of the
fracture margins
6)
. In the ankylosed spine where compen-
satory disc and facet joint movement in response to load is
prevented, it seems likely that bony deformation and, the-
refore, stress fractures would tend to occur most frequently
at the thoracolumbar and lumbosacral junctions
2)7)10)17)29)32)
.
Once a fracture has occurred, the long rigid lever arm
represented by the ankylosed spine tends to concentrate
stress and deformation at the fracture site. This may contribute
subsequently to the formation of pseudoarthrosis. Disc space
or end plate horizontal fractures with associated posterior
element involvement are common in long-standing ankylosis
spondylitis and reflect the bio-mechanical effect of trauma
or subclinical stress on a rigid spine
20)
.
An occurrence of minor spinal trauma can lead to problems
in diagnosis. Fractures in ankylosing spondylitis can be
overlooked because ligamentous and disc ossification fre-
quently obscure transverse and oblique fractures on plain
radiographs
21)
. In our case, the delay in diagnosis was due
to the associated severe head injury which caused the failure
of physicians to detect subtle spinal lesion during initial
evaluation. When a patient is represented to a physician
who is unfamiliar with this type of problem, the diagnosis
of spinal fracture may not be considered, or it may be
dismissed readily when radiographs fail to demonstrate a
spinal fracture. The difficulty in radiographic visualization
of these fractures is a potentially serious problem
15)27)
. A
delay in correct radiographic diagnosis at emergency room
can result in subsequent development of spinal cord damage.
Delayed onset of neurologic deficit due to instability was
found to be present in 2 cases out of 13 patients
21)
. Fractures
can frequently occur as a result of even minimal trauma
and may be associated severe neurologic deficits. Fractures
that occur in ankylosing spondylitis are potentially lethal





An Occult Fracture in a Ankylosing Spondylitis Patient
26 1 1997 150
and associated with severe spinal cord injury. Although the
majority of fractures occur in the lower cervical spine, they
may occur at any levels and often result in quadriple-
gia
1)13)17)27)29)
. Radiographically, the fractures most commonly
occur through the intervertebral disc space. However hori-
zontal fractures through the vertebral bodies adjacent to the
vertebral endplate, similar to the Chance or seat belt fra-
cture, with extension through the posterior elements may
also occur
21)
.
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 considered to be unstable due to
the loss of ligamentous support
3)4)15)27)
. The loss of normal
spinal segmental flexibility and the accompanying osteo-
porosis predispose the ankylosed spine to injury
22)31)
. It is
essential that this borne in mind during the initial handling
of the patient and during the period of fracture healing. The
importance of careful immobilization can not be stressed
too highly. All patients with known ankylosing spondylitis
should be warned by their physicians of the inordinate
susceptibility to spinal fractures. These patients after trauma,
or even if they note spontaneous back pain associated with
a jerking or grating sensation, should immobilize themselves
and immediately seek medical attention, as recommended
by Osgood et al. This is most imperative with cervical and
lower thoracic sensations
18)
.
Radiographic recognition in the patient presenting sudden
focal pain and tenderness is important for selection of proper
therapy. If bony irregularity and sclerosis begin to develop,
a pseudoarthrosis rather than a pyogenic or granulomatous
infection should be suspected and rigid internal fixation
and surgical fusion may be required
20)24)
. Fractures of the
thoracic and lumbar spine in ankylosing spondlyitis generally
have fewer neurologic complications than cervical fractures
and heal with moderate immobilization. Conservative treat-
ment with external support by a brace is associated with a
high rate of fracture union and a low rate of complications
and mortality. Surgical intervention may be indicated for
treatment of incomplete or evolving neurologic lesions, and
in the management of fractures that can not be stabilized
by nonoperative means
5)
. We think that this case report
presents a challenge to physicians for management of brain-
injury associated ankylosing spondylitis where thorough
examination of radiographs are mandatory in the initial
evaluation.


Conclusion

Although complications are uncommon from minor spinal
trauma in patients with ankylosing spondylitis, they should
be kept in mind, especially in head injured patients. Thorough
clinical and roentgenographic examination of the entire ver-
tebral column is recommended in patients with ankylosing
spondylitis who have sustained injury.




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