Trauma Cases from Harborview Medical Center

Predisposition for Spinal Fracture in Ankylosing

Spondylitis
Julian A. Hanson1 and Sohail Mirza2
Share
+ Affiliations:
1
Department of Radiology, Harborview Medical Center, University of Washington School of
Medicine, 325 Ninth Ave., Seattle, WA 98104.
2
Department of Orthopedics, Harborview Medical Center, University of Washington School
of Medicine, Seattle, WA 98104.
Citation: American Journal of Roentgenology. 2000;174: 150-150.
10.2214/ajr.174.1.1740150

Citation
Full Text
Figures
References
PDF
PDF Plus
Add to Favorites
Permissions
Download Citation

Choose

A 40-year-old man with established ankylosing spondylitis of the lower spine was struck by a
car and sustained an isolated back injury with thoracolumbar junction tenderness and
swelling. Mild bilateral hip flexion weakness was present with no other neurologic deficit.
Lumbar spine radiographs showed an unstable extension fracturedislocation through the
L1-L2 disk space (Fig. 1A) and characteristic features of ankylosing spondylitis. He
underwent posterior fusion and instrumentation from T12 to L3. Minimal iliopsoas weakness
persisted.
 Fig. 1 .40-year-old man with ankylosing spondylitis who was
struck by car and sustained isolated back injury. Two years later he
was readmitted with lower back pain after series of falls.

A, Lateral lumbar spine radiograph shows extension fracture-

dislocation through L1-L2 disk space (black arrow). Note
ankylosis of posterior spinal elements (White arrow).

View larger version

(98K)

Two years later the patient was readmitted with lower back pain after a series of falls. The
lateral lumbar spine radiograph (Fig. 1B) showed new widening of the L4-L5 disk space and
a transverse fracture through the fused articular facets; these findings were confirmed on CT
(Fig. 1C). He underwent extension of the posterior fusion and instrumentation to the L5 level
without further neurologic deterioration.

Fig. 1 .40-year-old man with ankylosing spondylitis who was

struck by car and sustained isolated back injury. Two years later he
was readmitted with lower back pain after series of falls.

B, Two years later, lateral lumbar spine radiograph shows new

widening of L4-L5 disk space (thick arrow) with transverse fracture
through ossified facet joints below prior fusion (thin arrow).

View larger version

(123K)
 Fig. 1 .40-year-old man with ankylosing spondylitis who
was struck by car and sustained isolated back injury. Two
years later he was readmitted with lower back pain after
series of falls.

C, Axial CT scan with 3-mm collimation and sagittal

reformation confirms injury (arrow).

View larger version (158K)

The diffuse paraspinal ossification and inflammatory osteitis of advanced ankylosing

spondylitis creates a fused, brittle spine that is susceptible to fracture. Even minor trauma can
produce an unstable injury as a result of disruption of the ossified supporting ligaments.

Thoracolumbar fractures are reported less frequently than cervical injuries in patients with
ankylosing spondylitis [1, 2]. Three recognized patterns are simple vertebral compression
fractures, transversely oriented shear fractures, and stress fractures associated with
pseudoarthrosis [3].

Simple vertebral compression fractures are osteoporosis-related injuries that occur early in
the course of the disease, before ankylosis, and typically result in stable kyphosis [3].
Transversely oriented shear fractures are acute fractures of the ankylosed spine that
invariably disrupt the ossified supporting ligaments and usually traverse the disk space.
Disruption of all three columns of the spine predisposes the fracture to displacement and
neurologic injury [3]. Stress fractures associated with pseudoarthrosis are subacute injuries
that constitute part of the spectrum of spondylodiscitis, a destructive discovertebral
(Andersson) lesion, that tends to occur in the thoracolumbar region [4, 5]. End-plate
erosions and disk height changes, with vertebral sclerosis or osteolysis, can be seen
radiographically. Although the inflammatory process may play a role, many cases are
probably caused by the nonunion of stress fractures [4]. These fractures are more stable than
transversely oriented shear fractures, with infrequent neurologic sequelae [3].

The recognition of minimally displaced fractures in patients with ankylosing spondylitis is

compromised by coexisting osteopenia and deformity. One must specifically search for disk
space widening and discontinuity of the ossified paraspinal ligaments. New back pain in
patients with ankylosing spondylitis or other diseases with paraspinal ossification should be
assumed to be caused by fracture until disproven. Axial CT has potential diagnostic
limitations because of the transverse fracture plane; sagittal reformations should be obtained.
In problem cases MR imaging and radionuclide scintigraphy [6] can be helpful.

Our patient sustained two unstable transdiskal lumbar spine injuries within a 2-year period,
reflecting the predisposition for spine fracture in ankylosing spondylitis. Prompt reduction
and stabilization of the first injury resulted in favorable neurologic outcome. The site of the
second fracture, which followed only minor trauma, was influenced by altered biomechanics
at the margin of the previous fusion.

This is another in the continuing series on radiology in trauma cases from the Harborview
Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Alexander B. Baxter.

Address correspondence to F. A. Mann

Choose
References
1.Thorngren KG, Liedberg E, Aspelin P. Fractures of the thoracic and lumbar spine in
ankylosing spondylitis. Arch Orthop Trauma Surg 1981; 98:101-107 [Crossref] [Medline]
2.Olerud C, Frost A, Bring J. Spinal fractures in patients with ankylosing spondylitis. Eur
Spine J 1996; 5:51-55 [Crossref] [Medline]
3.Trent G, Armstrong GWD, O'Neil J. Thoracolumbar fractures in ankylosing spondylitis:
high risk injuries. Clin Orthop 1988; 227:61-66 [Medline]
4.Gelman MI, Umber JS. Fractures of the thoracolumbar spine in ankylosing spondylitis. AJR
1978; 130:485-491 [Abstract]
5.Rasker JJ, Prevo RL, Lanting PJH. Spondylodiscitis in ankylosing spondylitis, infection or
trauma? A description of six cases. Scand J Rheumatol 1996; 25:52-57 [Crossref] [Medline]
6.Resnick D, Williamson S, Alazraki S. Focal spinal abnormalities on bone scans in
ankylosing spondylitis: a clue to the presence of fracture or pseudarthrosis. Clin Nucl Med
1981; 6:213-217 [Crossref] [Medline]

Read More: http://www.ajronline.org/doi/full/10.2214/ajr.174.1.1740150