spine
Spine Fracture in Ankylosing Spondylitis
advanced
6 min
28 marks
6 questions
Clinical Scenario
A 62-year-old man with known ankylosing spondylitis presents after a fall from standing height. He has severe neck pain and is unable to move his head. He has progressive weakness in all four limbs over the past 2 hours. He has a long-standing rigid kyphotic spine. On examination, he has 2/5 power in upper limbs and 3/5 in lower limbs with hyperreflexia.
Sagittal CT demonstrating a hyperextension fracture-dislocation through a completely ankylosed cervical spine at C6-7 in a patient with ankylosing spondylitis. The fracture extends through the fused disc space and facets (three-column injury). There is posterior displacement with likely epidural hematoma. The remainder of the spine shows complete ankylosis with bridging syndesmophytes.
Image source: Open Access medical literature (NIH/PubMed Central) • CC-BY License
Questions
Question 1 (4 marks)
Describe the imaging findings and why is this injury pattern unique?
Question 2 (5 marks)
What are the special considerations in managing AS spine fractures?
Question 3 (6 marks)
What investigations are required and what are you looking for?
Question 4 (5 marks)
Describe your management algorithm and surgical approach.
Question 5 (4 marks)
What are the technical considerations for surgical fixation?
Question 6 (4 marks)
What are the expected outcomes and complications?
Exam Day Cheat Sheet
Must Mention
- •Three-column injury (long bone analogy)
- •Low-energy mechanism
- •CT entire spine (5-10% have second fracture)
- •MRI for epidural hematoma (30-40%)
- •Surgical stabilization preferred
- •Long constructs (3-4 levels each side)
- •Careful handling (fragile spine)
- •Awake fiberoptic intubation if cervical
Common Pitfalls
- •Underestimate severity
- •Miss second fracture
- •Miss epidural hematoma
- •Short constructs
- •Rough handling
- •Delayed surgery
- •Forced positioning