diagnosing the condition both occur frequently.
Patients w ith AS (and som etim es w ith DISH) h ave becom e used to experiencing episodes of spinal pain and do not alw ays becom e alarm ed after a t rivial fall or accident, and as a result they seek m edical h elp only after an increase in sym ptom s. Physicians are not alw ays fam iliar w ith the radiographic abnorm alities associated w ith AS and DISH, and m ay not recognize frac-t ures on roufrac-tine sfrac-t udies. Furfrac-therm ore, anky-losed cer vical spin e fractures w ith a B3 t ype hyperextension con guration often hinge on a posteriorly located fulcrum and m ay close dow n w hen patients are lying supine and hav-ing their head supported by cushions.23 As a general rule, a physician needs to proactively r u le ou t a fract u re in pat ien ts w ith any sign s of spin al ankylosis com plaining of neck pain or spinal pain after su ering a traum atic event, h ow ever sm all. In som e cases the fract ure is visible on ly on MRI, an d th is m odalit y sh ou ld be u sed liberally, as th e con sequ en ces of dis-ch arging a pat ien t w ith a m issed an kylosed spine fract ure m ay be disastrous.24
A second com m on pitfall is secondar y dete-rioration of neurologic function after hospital adm ission due to spinal cord injury caused by loss of spinal alignm ent.3 Every m anipulat ion or transfer of the patient should be perform ed w ith m axim um at tention to m aintaining align-m ent of the coalign-m plete spinal colualign-m n. The cor-rect m aneuver to tran sfer a patient or to change
a patient’s position is by using the log-roll tech-nique. This technique requires at least three (but preferably m ore) w ell-instructed individ-uals for safe execution. Alth ough halo-vest x-ation of fract ures of the ankylosed spin e is not recom m ended as de nitive treatm ent, it m ay be helpful in providing su cient stabilization to decrease the risk of secondar y neurologic de cit during m an ipulation or t ran sfer of the patient. Furtherm ore, halo-vest xation m ay be valuable w hile positioning the patient on the operating table and to m ain tain gross align-m ent during surger y.
A th ird pitfall can be en cou n tered du ring th e n al steps of su rgical xat ion of th e an -kylosed cervical spine. Preexisten t deform ities should be acknow ledged and respected w h en xating the cer vical spin e in its nal position, as (over)correction of the, usually kyphotic, deform it y m ay not be tolerated and could lead to iatrogen ic spinal cord injury due to stretch -ing or vascular com prom ise.24 Therefore, the surgeon should tr y to reconstruct the m ost probable pretraum a alignm ent of the cer vical spine based on all radiographic st udies (preferably also from an earlier date) and try to ap -proxim ate this previous state w hen connecting rods to the im planted screw s.
■ Chapter Summary
Ankylosis of the cer vical spine is a relatively frequent nding caused by AS and DISH. As cer vical segm ents becom e progressively fused, the exibilit y of the neck decreases consider-ably, and the biom echanical characteristics of th e cer vical spin e in creasingly resem ble th at of long bones. As a result of stress shielding, the bone m ineral densit y in the ankylosed spi-nal colum n is t ypically low er than in a control populat ion. The com bination of cer vical anky-losis and poor bone strength results in a st i and brit tle neck susceptible to fracture after even m inim al traum a. During transport and di-agnostic workup, until de nitive treatm ent can be started, great care sh ould be taken to pre-vent further fract ure dislocation and iatrogenic spinal cord injur y. Fract ures of the ankylosed
Cervical Trauma in Combination
145
cervical spine can be di cult to diagnose due to preexisting abnorm alities confounding inter-pretation of radiographic st udies, inconclusive results due to insu cient/inappropriate im ag-ing techniques, patient delay in presentag-ing an d physician delay in diagnosing, and underesti-m ation of the trauunderesti-m atic iunderesti-m pact.
In patients w ith signs of ankylosis of the spinal colum n and w ith neck or back pain fol-low ing (m inor) traum a, physicians should have an ext rem ely h igh in dex of su sp icion for a spinal fract ure. Treatm ent of fractures of the ankylosed cervical spine has som e sim ilarities w ith long bone fracture treatm ent principles.
Surgical xation is usually the treatm ent of choice, as indirect fract ure stabilization (w ith h alovest xat ion or collar) is often in su -cien t an d m ay lead to fract u re dislocat ion , secon dary neurologic de cits, or form ation of pseudarthrosis. In general, long bridging-t ype constructs should be used to provide adequate stabilizat ion at the fract ure site w hile the in-strum entation should preferably n ot end at vulnerable locations such as the cer vicotho-racic junction . The outcom e of the m anage-m ent of patients w ith an kylosed cer vical spine fract ures depends m ainly on their neurologic
stat us at adm ission and prevention of second-ary neurologic injury.
Pearls
Maintain a high index of suspicion for cervical an-kylosed spine fractures in every trauma patient with signs of spinal ankylosis and tenderness of the neck.
Protecting the cervical spine is of extreme im -portance in patients with cervical ankylosed spine fractures until de nitive treatment has been established.
Treatment principles for cervical ankylosed spine fractures follow long bone fracture management to a large extent.
Early mobilization and ambulation are key factors for good clinical outcome following cervical an-kylosed spine fracture.
Pitfalls
Failure to recognize a cervical ankylosed spine fracture may have disastrous consequences.
Preexisting deformities should be respected when immobilizing patients with (known) anky-losing disorders of the spine prior to transfer.
Secondary neurologic de cits have great nega-tive impact on ultimate clinical outcome and may often be avoidable.
References
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■ Introduction
Rheum atoid arthritis (RA) is a chronic, in am -m ator y autoi-m -m une disorder ch aracterized by sym m etric erosive synovitis of the peripheral joints. It a ects 1 to 2% of the w orld population and often entails early involvem ent of the cer-vical spine, a ecting anyw here from 17 to 86%
of patients.1 It can lead to progressive destruc-t ion of destruc-the synovial joindestruc-ts, ligam endestruc-ts, and bone in the cer vical spine, particularly in the atlan-toaxial segm ent. This progressive destruction can further lead to instabilit y that generally follows three characteristic patterns, w hich m ay occur together or alone: atlantoaxial im paction (AAI), atlantoaxial sublu xation (AAS), an d sub-axial sublu xation (SAS). Each form of instabil-it y can in t urn lead to spinal cord com pression and neurologic symptom s.2–8 With the increased use of disease-m odifying antirheum atic drugs (DMARDs), th e need for surgical decom pres-sion an d stabilization for cervical spine pathol-ogy due to RA has fallen.9,10 Nevertheless, the spine surgeon caring for patients w ith RA in the set ting of cervical spin e traum a m ust be aware of the speci c challenges this patient pop-ulation presents. Preexisting instabilit y, neural com pression, deform it y, com prom ised bone qualit y, and im paired healing capabilit ies can all com plicate the treatm ent of cer vical spine traum a in pat ients w ith RA. Spine traum a cen -ters should be en couraged to develop sound
treatm ent protocols to e ectively t reat these unique patients.