Spine Fractures in Patients with Ankylosing Spondylitis
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Published:
Feb 11, 2021
Keywords:
Ankylosing Spondylitis, Fractures, Treatment, Complications
Main Article Content
Abstract
Introduction: Ankylosing Spondylitis (AS) is a progressive inflammatory disorder that affects the axial skeleton including the sacroiliac joints. Patients are 4 times more likely to suffer a fracture (10% at 10 years of illness), and there is a high percentage of delay in diagnosis. Stiffness and osteoporosis are key to suffering these injuries. CT and MRI scannings play a fundamental role in diagnosis. The current choice for treatment is decompression and surgical fixation. A series of cases is presented in order to: consider diagnostic difficulties; describe the injuries and therapeutic decision; analyze the presentation of complications andcarry out a bibliographic update.
Materials and Methods: This is a retrospective multicenter study of a case series of 6 patients.
Results: Six males with an average age of 58.1 years. Four presented a fall from the standing position. The delay in diagnosis was 12.8 days on average. The most affected areas were thoracic and lumbar, with a predominant mechanism of hyperextension. Four patients underwent surgery.
Discussion: Fractures in patients with AS are frequent complications related to osteoporosis. CT is the sensitive and specific method for diagnosing the lesion. The current literature supports the need for subsequent surgical treatment.
Conclusions: AS carriers are more at risk of suffering a low-energy trauma fracture. A delay of 12.8 days in diagnosis. Surgical treatment, with long fixations and posterior release, is the most widely used treatment. We have not observed post treatment complications.Level of evidence: IV
Materials and Methods: This is a retrospective multicenter study of a case series of 6 patients.
Results: Six males with an average age of 58.1 years. Four presented a fall from the standing position. The delay in diagnosis was 12.8 days on average. The most affected areas were thoracic and lumbar, with a predominant mechanism of hyperextension. Four patients underwent surgery.
Discussion: Fractures in patients with AS are frequent complications related to osteoporosis. CT is the sensitive and specific method for diagnosing the lesion. The current literature supports the need for subsequent surgical treatment.
Conclusions: AS carriers are more at risk of suffering a low-energy trauma fracture. A delay of 12.8 days in diagnosis. Surgical treatment, with long fixations and posterior release, is the most widely used treatment. We have not observed post treatment complications.Level of evidence: IV
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How to Cite
Bazán, P. L., Bravo, M. A., Gutiérrez, E. E., Terraza, S., Cortés, C., Borri, Álvaro E., Medina, M., & Ciccioli, N. M. (2021). Spine Fractures in Patients with Ankylosing Spondylitis. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 86(1), 58-63. https://doi.org/10.15417/issn.1852-7434.2021.86.1.1094
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Clinical Research
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References
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PMID: 14627178
11. El Maghraoui A, Bensabbah R, Bahiri R, Bezza A, Guedira N, Hajjaj-Hassouni N. Cervical spine involvement in
ankylosing spondylitis. Clin Rheumatol 2003;22:94-8. https://doi.org/10.1007/s10067-002-0681-2
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13. Altenbernd J, Bitu S, Lemburg S, Peters S, Seybold D, Meindl R, et al. Vertebral fractures
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org/10.1055/s-2008-1027886
14. Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing
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17. Montala N, Juanola X, Collantes E, Munoz-Gomariz E, Gonzalez C, Gratacos J, et al. Prevalence of vertebral
fractures by semi-automated morphometry in patients with ankylosing spondylitis. J Rheumatol 2011;38:893-7.
https://doi.org/10.3899/jrheum.100851
18. Donnelly S, Doyle DV, Denton A, Rolfe I, McCloskey EV, Spector TD. Bone mineral density and vertebral
compression fracture rates in ankylosing spondylitis. Ann Rheum Dis 1994;53(2):117-21.
https://doi.org/10.1136/ard.53.2.117
19. Jun JB, Joo KB, Her MY, Kim TH, Bae SC, Yoo DH, et al. Femoral bone mineral density is associated with
vertebral fractures in patients with ankylosing spondylitis: a cross-sectional study. J Rheumatol 2006;33(8):1637-41. PMID 16881119
20. Klingberg E, Geijer M, Gothlin J, Mellstrom D, Lorentzon M, Hilme E, et al. Vertebral fractures in ankylosing
spondylitis are associated with lower bone mineral density in both central and peripheral skeleton. J Rheumatol
2012;39:1987-95. https://doi.org/10.3899/jrheum.120316
21. Muñoz-Ortego J, Vestergaard P, Rubio JB, Wordsworth P, Judge A, Javaid MK, et al. Ankylosing spondylitis is
associated with an increased risk of vertebral and non-vertebral clinical fractures: a population-based cohort study. J Bone Miner Res 2014;29(8):1770-6. https://doi.org/10.1002/jbmr.2217
22. Vosse D, Landewé R, van der Heijde D, van der Linden S, van Staa TP, Geusens P. Ankylosing spondylitis
and the risk of fracture: results from a large primary care-based nested casecontrol study. Ann Rheum Dis
2009;68(12):1839-42. https://doi.org/10.1136/ard.2008.100503
23. Zhu R1, Song W, Hu W, Jiang Z, Yuan J, Cui Z, Wan J, Liu Y, Feng S, Zhang X. The treatment strategies for spine
fractures in patients with ankylosing spondylitis: A case report. Medicine (Baltimore) 2017;96(44):e8462.
https://doi.org/10.1097/MD.0000000000008462
24. Heyde CE, Fakler JK, Hasenboehler E, Stahel PF, John T, Robinson Y, et al. Pitfalls and complications in the
treatment of cervical spine fractures in patients with ankylosing spondylitis. Patient Saf Surg 2008;2:15. https://doi.org/10.1186/1754-9493-2-15
25. Lu GH, Wang B, Li J, Kang YJ, Lu C, Ma ZM, et al. Combined anterior and posterior approach for cervical
fracture-dislocation with ankylosing spondylitis. Zhonghua Wai Ke Za Zhi 2007;45:373-5. PMID: 17537319
26. Shen FH, Samartzis D. Surgical management of lower cervical spine fracture in ankylosing spondylitis. J Trauma 2006;61:1005-9. https://doi.org/10.1097/01.ta.0000208125.63010.04
27. Longo UG, Loppini M, Petrillo S, Berton A, Maffulli N, Denaro V. Management of cervical fractures in ankylosing spondylitis: anterior, posterior or combined approach? Br Med Bull 2015;115:57-66. https//doi.org/10.1093/bmb/ldv010
spondylitis. Rheumatol Int 2016;36(10):1335-46. https://doi.org/10.1007/s00296-016-3524-1
2. Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic
review of the literature on treatment, neurological status and complications. Eur Spine J 2009;18(2):145-56.
https://doi.org/10.1007/s00586-008-0764-0
3. Finkelstein JA, Chapman JR, Mirza S. Occult vertebral fractures in ankylosing spondylitis. Spinal Cord
1999;37(6):444-7. https://doi.org/10.1038/sj.sc.3100837
4. Davey-Ranasinghe N, Deodhar A. Osteoporosis and vertebral fractures in ankylosing spondylitis. Curr Opin
Rheumatol 2013;25:509-16. https://doi.org/10.1097/BOR.0b013e3283620777
5. Jacobs WB, Fehlings MG. Ankylosing spondylitis and spinal cord injury: origin, incidence, management, and
avoidance. Neurosurg Focus 2008;24(1):E12. https://doi.org/10.3171/FOC/2008/24/1/E12
6. Waldman SK, Brown C, Lopez de Heredia L, Hughes RJ. Diagnosing and managing spinal injury in patients with
ankylosing spondylitis. J Emerg Med 2017;44(4):e315-e319. https://doi.org/10.1016/j.jemermed.2012.11.002
7. Sambrook PN, Geusens P. The epidemiology of osteoporosis and fractures in ankylosing spondylitis. Ther Adv
Musculoskelet Dis 2012;4(4):287-92. https://doi.org/10.1186/ar3724
8. Ghozlani I, Ghazi M, Nouijai A, Mounach A, Rezqi A, Achemlal L, et al. Prevalence and risk factors of osteoporosis and vertebral fractures in patients with ankylosing spondylitis. Bone 2009;44:772-6.
https://doi.org/10.1016/j.bone.2008.12.028
9. Vosse D, de Vlam K. Osteoporosis in rheumatoid arthritis and ankylosing spondylitis. Clin Exp Rheumatol
2009;27(4 Suppl 55):S62-S67. Disponible en: https://www.clinexprheumatol.org/article.asp?a=3710
10. Yilmaz N, Pence S, Kepekci Y, Geyikli I, Ozaslan J. Association of immune function with bone mineral density
and biochemical markers of bone turnover in patients with anklylosing spondylitis. Int J Clin Pract 2003;57:681-5.
PMID: 14627178
11. El Maghraoui A, Bensabbah R, Bahiri R, Bezza A, Guedira N, Hajjaj-Hassouni N. Cervical spine involvement in
ankylosing spondylitis. Clin Rheumatol 2003;22:94-8. https://doi.org/10.1007/s10067-002-0681-2
12. Longo UG, Loppini M, Denaro L, Maffulli N, Denaro V. Conservative management of patients with an osteoporotic vertebral fracture: a review of the literature. J Bone Joint Surg Br 2012;94:152-7.
https://doi.org/10.1302/0301-620X.94B2.26894
13. Altenbernd J, Bitu S, Lemburg S, Peters S, Seybold D, Meindl R, et al. Vertebral fractures
in patients with ankylosing spondylitis: a retrospective analysis of 66 patients. Rofo 2009;181:45-53. https://doi.
org/10.1055/s-2008-1027886
14. Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing
spinal disorders. Spine 2010;35:E458-64. https://doi.org/10.1097/BRS.0b013e3181cc764f
15. Luksanapruksa P, Millhouse PW, Carlson V, Ariyawatkul T, Heller J, Kepler CK. Comparison of surgical outcomes of the posterior and combined approaches for repair of cervical fractures in ankylosing spondylitis. Asian Spine J 2019;13(3):432-40. https://doi.org/10.31616/asj.2018.0197
16. Pray C, Feroz NI, Nigil Haroon N. Bone mineral density and fracture risk in ankylosing spondylitis: a metaanalysis. Calcif Tissue Int 2017;101(2):182-92. https://doi.org/10.1007/s00223-017-0274-3
17. Montala N, Juanola X, Collantes E, Munoz-Gomariz E, Gonzalez C, Gratacos J, et al. Prevalence of vertebral
fractures by semi-automated morphometry in patients with ankylosing spondylitis. J Rheumatol 2011;38:893-7.
https://doi.org/10.3899/jrheum.100851
18. Donnelly S, Doyle DV, Denton A, Rolfe I, McCloskey EV, Spector TD. Bone mineral density and vertebral
compression fracture rates in ankylosing spondylitis. Ann Rheum Dis 1994;53(2):117-21.
https://doi.org/10.1136/ard.53.2.117
19. Jun JB, Joo KB, Her MY, Kim TH, Bae SC, Yoo DH, et al. Femoral bone mineral density is associated with
vertebral fractures in patients with ankylosing spondylitis: a cross-sectional study. J Rheumatol 2006;33(8):1637-41. PMID 16881119
20. Klingberg E, Geijer M, Gothlin J, Mellstrom D, Lorentzon M, Hilme E, et al. Vertebral fractures in ankylosing
spondylitis are associated with lower bone mineral density in both central and peripheral skeleton. J Rheumatol
2012;39:1987-95. https://doi.org/10.3899/jrheum.120316
21. Muñoz-Ortego J, Vestergaard P, Rubio JB, Wordsworth P, Judge A, Javaid MK, et al. Ankylosing spondylitis is
associated with an increased risk of vertebral and non-vertebral clinical fractures: a population-based cohort study. J Bone Miner Res 2014;29(8):1770-6. https://doi.org/10.1002/jbmr.2217
22. Vosse D, Landewé R, van der Heijde D, van der Linden S, van Staa TP, Geusens P. Ankylosing spondylitis
and the risk of fracture: results from a large primary care-based nested casecontrol study. Ann Rheum Dis
2009;68(12):1839-42. https://doi.org/10.1136/ard.2008.100503
23. Zhu R1, Song W, Hu W, Jiang Z, Yuan J, Cui Z, Wan J, Liu Y, Feng S, Zhang X. The treatment strategies for spine
fractures in patients with ankylosing spondylitis: A case report. Medicine (Baltimore) 2017;96(44):e8462.
https://doi.org/10.1097/MD.0000000000008462
24. Heyde CE, Fakler JK, Hasenboehler E, Stahel PF, John T, Robinson Y, et al. Pitfalls and complications in the
treatment of cervical spine fractures in patients with ankylosing spondylitis. Patient Saf Surg 2008;2:15. https://doi.org/10.1186/1754-9493-2-15
25. Lu GH, Wang B, Li J, Kang YJ, Lu C, Ma ZM, et al. Combined anterior and posterior approach for cervical
fracture-dislocation with ankylosing spondylitis. Zhonghua Wai Ke Za Zhi 2007;45:373-5. PMID: 17537319
26. Shen FH, Samartzis D. Surgical management of lower cervical spine fracture in ankylosing spondylitis. J Trauma 2006;61:1005-9. https://doi.org/10.1097/01.ta.0000208125.63010.04
27. Longo UG, Loppini M, Petrillo S, Berton A, Maffulli N, Denaro V. Management of cervical fractures in ankylosing spondylitis: anterior, posterior or combined approach? Br Med Bull 2015;115:57-66. https//doi.org/10.1093/bmb/ldv010