Fracture-dislocation of the cervical spine with ankylosing spondylitis

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1 Fracture-dislocation of the cervical spine with ankylosing spondylitis Report of two cases CARROLL OSGOOD, M.D., Louis G. MARTIN, M.D' AND ELLIOTT ACKERMAN, M.D. Departments of Neurosurgery, Neuroradiology, and Orthopedic Surgery, Emory University School of Medicine, Atlanta, Georgia Two cases of cervical fracture-dislocation causing neurological deficits in patients with ankylosing spondylitis are presented. Review of the literature shows that these patients have a higher incidence of neurological deficits (70%) than comparable patients without ankylosing spondylitis (44%). Predisposing factors and treatment are discussed. KEY WORDS ankylosing spondylitis cervical fracture-dislocation instability skeletal traction neurological deficit T t-re high incidence of neurological deficits in patients with ankylosing spondylitis or "bamboo spine" who suffer cervical fracture dislocation is not generally appreciated. Two cases are presented. Case 1 Case Reports A 47-year-old man whose spine had been fused in marked flexion from ankylosing spondylitis since 1944 was injured in an automobile accident on December 22, When seen at a local hospital he had pain and numbness in the left arm and a fracture of C6-7, but was otherwise neurologically intact. He was placed in a Thomas collar and transferred to Crawford Long Hospital in Atlanta, Georgia, for further treatment. Examination. There was weakness of the left triceps and wrist extensors, and hypesthesia over the C-7 and C-8 dermatomes of the left hand. Any motion of the head caused severe pain in the shoulders, most marked on the left. The remainder of the neurological examination was normal. Cervical spine films showed a through-andthrough horizontal fracture of the seventh cervical vertebral body and fused posterior elements and ligaments (Fig. l left). The patient wished to avoid skeletal traction and was therefore kept in the Thomas cervical collar. On December 23, he noticed "tingling" in his legs, although objective sensory and motor function were still normal, and about 3 hours later developed a C6-7 level quadriplegia. X-ray films demonstrated an anterior subluxation of C-6 on C-7, and the patient was taken to the operating room. Operation. With the patient in the sitting position under local anesthesia, Crutchfield tongs were inserted and 35 lbs of traction applied vertically; there was prompt relief of shoulder and arm pain. He was then 76,4 J. Neurosurg. / Volume 39 / December, 1973

$" Preoperative cross table lateral supine view showing a fracture through the upper portion of the seventh cervical vertebral body. No significant dislocation has occurred. Lower.$

2 Fracture-dislocation of the cervical spine with ankylosing spondylitis F~. 1. Case 1. Upper." Preoperative cross table lateral supine view showing a fracture through the upper portion of the seventh cervical vertebral body. No significant dislocation has occurred. Lower." Postoperative x-ray film after C6-7 laminectomy, posterior wiring, and anterior interbody fusion of C-6 to T-I. J. Neurosurg. / Volume 39 / December,

$Bilateral transverse fractures through the articular facets of the C6-7 joint were seen, with a 5 or 6 mm separation of the fracture margins. When the dura was opened the cord appeared grossly normal.$

3 Carroll Osgood, Louis G. Martin and Elliott Ackerman intubated transnasally, and a C6-7 laminectomy performed. Bilateral transverse fractures through the articular facets of the C6-7 joint were seen, with a 5 or 6 mm separation of the fracture margins. When the dura was opened the cord appeared grossly normal. Although a transverse bony ridge could be felt anteriorly, there was no evidence of subarachnoid block. An elliptical piece of dural substitute was sutured into place in the hope of avoiding any further constriction. A doubled No. 20 stainless steel wire was then placed around the C-5 neural arch and fastened posteriorly to the C-7 spinous process. Postoperative Course. Crude tactile sensation returned in the legs, but the patient could not move them voluntarily, nor extend his arms. He experienced significant neck and shoulder pain when traction was released or when he moved his head. Repeat films showed anteroposterior instability. Second Operation. On January 7, 1970, an anterior interbody fusion of C-6 to T-1 was performed using an iliac crest graft. The patient was left in 10 lbs of Crutchfield traction until February i8 (Fig. 1 right). He has recovered some pain and tactile sensation over his left leg and foot, but still has an incomplete C6-7 quadriplegia as evidence of the anterior cord injury. Case 2 A 43 -year-old man with ankylosing spondylitis and a completely fused "bamboo" spine was admitted on July 14, 1970, 10 days after having been injured. At the time of injury he heard a "loud snap" in his neck and instantly became weak in all four extremities, and soon developed a sensory loss below the waist and intense cervical pain and muscle spasms. The quadriparesis resolved during the next 24 hours except for paresthesias over both thumbs, but the cervical pain and muscle spasm persisted. Physical Examina'tion. Motor function was normal, Babinski responses plantar, and reflexes symmetrical except for an inverted brachioradialis reflex on the right. Vibration and position sense over the feet were intact, but there was incomplete pain sensation below T-6. The head and neck were held in rigid flexion, almost on the chest wall; x-ray films showed C-5 subluxed 5 mm forward onto C-6, secondary to a fracture through both anterior and posterior elements at C5-6 (Fig. 2 left). Operation. Crutchfield tongs were inserted and 15 lbs of traction applied horizontally. This caused considerable posterior extension of C5-6 and further slippage of the C-5 FIG. 2. Case 2. Left." Preoperative cross table lateral supine x-ray film demonstrating a fracture through the calcified C5-6 interspinous ligaments and the superior articular facet of C-6, with 6 mm of anterior subluxation of C-5 on C-6. Right: X-ray film after application of Crutchfield traction in a horizontal direction shows complete fracture separation and marked extension deformity. 766 J. Neurosurg. / Volume 39 / December, 1973

$This constitutes a "neutral" position for the patient with ankylosing spondylitis. fracture end forward onto C-6 (Fig. 2 right), because of the marked unusual forward flexion of the patient's neck.$ The patient rapidly became quadriplegic.

The patient rapidly became quadriplegic.

4 Fracture-dislocation of the cervical spine with ankylosing spondylitis FIG. 3. Case 2. The direction of the traction has now been reapplied to maintain the head and neck in flexion. This constitutes a "neutral" position for the patient with ankylosing spondylitis. fracture end forward onto C-6 (Fig. 2 right), because of the marked unusual forward flexion of the patient's neck. The patient rapidly became quadriplegic. Traction was discontinued and then reapplied in such a way as to provide a "neutral" direction of pull; the traction pulley was raised much higher off the bed than usual to maintain the head and neck in forward flexion (Fig. 3). Postoperative Course. The C-6 quadriplegia persisted, although good anatomical reduction was achieved (Fig. 4). The patient regained weak dorsiflexion of his toes and some tactile sensation over his feet, but had no useful motor function below the biceps on the right or triceps on the left. He had several episodes of partial intestinal obstruction, felt to be secondary to immobilization, and a prominent, flexed, tumbosacral spine, until cervical traction was discontinued 10 weeks later and a fourposter collar applied. The patient's rib cage was also rigid and fixed, and several pulmonary infections occurred before he was transferred to a Foster frame especially adapted to maintain his head and neck in their usual flexion position whether he was prone or horizontal (Fig. 3). The fracture site healed slowly but was considered stable at 31 months; x-ray films with the neck in FIG. 4. Case 2. Anatomic reduction has now been achieved by more vertical alignment of the traction vector. slight flexion and extension revealed no motion, and large amounts of callus. Discussion Ankylosing spondylitis is a chronic, idiopathic disease that begins in the sacroiliac joints and progresses to involve all the synovial joints and ligaments of the spinal column? The end result is a stick-like fused, osteoporotic "bamboo" spine, which is inordinately susceptible to fracture. 2,8 The bony and ligamentous injuries of the fused spine heal more slowly than cervical fracture-dislocations in the non-arthritic patient. Their manner of healing is similar to that of a long bone fracture. Adding our two cases to the previously reported 42 cases of cervical fracturedislocation in ankylosing spondylitis, ~ we find that 31 patients (75%) suffered neurological damage. In a series of 77 cervical fracture-dislocations in non-ankylosed spines, only 34 patients (44%) suffered neurological damage, and none of these became worse after institution of Crutchfield traction. 9 I. Neurosurg. / Volume 39 / December,

$Martin and Elliott Ackerman Woodruff and Dewing TM reported fracture of an alkylosed cervical spine that resulted when a patient's head was left unsupported while being turned in a Stryker frame.$

5 Carroll Osgood, Louis G. Martin and Elliott Ackerman Woodruff and Dewing TM reported fracture of an alkylosed cervical spine that resulted when a patient's head was left unsupported while being turned in a Stryker frame. Lemmen and Lainge 6 cited cases of cervical spine fracture following relatively minor trauma as falling out of bed or riding in a truck over rough ground. Furthermore, these fractures are particularly unstable because many of the normally supporting cervical soft tissues and ligaments are themselves calcified and, therefore, also fractured at the time of injury. Cervical traction then is fraught with potential hazard in these cases and must be applied with great caution and in a neutral direction, which actually means maintaining considerable flexion for most of these patients. Rogers 9 reported a series of 77 non-arthritic cervical fracture-dislocations, none of which became worse while in traction. Several instances of patients becoming worse while in Crutchfield traction or inadequate cervical immobilization have been recorded. Hollin, et al.2 reported a C5-6 fracture-dislocation in a patient who turned his head to cough while in Crutchfield traction, became paraplegic, and died 4 days later. Janda, et al., 5 reported a patient with a spondylitic C6-7 fracture dislocation, treated initially with a cervical-dorsal brace, who became worse after 1 week in the brace (although his fracture had occurred 10 weeks previously) necessitating an emergency C2-7 laminectomy and C1-T1 bone graft and wiring; the patient's quadraparesis cleared gradually postoperatively. Lemmen and Lainge n reported a similar case of fracture-site instability in which reduction was still possible 6 months after injury. In our Case 1, complete cervical-dorsal immobilization by a halo-type device, or carefully applied skeletal traction, might have prevented further motion of the fracture ends and precluded subsequent cord compression. Emergency laminectomy and posterior wiring following onset of the neurological deficit unfortunately produced only slight improvement. In our Case 2, application of skeletal traction in a much too horizontal direction produced distraction of the fracture margins, further extension, and immediate irreversible spinal cord injury. The axis of skeletal traction in cases with chronic ankylosing spondylitis must conform to the patient's spinal axis prior to injury. In addition, the weight used for skeletal traction in such cases should be minimal (10 or 15 lbs), for the object of Crutchfield traction in these cases is not to obtain complete reduction of the dislocation but to immobilize the fracture site. Any additional weight may cause unwanted distraction and shifting of the cephalad fracture margin. Cervical dorsal immobilization, using halo-type traction, is probably the best form of cervical fixation for these patients? Even with accurately installed Crutchfield traction, the possibility of rotational dislodgement of the fracture ends during coughing, slight head movement, etc., remains. Lemmen and Lainge 6 reported spondylitic cervical fracture-dislocations with moderate quadraparesis in two patients initially treated successfully with Crutchfield tongs, but who then developed quadraplegia following slight movement of the head. One recovered good neurological function after emergency laminectomy, and the other died. Pecker, et al., 7 reported a case of paraplegia developing several hours after a C-6 fracture. At laminectomy an extradural hematoma was found and the patient subsequently recovered neurological function (the only such case). Woodruff and Dewing TM reported one case of C5-6 fracture-dislocation treated without neurological incident by only a cervical collar, worn for a month with a hospital stay of just a few days. However, they also mentioned a case of C5-6 fracture-dislocation in which there was no initial deficit, but then quadraplegia occurred 24 hours after injury (prior to the patient being seen by a physician) ; no recovery of function occurred after application of traction and she died shortly thereafter. It seems clear that application of a cervical collar alone will not offer sufficient immobilization for these extremely unstable fractures. The initial treatment of choice is most likely application of a cervical-dorsal halo traction apparatus; a body cast is required. Should neurological deficits develop, then emergency laminectomy should be performed with open reduction of the fracture, followed by posterior bone graft and wiring Neurosurg. / Volume 39 / December, 1973

6 Fracture-dislocation of the cervical spine with ankylosing spondylitis Halo traction incorporated in a body cast should then be reapplied and continued for a total of 6 months. If halo traction apparatus is not available, then Crutchfield or Vincke skeletal traction should be applied with great caution and in the necessary amount of flexion, with only 10 to 15 lbs of weight. Even after successful institution of Crutehfield skeletal traction, neurological deficits may occur later with minor head movement. A Thomas soft collar and bed rest cannot be expected to safely immobilize these fractures. References 1. Freeman GE Jr: Correction of severe deformity of the cervical spine in ankylosing spondylitis with the halo device. J Bone.It Surg 43#_: , Grisolia A, Bell RL, Peltier LF: Fractures and dislocations of the spine complicating ankylosing spondylitis..i Bone,It Surg 49A: , Hinck VC: Cervical fracture dislocation in rheumatoid spondylitis. Am.i Roentgen 82: , Hollin SA, Gross SW, Levin P: Fracture of the cervical spine in patients with rheumatoid spondylitis. Amer Surg 31: , Janda WE, Kelly PJ, Rhoton AL Jr, et al: Fracture-dislocation of the cervical part of the spinal column in patients with ankylosing spondylitis. Proe Staff Meet Mayo Clin 43: , Lemmen LJ, Lainge PG: Fracture of the cervical spine in patients with rheumatoid arthritis. J Neurosurg 16: , Pecker J, Javalet A, LeMenn G: Spondy- ]arthrite ankylosante et parapl6gie par h6matorachis extra-dural traumatique. Presse Med 68: , Rand RW, Stern WE: Cervical fractures of the ankylosed rheumatoid spine. Neurochirurgia 4: , Rogers WA: Fractures and dislocations of the cervical spine. An end-result study..i Bone,It Surg 39A: , Woodruff FB, Dewing SB: Fracture of the cervical spine in patients with ankylosing spondylitis. Radiology 80: t 7-21, 1963 Address reprint requests to: Louis G. Martin, M.D., Department of Radiology, Emory University School of Medicine, 80 Butler Street, S.E., Atlanta, Georgia I. Neurosurg. / Volume 39 / December,

Posterior cervical fusion in children

Posterior cervical fusion in children JOE M. MCWHORTER, M.D., EBEN ALEXANDER, JR., M.D., COURTLAND H. DAVIS, JR., M.D., AND DAVID L. KELLY, JR., M.D. Section on Neurosurgery, Department of Surgery, Bowman