SpineUniverse Case Study Library

Ankylosing Spondylitis with Thoracic Fracture

Do You Fix Both the Fracture and the Deformity?

History

The patient is a 70-year-old male with chronic back pain and worsening trouble standing up. He has shown long-standing ankylosing spondylitis.

He was referred to me after a non-union at a thoracic fracture site was seen.

Examination

The patient was unable to stand erect. He had to lean on the exam table to hold himself up so that his legs didn’t hurt (Lhermitte’s sign).

He had hip flexion contractures, and he was tender to percussion over the fracture site.

Pre-treatment Images

Figures 1A and 1B are the plain films, which were hard to interpret.

Fig 1A and 1B Polly Ankylosing Spondylitis Pre-op AP and Lateral X-raysFigures 1A and 1B

Fig 2 Polly Ankylosing Spondylitis Pre-op CT Scan
Figure 2: CT scan showing established non-union at T10, which explains his trouble walking and standing

Diagnosis 

The patient was diagnosed with a fracture at T10. He also has a fixed sagittal deformity.

Treatment Consideration 

The patient knew he needed the fracture fixed, but he also wanted the deformity corrected. This leads to the question: do you fix the fracture and the alignment at the same time? Or just the fracture, which is the more pressing issue? 

Surgical Positioning Consideration

Positioning is a huge issue for people with deformities like this. Intraoperative positioning options include:

  1. Sandbag
  2. Pillows
  3. Plaster half-shell
  4. Wilson frame

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Selected Treatment

The day before surgery, we had him crawl onto an OR table to see if he would fit. He fit on a Wilson frame and so that was used for positioning during surgery.

I chose to fix the fracture only, and it was fixed in situ. I used screws, and I intentionally went bicortical on some of the screws. I confirmed screw placement with intraoperative navigation and intraoperative CT scanning.

There was an intraoperative challenge: the anesthesiologist had trouble ventilating the patient because of his deformity. We had to flip him and found that he had an endotracheal tube kink. He was switched to an armored endotracheal tube, then flipped over, and the operation continued.

Post-treatment Images

Fig 3A and 3B Polly Ankylosing Spondylitis Post-op AP and Lateral X-rays
Figures 3A and 3B: Post-operative AP and lateral x-rays

Outcome

At 6-months post-op, the CT scan (not shown here) showed that the fracture was healed.

The patient returned to the OR electively at 6 months to fix the alignment issue. I did lumbar pedicle subtraction osteotomy. Figures 4A and 4B are the post-operative images following this elective surgery. Notice in Figure 4A how the chin is now off the chest.

When leaving the hospital after that operation, he cried tears of joy and said, “I can finally look people in the eyes again.”

 Fig 4A and 4B Polly Ankylosing Spondylitis Post-op AP and Lateral X-rays Deformity CorrectionFigures 4A and 4B

 

Fig 5A 5B 5C Polly Ankylosing Spondylitis Deformity Progression Figures 5A, 5B, and 5C: Progression of deformity correction. Pre-operative (left), following first surgery to treat the thoracic fracture (middle), and following the elective surgery to correct the deformity.

Case Discussion

This is a very typical case of ankylosing spondylitis with sagittal plane deformity and obviously a non-union. Sometimes it is difficult to distinguish between what we call spondylodiscitis and a true fracture. Regardless, the treatment would be to repair the non-union and correct the deformity.

Like anything else, we have different approaches. Sometimes when I see a fracture in ankylosing spondylitis, I use the opportunity to correct the deformity at the same time. This is very similar to Smith-Peterson osteotomy. In that case, the question would be whether you would do an anterior grafting as well to make it heal.

I think the correction of the sagittal deformity is important because it will help the healing of the fracture site, and I think this case proved that by combining the repair of the pseudoarthrosis and correction of the deformity, you can achieve a more lasting stability.

The complications to watch for in these cases are:

  • Neurologic complications. When you do an osteotomy, you must be very careful of neurologic compromise.
  • Dural leak. Because of the nature of anykylosing spondylitis, the dura is very thin.

I think the case was well done, and the goal of healing the pseudoarthrosis as well as correcting the deformity was well achieved.

Community Case Discussion (1 comment)

SpineUniverse invites spine professionals to share their thoughts on this case.


Great case and results David. Congratulations! In Sweden we have a lot of AS, and we see many fresh fractures, which allways are potentially very unstable. This patients shows a so called Andersson lesion, described initially by a Swedish radiologist in Stockholm. Today this lesion is considered a pesudarthrosis in AS, but historically it was often referred to as "spondylodiscitis". These lesions are commonly very painful. In a case like this we would propose to the patient simultaneous pseudo repair and L2 PSO. The gain for the patient with a PSO is, as you showed, tremendous, and justifies the risks. The decision is of course the patients, but if his general Health is OK, he will recover in a reasonable time. One issue is the pseudo repair, whether an isolated posterior repair is sufficient or whether the anterior pseudo has to be cleared out, which increase operation time somewhat, but is probably a good idea to optimise pseudo healing. This will add to the surgical trauma, but would still be a good
option. A combined procedure as described presupposes of course a well trained team
, on all hands. Unfortunately a PSO at the level of the pseudo (T10) most likely will not gain sufficient SVA correction, but in cases with pseudos t12 and lower I would suggest pseudo repair and correction by a PSO at the pseudo level.

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