Delays in Diagnosis of Vertebral Fractures Are Common in Patients With Spinal Ankylosing Disorders

Should you assume vertebral fracture in patients with SAD who present with pain following a fall? Alexander R. Vaccaro, MD, PhD, MBA, comments.

When patients with spinal ankylosing disorders (SAD) present with pain following a fall, always assume they have a vertebral fracture and brace them, said Alexander R. Vaccaro, MD, PhD, MBA, who is the Richard H. Rothman Professor and Chairman of the Department of Orthopaedic Surgery at the Sidney Kimmel Medical Center at Thomas Jefferson University in Philadelphia.

“In patients with SAD, even though the outer shell of the vertebral body appears to be well ossified and strong, the inner portion of the vertebral body is often almost hollow,” Dr. Vaccaro told SpineUniverse. “Thus, even a minor fall can cause a subtle fracture which over time may lead to significant instability. The second the patient presents with neck or back pain after a fall, assume that there is a vertebral fracture, and it is up to you to find it.”

older man falls down stairsWhen patients with spinal ankylosing disorders present with pain following a fall, always assume they have a vertebral fracture. Photo

“The same is true for other conditions that cause a stiffening of the spine, including diffuse idiopathic skeletal hyperostosis (DISH) and degenerative disc disease with osteophytic spur formation,” said Dr. Vaccaro, who also is Co-Director of the Delaware Valley Spinal Cord Injury Center, Co-Chief of Spine Surgery at the Sidney Kimmel Medical Center at Thomas Jefferson University, and President of the Rothman Institute.
X-ray image of a SAD thoracic fractureThoracic spinal fracture. Photo Courtesy of Dr. Vaccaro and colleagues’ systematic review of 21 studies on SAD found that timely detection of spinal fractures and injuries in patients with SAD is lacking, despite the availability of advanced imaging. In fact, delayed diagnoses were found in 15% to 41% of cases in the literature, the researchers reported in the September issue of the Journal of Orthopedic Trauma.

Imaging Recommendations

Computed tomography (CT) and magnetic resonance imaging (MRI) are recommended over radiographs to detect vertebral fractures in patients with SAD. However, finding fractures on CT and MRI remains challenging, Dr. Vaccaro said. Just because a fracture is not found initially on imaging does not mean the injury is not there, he said.

CT scans should be thin sliced and if possible 3-dimensionally formatted,” Dr. Vaccaro said. “If the fracture line is inline with the gantry of the CT scanner, the fracture can be missed because of volume averaging,” Dr. Vaccaro said.

The researchers recommend scanning the entire spine in patients with ankylosing spondylitis who are suspected to have spinal fracture, which requires consideration and diagnosis of multilevel involvement.

If a linear defect is not visible on CT scan, follow-up with an MRI of the entire spine, which also can help detect an epidural hematoma in addition to spinal fractures that may go unnoticed on CT scan, the researchers noted. These imaging modalities should be used as complimentary rather than alternate studies.

“Even if you never find the fracture, if the patient has significant pain, I often brace for 6 to 8 weeks to avoid mistakes,” Dr. Vaccaro said.

Hyperextension Fractures Are Most Common

The most common injuries found in the literature review were hyperextension fractures in the cervical spine, most often between C5 and C7, according to the report. Complications frequently occurred in these cases (84%); most commonly pneumonia, respiratory failure, and pseudarthrosis.

In addition to improving clinical suspicion of spinal fractures in patients with SAD, Dr. Vaccaro advised that patients should be advocates for their care. Patients should suggest to their physicians that they are at high risk for fracture due to their spinal condition, and a search for such an injury has been recommended in the literature if they experience pain after a fall, he said.

Medical Care for Patients With Ankylosing Spondylitis

Other components of care for SAD include collaboration with other specialists, Dr. Vaccaro said.

“When a patient comes into my office with a presumed or suspected diagnosis of ankylosing spondylitis, which is associated with multisystem disease, I refer the patient to a cardiologist to make sure that he or she doesn’t have an abnormal cardiovascular condition, such as an aortic dissection that may become a future problem,” Dr. Vaccaro said. Patients should also be evaluated for renal disease and ocular disease.

In terms of exercise and fall prevention, Dr. Vaccaro recommends aquatic therapy to improve the patient’s cardiovascular status, and has patients work on balancing and ambulation skills, including exercise that increases range of motion. In the home, Dr. Vaccaro advises patients to live on a single floor with carpeting and no slippery surfaces.

Dr. Vaccaro disclosed no relevant financial relationships.

Updated on: 06/11/19
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