Management of spine fractures in ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis: a challenge

Ankylosing spinal disorders (ASDs) such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are complex diseases regarding diagnostics, treatment, and patient outcome, especially in trauma. Originating from rigid biomechanics and low bone quality in considerably comorbid patients, serious spinal injury requires thorough and immediate imaging and is frequently missed. The aim of this study was to evaluate patient characteristics as well as procedures in patients with ASD in order to identify the major particularities of treatment.

A total of 60 patients aged 78.5 ± 8.9 years were retrospectively included. Preoperative imaging as well as surgical treatment procedures and postoperative patient outcome were analyzed, including 30-day readmissions.

CT imaging of the entire spine was performed within 24 hours after the initial trauma in 73.3% of patients. A delay in diagnostics (> 24 hours) occurred in 41.7% of patients transferred from primary care centers. At admission, 25.0% of patients had fracture-related neurological deficits (American Spinal Injury Association [ASIA] grades A and B in 4 patients, and ASIA grades C and D in 11 patients). A spinal epidural hematoma was found in 21.2% of patients and was symptomatic in 72.7% of those patients. Of the patients with fracture-related neurological deficits, 93.3% were operated on within 48 hours from symptom onset. One patient (1.7%) developed neurological deficits from diagnosis to surgery. Postoperatively, 18.3% of patients had surgical complications, and 76.7% of patients developed further medical issues, with pneumonia (38.3%), pulmonary decompensation (25.0%), and cardiac decompensation (20.0%) being the leading causes. The 30-day mortality rate was high at 10.0%.

Treatment of patients with ASDs is complex. While surgical outcome is usually good, the multimorbid nature of these patients results in a high rate of major medical complications. If an ankylosing disease is suspected, MRI of the entire spine is mandatory. Upon diagnosis, treatment should be performed in centers capable of managing all aspects of the regular complications these patients will develop.