AS renders the spine more susceptible to fractures from minor trauma. Fractures in individuals with AS have the potential to cause significant morbidity and mortality. Therefore, it is increasingly important to be attentive for a history of acute back pain when one is evaluating trauma in a patient with AS. Indeed, there may be an acute spinal fracture that needs evaluation with either plain radiographs or CT.

Ankylosing spondylitis (AS) is an inflammatory arthritic condition within the group of seronegative spondyloarthropathies. The condition is three times more common in males, starting in the 20 to 40-year-old age range and has a strong association (90 percent) with a positive HLA-B27. In 50 percent of AS cases, the disease affects the vertebrae, hips and shoulders, and it reportedly affects the SI joints in the other half of AS cases.

Anklyosing spondylitis affects the peripheral joints in 20 to 30 percent of the cases with the hips being the most common problem area. In severe cases of AS, a patient may even present to you with pulmonary fibrosis or aortic insufficiency.

We know about bilateral sacroiliitis, the initial sign of AS. We know about the global signs, which include prostatitis, anterior uveitis (most commonly), conjunctivitis, plantar fasciitis, Achilles tendonitis and costochondritis. Radiographic findings of AS include the classic vertebral syndesmophytes or “bamboo spine,” progressive degeneration of the SI joints, vertebral squaring and superficial erosions with reactive sclerosis and ankylosis. Other radiographic signs include kyphosis at the cervicothoracic and thoracolumbar junctions.

However, it is also important to keep in mind that AS renders the spine more susceptible to fractures from minor trauma. Fractures in individuals with AS have the potential to cause significant morbidity and mortality. Therefore, it is increasingly important to be attentive for a history of acute back pain when one is evaluating trauma in a patient with AS. Indeed, there may be an acute spinal fracture that needs evaluation with either plain radiographs or CT.

Often, post-trauma patients will present with two or more fractures that do not correspond to a specific region. Patients who have had previous spinal surgery with instrumentation are at increased risk for subsequent fractures caused by minor trauma. Those with an acute spinal fracture may have an associated ascending epidural hematoma that emphasizes the need for timely and appropriate treatment.

In a relevant case study of a post-trauma patient, a 73-year-old male with AS fell approximately 20 feet off a ladder. He had no head trauma, no loss of consciousness and, initially, no back pain. After a period of four to six hours, he began to develop severe and unremitting mid-thoracic back pain.

In the emergency room, the patient underwent X-rays and CAT scans of his entire spinal column. During the physical exam, clinicians did not note any neurologic deficits. However, radiographic evaluation revealed a fracture of the spinous process of T2, a burst fracture with dislocation of T3 and posterior element disruption at T2-T3 and a compression fracture of T4. Complicating this was a preexisting thoracic kyphosis of 70 degrees. Even though the patient was not neurologically compromised, treating clinicians made the decision to stabilize his spine in order to prevent instability.

Two days later, the patient underwent a C7-T6 spinal fusion. The surgeons accomplished the fusion through a posterior approach with bilateral hemilaminectomies from C7 through T3. They reduced the T3 fracture and utilized a 5.5mm titanium poly axial screw and rod system from T1 to T6. The surgeons employed cable fixation for the spinous process of C7 to T1. They decided not to correct his thoracic kyphotic deformity, which would have required a multilevel osteotomy-type procedure.

Postoperatively, the patient utilized an occipital thoracic orthosis. He did not have any complications following surgery and was discharged from the hospital six days after the fusion procedure with a home physical therapy program.

At four months post-op, the patient is doing quite well. He has no pain and has no motor or neurologic deficits. He is riding a stationary bike several miles a day and has started using five-pound weights for upper extremity exercises. He has transitioned from a hard to a soft cervical collar and is starting gentle range of motion exercises of his cervical spine.

There will be follow-up visits at two- to three-month intervals with clinical and radiographic evaluations to monitor his progress.

There are many aspects to the treatment of patients with AS. Early recognition and prevention of injury is key. It is important to remember that your patients with AS need radiographic evaluation when they present with back pain, especially when the pain is associated with trauma, no matter how minor. When one diagnoses a fracture, acting in a timely and decisive manor will facilitate better outcomes and prevent serious neurologic complications.