Multiple and simultaneous spine fractures in ankylosing spondylitis

Study Design. A case report. Objective. To report the unique occurrence and treatment of multiple and simultaneous spine fractures in a patient with progressed ankylosing spondylitis and preexisting multilevel spine instrumentation. Summary of Background Data. Ankylosing spondylitis is a complex inflammatory arthritic condition that renders the spine more susceptible to fracture than individuals who do not have ankylosing spondylitis. To our knowledge, in the patient with ankylosing spondylitis, the occurrence of nonregion-specific multiple and simultaneous spine fractures, and the role of internal instrumentation in subsequent fracture development have not been addressed in the literature. Methods. An 81-year-old white male with ankylosing spondylitis had 2 low-energy falls, resulting in 3 spine fractures. During the first fall, he had a displaced fracture at the T11 - T12 level without a spinal cord injury. Fracture treatment entailed posterior instrumentation with fusion at T8 - L2 and immobilization after surgery with a thoraco-lumbosacral orthosis brace, which led to successful healing of the injury. Approximately 2 years later, the patient had a second fall, and presented with simultaneous displaced fractures at the C6 - C7 and L2 - L3 levels, and an American Spinal Injury Association-A spinal cord injury. The cervical and lumbar fractures were both treated operatively via a 2-staged approach with posterior segmental instrumentation and fusion at C3 - T3 and at L2 - L5, respectively. A soft cervical collar and a thoracolumbosacral orthosis brace were worn after surgery. There were no intraoperative complications. Results. Although anatomic reduction and stable fixation of the spinal injuries were achieved, the patient's neurologic status following the second injury remained unchanged. His postoperative course was complicated by pulmonary failure that ultimately resulted in death by the 3-month postoperative time. Conclusions. Patients with ankylosing spondylitis have a strong susceptibility to spine fracture from minor trauma, which can have devastating outcomes. Nonregion-specific multiple and simultaneous spine fractures can occur, and require thorough radiographic evaluation with imaging of the entire spinal axis, appropriate operative planning, and meticulous perioperative treatment. Preexisting internal spine instrumentation may predispose the ankylosing spondylitis spine to multiple fractures, even following a minor traumatic event. As such, the clinician should be cognizant of the possible existence of multiple and simultaneous fractures in patients with ankylosing spondylitis with preexisting internal spine instrumentation.