Spinal Cord Injury Common After Traumatic Spinal Fracture in Patients with AS or DISH
Key findings
- Spinal cord injury (SCI) occurred in one-third of patients with ankylosing spinal disorders who sustained traumatic spinal fracture
- SCI after fracture increased the risk of death and complications
- Patients with ankylosing spondylitis and those with diffuse idiopathic skeletal hyperostosis were equally at risk of SCI after fracture
- Cervical fracture and spinal epidural hematoma are independent predictors of SCI after fracture
- Surgery for fracture did not increase the chance of neurologic improvement
Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are relatively uncommon, so even when spinal fracture has been studied in these conditions, little has been gleaned about spinal cord injury (SCI). In a retrospective study published in Journal of Neurosurgery: Spine, orthopedic surgeons at Massachusetts General Hospital found that SCI occurred in one-third of cases of traumatic spinal fracture in patients with AS or DISH, and often had serious consequences.
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Thomas D. Cha, MD, MBA, assistant chief of the Orthopaedic Spine Center and Joseph H. Schwab, MD, MS, orthopedic spine and oncology surgeon, identified 172 adults with AS or DISH who presented with a first-time traumatic fracture of the spine at two affiliated tertiary care centers between January 1, 1990, and January 1, 2016. Of these, 134 patients (78%) were diagnosed with AS, 26 patients (15%) were diagnosed with DISH, and for 12 patients (7%) no differentiation could be made between AS and DISH.
Among the 167 fracture patients with adequate data, 57 (34%) developed SCI, with no significant difference between the AS and DISH groups. Complete SCI occurred in 21 (38%) of the 57 patients.
Researchers found the independent predictors of SCI were a fracture in the cervical region and a spinal epidural hematoma (SEH) following fracture. Both factors nearly tripled the risk. In the 30 patients with an SEH, the finding was missed on initial CT in 17 cases. The researchers recommend MRI as initial imaging in this setting, because it can distinguish SEH from spinal subdural hematoma and non-traumatic spinal lesions.
SCI developed within 24 hours of fracture in 36 patients (63%). In 11 patients (19%), SCI developed 8 to 230 days after fracture (median 26 days). Four of those patients had been sent home without a fracture diagnosis, three did not visit a physician after a fall, three developed SCI after conservative fracture treatment, and one suffered a minor fall after initial surgical fracture treatment. A separate group of six patients developed SCI as a direct result of surgery for their fracture.
Of 44 patients with SCI who had sufficient follow-up, only 20 (45.5%) showed neurologic improvement after treatment. Whether patients had conservative or surgical treatment of fracture did not affect the chance of improvement.
Patients with SCI had significantly more complications than those who did not develop SCI. The most frequent early complications within 90 days after fracture were pneumonia, respiratory failure and altered mental status. Patients with SCI also had a significantly longer hospital stay and a significantly higher risk of death within one year (39%).
The researchers express hope that their findings will give physicians better insight into SCI as a common and serious complication of traumatic spinal fracture in patients with AS or DISH.
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