Fractures of the Thoracolumbar Spine in Ankylosing Spondylitis

MARTIN I. GELMAN’ AND JAMES S. UMBER2

Fractures through the disc or juxta-end plate region of the could be remembered. Slight anterior subluxation of Li on L2
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vertebra as well as the posterior elements have been ob- was also present. Current films showed healing of the Li-L2
served In the thoracic and lumbar spine in ankylosing spon- disc space and posterior elements fracture (fig. 3C). After 3
dylitis. These are usually associated with increasing pain, months of bed rest, the patient was placed in a Taylor brace.
usually do not produce neurologlc deficit, and may require Radiographs 3’/s months after initial trauma showed persistent
orthopedic fixation to heal. Irregularity and sclerosis at the spondylolisthesis at L5-Si ; however, the fracture through the
margins secondary to pseudarthrosis may develop and should posterior elements had healed.
not be confused with a pyogenic or granulomatous infection.
Blomechanically these fractures resemble the “seat beft type” Case 3
or Chance fracture probably because of shifting of the axis of A 52-year-old male with a long history of ankylosing spondy-
flexlon and extension in the ankylosed spine away from its litis sustained an injury to the thoracic spine from a tree falling
normal location in the center of the nucleus pulposus. on his back. Radiographs showed a horizontal extend- fracture
ing through the twelfth thoracic vertebral body to the adjacent
Localized destructive erosions near the anterior aspect superior vertebral plate and extending through the posterior
of the vertebral end plate are often seen in early ankylos- elements (figs. 44 and 4B). No neurologic deficit was present.
ing spondylitis and are generally attributed to inflamma- He was treated with a corset but experienced persistent pain
with motion over the twelfth thoracic vertebral body. Nine
tion. In long-standing disease, advanced lesions involv-
months after the initial trauma, radiographs showed evidence
ing the disc or the juxta-end plate region of the vertebral
of nonunion and pseudarthrosis (fig. 4C). At this time a spinal
body can be observed, showing extension posteriorly
fusion with Harrington rod instrumentation was performed. At
through the posterior elements. Rather than inflamma- surgery the entire spine was found to be fused except for
tory destruction, these more advanced lesions may rep- motion between the spinous processes of T12 and Li and the
resent fractures which have occurred in response to corresponding lamina due to nonunion and pseudarthrosis.
minor stress or major trauma. Although there is usually Eight months after surgery, radiographs demonstrated union of
no neurologic deficit, the lesions can cause persistent the vertebral body and lamina fractures (fig. 4D).
pain incorrectly attributed to the spondylitis. While these Comment. The biomechanics of this injury will be discussed
lesions may heal spontaneously, some cases require later. The mechanism of injury in a fracture such as this
suggests that Harrington compression rather than distraction
orthopedic fixation. We describe the radiographic ap-
rods might be a more appropriate choice of hardware.
pearance and significance of these fractures as well as
their biomechanical pathogenesis. Case 4
A 51-year-old male with a 25 year history of ankylosing
Case Reports spondylitis was hospitalized for increasingly severe low back
pain after a fall from a horse 2 months previously. No neurologic
Case 1 deficit was present. Radiographs showed a transverse fracture
A 63-year-old male with a long history of ankylosing spondy- through the first lumbar vertebral body adjacent to the inferior
litis was hospitalized for multiple trauma following an auto- vertebral end plate with extension through the posterior ele-
bicycle accident. He sustained an ‘opening-wedge’ ‘ fracture of ‘
ments (figs. 54 and SB). Tomography demonstrated irregular
the twelfth thoracic-vertebral body (fig. 1) as well as a fracture fracture margins and adjacent sclerosis (fig. SC). After a short
of the odontoid process and fractures of the right femoral period of bed rest, the patient was discharged to be followed at
neck, tibia, and fibula. No neurologic changes were present, home.
and an anterior rod fusion was performed. The patient re-
covered gradually and uneventfully. Discussion

Fractures through the cervical spine in ankylosing

Case 2
spondylitis have been well documented in the literature,
A 49-year-old male with a long-standing history of ankylosing
usually occurring through the ossified disc space or
spondylitis fell while getting out of his car and sustained a
vertebral body and extending posteriorly through the
traumatic spondylolisthesis at L5-Sl with fracture through the
posterior elements. These may occur following major or
posterior elements (fig. 2). Despite acute back pain, no neuro-
logic changes were detected. Films obtained 4’/2 years earlier minor trauma and cause little or no neurologic deficit
(figs. 34 and 38) had shown a fracture through the anterior [1-3]. The existence of similar fractures in the thoracic
bridging calcification at Ll-L2 with extension through the disc and lumbar spine has not been emphasized as clearly,
space and posterior elements, for which no traumatic episode probably because of confusion with inflammatory

Received May 6. 1977; accepted after revision November 4, 1977.

, Department of Radiology, University of Utah Medical Center, Salt Lake City, Utah 84132. Address reprint requests to M. I. Gelman.
2 Department of Orthopedic Surgery, University of Utah Medical Center, Salt Lake City, Utah 84132.

Am J Roentgenol 130:485-491, March 1978 485 0361 -803X/78/0300--0485 $02.00

C 1978 American Roentgen Ray Society
 486 GELMAN AND UMBER
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of the vertebral bodies have long been recognized as

secondary to inflammation in ankylosing spondylitis.
These occur in the anterosuperior and anteroinferior
corners of the vertebral bodies at points of attachment
of the vascular outer portion of the annulus fibrosus and
result in the characteristic squaring of the vertebral
bodies [4, 5]. Subsequent observation of a more destruc-
tive process involving the discovertebral junction of the
vertebral end plates has been made in patients with
advanced spinal ankylosis. Although several authors
have attributed these destructive lesions to inflammatory
changes of spondylitis [6, 7], it has become increasingly .4.’
apparent
abnormalities
that most represent
extend through
fractures,
the posterior
especially when
elements.
.:
Histology of these areas has revealed minimal inflamma-
tory cell component and callus formation with associated
eburnation, suggesting a traumatic rather than inflam-
matory etiology [4]. These observations have been doc-
umented in the rheumatology and orthopedic literature
but have received
ature [4, 5, 8-13].

Radiographic Features
scant attention in the radiologic liter-

>
Characteristics of the spinal fractures observed in our ..

patients with ankylosing spondylitis are summarized in

. .. .
table 1 Although
. the fracture most commonly occurs
through the intervertebral disc space, we have also Fig. 2.-Case 2. Film showing traumatic spondylolisthesis of L5 on
observed horizontal fractures through the vertebral bod- 51 with associated diastasis and posterior elements fracture.
 SPINAL FRACTURES IN ANKYLOSING SPONDYLITIS 487
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long been recognized as areas of increased stress con-

centration; the transitional nature of the spine at these would tend to concentrate stress and deformation at the
junctions is obvious. Fracture dislocation of the thora- site of fracture. This may contribute subsequently to the
columbar spine in an otherwise normal skeleton is most formation of pseudarthrosis.
common at the Ti2-Li level [i4-17]. Similarly, one of It is interesting to compare the x-ray appearance of
the etiologic factors contributing to lumbosacral spon- these thoracolumbar fractures to that of the seat belt
dylolisthesis seems to be the large amount of stress distraction type fracture at the same level [22-26]. Nor-
generated at the lumbosacral junction [18-21]. mally the axis of flexion and extension of the spine is
In the ankylosed spine where compensatory disc and somewhere near the center of the nucleus pulposus (fig.
facet joint movement in response to load is prevented, it 7A). With flexion the
anterior portion of the disc space
seems likely that bony deformation and therefore stress compresses, theposterior portion of the disc space
fracture would tend to occur most frequently at the widens, and the facet joints distract. With extension the
thoracolumbar and lumbosacral junctions. Although the converse is true. In seat belt injuries, the axis of flexion
fractures in our series occurred in one of these two is shifted anterior to the point of contact between the
regions, others have observed similar fractures from T9 seat belt and the anterior abdominal wall. The entire
to Si [4-7, 9, 10, 13]. Once a fracture has occurred, the spine. being posterior to the axis, is subjected to tensile
long rigid lever arm represented by the ankylosed spine (distraction) force as the body flexes over the seat belt.
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ft . ..

Fig. 4.-Case 3. A and B, Horizontal fracture adjacent to superior vertebral plate of T12 and extending through posterior elements (arrows). C,
Sclerosis and increased prominence of fracture line (arrows) indicating interval development of pseudarthrosis. 0, Bony healing with some residual
anterior compression 8 months after Harrington rod instrumentation and spinal fusion.
 SPINAL FRACTURES IN ANKYLOSING SPONDYLITIS 489

..
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I
.,. ;,.-‘.# e ‘.. A and B, Horizontal fracture adjacent I
vertebral end plate of Li with irregular margins (arrowheads) and exten-
sion through posterior elements (arrows). C, Tomogram delineating
irregularity and sclerosis suggesting pseudarthrosis.

The posterior elements of the spine, being furthest from

the axis of flexion, typically are distracted a greater
amount than the more anterior vertebral body.
When the disc space and facet joints are ankylosed,
they obviously are no longer capable of altering their
configuration in response to load. Bone can withstand
more compression force than tensile force, and there is
more bone mass anteriorly than posteriorly. Thus when
an ankylosed spine is loaded in flexion, the rigid poste-
nor elements would be expected to fail in tension before
the rigid anterior elements fail in compression (fig. 7B).
Conversely, if an ankylosed spine is loaded in extension,
the rigid anterior elements would be expected to fail in
tension before the rigid posterior elements fail in
compression, even though there is more cross-sectional flexion anteriorly increases the length of the lever arm
bone mass anteriorly (fig. 7C). between the axis and the posterior elements. This has
According to this model excessive flexion force deliv- the net effect of decreasing the tensile load delivered to
ered to the ankylosed spine would create seat belt type the posterior elements, since force times distance must
distraction fractures starting in the posterior elements. remain constant. Nonetheless, the inability of bone to
Indeed, Yau and Chan [9] noted that stress fractures in resist tension seems to be the limiting factor. In ankylos-
ankylosing spondylitis seem to start in the posterior ing spondylitis with hyperflexion loads, the posterior
elements, extending later into the vertebral body as elements fail first. The converse holds true with hyper-
pseudarthrosis develops. Excessive extension force de- extension injuries. Even though bone mass and lever
livered to the ankylosed spine would create anterior arm considerations tend to favor posterior element com-
opening-wedge type distraction fractures starting in the pressive failure, in at least some cases the ankylosed
anterior elements and extending into the posterior ele- anterior elements undergo tensile failure first. Because
ments. Case 1 appears to illustrate the latter mechanism. of the thoracic
normal kyphosis, one would expect to
Stated another way, the ankylosing process effectively see more posterior seat belt type fractures than anterior
shifts the axis of flexion of the spine anterior and the opening-wedge type fractures.
axis of extension posterior to its normal location in the The magnitude of shear force that will injure the
center of the nucleus pulposus. Also, shifting the axis of posterior elements of the fifth lumbar vertebra in the
 490 GELMAN AND UMBER

TABLE i
Characteristics of Spinal Fractures in Ankylosing Spondylitis

Case . . . Extentof .
Site of Fracture Diastasis Treatment Healing
No Trauma

1 . . T12 adjacent to inferior ver- Yes Major Anterior rod and fu- Yes
tebral endplate sion
2 . . L5-S1 disc space Yes Minor Taylor brace Yes
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L1-L2discspace Yes Minor None Yes

3 . . 12th thoracic vertebral body No Major Corset 9 months No
adjacent to superior verte- Harrington rod and Yes
bral endplate fusion
4 . . Li adjacent to inferior No Minor Bed rest Lost to fol-
vertebral endplate low-up
Note. - Fracture of posterior elements occurred in all patients. None of the patients had a neurologic deficit.

Fig. 6.-Fracture through disc space and posterior elements with irregularity of end plates and sclerosis indicating motion at fracture site and
pseudarthrosis.

normal spine is low and occurs commonly [18]. Unbal- tant for selection of proper therapy. External support by
anced shear force, forced rotation, and flexion overload a brace may eliminate pain and promote bony healing;
have all been implicated in explaining the mechanical however, if irregularity and sclerosis begin to develop, a
etiology of lumbosacral spondylolisthesis [2i]. Similar pseudarthrosis rather than a pyogenic or granulomatous
mechanisms might explain the etiology of traumatic infection should be suspected. This is especially true in
spondylolisthesis seen in case 2. the presence of an associated posterior element fracture.
Disc space or end plate horizontal fractures with as- Rigid internal fixation and surgical fusion may then be
sociated posterior element involvement are common in indicated.
long-standing ankylosing spondylitis and reflect the bio-
mechanical effect of trauma or subclinical stress on a ACKNOWLEDGMENTS
rigid spine. Radiographic recognition in the patient pre- We thank Dr. S. William Allred for contributing case 3; Drs.
senting with sudden focal pain and tenderness is impor- Harry Genant and Howard Steinbach for the case illustrated in
 SPINAL FRACTURES IN ANKYLOSING SPONDYLITIS 491
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Fig. 7.-A, Normal spine with axis of flexion and extension near the center of nucleus pulposus. B, Ankylosing process which shifts axis of flexion
anterior to normal position in center of nucleus pulposus. Fracture may occur through ankylosed posterior elements and extend through either
vertebral body (A) or ankylosed disc space (B). C, Ankylosed spine with axis of extension shifted posterior to normal location. Excessive extension
force creates “anterior opening wedge type” distraction fracture.

figure 6; and Mrs. Joan Bodell for help in preparing the manu- dislocations of the ankylosed thoracic spine in rheumatoid
script. spondylitis. J Trauma 7 :827-837, 1967
i3. Rivelis M, Freiberger RH: Vertebral destruction at unfused
REFERENCES segments in late ankylosing spondylitis. Radiology 93:251-
256, 1969
1. Kewalramani LS, Taylor AG, Albrand OW: Cervical spine 14. Holdsworth F: Fractures, dislocations, and fracture-dislo-
injury in patients with ankylosing spondylitis. J Trauma cations of the spine. J Bone Joint Surg [Am) 52:1534-
15:931-934, i975 i55i, i970
2. Bergmann EW: Fractures of the ankylosed spine. J Bone i5. Kaufer H, Hayes JT: Lumbar fracture dislocation. A study
Joint Surg fAmj 3i : 669-671 , 1949 of 21 cases. J Bone Joint Surg [AmJ 48 :712-730, i966
3. Woodruff FP, Dewing SB: Fracture of the cervical spine in i6. Morris JM, Lucas DB, Bresier B: Role of the trunk in
patients with ankylosing spondylitis. Radiology 80 : 17-21, stability of the spine. J Bone Joint Surg [Am] 43:327-351,
i 963 i 961
4. Cawley MID, Chalmers TM, Kellgren JH, Ball J: Destructive i7. Roaf A: A study of the mechanics of spinal injuries, J Bone
lesions of vertebral bodies in ankylosing spondylitis. Ann Joint Surg [Br] 42:810-823, i960
Rheum Dis 3i :345-358, 1972 i8. Weis EB: Stresses at the lumbosacral junction. Orthop Clin
5. Frank P, Gleeson JA: Destructive vertebral lesions in anky- NorthAm 6:82-9i, i975
losing spondylitis. BrJ Radiol 48:755-758, i975 i9. Lamy C, Bazergui A, Kraus H, Farfan HF: The strength of
6. Wholey MH, Pugh DG, Bickel WH: Localized destructive the and the etiology
neural arch of spondylolysis. Orthop
lesions in rheumatoid spondylitis. Radiology 74:54-56, CIin North Am 6 : 21 5-231 , 1975
1960 20. Nachemson A, Wiltse LL: Spondylolisthesis. Clin Orthop
7. Baggenstoss AH, Bickel WH, Ward LE: Rheumatoid granu- 1i7:2-3, i976
lomatous nodules as destructive lesions of vertebrae. J 21 . Farfan HF, Osteria V, Lamy C: The mechanical etiology of
Bone Joint Surg [Am] 34 :60i-609, i952 spondylosis and spondylolisthesis. Clin Orthop 117:40-55,
8. Rapp GF, Kernek CB: Spontaneous fracture of the lumbar 1976
spine with correction of deformity in ankylosing spondylitis. 22. Smith WS, Kaufer H: Patterns and mechanisms of lumbar
J Bone Joint Surg fAmJ 56 : i277-i278, i974 injuries associated with lap seat belts. J Bone Joint Surg
9. Yau A, Chan A: Stress fracture of the fused lumbo-dorsal [Am] 51 :239-254,
i969
spine in ankylosing spondylitis. J Bone Joint Surg [Br) 23. Rennie W, Mitchell N: Flexion distraction fractures of the
56:681-687, i974 thoracolumbar spine. J Bone Joint Surg [Am] 55:386-390,
10. Kanefield DG, Mullins BP, Freehafer AA, Furey JG, Horen- i 973
stein 5, Chamberlin WB: Destructive lesions of the spine in 24. Chance CQ: Note on a type of flexion fracture of the spine.
rheumatoid ankylosing spondylitis. J Bone Joint Surg [Am) BrJ Radio! 21 :452-453, 1948
5i :i369-i375, i969 25. Fletcher BD, Brogdon BG: Seat belt fractures of the spine
11. Good AE: Nontraumatic fracture of the thoracic spine in and sternum.JAMA 200:167-168, 1967
ankylosing spondylitis. Arthritis Rheum 10 :467-469, 1967 26. Carroll TB, Gruber FH: Seat belt fractures, a report of two
12. Hansen ST, Taylor TKF, Honet JC, Lewis FR: Fracture- cases. Radiology 91 :517-518, i968