[Occupational disease 2108. Degenerative changes of the cervical spine as a causality criterion in the assessment of discogenic diseases according to BeKV 2108]

Single anterior approach for cervical spine fractures at C5-T1 complicating ankylosing spondylitis

OBJECTIVES

To evaluate the outcomes of anterior approach for cervical spine fractures at C5-T1 in patients with ankylosing spondylitis (AS) and study the problems encountered in diagnosis and treatment.

PATIENTS AND METHODS

Ten patients with AS (all males; mean age 43.7±9.4 years) underwent anterior surgeries to treat fractures at C5-T1. Skull tractions were performed on patients with fracture dislocation preoperatively. After operation, all the patients wore a cervical collar for 3 months. Plain radiographs at follow-up were reviewed. If bone fusion could not be confirmed on plain radiograph, CT scan was employed. The pre- and postoperative neurological statuses were evaluated according to the Frankel grading system. Problems encountered in diagnosis and treatments were analyzed.

RESULTS

The mean follow-up was 41.2±22.7months. After operation, the displacements of fractures were significantly reduced(P<0.05). Bone fusions were observed in 9 patients at final follow-up. Frankel grades improved by 1.0±0.7 grade (P>0.05). Posterior complications occurred in four patients, including implants failure (n=1), subsidence of cage (n=1), hoarse voice (n=1) and pneumonias (n=2). The patient with implants failure required revision surgery and anterior-posterior fixation. Patient with subsidence of the titanium cage achieved bone fusion with prolonged cervical collar immobilization.

CONCLUSION

The diagnosis and treatment of cervical spine fractures at C5-T1 in AS patients are challenging, with high risk of neurological compromise and postoperative complications. The single anterior approach followed by postoperative immobilization with a cervical collar can yield acceptable results if the cases are properly selected.

Management of cervical fractures in ankylosing spondylitis: anterior, posterior or combined approach?

INTRODUCTION

Ankylosing spondylitis (AS) can lead to an increased risk of cervical fractures.

SOURCES OF DATA

A systematic review was undertaken using the keywords 'ankylosing spondylitis', 'spine fractures', 'cervical fractures', 'surgery' and 'postoperative outcomes' on Medline, Pubmed, Google Scholar, Ovid and Embase, and the quality of the studies included was evaluated according to the Coleman Methodology Score.

AREAS OF AGREEMENT

Surgery ameliorates neurological function in patients with unstable AS-related cervical fractures. The combined anterior/posterior and the posterior approaches are more effective than the anterior approach.

AREAS OF CONTROVERSY

The optimal approach, anterior, posterior or combined anterior/posterior, for the management of AS related cervical fractures has not been defined.

GROWING POINTS

Open reduction and internal fixation allows avoiding worsening and enhances neurological function in AS patients with cervical fractures.

AREAS TIMELY FOR DEVELOPING RESEARCH

Adequately powered randomized trials with appropriate subjective and objective outcome measures are necessary to reach definitive conclusions.

Injuries of the cervical spine in patients with ankylosing spondylitis: experience at two trauma centers

Object

The cervical spine in a patient with ankylosing spondylitis (AS) (Bechterew disease) is exposed to maximal risk due to physical load. Even minor trauma can cause fractures because of the spine’s poor elasticity (so-called bamboo spine). The authors conducted a study to determine the characteristics of cervical fractures in patients with AS to describe the standard procedures in the treatment of this condition at two trauma centers and to discuss complications of and outcomes after treatment.

Methods

Between 1990 and 2006, 37 patients were surgically treated at two institutions. All patients were examined preoperatively and when being discharged from the hospital for rehabilitation. Single-session (11 cases) and two-session anterior–posterior (13 cases), anterior (11 cases), posterior (two cases), and laminectomy (one case) procedures were performed. The injury pattern, segments involved, the pre- and postoperative neurological status, and complications were analyzed.

Preoperative neurological deficits were present in 36 patients. All patients experienced improvement postoperatively, and there was no case of surgery-related neurological deterioration. In patients in whom treatment was delayed because of late diagnosis, preoperative neurological deficits were more severe and improvement worse than those treated earlier. The causes of three deaths were respiratory distress syndrome due to a rigid thorax and cerebral ischemia due to rupture of the vertebral arteries. There were 12 perioperative complications (32%), three infections, one deep venous thrombosis, five early implant failures, and the three aforementioned fatalities. There were no cases of epidural hematoma. In all five cases in which early implant failure required revision surgery, the initial stabilization procedure had been anterior only. A comparison of complications and the outcomes at the two centers revealed no significant differences.

Conclusions

The standard intervention for these injuries is open reduction, anterior decompression and fusion, and anterior–posterior stabilization; these procedures may be conducted in one or two stages. Based on the early implant failures that occurred exclusively after single-session anterior stabilizations (five of 10—a failure rate of 50%), the authors have performed only posterior and anterior procedures since 1997 at both centers. Diagnostic investigations include computed tomography scanning or magnetic resonance imaging of the whole spine, because additional injuries are common. The causative trauma may be very slight, and diagnosis may be delayed because plain radiographs can be initially misinterpreted. In cases in which diagnosis is delayed, patients present with more severe neurological deficits, and postoperative improvement is less pronounced than that in patients in whom a prompt diagnosis is established. Because of postoperative pulmonary and ischemic complications, the mortality rate is high. In the present series the mortality rate was lower than the mean rate reported in the literature.

Prevalence of cervical spondylosis and musculoskeletal symptoms among coolies in a city of Bangladesh

To assess the prevalence of cervical spondylosis and musculoskeletal symptoms among coolies a cross-sectional study was performed in Narayangonj City of Bangladesh on a random sample of 98 male coolies, using a questionnaire and the results of cervical spine X-rays. Statistical associations were investigated using the chi-square test. The results show a considerably higher prevalence of cervical spondylosis among the coolies (39.8%). More than half (51.3%) of the cases of cervical spondylosis were in subjects below the age of 40 yr, and a significant association was found between age group and prevalence of cervical spondylosis. The study also observed a significant association between duration of occupation and prevalence of cervical spondylosis. Coolies who had worked for 10 to 15 yr, or more than 15 yr, had higher rates of cervical spondylosis. In this study it was found that those who carried heavier loads suffered more from cervical spondylosis. Musculoskeletal symptoms in multiple body regions (two or more) were more prevalent (61.2%) than those in single body region (29.6%). Symptoms in the hands/fingers were the most frequent followed by the back and arms/forearms. In conclusion, the high prevalence of cervical spondylosis and musculoskeletal symptoms among professional coolies may be associated with the practice of carrying heavy loads on the head. Further study with a large sample of population is required to investigate this problem and to explore preventive measures.