 Today I'd like to talk about fractures in the ankle lobe spine, although I run a full elective spine practice in a whole manner of elective spine surgery. I also help staff to shop trauma hospital here in Baltimore and more and more we see fractures of patients in the elderly category with spines that are ankle lobes and become a very important subject for us and I think it's worth a rating where it's like. So today I'd like to talk a little bit about the differences between the ankylosis, spinalitis and dish, which are the two main forms of spinal ankylosis that we see. We'll talk about the common presentations of spinal fractures and ankylosis spine patients. And we'll talk about an algorithm of work up and treatment of these fractures really concentrating on awareness, high index of suspicion and appropriate management preoperatively. It's important to recognize that we're to recognize these fractures because the downside of missing a fracture is to be catastrophic, these fractures are much more unstable than the two most fine fractures that you see and they occur with very low energy. So I'll start with just a case presentation, but I think that's always very useful. Here is a very typical case, a 17 year old man presents the emergency room following a ground bubble fall. I have history diabetes and hypertension, but he's living independently at home on his own. In his history, we know the spine disease, he comes in, he is more insensory and intact and has no other injuries as this is a low energy injury. A CT scan is obtained and you can see that he's got a fracture of the spine at the T11-12 level. And what's important to understand about this fracture is not your typical compression fracture. You can see that there's a significant subluxation of T11-12 because these fractures go all the way through the spine and become unstable. So the questions become, what else do we want to know, what more everything might be need and treat me surgically and what else do we demand. So this is just, it was a study to put things in perspective. It was, they were the nationwide inpatient sample between 2011 and 2000, 2007 and 2011. And so that encompassed 12,400 admissions for ankylosing spondylitis of which 267 of those patients died while in hospital. And if you look at the risk factors for death for a patient with ankylosing spondylitis who is admitted to the hospital, clearly the most impressive risk factor is spinal cord injury and a cervical spine fracture. And God's ratio was over 13 compared to God's ratio dying from sepsis in the same patient population, 7. You can spin this the other way and they looked at 53,000 cervical spine fractures of those 408 had ankylosing spondylitis. And an ankylosing spondylitis group of those C-spine fractures, the God's ratio of mortality is 1.6. So you look at all cervical spine fractures, you look at all ankylosing spondylitis and there's a pretty good way cervical fractures or spine fractures in ankylosing spondylitis population is a significant problem with a high rate of mortality. Ankylosing spondylitis as most of you know is a progressive systemic inflammatory heart-creating condition that affects primarily the axial skeleton. It affects about 0.1 to 0.3% of the general population. And this picture is a very typical picture, a classic picture of a patient with ankylosing spondylitis because these patients, as their spines ossify, tend to develop progressive kyphosis. And back in the day when we didn't have good anti-inflammatory or inhibitors for recruitment of ankylosing spondylitis, this type of deployment is not uncommon. In these days you rarely see this type of severe kyphosis. But the mission with the kyphosis is that when these patients sustain trauma or they fall they have an extension type injury because their spine is already flat. So the mechanism of injury is almost always an extension node in a stiff spine. Any drain from the age of onset of ankylosing spondylitis is generally in the early years, usually in the 20s, patients present with classic morning stiffness which improves their activity, low back pain, limited ability to raise the spine, and then radiology climbing to see really adjoint ankylosis. And until 1827 positivity has been outed as one of the signs to make the diagnosis of ankylosing spondylitis. The diagnosis itself is made through a set of criteria. And these criteria are in patients less than 45 years of age with more than 45 years of back pain. Either synchroliitis with one of these features or ankylating 27 with two of these features. So you can make a diagnosis either way. And notice in the criteria that you have things like eidus psoriasis and Crohn's disease. So the seronegative spondyloar properties fall in the same category. And the importance of that is that the type of ankylosis that occurs in the spine in these cases is very similar to the ankylosing spondylitis. Here is a typical X-ray of a patient with ankylosing spondylitis. They develop ankylosis of the anterior longitudinal ligament and disc, as well as the posterior bicep joints. You can see that the SI joint is completely used. This is sometimes known as a bamboo spine or a rubber jersey spine. Because of the stripes of a rubber jersey, it can be seen between the discs. The disc spaces are relatively spared, although they're ossified. But this leads to a skit spine, but also significant amount of osteoporosis and a very brittle spine. It's important to remember that patients can have systemic disease related to the ankylosis spondylitis, not only do they get purple joint arthritis, primarily in the hips and shoulders, but they also can have cardiac disease and pulmonary fibrosis. And these things play a large role in our management for and our other informatics in these patients. Because the spine crackers often require a surgical treatment, and we need to try to optimize their cardiopulmonary status prior to surgery so they can tolerate the surgical insult. Again, here's a picture from history of someone with severe ankylosis related to ankylosis spondylitis. And patients often require a spinal osteotomy to be able to look forward and see straight. That's not really part of the protocol for fractures, but for the chronic management of conventional therapy with NSAIDs, an exercise program, other secondary agents, and bioinformatics are commonly used to help control the patient. This syndrome is the other paradigm for ankylosis spondylitis. It's somewhat different. In this syndrome, we see the auspication of the lymph nodes in the spine, but in a much more robust form. This does not occur in ankylosis spondylitis. The auspication generally occurs from distal to proximal. The SI joints are involved first, and then it marches up the spine, sparing the C2 articulation. In this syndrome, you see primarily ankylostasis in the thoracic region. And you get what they call flowing syngesmophytes. They're very large osteophytes that look like candle wax dripping, across the disc space. Again, we're relative preservation of the disc space. This is not a small osteophyte. We see with spondylosis, it's a different process. In this time, the set joints and the posterior elements are not involved, and ankylosis occurs across the disc space. It can occur in other emphasis around the body. It's more common in patients over the age of 50, as opposed to ankylosis spondylitis, which Eric mentioned earlier. It's associated with obesity and kind of diabetes. It's an interesting phenomenon, where the graphical unit of the osteophytes are almost always on the right side of the spine. It's felt that the pulsations are in the order on the left side of the spine, actually preventing large osteophytes from forming in that area. Resnick's criteria are used to make the diagnosis. Again, you have presence of these glowing castifications and aspectations along the anorexia. That's at least four continuous removal bodies, relative preservation of the removal of disc height, and absence of the opposite of joint ankylosis and ankylotic joint development. Overall, you can look at these different syndromes and look at ankylosis spondylitis, secondary psoriatico-rider syndrome, which is a very similar case. Most of the osteophytes are anterior. Aspectations of pulsed ankylosis and ligaments are usually seen commonly in the case of Japanese descent and sometimes in the African-American population, where the osteophytes occurred along the posterior aspect of the cervical spine and could cause myelopathy as they started to press the spinal cord and then there is also a sugeromal acid which can play them in the cervical spine to cause spinal cord compression. But you can see in the dissyndrome, fibocytes are very large. These can even cause difficulty with dysphagia and interfere with the mechanics of swallowing when they get it to be overly important. This syndrome is a little bit of a controversy in the sense that although the resonant classification or the resonant criteria are used, different papers have been published over the years with different criteria. There are three to four levels involved, whether it is complete ankylosis or not, whether it is spinal or peripheral. Suffice to say, it is not as well defined perhaps as ankylosis and spondylitis, but in general we have a sense of what we are talking about. About 7% of men and 4% of women over the age of 30 will present with this syndrome. Fractures are conflicted. The distinction of ankylosis and spondylitis, fractures in the dissyndrome tend to occur at the immediate body level. So in ankylosis and spondylitis, because the osteophytes across the disc space are so linear and thin that where the brink almost always occurs through the old disc space area, where in this syndrome where the osteophytes are much thicker, the fractures occur through the body, other than through the life, so they're different in their pattern, but again, the most malignant type of fracture you can see are these extension-type fractures, the thoracic spine. Normally in a typhonic posture, if someone falls and hits their head or there's a car and has a steering wheel hit their spine, there's an extension-type moment and the spine will crack through an extension-type pattern, which is different than a typical compression fracture, which is more of a flexion-type injury common to see elderly. Here's our table. It just goes through everything we talked about. Prepare a gist, angle a spondylitis, whether or not there is mobility, pain, until age 2070 is not common in this population at all. There are different syndromes, like the fact that they need to do the same outcome often. This was a meta-analysis looking at spine fractures and they looked at 22 studies and they found the odds ratio of vertebral fractures and angle a spondylitis is about almost two. It's about twice as common as a general population can ever suffer a spine fracture. At the same time, there's no increased risk of hip fracture, so it's not just generalized osteoporosis that causes these pieces to fracture, but it's something else about their spine. It's clear that low bone marrow density in the hip is a factor that's at risk in places if you become osteoporotic or it's at work, then that disease duration and measures of disease intensity also play a role in hip development of these fractures. We have some inflammatory bowel problems that are close to a significant risk for fractures and angle a spondylitis. Again, here's another study looking at 290 patients with two-year follow-up and it was made to stay studied because 20% of the patients in this study had a fracture at baseline when they were first seen and only two were symptomatic, so not all fractures in angle a spondylitis present necessarily with symptoms and patients can continue to have fractures during the course of the time when they were studied and the fractures can worsen, and I put this picture in here to highlight the difference. So in the lower part here, you can see a very typical common compression fracture, which has gone onto healing and in some sense these fractures are very much similar to the fractures we see in other elderly patients, so sometimes the patients present more problematic fractures and see that they've actually had asymptomatic fractures. And that's just a tribute to the fact that they are osteoporotic and even in an angle of spina you can have the typical type of fractures that you see, but the problematic fractures are these. You can see that what happens, we talk about this as being like a piece of bamboo or a, if you think of the spine as a ring, right there's a bone ring surrounding the spinal canal and the body and the back is in neural arch, but if this is completely rigid, try to break a pretzel in one place. If you have a rigid ring, it always breaks in multiple places when it breaks. So the fractures are never just through the vertebral body, but they always extend all the way through the spine to the back and this section is extremely rigid and this section is extremely rigid. All the force concentration occurs through the fractures, so there's a great deal of force on the fractures and these fractures are very, very unstable. At the same time, the generality occurs in an area, either the cervical or thoracic region where we're dealing with spinal cord as opposed to in the lumbar spine where we have distal nerve roots only, so the risk of spinal cord damage is significant. Here's another study from 2017. They lifted over almost 200 patients over 26 years and they found that 34% of the patients who had cervical spinal cord injury with ankylosing spines were other patients who presented with spine fractures and ankylosing spines almost a third of them presented with spinal cord injury. Interesting or the thing that we're really telling is that half of those patients had a delayed presentation. So they had fractured their spine at some point, became symptomatic but did not come to the hospital until they had had symptoms for some time and the spinal cord injury began to become more symptomatic. So that many of these patients needed to know the patients in this category of any kind of even minimal trauma and come to the emergency room complaining that even any back pain made a full evaluation because many of them will develop spinal cord injury on a delayed basis if they're not treated appropriately. Cervical spine fractures certainly had a high ratio where more riskings than other fractures could develop spinal cord injury and the development of spinal epidural with a significant risk factor in the development of spinal cord injury. These fractures, because there's a large bone surface because it's a good deal of instability which will shear and rip the epidural penis flexes fractures even though it's fun to be recognized since the 1970s for having the potential for developing massive epidural humus in the absence of any real bone, significant bone looking injury and it itself caused massive spinal cord injury so we need to be very cognizant about here is a table that shows where these fractures occur they're much more common in the lower cervical region of course that is problematic because of the difficulty of the image the lower cervical spine on X-rays especially in very cathodic patients and you can see that in the AJA being a complete spinal cord injury patients presented with severe spinal cord damage a very little chance of needing neurologic functions whereas patients who are treated when they have mild spinal cord injuries frequently approve to a point where they're essentially neurologically fat so we can tax these patients when they're in this age of being brain and hopefully we can salvage their life here is another study which looked at 900 to over 900 patients spinal ids average age 68 to 85% now very typical you can see they had a broad range but most of these patients are in their 60s, 70s, 80s and many of them have multiple medical comorbidities so this is not a particularly healthy population more than half of them have cervical spine fractures and again close to a third had spinal cord injury in the cervical region and 16% in the thoracic region 29% of these patients suffer complications during their hospitalization because they have multiple medical comorbidities and in hospital mortality so not a substantial complication rate or mortality rate and once again the severity and significance of these injuries here's another article from the European Spinal Journal they put the meta-analysis they looked at both ankylosis and spondylitis and disc syndrome patients the delay in diagnosis again to be highlighted because we don't want this to happen in our emergency 70% of the ankylosis and spondylitis patients 9% of the disc syndrome patients have high rates of spinal cord injury 15% of both groups had secondary deterioration so these patients often deteriorate neurologically even in the hospital and mortality significant it's interesting to note the patients who admit to the hospital who are neurologically intact about 15% of them will deteriorate neurologically in practice they're so unstable and even under medical care it can be very very difficult to manage them successfully with transfers and motion through the hospital to their hospital today this is an interesting study because it highlights just how the mechanics of the spine make it so difficult to prove these are 14 patients with disc syndrome they have A1 as a compression factor A1 is a constipation system if you're simple, run-of-the-mill compression factor the kind of things we see in patients with a non-ankylosis spine all the time and these factors occur during these segments so this is a case control study the interesting thing they found was that of the patients with disc syndrome a significantly smaller percentage of these patients killed their practice spontaneously and more of them went on to malign them than the patients who were not disc syndrome so because the mechanics of the spine the stiffness of the spine concentrates mostly at the level of the fracture it makes it difficult for these fractures to heal so even in simple fractures there's a very high rate of non-union and even in simple fractures in these patients may require surgical treatment in order to go on a successful obviously a high degree of suspicion is necessary to make the diagnosis and that's the starting point so hopefully that last section of the talk will have raised your suspicion when you see patients in the room or in the office here was a study out of Scotland that today had 30 patients but they found that 60% of patients the fractures who had ankylosis and spondylitis were not visible on fine-ray grafts because of that problem 84% of them had a delayed presentation and 20% of the patients who were neurologically intact had deterioration prior to admission so here's a very typical kind of a wow fine x-ray you might get an older gentleman who had maybe a simple fall at home may have come to his head a little bit and said my neck my neck's been bothering me for a few days even if the patient can't remember any specific traumatic impact I think anyone who has a spine like this who has new onset can be there is a pretty full evaluation because the risks are so high but if you get a cascading just where his shoulder is I think this location of his spine and you can understand what's having the spinal cord right through this area and it's just amazing how obnoxious these fractures can look at any given time CT scan is really the diagnostic study of choice in this retrospective review of 124 patients they found that CT scan identified 95% 4 over 6 on MRI scan changes the treatment plan overall MRI open changes the treatment plan 3% of the time CT is in my mind a better study in the sense that it really gives us a better sense of the bone anatomy and when it comes to planning surgical treatment having good knowledge of the osteology anatomy helps us to understand what's going on so they recommended to use the MRI to limit the patients with non-enchelous levels with the disco, liver medicine so we think they may have broken to a part of their spine that's actually not on patients who have neuro-line the deficits they can't be identified by the CT scan so in time, jubilson patients whose neuro-line deficits do not match the presentation would expect from the level of the fracture on CT and those patients certainly do have a MRI scan and what you're going to find in those patients is a large epidural hematoma so here's a patient who had a fracture down near where there's high signal in the rectum of the bodies but the hematoma has nothing causing compression so in this study an average age for an patient with almost 74, 93% had low velocity injuries so they're not high injuries but and so type B fractures are extension fractures where the spine is cracked but this will be type C fractures or fractures that are completely dislocated to the spine but you can see that patients who have all these and 30% of those patients have significant epidural hematomas it may change their surgical management because if you think the fracture is down here and you just fix this weekend and don't do anything to evacuate the hematoma you're not really addressing the cause of the neuro-line deficit. I will say that occasionally if there's a suspicion the CT scan isn't diagnostic MRI scan the law can show pain in the vertebral body that may help us to make the diagnosis to find a large CT if the work force slide maybe the most important of all although it's interoperative but that's not the point but the point of it is this when these patients are managed in the hospital to the fact that their spine was a certain shape free injury and the best way to decompress the spinal canal or preserve neurologic function is to maintain that preoperative deformity we've seen multiple patients who come in a hospital sitting up in their bed and he asks their family is this what grandpa he looks like and they say no he hasn't looked straight ahead for the past 20 years so and if you look at his cat scan or his x-ray that point you see he's got a master's degree dislocated or neuro-dislocated spine so although we are always taught in medical school and in ETLS their patients should be on a flat board and they're hanging their ACBs down and hold their heads still one patient group in which allowing the patient's neck to flex forward and support it in its normal position may be especially as patients are transported around the hospital although their head needs to be stabilized we may not always destabilize it in the kind of position which we normally think about from the spine interventions but we try to reproduce the normal or the normal position that they're at in order to keep their spine in appropriate alignment to protect their spinal cord and this being very very challenging especially in the operating room when we go to position spaces for surgery and turn them prone we have to come up with all kinds of creative ways of thinking in order to position the spaces appropriately in the operating room we'll go back to the case that I presented at first just to give you another representation or another example of this kind of thing here's our 70-year-old man had a low energy ground level fall came in with this injury and we recognize that this injury has a subluxation so there's a dislocation of the spine as it travels all the way through the spine you can see there in the fracture gap indicating that there's mobility or motion no other injuries this gentleman despite his age clearly indicated for surgical treatment so we take him to the operating room and we're going to do fixation so we bring the operating room we put him on the operating table like this this is not a particular patient but it's an example of someone who has the same type of injury and we use SS, EP8 and NEP or somatic sensory road potentials we always get baseline signals we always get a set of road potentials prior to the infection of surgery many of these patients may have diabetes they may have peripheral neuropathy they're elderly and it's nice to know that you have signals before you flip because you have to be one of those and this is the issue here's the take everything we could to position him back into the position that he was preoperative so you can see he's on a crane that is cathartic you let his head fall down you let his legs on we're literally trying to flex the spine back to its normal position prior to surgery and despite that when we fixation on the table you can see that the spine extends there's a subluxation you can follow the posterior vertebral body line here there's a step off so he's dislocating through the fracture gap when we repeat that before we start to proceed you do a post-positioning run of SSEPs and NEPs and lo and behold he's lost his motor and it's very low potential so just by virtue of that position a simple maneuver turning him prone we compromise his spinal cord sufficiently to be problematic so the patient is before we put and even though we're already prepping it takes a while to get there we bring the stretcher back in we take the patient off the table we put him back into his other position or laying his side in a curled position to try to get the spine to go back in position and we'll try to arrange the table for even more kyphosis, change the head positioning change the leg positioning and once again position the patient in order to do the surgery eventually we're able to position the patient prone and do a posterior fixation and you can see here that the spine is now aligned and the spinal canal compressed and here you get a good sense of how this fracture travels through here and down and then it's here and it's often the case when you get these subluxations that the spinal cord gets pinked between the lamina above where the lamina the tibal body moves backwards so this spike of bone can keep you down the back of the tibal body of the spinal cord occasionally we'll do signals during surgery or it's impossible to position the patient accurately the thing to do in that situation is very quickly do a very small exposure puts the screws in just a few screws on one side get the spine reduced and holding while we do the rest of the procedure in general we treat fractures with very long constructs because the spine is so stiff and ankylosing they're so osteoporotic you get multiple points of fixation fractured or it'll hold it adequately without maintaining it in alignment so most of the time these patients get fairly long exposures and multiple screws that's why I say we need to have the cardiopulmonary function pretty aggressively because it's a pretty big surgery but overall three months later the fracture is healed and the patient gets done well what is what is new in this situation more and more we're able to do these types of surgeries we put the fixation so instead of making a long incision and exposing the whole spine we can get the patient positioned we can put the screws in with multiple small stabbing patients and then pass the rod in a sub-fascial plane and that'll release 90% of the surgical bleeding the surgical time is much shorter because we don't have to do dissection it's no longer the surgery much less so more and more these surgeries get done to a pretty painless type of fixation so what do they take that's really what I have and I think that's pretty close to 40 minutes so I think we're on time patient's ankle is just fine to lie ankle is just fine so there's a high risk for unstable spine fractures and even minimal trauma so a high kind except suspicious in any patient with this type of an injury who has even minimal trauma if they presented pain or back pain requires really a full evaluation to make sure we're not missing anything these should be our first immunodality of choice but MRI scan in certain circumstances especially if there's any indication that there might be an epidural human telmo or unexplained neurologic deficit common fracture patterns are what we call B3 with your extension injuries where the front of the spine becomes longer and the spine hinges on the back or tight see with your spinal dislocations or shearing type injuries and that's because the spine is still rigid makes it possible to break just the front and the back intact and just as important as the hindits of submission careful patient positioning during the patient's hospitalization to avoid spinal dislocation is crucial and everyone on the team the nurses, the physical therapists everyone needs to understand that these patients are a little different than our typical elderly patients with a fracture and treated really big gloves unfortunately over the years I've been in Maryland for almost 20 years we've seen patients on the floor come in with this type of fracture waiting certainly the next morning and because of an unrecognized situation patients have become completely paralyzed because their spine dislocated before we could safely get to the operating room even in the best circumstances in the best trauma places in the country there are still some patients who deteriorate neurologically in the hospital so thanks for watching see you next time bye