81-year-old man with neck, shoulder pain
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An 81-year-old man with significant medical comorbidities presented to the emergency room with neck and shoulder pain after a fall at a nursing home.
The patient complained of acute onset neck pain without radiation, left shoulder pain and a mild headache. The patient also complained of intermittent numbness in his right index finger, although this was no longer present by the time of the examination.
On initial presentation, a CT scan of the head revealed no intracranial process and chest and shoulder radiographs revealed no acute abnormalities. A CT of the cervical spine demonstrated multiple contiguous levels of flowing anterior osteophyte in the anterior longitudinal ligament. There was severe spondylosis with ankylosis of bilateral facet joints at several levels posteriorly and relative loss of global cervical lordosis. There was an extension deformity with distraction through the disc space of C6/7 with concomitant fractures at the bilateral lamina facet junction of C6. (Figures 1, 2 and 3). An MRI could not be obtained because the patient had an incompatible pacemaker.
Source: Daniel Kim, MD, MSc
On exam, the patient had mild tenderness to palpation of his posterior mid-cervical spine without palpable step-off or crepitus. Neurologic examination revealed 4/5 bilateral shoulder abduction, which was limited secondary to pain at both shoulders with positive provocative rotator cuff maneuvers. The rest of the motor exam from C4-T1 revealed 5/5 strength. The sensory exam was intact to light touch in all distributions bilaterally from C4-T1. The patient demonstrated a negative Hoffman’s test and inverted radial reflexes bilaterally with 2+ reflex at the bilateral biceps, triceps and brachioradialis.
What are the treatment options?
See answer below.
Posterior instrumented fusion of unstable three-column hyperextension cervical fracture
Any cervical trauma examination must initiate with an assessment of the ABCs: airway, breathing and circulation.
If there is any concern for airway compromise and tracheal intubation is required, it should be done with manual in-line stabilization to avoid any displacement of fractures/dislocations and possible catastrophic neurologic injury.
This patient demonstrates an unstable three-column fracture with fracture propagation through ankylosed disc space into the posterior elements bilaterally at the lamina facet junctions.
Options for treatment include: (1) nonoperative management with a rigid cervical orthosis; (2) posterior cervical instrumentation and fusion without decompression; (3) posterior cervical decompression and instrumented fusion; (4) anterior instrumented fusion; and (5) anterior cervical decompression plus posterior instrumented fusion
The first option is not recommended for this injury pattern due to the degree of instability with a complete disruption of the anterior, middle, and posterior columns at this level. While a cervical orthosis may work for stable diffused idiopathic skeletal hyperostosis (DISH) fractures, three-column injuries require surgical fixation to prevent potential catastrophic neurologic injury. An anterior-only approach is not recommended in this setting. Anterior fixation can serve as a reasonable temporizing measure in the setting of kyphotic deformity that prevents safe prone positioning. In this case, a long multilevel construct is recommended due to the stiff, long lever arm effect of the adjacent segments, which places significant biomechanical stress on the injury level. This is amenable to the posterior approach. Decompression is suggested in settings of neurologic compromise with any radiographic evidence of stenosis, most commonly from an epidural fracture hematoma. In the absence of neurologic deficit, fusion alone to confer stability is appropriate.
Operative technique
General anesthesia was administered, and an endotracheal tube was placed with inline manual traction of the neck with limitation of extension. Intraoperative neuromonitoring leads were placed, with preoperative baseline sensory and motor-evoked potentials established. The patient was placed in Mayfield tongs and turned prone onto a Jackson table with an electromechanical head positioning system for precise reduction. The post-positioning running electromyography (EMG) and motors were stable.
A standard midline posterior approach to the spine was used. Appropriate levels were confirmed with fluoroscopy. A spinous process clamp was attached to T2 and an intraoperative CT scan was done for stereotactic navigation. Navigated insertion of cervical lateral mass screws from C3-C6 and thoracic pedicle screws at T1 and T2 was performed in a standard fashion.
Approach to C6 fracture
The C6 fracture was then examined. The C5-6 posterior ligamentous complex (PLC) was fully calcified and fractured. The lamina was free-floating with fractures at bilateral lamina facet junctions but did not appear to cause compression (Figure 4), with intraoperative neuromonitoring signals fully intact. Decompression was deemed unnecessary in this case. The fracture reduction in a neutral position was carefully optimized using the electromechanical positioning arm. Bilateral cobalt chrome rods were placed with decortication and grafting using autogenous bone graft, as well as demineralized bone fiber allograft (Figures 5 and 6).
Standard layered closure was performed with the placement of a deep removable drain. Neuromonitoring signals including somatosensory and motor-evoked potentials, as well as running EMG were maintained throughout the procedure. Postoperatively, the patient was placed into a rigid cervical collar. There was no postoperative dysphagia, paresthesias or neurologic deficits. The patient recovered well on the spine unit and was transferred to a transitional care unit for prolonged acute rehabilitation due to chronic general deconditioning before his injury.
Discussion
Progressive ankylosis of the spine is a hallmark of two distinct diseases; ankylosing spondylitis (AS) and DISH. While neurologic deficits as a result of unstable spinal fractures are well known and notorious complications of longstanding AS, G.C. Murray and colleagues found neurological deficits are rare with DISH. Although an increasing amount of evidence suggests patients with spinal ankylosis due to DISH are also at risk for unstable fractures of the spine, the awareness for DISH is lower among clinicians, based on research by L.A. Westerveld, MD, PhD, and colleagues. The diagnosis of DISH is established when flowing ossification over at least four contiguous vertebrae is present on conventional radiographs with sparing of the intervertebral disc space and absence of other clinical skeletal manifestations of AS, according to research by Daniel K. Resnick, MD, and colleagues. Its etiology is currently unknown, yet several authors, including Charles W. Denko, MD, PhD, and colleagues, have described associations with advancing age, obesity and type 2 diabetes mellitus. Diffuse idiopathic skeletal hyperostosis also shows a male predominance (in a 3:2 ratio) and is rarely seen before the age of 50 years, a study by Westerveld and colleagues showed. Spine fractures are caused due to long lever arms on which traumatic forces can act. These result in hyperextension fractures after a simple backward fall or low-velocity rear-impact motor vehicle accident. The diagnosis of DISH is a prognostic risk factor for increased vertebral fractures in the oldest of patients; however, Eijiro Okada, MD, PhD, and colleagues showed these patients often demonstrate increased bone mineral density on DEXA scans, which can be misleading.
Complications reported
Troy Caron, DO, and colleagues reported an overall mortality of 32% in their cohort; 21.1% of AS patients and 38% of DISH patients died within the follow-up period (6.5 months). Andrew J. Schoenfeld, MD, and colleagues described the outcome of patients with AS and DISH compared with age- and gender-matched control patients, after treatment for cervical spine fractures. After 3 months, 37.5% of AS patients, 7.4% of DISH patients and 7% of control patients had died. After 3 years, the mortality was 62.5%, 29.6% and 32.6%, respectively. Westerveld and colleagues reported on complications as well and noted, after operative treatment, 87.5% of AS patients and 85.7% of DISH patients had at least one complication. After nonoperative treatment, these percentages were 100% and 68.4%, respectively.
Apart from conventional radiographs, a CT scan is useful to identify the fracture pattern and confirm the integrity of the PLC per research by Okada and colleagues, especially when the PLC is ossified. Although MRI was contraindicated in our case due to an incompatible pacemaker, MRI should be considered in the presence of an unclear neurological exam or deficit. In the absence of neurological deficit, the utility of MRI has limited clinical application in DISH. MRI should be strongly considered for any AS patient regardless of neurologic status, findings from Nadish G. Shah, MD, and colleagues showed.
Treatment for ankylosed spine fractures in DISH patients may be operative or nonoperative depending on the patient’s age, medical comorbidities, fracture pattern and neurologic status. Nonoperative treatment is usually performed by bracing and bed rest, while operative treatment is posterior spinal fusion. The indications for operative treatment include unstable fracture patterns with the involvement of the PLC and neurological deficit. The decision for decompression is based on whether there is a neurological deficit.
Conclusion
The recognition of DISH is important as the mechanism of injury is often low-energy and subtle trauma. Although the current recommendation is for these spinal injuries to be treated surgically, stable fractures without any associated neurologic deficits have often been successfully managed with immobilization alone. When surgical intervention is needed, long-segment posterior instrumented fusion is the standard of care to counter the long, lever arm mechanism.
- References:
- Caron T, et al. Spine. 2010;doi:10.1097/BRS.0b013e3181cc764f.
- Denko CW, et al. Rheumatology International. 2006;doi:10.1007/s00296-005-0588-8.
- Murray GC, et al. Am J Med. 1981;doi:10.1016/0002-9343(81)90860-3.
- Okada E, et al. J Orthop Sci. 2017;doi:10.1016/j.jos.2016.09.011.
- Resnick D, et al. Radiology. 1976;doi:10.1148/119.3.559.
- Schoenfeld AJ, et al. Spine J. 2011;doi:10.1016/j.spinee.2011.01.018.
- Shah NG, et al. Spine J. 2020;doi:10.1016/j.spinee.2020.10.027.
- Westerveld LA, et al. Spine J. 2014;doi:10.1016/j.spinee.2013.06.038.
- For more information:
- Daniel Kim, MD, MSc, is a spine surgery fellow; Kedar Padhye, MD, is a spine surgery fellow; and Eiman Shafa, MD, is attending surgeon, spine surgery, at Twin Cities Spine Center. They can be reached at 913 East 26th St., #600, Minneapolis, MN 55404. Kim’s email: dckim@tcspine.com. Padhye’s email: kppadhye@tcspine.com. Shafa’s email: eshafa@tcspine.com.
- Edited by Travis Frantz, MD, and Ian Savage-Elliott, MD. Frantz is a sports medicine and shoulder fellow at TRIA Orthopaedic Center in Minneapolis. He completed his orthopedic surgery residency at The Ohio State University Wexner Medical Center in Columbus, Ohio. Savage-Elliott is a chief resident in the department of orthopedic surgery at Tulane University Medical Center in New Orleans. He will pursue fellowship training in foot and ankle and sports medicine following residency completion. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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