Cervical spine trauma is more common in patients with ankylosing spondylitis due to a rigid spine, poor balance, and osteoporosis. Injuries are serious with high mortality rates of 35-50% occurring from hyperextension mechanisms. Upper cervical injuries have increased risks of fractures of the odontoid process and transverse ligament due to joint destruction and ossification. Management involves traction and halo vest or internal fixation. Subaxial injuries below C3-C6 disrupt all spinal elements and have increased risks of neurological injury. Treatment requires traction, halo vest, or anterior and posterior fixation spanning two levels above and below the injury. Thoracic fractures are difficult to immobilize and require surgical alignment

1. Lorem Ipsum Dolor
Cervical Spine
Trauma In
Ankylosing
Spondylitis
Dr Asheesh Tandon
MCh. Neurosurgery
Aditya Superspeciality
Hospital Jabalpur

2. Increased Incidence
❖ Incidence of Cerv. Trauma significantly higher than
general population
❖ Poor balance
❖ Osteoporotic and
❖ Rigid immobile spine

3. Cervical fractures
❖ Cervical Trauma in Ank Spond - Serious
❖ Mortality - 35 - 50%
❖ Hyperextension - most common Mechanism of injury

4. Pathogenesis
❖ Facet jt destruction - eventual ossification, jt narrowing
and ankylosis
❖ Annular calcification decreases the movt. and elasticity of
IVD
❖ Spinal ligaments become calcific leading to multiple fused
vertebral segments behaving as a long bone fracture
❖ Increased risk of formation of epidural hepatoma following
inj.

5. Upper Cervical Injury
❖ Increased susceptibility to AAD, odontoid process fractures
and hangman’s
❖ Injury to brittle transverse ligament and osteopenia
predisposing factors
❖ Present with severe neck pain following minor trauma with
or without myelopathy
❖ Full imaging - X-rays, Thin Cut CT scan(for fracture
delineation) and MRI (to see for big injury and cord
impingement)

6. Management of Upper Cervical
Injuries
❖ Apply Cervical traction (wt around 5 pounds gradual
escalation)
❖ If reduction achieved - Halo (3mnths) or fixation
❖ Halo vests - decubitus ulcers (cervico thoracic
kyphosis), Pin tract infection or failure of fusion
❖ If closed reduction fails or neurol deterioration - internal
fixation

7. Internal fixation
❖ Mostly C1 lat mass and C2 pedicle screw fixation used
❖ Should be augmented with dorsal cable and graft
construct

8. Sub Axial Cervical Spine
Injuries
❖ C3 to C6
❖ Injury usually disrupts all spinal elements leading to
increased risk of neurol injury
❖ Invest as for CVJ injuries
❖ Realignment is difficult and treacherous
❖ Traction - axis of force anterior and superior in
alignment with pre trauma posture

9. Management - Subaxial Injury
❖ Traction - gradual increasing wt upto 10pounds
❖ If realignment achieved - halo vest for 3 months
❖ Otherwise fixation. Eep if neural structures are being
compromised decompression and fixation
❖ If anterior elements compromised - ant decamp and
fixation
❖ Fixation - 2 levels above and 2 below. No loss of range
of most in view of ankylosis

10. Anterior stabilisation Pearls
❖ Top and bottom screws inserted first to secure the plate
❖ Simultaneous insertion of rostral and caudal screws
prevents stripping of screws
❖ Traction released prior to screw insertion
❖ Bicortical fixation preferable (osteoporosis)
❖ If concern of strength of fixation - halo vest or posterior
fixation

12. Posterior
Stabilisation/Surgery
❖ In AS neural decamp achieved with
realignment
❖ Post stabilisation as augmentions for ant
fixation
❖ If anterior elements intact with posterior
linear fracture
❖ In case of spinal hepatoma - laminectomy
with stabilisation
❖ If possible prevent injury to C2 lamina its
or ligaments
❖ Preference of interspinous fixation along
with lateral mass screws
❖ Cross linking must for additional stability

13. Crevice Thoracic Injury
❖ Very difficult to manage such fractures with traction - not
recommended
❖ Difficult to immobilise this area with halo vest
❖ So alignment and stability achieved surgically

14. Anterior approach
❖ If possible utilise this approach for grafting and fixation
❖ Not always possible - poor intro visualisation on C Arm
❖ Exaggerated thoracic kyphosis

15. Posterior Approach
❖ Augments ant stabilisation
❖ Lateral mass in cervical spine and pedicle screws in
thoracic spine for fixation
❖ Placement of laminar hook at most caudal level is
recommended for additional support

16. Conclusion
❖ Mgment of cervical spine fractures in AS- complex and
difficult
❖ Non op t/t insufficient in many pts in view of risk of
decubitus ulcers and insufficient immobilisation
❖ Additional posterior fixation and longer segment fixation
is recommended

17. Many thanks