Fracture in DISH/AS

A fracture in a patient with diffuse idiopathic skeletal hyperostosis (DISH) or

ankylosing spondylitis (AS) must be monitored and managed aggressively. These
fractures have high risk of immediate/delayed neurologic deterioration, as well as
high mortality rate.

Overview

• AS: bamboo spine with diffuse ankylosis and ossification of ligaments, joints,
and discs (Fig. 1)
• DISH: anterolateral ossification between 4+ successive vertebrae (Fig. 2)
• Most often in cervical spine and due to hyperextension
• 20 % 3-month mortality after trauma
• ⅔ fractures from low-energy trauma
• >50 % present with neurologic compromise (especially AS)
• 14 % have delayed neurologic deterioration
• 17 % diagnosed >24 h after injury

° Half due to delay in seeking care, half from delay in MD diagnosis

° 81 % who had diagnostic delay experienced neurologic compromise
• Usually fracture through vertebral body (especially with DISH), although can
fracture through disc
• Fractures often unstable since surrounding ligaments and tissues fracture as well
(Figs. 1 and 2)

© Springer International Publishing Switzerland 2017 45

M.C. Makhni et al. (eds.), Orthopedic Emergencies,
DOI 10.1007/978-3-319-31524-9_14
46 M.C. Makhni et al.

Fig. 1 AS—fracture through C6 body into C5–6 posterior elements

Fig. 2 DISH
Fracture in DISH/AS 47

History

• Do you have any weakness, numbness, or tingling?

Physical Exam

• Trauma evaluation (Appendix A)

• Serial complete neurologic exams (Appendix A)

Imaging

• C-spine XRs—AP, lateral

• C-spine CT—obtain for all to detect occult fractures *IMPORTANT*
• C-spine MRI—consider for neurologic deficit—assess hematoma
• Consider imaging of entire spine

Treatment Plan

Non-operative

• Indicated for stable fracture without neurologic compromise

• Immobilization with c-collar or halo
• Consider low-weight traction if displaced
• Must do serial neurologic exams to assess for progressive deficit
*IMPORTANT*

Surgery

• Up to 83 % of patients may undergo operative fixation (especially with AS)

• More likely to lead to improved complication, mortality, and neurologic recovery
rates but must give patients option of nonsurgical treatment due to high risks of
surgery
• Indications

° Neurologic compromise
° Unstable fracture
° Epidural hematoma
48 M.C. Makhni et al.

• Anterior versus posterior approach based on osteoporosis, location of hematoma,

location of fracture
• High risk of nonunion, hardware failure, progressive deformity

References

Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients

with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010 May 15;35(11):E458–64.
Westerveld LA, Verlaan JJ, Oner FC.Spinal fractures in patients with ankylosing spinal disorders:
a systematic review of the literature on treatment, neurological status and complications. Eur
Spine J. 2009 Feb;18(2):145–56.
Whang PG, Goldberg G, Lawrence JP, Hong J, Harrop JS, Anderson DG, Albert TJ, Vaccaro AR.
The management of spinal injuries in patients with ankylosing spondylitis or diffuse idiopathic
skeletal hyperostosis: a comparison of treatment methods and clinical outcomes. J Spinal
Disord Tech. 2009 Apr;22(2):77–85.