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Review Question - QID 219566

QID 219566 (Type "219566" in App Search)
A 72-year-old female presents to the emergency department after suffering a fall from standing. She complains of cervical neck pain. Her exam is positive for focal tenderness along the posterior neck with no neurological deficits. Plain films of the cervical spine show a fracture at the superior end plate of C6. A CT is obtained, and a mid-sagittal cut is shown in Figure 1. An MRI is also completed which confirms fracture extension into the posterior elements. What is the preferred treatment for this patient’s injury?
  • A

Posterior spinal fusion from C5-C7

17%

139/842

Posterior spinal fusion from C3-T2

71%

595/842

Anterior spinal fusion from C5-C6

5%

41/842

Halo Orthosis immobilization

1%

10/842

Cervical collar immobilization

6%

51/842

  • A

Select Answer to see Preferred Response

This patient presents with a cervical spine fracture in the setting of diffuse idiopathic skeletal hyperostosis (DISH). DISH-associated spinal fractures with extension into the posterior elements are treated with long spinal fusion.

DISH is a common disorder that causes spinal segments to fuse into contiguous segments. In the cervical spine, this fusion is characterized by anterior-based non-marginal syndesmophytes that preserve the disc space. This fusion alters the biomechanics of the cervical spine. A fracture in an ankylosed cervical spine creates a long lever arm that can cause significant displacement at the fracture site. Due to the biomechanics of these fused segments, long-segment fixation and fusion constructs are recommended to prevent construct failure. The construct depends on the fracture pattern and the patient characteristics; however, ideal fixation includes the three levels above and below the fractured segment.

Caron et al published a retrospective review of 122 spine fractures in patients with ankylosing spinal disorders over a seven-year period. Treatment consisted primarily of multilevel posterior instrumentation three levels above and below the injury. The overall mortality was 32%, which was correlated with age over 70, number of comorbidities, and low mechanism injury. The authors recommend multilevel posterior segmental instrumentation for the treatment of patients with spine fractures and DISH.

Le et al published an updated review article in 2021 regarding the management of DISH. They report that surgery is associated with lower mortality rates than nonsurgical management. They highlight that ankylosed segments also have decreased bone quality secondary to stress shielding. This weak bone along with the long lever arms highlights why long fusion constructs above and below the fracture are needed for stability.

El Tecle et al published a review article on the management of spinal fractures in patients with ankylosing spondylitis. While the patient population and pathology are different from DISH. The 2 conditions create similar biomechanical environments in the spine, namely brittle bone with long lever arms. The authors also recommend long segmental fixation and fusion.

Figure 1 shows the sagittal view of a cervical spine CT. The CT shows anterior bridging syndesmophytes with a fracture through the end plate at C6.

Incorrect Answers:
Answer 1: A single level above and below the fractured level does not provide adequate fixation.
Answer 3: Anterior cervical spine fixation in this setting is associated with higher failure rates.
Answer 4 and 5: Non-operative management of this injury is associated with higher mortality rates.

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