Iatrogenic Intraoperative Spinal Cord Injury in an Ankylosing Spondylitis Patient Undergoing Thoracolumbar Fracture fixation

Abstract

After initial injury, ankylosing spondylitis (AS) patients continue to be at higher risk for secondary neurologic deterioration. Approximately 3%–25% of spinal cord injuries occur after the initial trauma, either during transit or in the early course of management. However, neurological deterioration following repositioning after surgery has not been reported. A 52-year-old male, a known case of AS, presented with an un-displaced three-column fracture at the T12/L1, after a fall. He did not have any neurological deficit and underwent T10 to L2 percutaneous pedicle screw-rod fixation. Intraoperative neural monitoring (IONM) data demonstrated no changes. He was then turned into the supine position, and when he was extubated, he had grade 0/5 power in both lower limbs. Fluoroscopy revealed displacement at the fracture site, which had occurred when the patient was flipped over after surgery. Immediately, he was again intubated and open reduction of fracture, decompression, and revision of fixation were done. IONM data indicated some recovery. He woke up with grade 2/5 power in his lower limbs. Physiotherapy and rehabilitation were continued, and by the end of 1 year, he had regained his preoperative neurological status. However, the fracture gap persisted with distal screw loosening and pull-out at 15-month follow-up, for which proximal and distal extension of fusion was performed. At 2-year follow-up after the revision surgery, the fracture had healed well. The patient’s significant recovery underscores the importance of prompt intervention in intraoperative spinal injuries, offering valuable insights for surgeons managing AS patients. AS patients are more prone to developing neurological deterioration in the perioperative period, and great care must be taken while handling these patients.