Surgical Treatment of a Cervical Spine Fracture in an Ankylosing Spondylitis Patient With Severe Global Spine Kyphosis and Chin-On-Chest Deformity

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Surgical Treatment of a Cervical Spine Fracture in an Ankylosing Spondylitis Patient With Severe Global Spine Kyphosis and Chin-On-Chest Deformity

Ankylosing spondylitis (AS) is a chronic inflammatory disease that attacks the spine, causing stiffness, pain, and eventually kyphosis—permanent curvature of the spine. For most people with AS, kyphosis affects the lower (lumbar) or middle (thoracic) back. But in rare cases, it spreads to the neck (cervical spine) and upper back, leading to a “chin-on-chest” deformity. Imagine not being able to lift your chin to eat, drink, or look someone in the eye. Now, add a fracture to that already debilitating condition. How do you treat it? A team from Peking University Third Hospital recently shared their solution in a case report—offering hope for patients with this complex combination of AS, severe global spine kyphosis, and cervical fracture.

The Patient’s Story

The patient was a 71-year-old woman who had lived with AS for 40 years. For two decades, she’d struggled with severe global spine kyphosis—a C-shaped curve that curved her entire spine forward, pressing her chin tightly against her chest. Then, she fell while walking. The fall didn’t just cause pain—it fractured her C7 vertebra (the last bone in the neck) in three columns (meaning all parts of the vertebra were damaged) and injured the C6 appendix (a small bony projection on the vertebra). Her pain was intense (7/10 on the visual analog scale, or VAS), her neck could barely move, and she could no longer chew or swallow properly. Her neck disability index (NDI)—a score that measures how much neck pain limits daily activities—was 78%, putting her at near-total disability.

Imaging Reveals Severe Deformity

X-rays and CT scans painted a clear picture of her condition:

  • Lumbar kyphosis (lower back): 18° (normal is minimal to mild curvature).
  • Thoracic kyphosis (middle back): 72° (normal is 20–40°).
  • Cervicothoracic kyphosis (neck to upper back): 56.5°.
  • Chin-brow vertical angle (CBVA): 130° (normal is ~90°).

Even when she tried to lie down, her spine’s curvature kept her in a semi-sitting position. The team first used 4 kg of skull traction (a device that pulls the skull gently to align the spine) to ease her pain. But conservative treatment—months of traction and a custom halo-vest—wasn’t an option: she and her family worried about the risk of nerve damage and didn’t want to spend months immobilized. Surgery was the only way forward.

Anesthesia and Positioning: Overcoming Unique Hurdles

Anesthesia was the first challenge. For patients with chin-on-chest deformity, regular endotracheal intubation (putting a tube down the throat while unconscious) is almost impossible—they can’t lie flat, and their jaw/neck don’t move enough to open the airway. The anesthesiologists chose awake nasotracheal intubation: they guided a tube through her nose while she was awake, then gave her general anesthesia.

Next, positioning: her severe thoracolumbar kyphosis made lying on her stomach (prone position) impossible. Instead, the team placed her in a sitting position with continuous skull traction—a method used successfully in past AS cases (like one reported by Kim et al. in 2012). While sitting carries a risk of air embolism (air bubbles in the blood), the team took precautions (e.g., monitoring vital signs closely) to avoid complications.

Surgical Strategy: Stabilize, Don’t Overcorrect

The team’s goal was simple: fix the fracture, relieve pain, and restore the patient’s pre-injury function—not aggressively correct her decades-old deformity. They chose a posterior approach (operating from the back of the neck) for minimal invasiveness and better access to the fractured vertebrae. Here’s what they did:

  1. Screw Placement: They inserted C2–C5 lateral mass screws (safer for cervical vertebrae than pedicle screws) and T1–T3 pedicle screws (to stabilize the upper back).
  2. Decompression: A C6–C7 laminectomy (removing the back part of the vertebra) relieved pressure on her spinal cord.
  3. Realignment: Layers of sheets were placed between her chin and chest to gently stretch and realign the spine. Fluoroscopy (real-time X-ray) confirmed the fracture was reduced and there was 10 cm of space between her chin and sternum—enough to eat and breathe normally.
  4. Fixation: Rods were attached to the screws and locked into place to hold the spine aligned.

The surgery took just 400 mL of blood—very little for such a complex procedure.

Post-Operative Results: Pain Gone, Function Restored

The patient woke up without complications. She was discharged on day 6 wearing a soft neck collar. Post-op CT scans showed her cervical spine had returned to its pre-injury alignment, with cervicothoracic kyphosis reduced to 34.5°.

Five months later, the fracture was healing, and her deformity correction held. Her pain was gone (VAS 0), and her NDI dropped to 13%—meaning she could do most daily tasks (e.g., dressing, eating, walking) independently again. She was thrilled to return to her pre-injury life.

Why This Case Matters

Cervical fractures are common in AS patients—31% of those with cervicothoracic kyphosis have them, according to a 2006 study by Simmons et al. But severe global kyphosis (a C-shaped curve affecting the entire spine) with a 130° CBVA is extremely rare. The team’s success hinged on three key choices:

  1. Patient-Centered Priorities: They focused on pain relief and function over aggressive deformity correction (osteotomy was considered but rejected due to the patient’s age and preferences).
  2. Tailored Anesthesia: Awake nasotracheal intubation solved the airway challenge without risking obstruction.
  3. Practical Positioning: The sitting position allowed surgery when prone positioning was impossible.

Conclusion

For older patients with AS, severe global kyphosis, and cervical fractures, the goal should be stabilization and symptom relief—not perfect spinal alignment. This case shows that customized approaches (e.g., awake intubation, sitting position, posterior fixation) can lead to successful outcomes, even for the most complex cases. While long-term follow-up is needed, the patient’s 5-month results are promising: no pain, restored function, and a return to normal life.

The patient provided written consent for her images and clinical information to be published, with her identity protected.

References

  1. Belanger TA, Milam RA 4th, Roh JS, Bohlman HH. Cervicothoracic extension osteotomy for chin-on-chest deformity in ankylosing spondylitis. J Bone Joint Surg Am 2005;87:1732–1738. doi: doi.org/10.2106/JBJS.C.01472
  2. Simmons ED, DiStefano RJ, Zheng Y, Simmon EH. Thirty-six years experience of cervical extension osteotomy in ankylosing spondylitis: techniques and outcomes. Spine (Phila Pa 1976) 2006;31:3006–3012. doi: doi.org/10.1097/01.brs.0000250663.12224.d9
  3. Kim KT, Lee SH, Son ES, Kwack YH, Chun YS, Lee JH. Surgical treatment of “chin-on-pubis” deformity in a patient with ankylosing spondylitis: a case report of consecutive cervical, thoracic, and lumbar corrective osteotomies. Spine (Phila Pa 1976) 2012;37:E1017–E1021. doi: doi.org/10.1097/BRS.0b013e31824ee031
  4. Schneider PS, Bouchard J, Moghadam K, Swamy G. Acute cervical fractures in ankylosing spondylitis: an opportunity to correct preexisting deformity. Spine (Phila Pa 1976) 2010;35:E248–E252. doi: doi.org/10.1097/BRS.0b013e3181c7c8d2
  5. Koller H, Hartmann S. Fixed cervical high-grade kyphosis: chin-on-chest deformity-treatment plan. Orthopade 2018;47:505–517. doi: doi.org/10.1007/s00132-018-3564-1
  6. Guo XH, Ji HQ. Surgical treatment of a cervical spine fracture in an ankylosing spondylitis patient with severe global spine kyphosis and chin-on-chest deformity. Chin Med J 2019;132:2644–2646. doi: doi.org/10.1097/CM9.0000000000000439

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