Fig. 18.1 Highly unstable fracture of the thoracic spine in a patient with DISH syndrome showing complete rupture of the vertebral column at the level of the twelfth thoracic vertebra (green arrow)

Fig. 18.2 Long-range instrumentation with screws, rods and bone cement are used due to poor bone quality

Fig. 18.3 CT examination of a patient with Bechterew’s disease (ankylosing spondylitis) and a cervical spine injury showing an unstable fracture at the level of the fourth cervical vertebra after a minor fall. Risk of paralysis!
Fig. 18.4 X-ray of the cervical spine shows the typical image of a "bamboo spine" and fracture of the fourth cervical vertebra

Fig. 18.5 Treatment using screw fixation along the cervical vertebral column from the front and back (ventrodorsal spondylodesis) to restore stability

Frequent rheumatic diseases of the spine that cause stiffening include, e.g. ankylosing spondylitis (Bechertew's disease) or diffuse idiopathic skeletal hyperostosis (DISH or Forestier’s disease). The exact cause of both disorders has not yet been conclusively verified. Depending on the disease severity, duration and course, complete ossification of the vertebral bodies and joints occurs with loss of the vertebral column’s natural mobility. In the x-ray, one can see what is known as a "bamboo spine" (Fig. 18.4). It is precisely this stiffness which causes an increased vulnerability to injury with an increased risk of sustaining an unstable fracture. These vertebral fractures and injuries of the cervical (Fig. 18.3), thoracic and lumbar spine (Fig. 18.1) of patients with these specific diseases, therefore, always require a particularly critical assessment.

Two examples should illustrate this: these particular patients are often already significantly restricted in their everyday lives and more likely to fall. In the case of a fall, large leverage forces act on the stiff spine with brittle bone material. This results in injuries and vertebral fractures with pronounced instability (Fig. 18.1 and Fig. 18.3). The vertebral fractures are equivalent to a "rupture" of the entire spine. The risk of concomitant neurological injuries is also greater.

In the thoracic and lumbar spine, often only long-range osteosynthesis with screws in three vertebral bodies above and below the vertebral fracture provide the required stability (Fig. 18.2). A small (percutaneous) incision is preferred for the insertion of the screws and rods. In the second case, the fracture of the cervical spine must be treated from the front as well as the back in order to ensure adequate stability (Fig. 18.5). Problems such as screw breakage or loosening, particularly in brittle bone, should be avoided in this way. In the case of marked deformation (hump formation, hyperkyphosis) already present before an accident, attempts are then also made to treat and correct this condition during the course of the operation.