Post-traumatic spinal hematoma in ankylosing spondylitis



The purpose of this study is to examine the incidence, location, and magnetic resonance imaging (MRI) features of spinal epidural hematoma (SEH) and spinal subdural hematoma (SSH) in post-traumatic ankylosing spondylitis (AS) patients.


A total of 2256 consecutive referrals for urgent and emergency MRI scans of the spine over a period of eight years and nine months were manually reviewed for any mentions indicating axial ankylosis and post-traumatic spinal hematoma. We found 164 patients with ankylosed spines complicated by spinal fracture, of whom 32 had AS. Of the 132 excluded patients, 80 had diffuse idiopathic skeletal hyperostosis (DISH). The primary outcome was the presence of spinal hematoma, and the secondary outcome was spinal canal narrowing and spinal cord impingement. Two musculoskeletal radiologists and one fellow in musculoskeletal radiology reviewed the images for the presence of spinal hematoma and related signal characteristics, blinded to one another and initial reports.


Of 28 post-traumatic AS patients, 19 had SEHs and five had spinal SSHs. There was a statistically significant difference between Frankel grades before and after surgery in respect of neurological improvement (p = 0.008). Patients who had radiologically proven spinal cord impingement showed more severe neurological deficits (p = 0.012). Hematomas with T1 heterogeneity showed a significantly increased delay (p = 0.047) between injury and imaging, while other signal characteristics were only approximate.


Both SEH and SSH are common complications in post-traumatic AS patients. Patients benefit from surgery, but the relevance of spinal hematoma as a separate factor causing neurological deficit remains unclear.

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Data availability

Not applicable.



Ankylosing spondylitis


Computed tomography


Diffuse idiopathic skeletal hyperostosis


Interquartile range


Magnetic resonance imaging


Spinal epidural hematoma


Spinal subdural hematoma


Short tau inversion recovery


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We thank Paula H. Bergman for her expert assistance with the statistical analysis.

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All authors contributed to the study conception and design. Material preparation and data collection were performed by Riku M. Vierunen. Data analysis were performed by Riku M. Vierunen, Mika P. Koivikko, and Frank V. Bensch. Statistical analyses were performed by Paula H. Bergman. The first draft of the manuscript was written by Riku M. Vierunen, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Riku M. Vierunen.

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This study was approved by the Ethics Committee of Helsinki University Hospital.

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Not applicable. This study was an observational retrospective registry study, and no consents were obtained.

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Not applicable. This study was an observational retrospective registry study, and no consents were obtained.

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Text blinded for the review include:

Materials & Methods 1st paragraph “Töölö Hospital as a part of Helsinki University Hospital”

Supplementary Information


Demographics and description of number and level of fractures, trauma mechanism, anticoagulation therapy, signs of decreased bone density on CT, spinal angulation on fracture level, neurological status before and after surgery, decompression, location of hematoma related to spinal cord, delay between injury and imaging, T1 and T2 signal intensity, T1 and T2 signal heterogeneity, mass effect of hematoma, and spinal cord injury, and impingement. The main fracture levels are indicated as transvertebral or transdiscal (when separated by slash). Abbreviations are indicated as follows: F, fall from standing height; Fhi, fall from over 2 m; Flo, fall from less than 2 m; MVA, motor vehicle accident; As, assault; Y, yes; L, lordosis; K, kyphosis; A, anterior; B, both; P, posterior; *, spinal subdural hematoma; +, hyperintense; −, hypointense; ±, isointense to muscle (DOCX 19 kb)

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Vierunen, R.M., Koivikko, M.P., Siironen, J.O. et al. Post-traumatic spinal hematoma in ankylosing spondylitis. Emerg Radiol (2021).

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  • Ankylosing spondylitis
  • Magnetic resonance imaging
  • Spinal epidural hematoma
  • Spinal fracture
  • Spinal subdural hematoma