case_images: PMC5553497_01
case_images: X-ray of both hands showed typical mutilating changes.
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case_images: PMC5553497_01_10-1055-s-0037-1601321-i1600098cr-1.jpg
case_images: FI1600098cr-1
case_images: Patient history : a 58-year-old woman had RA with typical mutilating-type joint involvements for 30 years and was treated with oral glucocorticoid (5 mg) and methotrexate (6 mg) ( Fig. 1 ).
case_images: (
  A
  ) Lateral radiography of the cervical spine revealed ankylosis at craniovertebral junction and anterior subluxation at C2-C3. (
  B
  ) Magnetic resonance imaging demonstrated marked severe compression of the spinal cord at C2-C3 and moderate compression at the cervicothoracic junction.
case_images: 10-1055-s-0037-1601321-i1600098cr-2.jpg
case_images: PMC5553497_01_10-1055-s-0037-1601321-i1600098cr-2.jpg
case_images: FI1600098cr-2
case_images: Lateral radiography of the upper thoracic spine revealed stepladder deformity; however, there was no vertebral column fracture in the thoracic and lumber spine ( Fig. 2 ). 
case_images: (
  A,B
  ) Anteroposterior and lateral radiography of the cervical spine after O-T5 fixation. After the first surgery, anterior displacement of C2 on C3 was completely reduced. (
  C
  ) However, vertebral fracture of T5 at the lowest level of the fusion area developed.
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case_images: PMC5553497_01_10-1055-s-0037-1601321-i1600098cr-3.jpg
case_images: FI1600098cr-3
case_images: Operation 1 : the patient underwent occipitothoracic fusion (O-T5 fusion) using RRS Loop Spinal System (Robert Reid Inc., Tokyo, Japan) with multiple thoracic hooks ( Fig. 3A, B ). T5 at the lowest level of the fusion area ( Fig. 3C ). This adjacent level fracture had not worsened and was cured with no complaint by conservative treatment.
case_images: (
  A
  ) Lateral radiography of the whole spine and (
  B
  ) T2-weighted magnetic resonance imaging revealed multiple vertebral fractures (T5, 7, 10, 11, L1, 2, 3, 5) and osteonecrosis of T11.
case_images: 10-1055-s-0037-1601321-i1600098cr-4.jpg
case_images: PMC5553497_01_10-1055-s-0037-1601321-i1600098cr-4.jpg
case_images: FI1600098cr-4
case_images: With this fracture as a start, she had multiple vertebral fractures of T7, 10, 11, L1, 2, 3, and 5 during 4 months, and thoracolumbar kyphotic deformity has progressed rapidly ( Fig. 4A, B ).
case_images: Anteroposterior and lateral radiography of the whole spine after occipitosacral fusion. Anterior fibula strut bone graft was also done at T10-T12 and T12-L3.
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case_images: PMC5553497_01_10-1055-s-0037-1601321-i1600098cr-5.jpg
case_images: FI1600098cr-5
case_images: Operation 2 : In 2006, she underwent posterior and anterior combined correction surgery for her sagittal spinal deformity ( Fig. 5 ).
case_images: (
  A
  ) Pelvic X-ray showed no abnormal findings. (
  B
  ) Axial computed tomography (CT) images of the left sacrum and ilium showed linear fracture gaps of reaching to iliac bone harvesting sight. (
  C
  ) Axial CT images of the bilateral pubis showed fracture lines. (
  D
  ) Posttreatment pelvic X-ray showed oval deformity of the pelvic ring.
case_images: 10-1055-s-0037-1601321-i1600098cr-6.jpg
case_images: PMC5553497_01_10-1055-s-0037-1601321-i1600098cr-6.jpg
case_images: FI1600098cr-6
case_images: Judging from the results of these examinations, the patient was diagnosed as having insufficiency fracture of the sacral and sacroiliac joint ( Fig. 6A-C ). She recovered with bed rest followed by light physical therapy for 6 weeks and achieved full weight-bearing 3 months after the injury ( Fig. 6D ).