Spinal Fracture in Patients With Ankylosing Spondylitis: Cohort Definition, Distribution of Injuries, and Hospital Outcomes

Hounsfield units in assessing bone mineral density in ankylosing spondylitis patients with cervical fracture-dislocation

BACKGROUND

Cervical spine fracture-dislocations in patients with ankylosing spondylitis (AS) are mostly unstable and require surgery. However, osteoporosis, one of the comorbidities for AS, could lead to detrimental prognoses. There are few accurate assessments of bone mineral density in AS patients.

AIM

To analyze Hounsfield units (HUs) for assessing bone mineral density in AS patients with cervical fracture-dislocation.

METHODS

The HUs from C2 to C7 of 51 patients obtained from computed tomography (CT) scans and three-dimensional reconstruction of the cervical spine were independently assessed by two trained spinal surgeons and statistically analyzed. Inter-reader reliability and agreement were assessed by interclass correlation coefficient.

RESULTS

The HUs decreased gradually from C2 to C7. The mean values of the left and right levels were significantly higher than those in the middle. Among the 51 patients, 25 patients (49.02%) may be diagnosed with osteoporosis, and 16 patients (31.37%) may be diagnosed with osteopenia.

CONCLUSION

The HUs obtained by cervical spine CT are feasible for assessing bone mineral density with excellent agreement in AS patients with cervical fracture-dislocation.

Analysis of risk factors affecting postoperative neurological recovery in patients with cervical spine fracture in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic progressive inflammatory disease that mainly affects the spine and involves the sacroiliac and peripheral joints. Low-energy trauma can often lead to spinal fractures and spinal cord injuries (SCIs), the treatment of AS is challenging. The prognosis of neurological function in patients with AS cervical fracture and SCI is a major problem that must sought clinician attention on urgent basis. A total of 106 patients with AS cervical fractures who underwent surgical treatment at Shanghai Changzheng Hospital between August 2009 and 2021 were included in this study. All the patients were divided into 2 groups (improved group and the control group) based on their neurological function improvement at 1 year mark after the surgery. The baseline characteristics, perioperative factors, and procedural outcomes of all the patients including injury type, AS drug treatment, the injured segment, ossified anterior longitudinal ligament injury, spinal hypersignal, decompression time window, operation duration, blood loss, preoperative and postoperative American Spinal Injury Association (ASIA) score were recorded and analyzed. Among the 106 patients, 79 demonstrated improved neurological function at 1 year mark after the surgery. Binary univariate logistic regression analysis revealed significant differences in injury type (P = .018), ossified anterior longitudinal ligament injury (P = .01), operation duration (P = .002), spinal hypersignal (P = .001), preoperative ASIA score (P < .001), and prior AS drug treatment (P = .012). No significant differences were observed in the other variables (P > .05). Binary multivariate logistic regression analysis identified spinal hypersignal (OR = 37.185, P = .028), preoperative ASIA score (OR = 0.16, P = .012) and previous AS drug treatment (OR = 0.296, P = .049) as factors associated with postoperative neurological function improvement. The preoperative ASIA score and previous drug treatment of AS were identified as protective factors affecting the improvement of neurological functions in patients with AS cervical fracture after surgery. Preoperative T2-weighted spinal hypersignal was identified as an independent risk factor affecting the improvement of neurological function recovery in patients with AS cervical fracture after the surgery.

Decreasing incidence of cervical spine fractures in patients with ankylosing spondylitis: a population-based study in Southeast Norway

BACKGROUND CONTEXT

Individuals diagnosed with ankylosing spondylitis (AS) face an increased risk of spine fractures, specifically cervical spine fractures (CS-Fxs). In the past two decades, biological disease-modifying antirheumatic drugs (bDMARDs) have provided considerable relief from pain and an enhanced sense of wellbeing for a large segment of AS patients. Despite these improvements, it remains unclear whether extended use of bDMARDs can indeed reduce the risk of spine fractures.

PURPOSE

In this study, we aimed to investigate the evolving patterns and epidemiology of traumatic CS-Fxs in both AS and non-AS populations. We hypothesized that the risk of CS-Fxs among AS patients would show a decreasing trend over time, while the risk among non-AS patients would remain constant.

STUDY DESIGN/SETTING

Retrospective cohort study based on a prospective database.

PATIENT SAMPLE

A total of 3,598 consecutive patients with CS-Fxs were treated at Oslo University Hospital over an 8-year period.

OUTCOME MEASURES

CS-Fxs in AS patients were contrasted with non-AS-related CS-Fxs in terms of temporal trends, age, sex, injury mechanism, associated cervical spinal cord injury (cSCI), need for surgical fixation, and 30-day mortality.

METHODS

Data regarding all CS-Fxs diagnosed between 2015 and 2022 were extracted from the Southeast Norway population-based quality control database for traumatic CS-Fxs. Categorical data were summarized using frequencies, and continuous data were summarized using medians. The Wilcoxon rank-sum test was used to compare continuous variables, and the chi-squared test and Fischer exact test were used to compare categorical variables. To investigate the trend in the incidence of fractures, two different Poisson models were fitted with the number of non-AS and AS fractures as dependent variables and the year as the explanatory variable.

RESULTS

Over an 8-year period, we registered 3,622 CS-Fxs in 3598 patients, with AS patients accounting for 125 of these fractures. Relative to their non-AS counterparts, AS patients presented a 9-fold and 8-fold higher risk of initial and subsequent CS-Fxs, respectively. We observed a declining trend in AS-related CS-Fxs with an annual linear decrease of 8.4% (p=.026), whereas non-AS-related CS-Fxs showed an annual linear increase of 3.7% (p<.001). AS patients sustaining CS-Fxs were typically older (median age 70 vs 63 years), predominantly male (89% vs 67%), and more frequently experienced injuries due to falls (82% vs 57%). They also exhibited a higher prevalence of subaxial CS-Fxs (91% vs 62%), fewer C0-C2 CS-Fxs (14% vs 44%), a higher rate of associated cSCI (21% vs 11%), and a greater tendency for surgical fixation (66% vs 21%). We observed a 30-day mortality rate of 11% in AS patients and 5.4% in non-AS patients (p=.005).

CONCLUSIONS

The results of this study confirm the elevated risk of CS-Fxs among AS patients, although this risk appears to show a decreasing trend. The most plausible explanation for this risk reduction is the widespread application of bDMARDs.

Comparison of Posterior Approach and Combined Anterior-Posterior Approach in the Treatment of Ankylosing Spondylitis Combined With Cervical Spine Fracture: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review.

OBJECTIVE

To compare the efficacy of the posterior approach and combined anterior-posterior approach in the treatment of ankylosing spondylitis (AS) with cervical spine fracture by meta-analysis.

METHODS

The databases PubMed, Web of Science, Embase, and Cochrane Library were searched for studies on the comparison of the posterior approach group and the combined anterior-posterior approach group in the treatment of ankylosing spondylitis combined with cervical spine fracture from database establishment to August 2023. The procedure time, intraoperative blood loss, the rates of neurological improvement, mean change in the postoperative neurological function, complication rates, rates of revised surgery, and mortality were extracted. Meta-analysis was performed using RevMan 5.4 software provided by Cochrane Library.

RESULTS

A total of 11 retrospective cohort studies with a total of 215 patients were included in this study. The posterior approach group had lower intraoperative blood loss than the combined anterior-posterior approach group [Mean difference (MD) = -146.05, 95%CI(-187.40,-104.69), P < .00001]; the operation time was significantly less in the posterior approach group than in the combined anterior-posterior approach group [MD = -95.34, 95%CI(-113.13,-77.55), P < .00001]. There were no statistically significant differences in the neurological improvement rates, mean changes in postoperative neurological function, complication rates, modified surgery rates, and mortality rates.

CONCLUSION

Both the posterior approach and combined anterior and posterior approach can achieve good results. Clinicians should develop an individualized approach based on the patient's fracture type, degree of spinal cord injury, fracture stability, fracture dislocation, general condition, and underlying disease.

Clinical Outcome Analysis of Robot-Assisted Pedicle Screw Insertion in the Treatment of Ankylosing Spondylitis Complicated with Spinal Fractures

BACKGROUND

Vague spinal anatomical landmarks in patients with ankylosing spondylitis (AS) make intraoperative insertion of pedicle screws difficult under direct vision. Currently, the clinical outcome is significantly improved with robot guidance. This study aims to explore the efficacy of robot-assisted pedicle screw insertion in treating AS combined with spinal fractures.

METHODS

Forty patients (341 screws) who underwent pedicle screw insertion with AS complicated with spinal fractures were included. According to different surgical methods, 16 patients (135 screws) were classified into the robot group and 24 (206 screws) into the free-hand group. Intraoperative blood loss, operative duration, and adverse events were compared between the 2 groups. Gertzbein and Robbins classification was used to classify the accuracy of screw position. Clinical outcomes were evaluated by Visual Analog Scale, Japanese Orthopedic Association, and Oswestry Disability Index.

RESULTS

No statistically significant differences between baseline data of the groups. The difference in the blood loss between groups wasn't significant, nor was the operative duration. No severe adverse events related to pedicle screw insertion were reported in either group. Notably, the accuracy of screw insertion was significantly higher in the robot group (129/135) than in the free-hand group (182/206). The lateral perforation prevalence didn't differ among groups. Visual Analog Scale in the third month postoperatively was lower in the robot group than in the free-hand group, with a significant difference.

CONCLUSIONS

The study demonstrates statistically superior accuracy and surgical outcome of robot-assisted pedicle screw insertion in the treatment of AS complicated with spinal fractures compared with the traditional free-hand operation.

Clinical features and outcomes of spine surgery in patients with ankylosing spondylitis

OBJECTIVES

The study aimed to comprehend the clinical features and outcomes of surgical treatments for spinal disorders in patients with ankylosing spondylitis (AS).

METHODS

This retrospective study enrolled patients with AS who underwent spine surgery between 2000 and 2019 in our facility.

RESULTS

Thirteen patients with AS underwent spine surgeries. The mean age was 56.2 years, and the mean disease duration was 25.1 years at the time of surgery. Nine patients had vertebral fracture, two had kyphotic deformity, and two had myelopathy due to the spinal ligament ossification. Fracture cases included five patients with secondary pseudarthrosis/delayed palsy due to conservative treatment failure. Spinal fixation was performed in all patients. Pedicle subtraction osteotomy for kyphosis and laminectomy for myelopathy were also conducted. All patients improved after surgeries. One patient with kyphotic deformity underwent additional surgery of bilateral hip prosthesis, which resulted in better spine alignment. Four cases of perioperative complications were observed.

CONCLUSION

Myelopathy was newly found as the aetiology requiring surgery in patients with AS. This summarized case series could help physicians to identify patients with surgically treatable spinal disorders among patients with AS.

Spinal fractures in fused spines: nonoperative treatment is a reliable alternative

INTRODUCTION

Spinal fractures in fused spines such as in ankylosing spondylitis or DISH are typically of type B or C fractures where operative treatment is recommended. The mortality rate in non-operatively treated patients is reported to be 51%. The purpose of this study was to investigate the mortality rate, complication rate and demographics of patients following non-operatively treatment in fused spine injuries.

METHODS

Between 2019 and 2021, a retrospective study was conducted including all patients who presented to our trauma center with a spinal fracture of a fused spine. Radiology and patient charts were analyzed for fracture pattern, complications, neurological deficit, comorbidities, and mortality rate.

RESULTS

A total of 49 patients were found at a mean age was 79.8 ± 10.9 years and primarily males were affected in 65.3%. All fractures were of type B and the thoracic spine was involved in 85.7%. The mean follow-up was 6.3 ± 8.2 months and fusion was obtained in all patients. No neurological deficit was observed in any. A total of 13 patients died at a mean age of 86.5 ± 10.0 years after 157.1 ± 158.1 days. 6 patients (10.2%) deceased within the first 6 weeks at a mean age of 91.8 ± 3.8 years. One patient each suffered from heart failure, an acute delirium, end stage colon cancer and subdural hemorrhage.

CONCLUSION

This study shows that the mortality rate in the first 6 weeks following a fracture in a fused spine is 10.2% for patients above the age of 90 years. Therefore, non-operative treatment should be taken into consideration as the mortality rate in other studies may be overestimated.

LEVEL OF EVIDENCE

III, retrospective study.

Thoracic Spine Fracture After Cardiopulmonary Resuscitation in a Patient with Ankylosing Spondylitis: A Case Report

CASE

A 32-year-old man with a history of ankylosing spondylitis presented to the emergency department because of sepsis secondary to Fournier's gangrene and subsequently went into cardiac arrest requiring cardiopulmonary resuscitation (CPR). On the twelfth hospital day, a fracture through the T5-T6 intervertebral disk space was incidentally found on a chest, abdominal, and pelvic Computed Tomography (CT) scan. The rounds of CPR were the only traumatic event that the patient underwent before the discovery of the spine fracture.

CONCLUSION

A low threshold for advanced imaging should be held to rule out occult spine fractures in patients with ankylosed spines after receiving CPR.

Can a Nomogram Predict Survival After Treatment for an Ankylosing Spondylitis Cervical Fracture in a Patient With Neurologic Impairment? A National, Multicenter Study

BACKGROUND

Ankylosing spondylitis-related cervical spine fracture with neurologic impairment (ASCF-NI) is a rare but often lethal injury. Factors independently associated with survival after treatment remain poorly defined, and identifying patients who are likely to survive the injury remains challenging.

QUESTIONS/PURPOSES

(1) What factors are independently associated with survival after treatment among patients with ASCF-NI? (2) Can a nomogram be developed that is sufficiently simple for clinicians to use that can identify patients who are the most likely to survive after injury?

METHODS

This retrospective study was conducted based on a multi-institutional group of patients admitted and treated at one of 29 tertiary hospitals in China between March 1, 2003, and July 31, 2019. A total of 363 patients with a mean age of 53 ± 12 years were eventually included, 343 of whom were male. According to the National Household Registration Management System, 17% (61 of 363) died within 5 years of injury. Patients were treated using nonsurgical treatment or surgery, including procedures using the anterior approach, posterior approach, or combined anterior and posterior approaches. Indications for surgery included three-column injury, unstable fracture displacement, neurologic impairment or continuous progress, and intervertebral disc incarceration. By contrast, patients generally received nonsurgical treatment when they had a relatively stable fracture or medical conditions that did not tolerate surgery. Demographic, clinical, and treatment data were collected. The primary study goal was to identify which factors are independently associated with death within 5 years of injury, and the secondary goal was the development of a clinically applicable nomogram. We developed a multivariable Cox hazards regression model, and independent risk factors were defined by backward stepwise selection with the Akaike information criterion. We used these factors to create a nomogram using a multivariate Cox proportional hazards regression analysis.

RESULTS

After controlling for potentially confounding variables, we found the following factors were independently associated with a lower likelihood of survival after injury: lower fracture site, more-severe peri-injury complications, poorer American Spinal Injury Association (ASIA) Impairment Scale, and treatment methods. We found that a C5 to C7 or T1 fracture (ref: C1 to C4 and 5; hazard ratio 1.7 [95% confidence interval 0.9 to 3.5]; p = 0.12), moderate peri-injury complications (ref: absence of or mild complications; HR 6.0 [95% CI 2.3 to 16.0]; p < 0.001), severe peri-injury complications (ref: absence of or mild complications; HR 30.0 [95% CI 11.5 to 78.3]; p < 0.001), ASIA Grade A (ref: ASIA Grade D; HR 2.8 [95% CI 1.1 to 7.0]; p = 0.03), anterior approach (ref: nonsurgical treatment; HR 0.5 [95% CI 0.2 to 1.0]; p = 0.04), posterior approach (ref: nonsurgical treatment; HR 0.4 [95% CI 0.2 to 0.8]; p = 0.006), and combined anterior and posterior approach (ref: nonsurgical treatment; HR 0.4 [95% CI 0.2 to 0.9]; p = 0.02) were associated with survival. Based on these factors, a nomogram was developed to predict the survival of patients with ASCF-NI after treatment. Tests revealed that the developed nomogram had good performance (C statistic of 0.91).

CONCLUSION

The nomogram developed in this study will allow us to classify patients with different mortality risk levels into groups. This, coupled with the factors we identified, was independently associated with survival, and can be used to guide more appropriate treatment and care strategies for patients with ASCF-NI.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Cervical spine fractures in ankylosing spondylitis patients: an analysis of the presentation and clinical results of 110 surgically managed patients in two spine centers

PURPOSE

In this work, a two-center study was performed to study the clinical presentation of cervical spine fractures in ankylosing spondylitis (AS) patients and assess the surgical management of these fractures.

METHODS

A retrospective analysis of prospectively collected data in two level-1 spine surgery centers was performed. Both spine centers have a standard database for all admitted patients. Inclusion criteria were surgically treated AS with cervical spine fracture diagnosis (from C1 to Th3) and postoperative follow-up minimum of 12 months.

RESULTS

One hundred ten patients (105 male/5 female) were included. The mean age was 62 ± 10 years. The mean time between trauma and surgery was 49 ± 42 days. There was a history of mild trauma in 72 patients (65.4%). The clinical presentation was a pain in all patients. Twenty-seven (24.6%) had a neurological deficit at admission. The most common fracture level was C6/7 in 63 patients (57.23%). The VAS was 7 ± 1, and NDI was 34 ± 8 in the preoperative assessment. The mean preoperative kyphosis angle was 48 ± 26° between C2 and C7. Positioning and preparing of the patients on the operation table took a mean of 57 ± 28 min. The surgical approach was dorsal in 59 patients (53.6%), combined in 45 patients (40.9%), and ventral in 6 patients (6,5%). The mean number of the fixed levels was 6 ± 2 levels. Intraoperative complications occurred in 9 patients (8.2%). Postoperative Cobb angle improved to a mean of 17 ± 9 degrees. Neurological improvement occurred in 20/27 patients. In 12 patients, the recovery was complete. The mean postoperative follow-up was 46 ± 18 months. VAS improved to 3 ± 1, and NDI improved to 14 ± 6 at the last postoperative visit. The improvement was clinically significant (p = 0.01 and 0.00, respectively).

CONCLUSION

High suspicion of cervical spine fractures is necessary for patients with AS. CT and MRI images are necessary to rule out cervical spine fractures in AS patients, especially to detect occult fractures. Surgical treatment is safe, and the posterior approach with long-segment fusion is the approach of choice in this group of patients.

Comparative study of halo-vest reduction and skull traction reduction in the treatment of cervical fracture dislocation in patients with ankylosing spondylitis

Background

This study aimed to investigate the safety and efficacy of the halo-vest in the treatment of cervical fracture in patients with ankylosing spondylitis (AS) and kyphosis.

Methods

From May 2017 to May 2021, 36 patients with cervical fractures with AS and thoracic kyphosis were included in this study. The patients with cervical spine fractures with AS underwent preoperative reduction by halo-vest or skull tractions. Instrumentation internal fixation and fusion surgery were then performed. The level of cervical fractures, the operative duration, blood loss, and treatment outcomes were investigated preoperatively and postoperatively.

Results

A total of 25 cases were included in the halo-vest group and 11 cases were included in the skull tractions group. The intraoperative blood loss and the surgery duration were significantly less in the halo-vest group than in the skull traction group. A comparison of American Spinal Injury Association scores at admission and final follow-up showed that the neurological function of patients improved in both groups. All patients had reached solid bony fusion during the follow-up.

Conclusion

This study presented a unique approach to use halo-vest treatment fixation of unstable cervical fracture in patients with AS. The patient should also have early surgical stabilization with a halo-vest to correct spinal deformity and avoid worsening of neurological status.

A Novel Classification of Cervical Spine Trauma in Ankylosing Spondylitis and Corresponding Surgical Outcomes

OBJECTIVE

Currently, there are no reports on the specific classification of cervical spine trauma (CST) in ankylosing spondylitis (AS) based on the trauma mechanism. In this study, we aimed to describe a novel classification of CST in AS with more details, and put forward the corresponding surgical outcomes related to different types, hoping to provide a practical reference for clinical decision-making and academic communication.

METHODS

From January 2008 to December 2021, AS patients who experienced CST were retrospectively reviewed and included. Clinical data including gender, age, reason of trauma, time interval between AS diagnosis and trauma were collected. The American Spinal Injury Association (ASIA) grade system was used to describe patients' neurological status. Based on the combination of surgical experience and follow-up observation, the lower cervical spine trauma in AS patients was divided into three main types, namely single level fracture-dislocation (type 1), spinal cord injury without fracture-dislocation (type 2), and Andersson lesion (type 3). Furthermore, we performed detailed subtypes according to whether cervical spine was completely fused and the location of injury. Meanwhile, according to different approaches, surgical methods mainly included Anterior Cervical Discectomy and Fusion (ACDF), Anterior Cervical Corpectomy and Fusion (ACCF), Posterior Expansive Open-door Cervical Laminoplasty (PEOLP), Posterior Cervical Laminectomy Decompression and Fusion (PCLDF), and their combination. Postoperative general and surgery-related complications were also recorded.

RESULTS

A total of 102 patients were enrolled, including 91 males and 11 females, with an average age of 51.9 years. Their average interval time between AS diagnosis and injury was 27.8 years. Patients with high-energy and low-energy trauma were 54 and 48 respectively. There were 79 patients suffering spinal cord nerve impairment after trauma. With regard to the distribution of different types, the number of patients in type 1, type 2, and type 3 were 86, 14, and two, respectively. For different types, PCLDF was the most commonly used surgical method, accounting for 55.9%, while ACCF was only applied for one time. In type 1, the frequencies of ACDF, ACCF, PCLDF, and ACDF+PCLDF were 10.5%, 1.2%, 55.8%, and 32.5%. In type 2, the frequencies of ACDF, PCLDF, ACDF+PCLDF, and PEOLP were 7.1%, 50.0%, 7.1%, 35.8%. Postoperatively, 21 patients achieved neurological function improvement. The incidences of general and surgery-related complications were 19.6% and 5.9%, respectively. All patients achieved bone fusion and durable decompression at the last follow-up.

CONCLUSIONS

Our novel classification could enrich the scope of CST in AS patients and provide valuable references to the corresponding clinical management. Besides, there are strict indications of different surgical methods, factors like patient's physical condition, trauma type, surgical purpose, and expected efficacy were all required to consider before making a clinical decision.

Surgical Approach to Cervical Fractures in Ankylosing Spondylitis Patients: Rationale and Surgical Strategy

BACKGROUND

Current literature lacks objective criteria to determine surgical management in patients with ankylosing spondylitis who sustain cervical fractures. The purpose of our study was to analyze the determinants for stratifying surgical approach, evaluate the outcome in patients, and postulate a management strategy.

METHODS

This was a retrospective study of patients with ankylosing spondylitis who underwent surgery for cervical spine injury with a minimum follow-up of 2 years. Neurological recovery, fracture pattern including translation and angulation, surgical duration, blood loss, and postoperative complications were recorded, and a comparative analysis of these factors with anterior, posterior, and combined surgical approaches was performed.

RESULTS

The study included 43 men with a mean age of 57 years; 49% underwent anterior-only stabilization, 16% underwent posterior-only stabilization, and 35% underwent combined anteroposterior stabilization. Mean operative time was significantly lower in anterior-only (81.4 minutes; P < 0.05) and posterior-only (124 minutes; P < 0.05) approaches compared with combined approach (266.6 minutes). Mean blood loss was significantly lower in anterior-only (87.5 mL, P < 0.05) approach compared with posterior-only (714.7 mL) and combined (912.7 mL) approaches. Mean translation was 1.8 mm, 1.7 mm, and 3.7 mm in anterior, posterior, and combined approaches (P < 0.05), respectively.

CONCLUSIONS

Our study provides insights into management of cervical spine fractures in ankylosing spondylitis patients. A fracture displacement ≤2 mm may be successfully managed by an anterior approach, while the posterior approach may be beneficial in similar fractures warranting instrumentation extending to the thoracic spine. All other fractures warrant a combined surgical approach.

Post-Transcriptional Regulatory Crosstalk between MicroRNAs and Canonical TGF-β/BMP Signalling Cascades on Osteoblast Lineage: A Comprehensive Review

MicroRNAs (miRNAs) are a family of small, single-stranded, and non-protein coding RNAs about 19 to 22 nucleotides in length, that have been reported to have important roles in the control of bone development. MiRNAs have a strong influence on osteoblast differentiation through stages of lineage commitment and maturation, as well as via controlling the activities of osteogenic signal transduction pathways. Generally, miRNAs may modulate cell stemness, proliferation, differentiation, and apoptosis by binding the 3'-untranslated regions (3'-UTRs) of the target genes, which then can subsequently undergo messenger RNA (mRNA) degradation or protein translational repression. MiRNAs manage the gene expression in osteogenic differentiation by regulating multiple signalling cascades and essential transcription factors, including the transforming growth factor-beta (TGF-β)/bone morphogenic protein (BMP), Wingless/Int-1(Wnt)/β-catenin, Notch, and Hedgehog signalling pathways; the Runt-related transcription factor 2 (RUNX2); and osterix (Osx). This shows that miRNAs are essential in regulating diverse osteoblast cell functions. TGF-βs and BMPs transduce signals and exert diverse functions in osteoblastogenesis, skeletal development and bone formation, bone homeostasis, and diseases. Herein, we highlighted the current state of in vitro and in vivo research describing miRNA regulation on the canonical TGF-β/BMP signalling, their effects on osteoblast linage, and understand their mechanism of action for the development of possible therapeutics. In this review, particular attention and comprehensive database searches are focused on related works published between the years 2000 to 2022, using the resources from PubMed, Google Scholar, Scopus, and Web of Science.

Clinical outcomes for andersson lesion in patients with ankylosing spondylitis by transforaminal thoracolumbar intervertebral fusion surgery

BACKGROUND

Andersson lesion (AL) is a rare complication of ankylosing spondylitis (AS). Its clinical outcome of surgical treatment needs further exploration.

OBJECTIVE

To evaluate the clinical and radiological outcomes of transforaminal thoracolumbar intervertebral fusion (TTIF) in the treatment of AS patients with thoracolumbar AL.

METHODS

Fourteen patients with thoracolumbar AL who suffered from back pain, spinal instability or kyphotic deformity were retrospectively recruited. The clinical outcomes were evaluated with Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Radiological outcomes were measured with local kyphotic (LK) angle and general kyphotic (GK) angle.

RESULTS

Before surgical treatment for the AL patients, their VAS score and ODI score was 8.0 ± 0.2 and 64.0 ± 6.9, respectively. After TTIF surgery, VAS score of the patients was improved to 2.4 ± 0.5 (p< 0.01) and ODI score was decreased to 17.0 ± 3.7 (p< 0.01). One patient with neurological deficit showed an improvement in the Frankel grade from C to D and all others were grated E-level before and after surgery. For radiological outcomes, patients' LK angle was reduced from 18.5 ± 7.2 to 11.0 ± 6.4 (p< 0.01) and GK angle was reduced to 38.6 ± 8.8 from 42.8 ± 10.4 (p< 0.01) at the 1-year follow-up.

CONCLUSION

For AS patients with thoracolumbar AL, we propose that TTIF is an effective and safe operative treatment, which can achieve good fusion, satisfactory radiological and clinical outcomes.

3D Visualisation of the Spine

The 3D visualisation of the spine is thought of from multiple viewpoints. Firstly, radiological imaging is considered, with plain radiography, CT and MRI imaging discussed in detail with relevant applications to spinal surgery.3D printing can be used in spinal surgery with multiple applications including education, pre-operative planning for complex cases and making patient-specific guides and implants. The rapidly growing field of intraoperative navigation and robotics have been discussed, in addition to their benefits and limitations within spinal surgery, as well as some technical tips.An understanding of relevant anatomy and biomechanics is necessary for any surgeon, and so this chapter describes the key concepts to be familiar with, particularly the spinal motion segment and the different methods for classifying spinal injuries and how that relates to stability. The concepts discussed have been brought together by applying this knowledge to some interesting clinical cases. They highlight the importance of 3D visualisation of the spine, which must be considered throughout the decision-making process when managing patients. Spinal surgeons use multiple imaging modalities, knowledge of anatomy and biomechanics, as well as considering the need for navigation in more complex cases, all on a daily basis. With the advancement of technology available for 3D visualisation of the spine, we will be able to improve patient outcomes even further in the future.

Outcomes of spinal cord injury following cervical fracture in ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis (DISH): A prospective cohort study

INTRODUCTION

The ankylosed spine is prone to increased fractures risk even after minor trauma. The lower cervical spine is most frequently injured, and fractures of the ankylosed spine tend to precipitate spinal cord injury (SCI). The objective of the current study is to assess the incidence, management, and outcomes of patients with ankylosis of the spine sustaining a cervical fracture with associated SCI over a 7-year period.

MATERIAL AND METHODS

Prospective cohort study. Patients referred to the institution with a cervical fracture associated with SCI on a background of AS or DISH from 2009 to 2017 were reviewed. Demographics, mechanism of injury, fracture type, neurological level of injury, time to surgery, surgical management, neurological status (AIS), spinal cord independence measure (SCIMIII) scale at admission and discharge, and hospital length of stay. In September 2019 the summative data was analyzed using NDI, VAS, SV-QLI/SCI and length of survival were analyzed for statistical significance. Pathological fractures and dementia were excluded.

RESULTS

1613 patients with traumatic SCI were admitted in this period of whom 37 (12 AS and 25 DISH) met the inclusion criteria (mean age 65 years AS; 67 DISH). Fracture-dislocation was the most frequent fracture type (33% AS patients, 24% DISH patients). C4 was the most common neurological level of injury. SCIMIII score at admission was 1 point and 59 at discharge. AIS at admission was A (50%). At time of discharge no patient had neurologically deteriorated. Post-discharge mortality was 58% in AS patients and 32% in DISH patients (p=0.13).

CONCLUSIONS

Both AS and DISH patients have high levels of disability and mortality associated with trauma to the cervical spine. Despite their distinct clinical differences, in this cohort there were no statistically significant differences between AS and DISH patients regarding fracture type, SCIMIII, AIS, hospital stay, mortality, VAS, and SV-QLI/SCI after cervical fracture over 7 years follow-up.

Iatrogenic Vertebral Fracture During Intramedullary Nailing for Femoral Fracture: A Case Report

CASE

A 73-year-old woman with advanced ankylosing spondylitis (AS) underwent closed reduction and internal fixation using antegrade intramedullary nailing because of midshaft fracture of her right femur. After the surgery had been performed, a fracture and dislocation at T12-L1 was detected. Therefore, emergency spinal decompression and posterior instrumentation placement from T11 to L5 were then performed.

CONCLUSION

Patients with advanced AS have a high risk of vertebral fracture, so special care must be taken not to transmit excessive stress on the spine for surgical reduction and manipulation of the lower extremity.

Instantaneous death risk, conditional survival and optimal surgery timing in cervical fracture patients with ankylosing spondylitis: A national multicentre retrospective study

Background

The mortality rate in patients with ankylosing spondylitis (AS) and cervical fracture is relatively high.

Objectives

This study aimed to investigate the instantaneous death risk and conditional survival (CS) in patients with AS and cervical fracture. We also studied the relationship between surgical timing and the incidence of complications.

Methods

This national multicentre retrospective study included 459 patients with AS and cervical fractures between 2003 and 2019. The hazard function was used to determine the risk of instantaneous death. The five-year CS was calculated to show the dynamic changes in prognosis.

Results

The instantaneous death risk was relatively high in the first 6 months and gradually decreased over time in patients with AS and cervical fracture. For patients who did not undergo surgery, the instantaneous risk of death was relatively high in the first 15 months and gradually decreased over time. For patients with American Spinal Injury Association impairment scale (ASIA) A and B, the 5-year CS was 55.3% at baseline, and improved steadily to 88.4% at 2 years. Odds ratios (ORs) for pneumonia, electrolyte disturbance, respiratory insufficiency, and phlebothrombosis decreased as the surgery timing increased.

Conclusion

Deaths occurred mainly in the first 6 months after injury and gradually decreased over time. Our study highlights the need for continued surveillance and care in patients with AS with cervical fractures and provides useful survival estimates for both surgeons and patients. We also observed that early surgery can significantly increase functional recovery, and decrease the incidence of complications and rehospitalisation.

Factors Associated With Major Complications and Mortality During Hospitalization in Patients With Ankylosing Spondylitis Undergoing Surgical Management for a Spine Fracture

STUDY DESIGN

Retrospective study.

OBJECTIVES

To analyze factors associated with major complications (MC) in patients with ankylosing spondylitis (AS) undergoing surgical management for a spine fracture.

METHODS

Included were all persons with spine fractures and AS in a teriary health care center between 2003 and 2019. Clinical data and MC were characterized with descriptive characteristics. Multivariable analyses were used to find factors associated with MC.

RESULTS

In total, 174 traumatic fracture incidents in 166 patients with AS were included, with a mean patient age of 70.7 ± 13.1 years. The main reason for spine fracture was minor trauma (79.9%). Spinal cord injuries (SCI) were described in 36.7% of cases. The majority of patients (54.6%) showed more than one fracture of the spine, with cervical fractures being the most common (50.5%). Overall, the incidences of surgical site infection, implant failure, nosocomial pneumonia (NP), and mortality were 17.2%, 9.2%, 31%, and 14.9%, respectively. ICU stay > 48 hours was associated with MC (including death). Posterior approach for spondylodesis, ICU stay > 48 hours and cervical SCI were related to MC (excluding death). Age > 70 years, NP and Charlson comorbidity index > 5 points were associated with in-hospital mortality.

CONCLUSIONS

Patients with AS and surgical treatment of spine fractures are at high risk for MC. Therefore, our results might give physicians better insight into the incidence and sequelae of major complications and therefore might improve patient and family expectations.

Treatment of ankylosing spondylitis complicated with a thoracolumbar Andersson lesion by posterior closed osteotomy, debridement and fusion through the fracture line

Background

An Andersson lesion (AL) is a fatigue fracture occurring across three columns in ankylosing spondylitis (AS), resulting in spinal pseudarthrosis (SP) formation, most commonly in the thoracolumbar segment. However, there is still great controversy and few reports on the best surgical method for the treatment of AS combined with thoracolumbar AL. The purpose of this study was to investigate the efficacy of posterior closed osteotomy, debridement and fusion through the fracture line for the treatment of this disease.

Methods

The clinical data of 13 patients (male 8, female 5, mean age 50.6 years) with AS combined with thoracolumbar AL treated with posterior closed osteotomy, debridement and fusion through the fracture line were retrospectively analysed. The following parameters of the full-length lateral spine radiographs were measured preoperatively and at the last follow-up: cervical 7 tilt (C₇T), global kyphosis (GK), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), local kyphosis (LK), angle of the fusion levels (AFL), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and sagittal vertical axis (SVA). The visual analog scale (VAS), Oswestry disability index (ODI) and Scoliosis Research Society-22 (SRS-22) scores were recorded preoperatively and at the last follow-up.

Results

The mean operation time was 345 min, the mean blood loss was 673 mL, and the mean follow-up time was 21.9 months. Compared with the preoperative values, the C₇T, GK, TK, TLK, LK, AFL, PT, SS and SVA values of all patients were significantly improved at the last follow-up (P < 0.05); GK improved from 81.62 ± 16.11 to 50.15 ± 8.55, with an average of 31° of correction (F = 75.945, P<0.001). The VAS, ODI and SRS-22 scores also significantly improved (P < 0.05). At the last follow-up, bone fusion was found in all fracture ends. One patient developed numbness in the lower limbs after surgery and recovered after 3 months of rehabilitation; none of the remaining patients experienced postoperative complications.

Conclusions

Posterior closed osteotomy, debridement and fusion through the fracture line completely removes the necrotic tissue around the SP, relieves symptoms, and corrects kyphosis simultaneously. It reduces the tension behind the fracture line or changes the tension into compressive stress, enabling stable repair of the fracture and avoiding anterior surgery. It is a safe and effective operation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05770-3.

Kyphoplasty for thoracic and lumbar fractures with an intravertebral vacuum phenomenon in ankylosing spondylitis patients

Background

Intravertebral vacuum phenomenon (IVP) is a special sign after vertebral fractures, which is common in patients with ankylosing spondylitis (AS) and may indicate pseudarthrosis and bone nonunion that lead to spinal instability. The objective of this study is to evaluate the efficacy and safety of kyphoplasty (KP) in treating such types of vertebral fractures with AS.

Methods

Sixteen patients with AS suffering from thoracic or lumbar fractures with IVP received KP from 2015 to 2020 and were monitored for more than 1 year. The visual analog scale (VAS) score was used to evaluate back pain relief. The Oswestry Disability Index (ODI) questionnaire was used to assess the improvement of the patients' living quality. The anterior and middle vertebral height restoration ratio (AVH, MVH) and the kyphotic angle (KA) were used to evaluate the radiographic results.

Results

The mean follow-up period was 20.8 months (12–28 months). The VAS and ODI significantly reduced at 3 days, 3 months after surgery, and at the last follow-up compared with the preoperative outcomes (p < 0.05). The AVH and MVH were significantly increased compared with the preoperative outcomes (p < 0.05). There was a significant correction in the KA between pre- and postoperative assessments (p < 0.05). Asymptomatic intradiscal polymethylmethacrylate (PMMA) cement leakage was found in two patients.

Conclusions

For thoracic or lumbar fractures with IVP in AS patients, KP may be safe and effective, which achieves pain relief and satisfying functional improvement, restores the anterior and middle height, and corrects the kyphotic angle of the fractured vertebra.

Spinal cord injury and spinal fracture in patients with ankylosing spondylitis

Background

Spinal cord injury (SCI) and spinal fracture are major complications in patients with ankylosing spondylitis (AS) who sustain spinal trauma. The purpose of this study was to investigate the incidence, predictors, and sequelae of spinal trauma in patients with AS.

Methods

This retrospective study included patients with AS who were admitted for spinal trauma between January 1, 2006, and June 30, 2016. The study compared clinical outcomes of patients between group 1: SCI alone, group 2: spinal fracture alone (no SCI), and group 3: both SCI and spinal fracture.

Results

Of the 6285 patients with AS admitted during the retrospective study period, only 105 suffered from spinal trauma and were enrolled in the study. Case number in group 1, 2, and 3 was 11(10.48%), 45(42.85%), and 49(46.67%), respectively. Among the patients with spinal fractures, 52.1% had SCI. Bamboo spine was significantly more prevalent in the fracture group than in the nonfracture group (78.7% vs. 36.4%; P = 0.006). Patients with SCI had more instances of subluxation or dislocation (48.3% vs. 8.9%; P < 0.001) and more cases of spinal epidural hematoma (SEH; 21.7% vs. 2.2%; P = 0.003) than patients without SCI. The rate of delayed diagnosis for spinal fracture was 31.4%, with one-third of patients developing delayed SCI. Among the patients with incomplete SCI, 58.3% achieved neurological improvement after treatment (P = 0.004).

Conclusions

Patients with AS and bamboo spine at radiograph had a higher rate of spinal fracture, which may be an important factor in SCI in patients with AS. Spinal fractures involving the C3–C7 region, subluxation or dislocation, severe spinal fracture, and SEH were found to be predictive of SCI, and SCI in patients with AS resulted in higher mortality and complication rates.

Impact of age on mortality and complications in patients with Ankylosing Spondylitis spine fractures

OBJECTIVE

The aim of this retrospective cohort study was to study the impact of age on in-hospital complications and mortality following surgery for Ankylosing Spondylitis (AS) associated spine fractures.

METHODS

We extracted data from the Nationwide Inpatient Sample (NIS) database (1998-2018) using ICD-9/10 codes. Patients with a primary diagnosis of AS associated spine fractures who underwent fusion surgery were included. Complications and in-hospital mortality were analyzed.

RESULTS

A total cohort of 8526 patients was identified. Overall, the median age of the cohort was 69 years. AS associated fractures were equally distributed among cervical and thoracolumbar regions. Overall, complications were noted in 48% of patients and pulmonary complications were the most common (32%) followed by renal (13%) and infection (12%). Complications were seen in 57.3% of patients ≥ 70 years of age compared to 38.4% of patients < 70 years of age (p < .0001). Also, 9.9 % of patients ≥ 70 years of age had in-hospital mortality compared to 3.1 % of patients < 70 years of age (p < .0001). Based on surgical approaches, elderly patients (≥70 years) who underwent anterior, posterior, and anterior + posterior approaches had 19.8%, 7.4% and 16.4% in-hospital mortality compared to 5.3%, 2.2% and 7.4% respectively for patients < 70 years.

CONCLUSIONS

Elderly patients (≥70 years of age) were 3.2 times more likely to have in-hospital mortality and higher complications compared to younger patients (57% vs. 38%). Cervical compared to thoracolumbar fractures and anterior compared to posterior surgical approaches were associated with higher complications and in-hospital mortality.

Single versus dual operative spine fractures in ankylosing spondylitis

OBJECTIVE

Ankylosing spondylitis, the most common spondyloarthritis, fuses individual spinal vertebrae into long segments. The unique biomechanics of the ankylosed spine places patients at unusually high risk for unstable fractures secondary to low-impact mechanisms. These injuries are unique within the spine trauma population and necessitate thoughtful management. Therefore, the authors aimed to present a richly annotated data set of operative AS spine fractures with a significant portion of patients with simultaneous dual noncontiguous fractures.

METHODS

Patients with ankylosing spondylitis with acute fractures who received operative management between 2012 and 2020 were reviewed. Demographic, admission, surgical, and outcome parameters were retrospectively collected and reviewed.

RESULTS

In total, 29 patients were identified across 30 different admissions. At admission, the mean age was 71.7 ± 11.8 years. The mechanism of injury in 77% of the admissions was a ground-level fall; 30% also presented with polytrauma. Of admissions, 50% were patient transfers from outside hospitals, whereas the other half presented primarily to our emergency departments. Fifty percent of patients sustained a spinal cord injury, and 35 operative fractures were identified and treated in 32 surgeries. The majority of fractures clustered around the cervicothoracic (C4-T1, 48.6%) and thoracolumbar (T8-L3, 37.11%) junctions. Five patients (17.2%) had simultaneous dual noncontiguous operative fractures; these patients were more likely to have presented with a higher-energy mechanism of injury such as a bicycle or motor vehicle accident compared with patients with a single operative fracture (60% vs 8%, p = 0.024). On preoperative MRI, 56.3% of the fractures had epidural hematomas (EDHs); 25% were compressive of the underlying neural elements, which dictated the number of laminectomy levels performed (no EDH, 2.1 ± 2.36; noncompressive EDH, 2.1 ± 1.85; and compressive EDH, 7.4 ± 4 [p = 0.003]). The mean difference in instrumented levels was 8.7 ± 2.6 with a mean estimated blood loss (EBL) of 1183 ± 1779.5 mL. Patients on a regimen of antiplatelet therapy had a significantly higher EBL (2635.7 mL vs 759.4 mL, p = 0.015). Overall, patients had a mean hospital length of stay of 15.2 ± 18.5 days; 5 patients died during the same admission or after transfer to an outside hospital. Nine of 29 patients (31%) had died by the last follow-up (the mean follow-up was 596.3 ± 878.9 days).

CONCLUSIONS

Patients with AS who have been found to have unstable spine fractures warrant a thorough diagnostic evaluation to identify secondary fractures as well as compressive EDHs. These patients experienced prolonged inpatient hospitalizations with significant morbidity and mortality.

Percutaneous instrumentation with cement augmentation for traumatic hyperextension thoracic and lumbar fractures in ankylosing spondylitis: a single-institution experience

OBJECTIVE

The typical traumatic thoracolumbar (TL) fracture in patients with ankylosing spondylitis (AS) is a hyperextension injury involving all three spinal columns, which is associated with unfavorable outcomes. Although a consensus on the management of these highly unstable injuries is missing, minimally invasive surgery (MIS) has been progressively accepted as a treatment option, since it is related to lower morbidity and mortality rates. This study aimed to evaluate clinical and radiological outcomes after percutaneous instrumentation with cement augmentation for hyperextension TL fractures in patients with AS at a single institution.

METHODS

This cohort study was completed retrospectively. Back pain was assessed at preoperative, postoperative, and final follow-up visits using the visual analog scale (VAS). Patient-reported outcomes via the Oswestry Disability Index (ODI) and the new mobility score (NMS) were obtained to assess disability and mobility during follow-up. Radiological outcomes included the Cobb angle, sagittal index (SI), union rate, and implant failure. Intra- and postoperative complications were recorded.

RESULTS

A total of 22 patients met inclusion criteria. The mean patient age was 74.2 ± 7.3 years with a mean follow-up of 39.2 ± 17.4 months. The VAS score for back pain significantly improved over the follow-up period (from 8.4 ± 1.1 to 2.8 ± 0.8, p < 0.001). At the last follow-up, all patients had minor disability (mean ODI score 24.4 ± 6.1, p = 0.003) and self-sufficiency of mobility (mean NMS 7.5 ± 1.6, p = 0.02). The Cobb angle (5.2° ± 2.9° preoperatively to 4.4° ± 3.3° at follow-up) and SI (7.9° ± 4.2° to 8.8° ± 5.1°) were maintained at follow-up, showing no loss of segmental kyphosis. Bone union was observed in all patients. The overall complication rate was 9.1%, while the reoperation rate for implant failure was 4.5%.

CONCLUSIONS

Percutaneous instrumentation with cement augmentation for traumatic hyperextension TL fractures in AS demonstrated good clinical and radiological outcomes, along with a high bone union level and low reoperation rate. Accordingly, MIS reduced the complication rate in the management of these injuries of the ankylosed spine.

Rates of early complications and mortality in patients older than 80 years of age after surgical treatment of acute traumatic spinal fractures: ankylosing spondylitis versus osteoporosis

OBJECTIVE

The purpose of this retrospective cohort study was to analyze the early complications and mortality associated with multilevel spine surgery for unstable fractures in patients older than 80 years of age with ankylosing spondylitis and to compare the results with an age- and sex-matched cohort of patients with unstable osteoporotic fractures.

METHODS

A retrospective review of the electronic medical records at a single institution was conducted between January 2014 and December 2019. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were stratified using the age-adjusted Charlson Comorbidity Index (CCI).

RESULTS

Among 11,361 surgically treated patients, 22 patients with ankylosing spondylitis (AS group) and 24 patients with osteoporosis (OS group) were identified. The mean ages were 83.1 ± 3.1 years and 83.2 ± 2.6 years, respectively. A significant difference in the mean CCI score was found (7.6 vs 5.6; p < 0.001). Multilevel posterior fusion procedures were conducted in all patients, with 6.7 ± 1.4 fused levels in the AS group and 7.1 ± 1.1 levels fused in the OS group (p > 0.05). Major complications developed in 10 patients (45%) in the AS group compared with 4 patients (17%) in the OS group (p < 0.05). The 90-day mortality was 36% in the AS group compared with 0% in the OS group (p < 0.001).

CONCLUSIONS

Patients older than 80 years of age with AS bear a high risk of adverse events after multilevel spinal fusion procedures. The high morbidity and 90-day mortality should be clearly discussed and carefully weighed against surgical treatment.

The role of an anterior approach in the treatment of ankylosing spondylitis-associated cervical fractures: a systematic review and meta-analysis

OBJECTIVE

Cervical fractures in patients with ankylosing spondylitis can have devastating neurological consequences. Currently, several surgical approaches are commonly used to treat these fractures: anterior, posterior, and anterior-posterior. The relative rarity of these fractures has limited the ability of surgeons to objectively determine the merits of each. The authors present an updated systematic review and meta-analysis investigating the utility of anterior surgical approaches relative to posterior and anterior-posterior approaches.

METHODS

After a comprehensive literature search of the PubMed, Cochrane, and Embase databases, 7 clinical studies were included in the final qualitative and 6 in the final quantitative analyses. Of these studies, 6 compared anterior approaches with anterior-posterior and posterior approaches, while 1 investigated only an anterior approach. Odds ratios and 95% confidence intervals were calculated where appropriate.

RESULTS

A meta-analysis of postoperative neurological improvement revealed no statistically significant differences in gross rates of neurological improvement between anterior and posterior approaches (OR 0.40, 95% CI 0.10-1.59; p = 0.19). However, when analyzing the mean change in neurological function, patients who underwent anterior approaches had a significantly lower mean change in postoperative neurological function relative to patients who underwent posterior approaches (mean difference [MD] -0.60, 95% CI -0.76 to -0.45; p < 0.00001). An identical trend was seen between anterior and anterior-posterior approaches; there were no statistically significant differences in gross rates of neurological improvement (OR 3.05, 95% CI 0.84-11.15; p = 0.09). However, patients who underwent anterior approaches experienced a lower mean change in neurological function relative to anterior-posterior approaches (MD -0.46, 95% CI -0.60 to -0.32; p < 0.00001). There were no significant differences in complication rates between anterior approaches, posterior approaches, or anterior-posterior approaches, although complication rates trended lower in patients who underwent anterior approaches.

CONCLUSIONS

The results of this review and meta-analysis demonstrated the varying benefits of anterior approaches relative to posterior and anterior-posterior approaches in treatment of cervical fractures associated with ankylosing spondylitis. While reports demonstrated lower degrees of neurological improvement in anterior approaches, they may benefit patients with less-severe injuries if lower complication rates are desired.

Ankylosing spondylitis traumatic subaxial cervical fractures - An updated treatment algorithm

Ankylosing spondylitis (AS) is a rheumatologic disease characterized by ankylosis and ligament ossification of the spine with an elevated risk of vertebrae fractures at the cervical level or cervicothoracic junction. AS related cervical fractures (ASCFs) require early diagnosis and a treatment plan that considers the high risk for additional fractures to avoid neurological complications or death. We present the case of a patient with an ASCF and a review of the literature with key recommendations that shape our algorithm for the proper diagnosis and treatment of ASCFs. We present the case of a 29-year-old male with an ASCF at C5-C6 treated initially with a short segment instrumented arthrodesis that required an additional operation to properly stabilize and protect his spine. Based on our experience with this case and a review of the literature, we discuss three recommendations to improve ASCF management. These include the need for early computed tomography/magnetic resonance image for proper diagnoses, combined surgical approach with long-segment stabilization for maximum stability. Delayed diagnosis or revision surgery, both of which are common in these patients who present with a stiffened and osteoporotic spine, may lead to spinal cord injury or neurologic deficits. Our recommendations based on the most recent evidence can help surgeons better manage these patients and decrease their overall morbidity and mortality.

Evaluation of the Swallowing and Voice Functions in Ankylosing Spondylitis Patients

This study aimed to evaluate the swallowing and voice functions in patients with ankylosing spondylitis. Thirty patients with ankylosing spondylitis (Group 1) and 30 healthy individuals (Group 2) were included in the study. Following the laryngoscopic evaluation of the patients, the fiberoptic endoscopic evaluation of swallowing was performed, and then, the penetration-aspiration score was determined. The participants were asked to fill the eating assessment tool form. Voice recordings obtained to evaluate sound disorders were measured acoustically and analyzed using the PRAAT program. In terms of swallowing, the penetration-aspiration score obtained as a result of the flexible endoscopic swallowing assessment and eating assessment tool score was found to be higher in Group 1 than in Group 2, and a statistically significant difference was noted (p ≤ 0.001). When analyzing the maximum phonation time (p < 0.001) and fundamental frequency (p = 0.408) values in phonation evaluation, a statistically significant difference was found between the two groups. Group 1 showed a deterioration in terms of jitter (p = 0.040) and shimmer (p = 0.007) compared to Group 2, and a statistically significant difference was noted. There was no statistically significant difference in the harmonic/noise ratio (mean ± standard deviation) between the two groups (p = 0.051). Swallowing and voice functions significantly affect quality of life. Therefore, approaches aimed to improve the associated symptoms have become increasingly important. In patients with ankylosing spondylitis, swallowing quality and phonation ability may be negatively affected. These patients should be monitored for hidden or overt food aspiration.Trial Registry: https://clinicaltrials.gov/ct2/show/NCT04437394.

Trends in hospitalizations for vertebral compression fracture in ankylosing spondylitis: data from the National Inpatient Sample 2000-2014

Ankylosing spondylitis (AS) patients are at increased risk of vertebral compression fractures (VCF). Our objective was to examine the yearly trend of VCF hospitalizations in AS patients as compared to rheumatoid arthritis (RA) and the general population. National Inpatient Sample (NIS) database (2000-2014) was used to identify adult (≥ 18 years) hospitalizations, based on validated ICD-9 diagnosis codes. The rate of VCF hospitalizations, as a primary diagnosis, was assessed in three mutually exclusive groups: AS, RA, and the general population. The prevalence of VCF hospitalization was highest in AS (2.70%), compared to 0.77% in RA and 0.35% in the general population. Over the 15-year period, VCF hospitalization in AS was noted to have an increasing trend (Annual Percent Change (APC) = 4.73, p < 0.05) in contrast to the stable trend in the general population (APC = 0.34, p = NS) and a declining trend in RA (APC -3.61, p < 0.05). VCF related to AS was also associated with a longer hospital stay as compared to the general population (8.1 days vs. 5.1 days, p < 0.05) and higher inpatient mortality (3.4% vs. 1.0%, p < 0.05). A higher rate of VCF hospitalization along with an increasing trend was noted in AS as compared to RA and compared to the general population. Better screening approaches and treatment strategies for AS patients with VCF risk are urgently needed to reduce hospitalizations and related complications. Key Points • An increasing trend of VCF hospitalization was noted in AS, in contrast to a declining trend in RA and a stable trend in the general population. • VCF in AS was associated with longer hospital stay and higher inpatient mortality than in RA and the general population.

Surgical Treatment for Cervical Spine Fracture in Patients With Ankylosing Spondylitis: Single Posterior Approach or Combined Anterior-posterior Approach?

STUDY DESIGN

A retrospective single-center study.

OBJECTIVE

We aimed to compare the clinical outcomes of cervical spine fracture accompanied with ankylosing spondylitis (ASCSF) treated by single posterior approach (PA) and combined anterior-posterior approach (CA) for patients who were followed up for >1 year.

SUMMARY OF BACKGROUND DATA

For ASCSF patients, surgical treatment has been widely accepted as a recommendable therapeutic option. But the optimal surgical approach is still under controversy, and few studies have focused on the comparison between PA and CA.

MATERIALS AND METHODS

From February 2007 to March 2019, 53 patients were enrolled and divided into the PA group (34 cases) and CA group (19 cases). Their general characteristics and clinical materials were recorded. From the aspects of reduction distance, bone fusion, neurological functional restoration, and postoperative complications, patients' surgical outcomes were evaluated qualitatively and quantitatively.

RESULTS

The reduction degree of dislocation (mean PA=2.05 mm, mean CA=2.36 mm, P=0.94) was close between the 2 groups. Besides, with a similar follow-up period (P=0.10), the rate of bone fusion (both 100%) and neurological functional restoration (PA=31.03%, CA=35.29%, P=0.77) were also without significant difference. The occurrence rate of postoperative complications tended to be higher in the CA group (31.58% vs. 23.53%) but with no significant difference (P=0.52). Nevertheless, the surgical duration time (mean=209.15 min) and blood loss (average=388.91 mL) of PA group were significantly less than CA group (mean duration time=285.34 min, mean blood loss=579.27 mL) (P<0.01).

CONCLUSIONS

Compared with to the CA approach and with the equally significant outcome, surgery by single PA was feasible and should be positively recommended for ASCSF patients, especially for those accompanying with a severe chin-on-chest deformity or poor physical conditions which restrain patients from tolerating a long surgery or major surgical trauma.

Atraumatic thoracic spinal fracture mimicking herpes zoster neuralgia: a case report

Background

Intercostal neuralgia is most common in patients with herpes zoster, but it might be the initial symptom of serious diseases, such as atraumatic spinal fracture, which may lead to serious consequences if not diagnosed and treated early. Severe intercostal neuralgia is rarely reported as the first symptom of ankylosing spondylitis with atraumatic vertebral fractures.

Case presentation

A 70-year-old Chinese Han man previously diagnosed with ankylosing spondylitis presented to the hospital with intense intercostal pain without trauma. The patient was initially suspected of having herpes zoster neuralgia; however, he subsequently experienced numbness and weakness of both lower limbs as well as constipation. Thoracic vertebral fracture and compression of the spinal cord were detected with magnetic resonance imaging, and he underwent emergency posterior thoracic spinal canal decompression, and intercostal neuralgia was relieved after surgery. Spinal tuberculosis and tumors were later excluded by pathological examination and follow-up results. A 6-month postoperative follow-up showed that the weakness and numbness of the left lower limb had significantly improved, and his urinary function had recovered.

Conclusions

Patients with ankylosing spondylitis could develop atraumatic spinal fractures. Severe intercostal neuralgia is an early indicator of spinal fractures, and spinal magnetic resonance imaging is crucial for the diagnosis.

Imaging features of spinal fractures in ankylosing spondylitis and the diagnostic value of different imaging methods

Background

Our study aimed to characterize the imaging appearance of spinal fractures in ankylosing spondylitis (AS) and identify situations in which the use of magnetic resonance imaging (MRI) is necessary.

Methods

A total of 70 cases of spinal fractures associated with AS were retrospectively enrolled. Two radiologists independently reviewed the preoperative images. The location, type, ligament injury, neurological injury, and epidural hematoma following spinal fractures were assessed.

Results

Only one patient had a vertebral compression fracture, and 69 patients had 77 transverse fractures involving three columns. The most frequent injuries in AS patients were type B3 (N=32, 43.8%) spine fractures, followed by type C (N= 20, 27.4%) spine fractures. There were significant differences in fracture types of the different spine regions (H=14.1, P<0.0001). Most type C spine fractures were located in the lower cervical spine, while most of the type B2 spine fractures were located in the thoracic spine. Transverse fractures were classified as shear or stress type fractures. In total, there were 62 shear fractures and 15 stress fractures. All of the transverse fractures were detected by computed tomography (CT). The accuracy of CT in the diagnosis of the exact anatomic involvement of transverse fractures was significantly higher than that of MRI (χ²=8.36, P=0.014). The anterior longitudinal ligament (ALL) was the most frequently torn ligament. Tears of ossified ligaments were best visualized by sagittal reformatted CT. Lower cervical fractures were more likely to be associated with neurological injury compared with fractures to other regions of the spine (χ²=7.24, P=0.025). There were six epidural hematoma cases, which were only detected by MRI, were found to have fractures of the lower cervical spine.

Conclusions

We recommend a whole-spine CT examination with three-dimensional reconstruction for detecting a suspected fracture in AS patients. In cases with neurological injury, MRI examinations are always mandatory. AS patients with lower cervical spine fractures require further investigation by MRI. Patients with non-lower cervical spine fractures without any neurological deficits do not need to undergo an immediate MRI.

Percutaneous, PMMA-augmented, pedicle screw instrumentation of thoracolumbar ankylotic spine fractures

Introduction

Fractures in the ankylotic spine may have an insidious presentation but are prone to displace with devastating consequences. The long lever arm of ankylosed spine fragments may lead to pulmonary and great vessel injury and is difficult to adequately immobilize. Conservative treatment will produce in many cases poor outcomes with high morbidity and mortality. Open surgical treatment is also fraught with technical difficulties and can lead to major blood loss and prolonged operative times.

In recent years, percutaneous instrumentation of non-ankylotic spine fractures has gained popularity, producing similar outcomes to open surgery with shorter operative times and reduced blood loss and hospital length of stay. We describe our experience implementing these techniques in ankylotic spine patients.

Methods

We retrospectively retrieved from our hospital’s electronic health records all patients treated for thoracolumbar spine fractures between 2008 and 2015 with a diagnosis of ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH). Operative and postoperative data, results, and complications were tabulated, and radiographic parameters were evaluated.

Results

Twenty-four patients with ankylotic spine disease underwent percutaneous augmented instrumentation between 2008 and 2015. The mean age was 76. All patients had at least one comorbidity. The mean number of ankylosed levels was 14. Mean operative time was 131 min. The average postoperative hemoglobin decrease was 1.21 gr/%, with only 4 patients requiring blood transfusion.

45.8% of the patients had postoperative medical complications. One patient (4.2%) had a superficial postoperative infection, and one patient died in hospital. The average hospital length of stay was 14.55 days.

All patients retained their preoperative ASIA grades, and 3 improved one grade. All patients united their fractures without losing reduction.

Conclusions

PMMA-augmented percutaneous instrumentation is an attractive surgical option for this difficult patient subset, especially when compared to other available current alternatives.

Spinal trauma in DISH and AS: is MRI essential following the detection of vertebral fractures on CT?

BACKGROUND

Both ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) cause a rigid spine, but through different pathophysiology. Recent data has shown that characteristic fracture patterns may also differ following trauma since the posterior osseous and soft tissue elements are often spared in DISH. CT and MRI are important in diagnosing spine injury, but given the differences between AS and DISH, the utility of obtaining both studies in all patients warrants scrutiny.

PURPOSE

To assess the prevalence of posterior element injury on CT and MRI in DISH and AS patients with known vertebral body injury detected on CT; to determine whether MRI demonstrates additional injuries in neurologically intact patients presumed to have isolated vertebral body injuries on CT.

STUDY DESIGN

Multicenter, retrospective, case-control study.

PATIENT SAMPLE

DISH and AS patients presenting after spine trauma between 2007 and 2017.

OUTCOME MEASURES

Review of CT and MRI findings at the time of presentation.

METHODS

One hundred sixty DISH and 85 AS patients presenting after spine trauma were identified from 2 affiliated academic hospitals serving as level 1 trauma and tertiary referral centers. A diagnosis of DISH or AS was verified by a board-certified emergency radiologist with 3 years of experience. Age, gender, mechanism of injury, fracture type, spine CT and MRI imaging findings, surgical intervention, and neurologic deficit were recorded. The CT and MRI studies were reviewed by the same radiologist for fracture location and type using the AO spine classification. No funding source or conflict of interest was present.

RESULTS

Median age was 72 and 79 years old for the AS and DISH groups, respectively. Both were predominantly male (81%) and most presented after a low energy mechanism of injury (74% and 73%). Type C AO spine injuries were seen in 52% of AS patients but only 4% of DISH patients. In patients with known vertebral body injury on CT, additional injury to the posterior elements on CT or MRI in DISH patients was 51% versus 92% in AS patients. However, in patients with an isolated vertebral body fracture on CT and no neurological deficit, MRI identified posterior element injury in only 4/22 (18%) DISH patients compared to 5 of 7 (71%) AS patients. None of the MRI findings in the DISH patients were considered clinically important while all 5 AS patients eventually underwent operative treatment despite having no neurological deficit. Epidural hematoma on MRI was seen in 43% of AS patients as opposed to 5% of DISH patients.

CONCLUSION

Based on our small sample size, CT alone may be adequate in DISH patients with isolated vertebral body fractures and no neurologic deficit, but an additional MRI should be considered in the presence of an unclear neurological exam or deficit. MRI should be strongly considered for any AS patient regardless of neurologic status.

First intention vertebroplasty in fractures within an ankylosed thoracolumbar spinal segment

PURPOSE

To evaluate the outcome of percutaneous vertebral cementoplasty (PVC) as the first-line treatment for traumatic thoracolumbar fractures within an ankylosed spinal segment.

MATERIALS AND METHODS

Thirty-one patients (15 men, 16 women; mean age: 79.2±11 [SD] years; age range: 66-95 years) with thoracolumbar fractures within an ankylosed spine segment without neurological impairment treated with PVC were retrospectively evaluated. All patients were controlled at six weeks and one year after PVC. Ankylosing conditions, fractures sites and types, radiological consolidation, spinal complications were assessed. Anterior/posterior vertebral height ratios were measured before and after PVC. Postoperative pain relief and treatment success (radiological fracture consolidation) rates were considered.

RESULTS

The 31 patients had a total of 39 fractures (19 stable [49%], 20 unstable [51%]) treated with PVC. Primary success rate of PVC (initial fracture consolidation without complication) was 61% (19/31). Seven patients (7/31; 23%) exhibited new fractures, and the secondary success rate of PVC (global fracture consolidation one year after repeat PVC) was 87% (34/39). Global consolidation rates of unstable fractures were 85% (17/20) of treated levels. Pain score was null in 84% patients (26/31) one year after PVC. There were no significant differences between pre-PVC (0.62±0.18 [SD]; range: 0.22-0.88) and post-PVC (0.60±0.18 [SD]; range: 0.35-0.88) vertebral height ratios (P=0.94).

CONCLUSION

PVC conveys a high overall success rate and effectively controls pain in patients with vertebral fractures within ankylosed spine segments.

Minimally Invasive versus Conventional Open Surgery for Fixation of Spinal Fracture in Ankylosed Spine

Introduction:

This was a retrospective study aimed to investigate the perioperative outcomes of long construct minimally invasive spinal stabilisation (MISt) using percutaneous pedicle screws (PPS) versus conventional open spinal surgery in the treatment of spinal fracture in ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH).

Material and Methods:

Twenty-one patients with AS and DISH who were surgically treated between 2009 and 2017 were recruited. Outcomes of interest included operative time, intra-operative blood loss, complications, duration of hospital stay and fracture union rate.

Results:

Mean age was 69.2 ± 9.9 years. Seven patients had AS and 14 patients had DISH. 17 patients sustained AO type B3 fracture and 4 patients had type B1 fracture. Spinal trauma among these patients mostly involved thoracic spine (61.9%), followed by lumbar (28.6%) and cervical spine (9.5%). MISt using PPS was performed in 14 patients (66.7%) whereas open surgery in 7 patients (33.3%). Mean number of instrumentation level was 7.9 ± 1.6. Mean operative time in MISt and open group was 179.3 ± 42.3 minutes and 253.6 ± 98.7 minutes, respectively (p=0.028). Mean intra-operative blood loss in MISt and open group was 185.7 ± 86.4ml and 885.7 ± 338.8ml, respectively (p<0.001). Complications and union rate were comparable between both groups.

Conclusion:

MISt using PPS lowers the operative time and reduces intra-operative blood loss in vertebral fractures in ankylosed disorders. However, it does not reduce the perioperative complication rate due to the premorbid status of the patients. There was no significant difference in the union rate between MISt and open surgery.

Management of cervical fractures in ankylosing spondylitis patients: immediate fixation effort via vertebroplasty with one-staged combined anterior and posterior fixation

The ankylosed spine is prone to fracture even as a result of minor trauma due to its changed biomechanical properties. Fractures in ankylosing spondylitis (AS) patients are highly unstable and surgical intervention for fixation is warranted. Implant failure rates are high and combined anterior and posterior fixation is required to enhance the fixation outcome. For fusion, anterior interbody fusion or posterior bone graft fusion is often adopted. Here, we introduce a new method which combines vertebroplasty with anterior and posterior approaches to improve pain control, facilitate the long-term fixation outcome and mechanics, and decrease perioperative risks with prompt stabilization, especially in patients with spine curve deformity. Here, we present two AS cases with cervical spine fracture treated with this new method.

Factors Associated With In-Hospital Outcomes of Traumatic Spinal Cord Injury: 10-year Analysis of the US National Inpatient Sample

INTRODUCTION

Traumatic spinal cord injury (SCI) is a life-altering event. Motor vehicle accidents and falls are common causes of traumatic SCI, and SCI outcomes may be affected by patients' ages and injury sites. This study aimed to investigate the factors associated with unfavorable in-hospital outcomes, focusing on the impact of patients' ages and SCI lesion sites.

METHODS

Data of 25,988 patients hospitalized with traumatic SCI in the US National Inpatient Sample (NIS) database from 2005 to 2014 were extracted and analyzed. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with SCI outcomes, including in-hospital deaths, adverse discharge, and prolonged hospital stays.

RESULTS

Multivariate analysis revealed that the oldest ages (>65 years) were significantly associated with increased in-hospital mortality compared with the youngest ages at all lesion sites (cervical, odds ratio [OR]: 5.474, 95% confidence interval [CI]: 4.465 to 6.709; thoracic, OR: 5.940, 95% CI: 3.881 to 9.091; and lumbosacral, OR: 6.254, 95% CI: 2.920 to 13.394). Older ages were also significantly associated with increased adverse outcomes at all sites (cervical, OR: 2.460, 95% CI: 2.180 to 2.777; thoracic, OR: 2.347, 95% CI: 1.900 to 2.900; and lumbosacral, OR: 2.743, 95% CI: 2.133 to 3.527). Intermediate ages (35 to 64) were also significantly associated with increased in-hospital death and adverse discharge at cervical and thoracic SCIs, but not at lumbosacral sites.

DISCUSSION

For hospitalized patients with traumatic SCI, older age independently predicts worse in-hospital outcomes, with greatest effects seen in patients aged 65 years and older. Study findings suggest that extra vigilance and targeted management strategies are warranted in managing SCI patients aged 65 years and older during hospitalization.

A posterior-only approach for ankylosing spondylitis (AS) with thoracolumbar pseudoarthrosis: a clinical retrospective study

Background

Surgical treatment has been recommended by most surgeons to treat pseudarthrosis in ankylosing spondylitis (AS). However, there is still some debate on the necessity of anterior fusion. There is very limited literature on the treatment and surgical outcomes of thoracolumbar pseudarthrosis in AS patients treated through a posterior-only approach.

Methods

From January 1, 2012 to December 31, 2017, a total of 42 cases diagnosed with thoracolumbar pseudarthrosis in AS patients with moderate kyphosis were included in this study. All of the patients received posterior-only kyphosis correction, internal fixation and fusion without anterior fusion, and underwent at least 2 years of follow-up. Clinical and radiographic results and complications were assessed.

Results

All of the patients were followed up for an average of 35.3 months (range, 24–48 months), and they achieved successful bone graft fusion at the pseudarthrosis sites. Satisfactory radiographic changes were achieved in these patients. The Cobb angles of global kyphosis (GK) were corrected from 53.2 ± 5.4 degrees preoperatively to 33.2 ± 4.3 degrees postoperatively, and to 36.1 ± 5.3 degrees at the latest follow-up. The Cobb angles of local kyphosis (LK) were corrected from 43.3 ± 4.6 degrees preoperatively to 26.8 ± 3.3 degrees postoperatively, and to 28.2 ± 3.6 degrees at the latest follow-up. The mean sagittal vertical axis (SVA) were corrected from 7.6 ± 4.2 cm preoperatively to 4.3 ± 2.1 cm postoperatively, and to 4.8 ± 2.3 cm at the latest follow-up. No serious neurological complication or deep wound infection was found in these 42 patients.

Conclusion

Posterior-only kyphosis correction and fixation without anterior fusion can achieve excellent bone fusion and satisfactory improvement in AS patients with thoracolumbar pseudarthrosis. This method may be a good choice for treating thoracolumbar pseudarthrosis in AS patients with moderate kyphosis.

The Risk and Consequences of Vertebral Fracture in Patients with Ankylosing Spondylitis: A Population-based Data Linkage Study

OBJECTIVE

To compare the long-term prevalence, incidence, and outcomes of vertebral fracture (VF) between ankylosing spondylitis (AS) patients and matched controls, including the role of extraarticular manifestations (EAM) and osteoporosis.

METHODS

This was a statewide observational study using linked health data for 2321 patients with AS and 22,976 controls presenting to hospital from 1980 to 2015. Data were analyzed using incidence rates (per 1000 person-yrs) and ratios (IRR), multivariable Cox proportional hazards regression, and Kaplan-Meier survival curves.

RESULTS

Over a median 13.92 (interquartile range 7.58-21.67) years of follow-up, patients with AS had a greater VF prevalence and greater incidence of developing a new VF compared to controls (9.3% vs 2.5%, 6.8% vs 1.9%, respectively, all P < 0.001). Patients with AS had an increased risk of developing a VF after adjustments for age, sex, and osteoporosis (HR 2.55, 95% CI 2.11-3.09) compared to controls; this risk remained throughout the study period. Patients with AS were 5 years younger at time of first VF (P = 0.008) and had a greater likelihood of a recurrent VF (IRR 4.64; 95% CI 4.54-4.75) compared to respective controls. Mortality overall was comparable between patients with AS and controls after adjustment for age, sex, osteoporosis, and VF status (HR 0.90; 95% CI 0.80-1.01).

CONCLUSION

The significantly increased risk of VF in patients with AS has not altered following the introduction of tumor necrosis factor inhibitor treatment. Although patients with AS experience a first VF at a younger age than controls, this does not lead to an increased risk of death.

Patients with ankylosing spondylitis suffering from AO Type B3 traumatic thoracolumbar fractures are associated with increased frailty and morbidity when compared with patients with diffuse idiopathic skeletal hyperostosis

Background

AO Type B3 hyperextension thoracolumbar fractures are the commonest fracture subtype in ankylosing spinal disorders. Although often considered together in spinal fractures, ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are distinct spondyloarthropathies with different pathophysiology. Few studies have compared the two entities in the setting of traumatic thoracolumbar fractures. The authors compare demographic metrics, injury profile, clinical and radiographical outcomes between patients with AS and DISH in patients suffering from AO Type B3 traumatic thoracolumbar fractures.

Methods

From January 2008 to December 2018, a retrospective analysis of consecutive surgically-managed patients with AO Type B3 fractures was performed. Demographic metrics, co-morbidity [Charlson-comorbidity index, modified frailty index (mFI), etc.], injury profile (level of injury, mechanism of injury, etc.), clinical (postoperative complication, etc.) and radiographical variables were collected. Differences between patients with AS and DISH were compared.

Results

Fourteen patients were identified. All patients had AS (n=6) or DISH (n=8). The mean age was 72.8±10.2 years and 78.6% of patients were neurologically intact at presentation. Medical and/or surgical complications occurred in 10 of 14 (71.4%) patients. As compared to patients with DISH, patients with AS were more likely to have low falls as the injury mechanism [odds ratio (OR): 35.0, P=0.026], have higher mFI (OR: 30.6, P=0.015), and experience a higher number of postoperative complications per patient (AS: 1.8/patient vs. DISH: 0.5/patient, P=0.024).

Conclusions

In the setting of AO Type B3 fractures, patients with AS are more frail and have higher in-hospital morbidity compared to patients with DISH. Despite both pathologies being ankylosing in nature, further studies are required to fully understand the clinical differences between the two entities to enable clinicians to apply a more targeted and nuanced approach in managing fractures in ankylosing spinal disorders.

Surgical Stabilization of a Cervical Fracture in a Patient with Ankylosing Spondylitis in the Sitting Position

Ankylosing spondylitis is a seronegative spondyloarthropathy promoting alteration of the integrity and biomechanics of the spine. This leads to a brittle and hyperkyphotic spine with an increased risk of cervical spine fracture. Cervical spine fractures in people with ankylosing spondylitis are often unstable three-column extension injuries that are managed with posterior long segment fusions. Kyphotic deformity, body habitus, and increased airway pressures complicate these procedures. A 65-year-old man presented with neck pain following a fall from a roof. He was found to have a displaced transverse three-column fracture of C6/7. The original plan was to perform a staged circumferential cervical fusion with anterior cervical fusion first to make prone positioning for posterior fusion safer. CT after anterior cervical fusion from C5 to C7 demonstrated improved alignment of the fractured posterior elements. Due to concern of increased peak airway pressures and awkward positioning, planned prone positioning for posterior approach was abandoned. A posterior long segment fusion from C4 to T3 was performed in the seated position. CT demonstrated the hardware was appropriately placed. The patient’s hospital course was uncomplicated, and he was followed up with cervical spine x-rays. Two years later, he denied neck pain or functional impairment and x-ray demonstrated healing of the fracture. Utilizing the sitting position for the posterior cervicothoracic fusion portion of a combined anterior-posterior approach can overcome complication-spurring positioning difficulties and provide proper surgical management of an unstable cervical spine fracture in a patient with ankylosing spondylitis.

[Debridement and interbody fusion via posterior pedicle lateral approach for ankylosing spondylitis with thoracolumbar Andersson lesion]

Objective

To investigate the safety and effectiveness of debridement and interbody fusion via posterior pedicle lateral approach in treatment of ankylosing spondylitis with thoracolumbar Andersson lesion (AL).

Methods

Between October 2011 and January 2017, 10 patients of ankylosing spondylitis with thoracolumbar AL were treated with debridement via posterior pedicle lateral approach and interbody fusion with bone grafting. There were 8 males and 2 females with an average age of 48.8 years (range, 31-79 years). The disease duration was 1.5-48.0 months (mean, 10.6 months). All patients were single-segment lesion, including 3 cases of T_{10, 11}, 4 cases of T_{11, 12}, and 3 cases of T₁₂, L₁. The preoperative visual analogue scale (VAS) score was 8.0±0.8, the Oswestry disability index (ODI) was 68.8%±5.5%, and the Cobb angle of local kyphosis was (26.3±7.1)°. According to American Spinal Injury Association (ASIA) scoring system, neurological impairment was assessed in 1 case of grade C, 4 cases of grade D, and 5 cases of grade E.

Results

All the operations of 10 patients completed successfully. The operation time was 120-185 minutes (mean, 151.5 minutes), and the intraoperative blood loss was 300-750 mL (mean, 450.0 mL). Dural sac tear occurred in 1 case during operation and was repaired, with no cerebrospinal fluid leakage after operation. All patients were followed up 24-50 months (mean, 31.2 months). At last follow-up, the VAS score was 1.9±0.9 and ODI was 13.0%±3.0%, showing significant differences when compared with preoperative ones (t=17.530, P=0.000; t=31.890, P=0.000). Neurological function was improved significantly at 24 months after operation, and rated as ASIA grade E. The Cobb angles were (12.6±4.6)° at 3 days and (13.6±4.6)° at 24 months after operation, which were significantly different from those before operation (P<0.05); there was no significant difference between 3 days and 24 months after operation (P>0.05). At 24 months after operation, the grafted bone obtained good fusion at AL segment. During the follow-up, there was no failure of internal fixation such as nail withdrawal, broken nail, and broken rod.

Conclusion

Debridement and interbody fusion via posterior pedicle lateral approach for the ankylosing spondylitis with thoracolumbar AL can achieve satisfactory effectiveness, good fusion, and a certain correction of local kyphosis.

Delayed Diagnosis of Ankylosing Spondylitis: A Missed Opportunity?

Ankylosing spondylitis is an inflammatory condition involving the axial spine, often associated with the human leukocyte antigen (HLA)-B27 genotype and supporting radiographic imaging findings. Patients develop symptomatic low back and/or hip pain beginning in late adolescence or early adulthood. Diagnosis of ankylosing spondylitis is based primarily on clinical presentation and imaging studies. In this article, we are presenting a case of a 40-year-old male patient who presented to the office with chief concerns of chronic mid-thoracic back pain and restricted range of motion of his neck. The imaging study obtained was suggestive of fusion of the sacroiliac joints. This article also highlights the presence of elevated inflammatory markers in the setting of the patients chronic symptomatic complaints which could have guided in early diagnosis.