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

An effective strategy for treatment of severe kyphosis secondary to ankylosing spondylitis: one-level modified osteotomy combined with shoulders lifting correction method

BACKGROUND

Severe kyphosis is a common condition in patients with advanced ankylosing spondylitis (AS). Although two-level osteotomy may serve as a potential alternative, it is often associated with increased blood loss and elevated surgical risks. To date, the optimal treatment for the challenging condition remains unclear. This study aims to introduce an effective strategy for the treatment of severe kyphosis secondary to AS, using one-level modified osteotomy combined with shoulders lifting correction method.

METHODS

Seventy AS kyphosis who were treated with the strategy from 2012 to 2022, were reviewed retrospectively. All patients were followed up for a minimum duration of 2 years. Spinal and pelvic parameters were measured, including pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumber lordosis (LL), PI and LL mismatch (PI-LL), thoracic kyphosis, global kyphosis (GK), T1 pelvic angle (TPA), sagittal vertical axis (SVA), osteotomized vertebral angle (OVA), and chin-brow vertical angle (CBVA). Parameters of local osteotomized complex were measured and calculated, including the height of osteotomized complex and the length of spinal cord shortening. Clinical outcome was evaluated using Scoliosis Research Society-22 and Oswestry Disability Index scores.

RESULTS

Seventy patients with average age of 39.8 years were followed-up for 29.3 months. Average operation time was 373.5 min, and average blood loss was 751.0 ml. Postoperatively, sagittal balance was successfully restored. GK decreased from 90.6° to 35.6°, LL decreased from 8.0° to -35.1°, TPA decreased from 56.8° to 27.8°, and SVA decreased from 24.4 cm to 8.7 cm (P < 0.05). A harmonious and matched spinopelvic alignment was achieved. PT decreased from 37.2° to 26.3°, PI-LL decreased from 54.1° to 10.2°, and SS increased from 9.2° to 19.7°(P < 0.05). Horizontal vision was obtained with postoperative CBVA of 8.8°. Average OVA correction was up to 47.3°, and the spinal cord was shortened by 24.3 mm, with a shortening rate of 36.0%. All patients demonstrated a favorable clinical outcome. No permanent nerve damage, screw loosening, rod breakage and main vascular injury were observed. One case required revision surgery due to screw cap loosening and delayed union. Solid bone fusion was achieved in all other patients.

CONCLUSIONS

One-level modified osteotomy combined with shoulders lifting correction method is a safe and effective strategy for the treatment of severe AS kyphosis. This strategy offers a promising alternative for managing severe AS kyphosis, and may be particularly well-suited for individuals with concurrent osteoporosis.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Isolated posterior stabilization in type B and C thoracolumbar fractures associated with ankylosing spine disorders: A single center experience with clinical and radiological outcomes

INTRODUCTION

Fractures in ankylosing spine disorders (ASD) are associated with high complication and mortality rates. During the posterior stabilization of these fractures, reduction is often partial, resulting in the persistence of a significant anterior diastasis. Our objective was to evaluate the safety and efficiency of isolated posterior stabilization in elderly ASD patients, without direct reduction of the anterior diastasis, in terms of clinical and radiological outcomes, complications, and mortality.

METHODS

This retrospective study included 46 patients, mean age 79.3 years, with ASD, who underwent isolated posterior stabilization, open or percutaneous, for thoracolumbar fractures. The average follow-up was 21.7 months, with a minimum follow-up of 6 months. Autonomy (Parker score) and radiological results (lordotic angulation) were analyzed pre-and post-operatively.

RESULTS

Autonomy was maintained at the last follow-up, with no significant difference in Parker's score. The consolidation rate was 94.6%. No implant failure was recorded. Despite the absence of an anterior procedure, lordotic angulation was significantly reduced by 2.6° at 6 months (p = 0.02). The rate of surgical complications following open surgeries was 10.9% (n = 5), of which 6.5% were infections. No surgical complications were reported in percutaneous surgeries. The rate of medical complications was 67.4% (n = 31), with a rate of 88.2% in the open surgery group, compared to 55.2% in the percutaneous surgery group. An open approach was associated with a five-fold higher risk of complications (p = 0.049). Nine patients died during follow-up (19.6%).

CONCLUSIONS

Isolated posterior stabilization in the treatment of thoracolumbar spine fractures in elderly ASD patients is a safe technique promoting autonomy preservation, and high radiological bony healing with acceptable complication and mortality rates. The persistent anterior gap is partially reduced when the spine is loaded and does not seem to require an anterior procedure, thus decreasing complications. Percutaneous surgery should be the technique of choice to reduce surgical complications.

Surgical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with ankylosing spondylitis

BACKGROUND

Spinal fractures in patients with ankylosing spondylitis (AS) mainly present as instability, involving all three columns of the spine, and surgical intervention is often considered necessary. However, in AS patients, the significant alterations in bony structure and anatomy result in a lack of identifiable landmarks, which increases the difficulty of pedicle screw implantation. Therefore, we present the clinical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with AS.

METHODS

A retrospective review was conducted on a series of 12 patients diagnosed with AS. All patients sustained thoracolumbar fractures between October 2018 and October 2022 and underwent posterior robotic-assisted percutaneous fixation procedures. Outcomes of interest included operative time, intra-operative blood loss, complications, duration of hospital stay and fracture union. The clinical outcomes were assessed using the visual analogue scale (VAS) and Oswestry Disability Index (ODI). To investigate the achieved operative correction, pre- and postoperative radiographs in the lateral plane were analyzed by measuring the Cobb angle.

RESULTS

The 12 patients had a mean age of 62.8 ± 13.0 years and a mean follow-up duration of 32.7 ± 18.9 months. Mean hospital stay duration was 15 ± 8.0 days. The mean operative time was 119.6 ± 32.2 min, and the median blood loss was 50 (50, 250) ml. The VAS value improved from 6.8 ± 0.9 preoperatively to 1.3 ± 1.0 at the final follow-up (P < 0.05). The ODI value improved from 83.6 ± 6.1% preoperatively to 11.8 ± 6.6% at the latest follow-up (P < 0.05). The average Cobb angle changed from 15.2 ± 11.0 pre-operatively to 8.3 ± 7.1 at final follow-up (P < 0.05). Bone healing was consistently achieved, with an average healing time of 6 (5.3, 7.0) months. Of the 108 screws implanted, 2 (1.9%) were improperly positioned. One patient experienced delayed nerve injury after the operation, but the nerve function returned to normal upon discharge.

CONCLUSION

Posterior robotic-assisted percutaneous internal fixation can be used as an ideal surgical treatment for thoracolumbar fractures in AS patients. However, while robot-assisted pedicle screw placement can enhance the accuracy of pedicle screw insertion, it should not be relied upon solely.

A reduction method for anterior opening displacement in thoracolumbarvertebral fractures with diffuse idiopathic skeletal hyperostosis using the skull clamp-assisted position

Diffuse idiopathic skeletal hyperostosis (DISH) frequently occurs in the spine, resulting in unstable fractures. Treating thoracolumbar fractures in patients with DISH is often difficult because the anterior opening of the vertebral body is exacerbated by dislocation in the prone position, making reduction difficult. In this study, we introduced a novel skull clamp-assisted positioning (SAP) technique. The patient is placed in a supine position with a skull clamp used in cervical spine surgery before surgery to prevent the progression of dislocation and to restore the patient's position. Using this method, the mean difference in local kyphosis angle improved from -2.9 (±8.4)° preoperatively to 10.9 (±7.7)° postoperatively. Furthermore, posterior displacement decreased from a preoperative mean of 5.5 (±4.3) mm to 0.3 (±0.7) mm postoperatively. Complications such as neurological sequelae, implant fracture, and surgical site infection were not observed through one year of postoperative follow-up. SAP may decrease invasiveness and complications. Longer-term studies and larger sample sizes are needed to establish long-term efficacy and benefits.

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.

Management of Thoracolumbar Vertebral Fractures and Dislocations in Patients with Ankylosing Conditions of the Spine

Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are bone-forming spinal conditions which inherently increase spine rigidity and place patients at a higher risk for thoracolumbar fractures. Due to the long lever-arm associated with their pathology, these fractures are frequently unstable and may significantly displace leading to catastrophic neurologic consequences. Operative and non-operative management are considerations in these fractures. However conservative measures including immobilization and bracing are typically reserved for non-displaced or incomplete fractures, or in patients for whom surgery poses a high risk. Thus, first line treatment is often surgery which has historically been an open posterior spinal fusion. Recent techniques such as minimally invasive surgery (MIS) and robotic surgery have shown promising lower complication rates as compared to open techniques, however these methods need to be further validated.

Surgical Management Thoracolumbar Fractures in Patients with Ankylosing Spondylitis: Technical Note with Case Series

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic inflammatory joint disease. Complications such as traumatic spinal fractures are mostly caused by hyperextension and are unstable. We report the cases of 5 patients with AS surgically treated for thoracolumbar fractures.

METHODS AND RESULTS

We shared our experience of posterior stabilization surgery performed for the treatment of thoracolumbar fractures after traumas such as fall-accident in patients with AS. Patients were all men, and their ages were between 52 and 77 years. The first 3 patients woke up with neurologic deficits and were managed surgically under general anesthesia. We managed the last 2 patients with unilateral short-level stabilization under local anesthesia followed by bilateral long-level stabilization under general anesthesia. No neurologic deterioration was found in the postoperative examination of these 2 patients. We assume that the reason for neurologic deterioration after general anesthesia is the relaxation of muscles. All 3 columns of the spine are affected in patients with AS and the stability is provided by the tone of the muscles around the spine.

CONCLUSIONS

To prevent postoperative neurologic complications after the surgical treatment of traumatic hyperextension thoracic and lumbar fractures in patients with AS, we recommend securing the fracture level with unilateral short-level stabilization under local anesthesia and then completing the operation with general anesthesia.

Percutaneous pedicle screw fixation without arthrodesis of 368 thoracolumbar fractures: long-term clinical and radiological outcomes in a single institution

PURPOSE

Traumatic thoracolumbar (TL) fractures are the most common vertebral fractures. Although a consensus on the preferred treatment is missing, percutaneous pedicle screw fixation (PPSF) has been progressively accepted as treatment option, since it is related to lower soft tissues surgical-injury and perioperative complications rate. This study aims to evaluate the long-term clinical-radiological outcomes after PPSF for TL fractures at a single tertiary academic hospital.

METHODS

This is a retrospective cohort study. Back pain was obtained at preoperative, postoperative and final follow-up using Visual Analog Scale. Patient-reported outcomes, the Oswestry Disability Index and the 36-Item Short Form, were obtained to asses disability during follow-up. Radiological measures included Cobb angle, mid-sagittal index, sagittal index (SI) and vertebral body height loss. A multivariate regression analysis on preoperative radiological features was performed to investigate independent risk factors for implant failure.

RESULTS

A total of 296 patients with 368 TL fractures met inclusion criteria. Mean follow-up was 124.3 months. The clinical and radiological parameters significantly improved from preoperative to last follow-up measurements. The multivariate analysis showed that Cobb angle (OR = 1.3, p < 0.001), SI (OR = 1.5, p < 0.001) and number of fractures (OR = 1.1, p = 0.05), were independent risk factors for implant failure. The overall complication rate was 5.1%, while the reoperation rate for implant failure was 3.4%.

CONCLUSIONS

In our case series, PPSF for TL injuries demonstrated good long-term clinical-radiological outcomes, along with low complication and reoperation rates. Accordingly, PPSF could be considered as a valuable treatment option for neurologically intact patients with TL fractures. Additionally, in this cohort, number of fractures ≥ 2, Cobb angle ≥ 15° and sagittal index ≥ 21° were independent risk factors for implant failure.

Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques

BACKGROUND CONTEXT

Posterior percutaneous long-segment internal fixation and open fixation with long-segment screws have been used to treat thoracolumbar fractures in ankylosing spondylitis patients.

PURPOSE

To observe the clinical effect of posterior percutaneous long-segment internal fixation in 26 ankylosing spondylitis (AS) patients with thoracolumbar fractures.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Forty-seven AS patients who were diagnosed with thoracolumbar fractures and treated from December 2014 to December 2018.

OUTCOME MEASURES

Visual analog scale score, Cobb angle, American Spinal Injury Association Grade, SF-Qualiveen score, pedicle screw misplacement rate, operative duration, blood loss, complications, bed rest duration and modified MacNab score.

METHODS

All patients were divided into the percutaneous group (PG) and the open group. Twenty-six patients were treated with percutaneous long-segment internal fixation, and the remaining 21 underwent open fixation with long-segment screws. The minimum follow-up period was 12 months.

RESULTS

The operations were successful in both groups. A patient in the PG showed class C wound healing, while the others showed class A healing, and some patients experienced perioperative complications. All patients were followed up for 12-48 months (mean, 33.81 months), and all patients showed clinical osseous fracture healing. Significant differences were found in operative duration, intraoperative blood loss and postoperative bed rest duration between the two groups (P < 0.05). No significant difference was found in improvement of the visual analog scale score, Cobb angle of spinal kyphosis or neurological function after the operation (P > 0.05).

CONCLUSIONS

As a minimally invasive procedure, posterior percutaneous long-segment internal fixation requires less time, results in less blood loss and causes less trauma. This procedure can also improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to those of traditional methods. With this curative clinical effect, this procedure can be used as an ideal surgical treatment for thoracolumbar fractures in AS patients, especially for elderly patients with underlying diseases and high surgical risk.

Reduction and Stabilization of an Extension-Distraction Injury in a Patient with Ankylosing Spondylitis: A Case Report

CASE

The authors reported a case of an 83-year-old man with ankylosing spondylitis throughout the cervical, thoracic, and lumbar spine who sustained a three-column T10 osteoligamentous extension-distraction injury after low-energy trauma. A closed reduction was performed using incremental flexion on a variable flexion-extension table and subsequent stabilization with robotic-assisted percutaneous pedicle screw placement. Postoperative radiographs at 7-month follow-up showed intact implants with adequate alignment with the patient remaining at neurological baseline.

CONCLUSION

A closed reduction method using a variable flexion-extension table with stabilization through percutaneous pedicle screw placement is a safe and appropriate method to achieve spinal realignment in select patients.

Innovation of Surgical Techniques for Screw Fixation in Patients with Osteoporotic Spine

Osteoporosis is a common disease in elderly populations and is a major public health problem worldwide. It is not uncommon for spine surgeons to perform spinal instrumented fusion surgeries for osteoporotic patients. However, in patients with severe osteoporosis, instrumented fusion may result in screw loosening, implant failure or nonunion because of a poor bone quality and decreased pedicle screw stability as well as increased graft subsidence risk. In addition, revision surgeries to correct failed instrumentation are becoming increasingly common in patients with osteoporosis. Therefore, techniques to enhance the fixation of pedicle screws are required in spinal surgeries for osteoporotic patients. To date, various instrumentation methods, such as a supplemental hook, sublaminar taping and sacral alar iliac screws, and modified screwing techniques have been available for reinforcing pedicle screw fixation. In addition, several materials, including polymethylmethacrylate and hydroxyapatite stick/granules, for insertion into prepared screw holes, can be used to enhance screw fixation. Many biomechanical tests support the effectiveness of these augmentation methods. We herein review the current therapeutic strategies for screw fixation and augmentation methods in the surgical treatment of patients with an osteoporotic spine.

[Surgical treatment of thoracic spine fracture in a patient with ankylosing spondylitis: case report and literature review]

OBJECTIVE

To describe the features of diagnosis and surgical treatment of thoracic spine fracture in a patient with ankylosing spondylitis.

MATERIAL AND METHODS

We present a patient with ankylosing spondylitis, blunt thoracic spine trauma and Th10-Th11 fracture, spinal cord compression and contusion and moderate lower extremity paresis. Preoperative and postoperative CT and MRI (after 8 months) were performed for control of decompression.

RESULTS

The authors identified the main factors affecting the quality of life of patients with spine fractures following ankylosing spondylitis and formulated treatment algorithm.

CONCLUSION

Active strategy is advisable for spine fractures following ankylosing spondylitis: spinal cord decompression, creation of anatomical compliance in the damaged vertebral segment and its fixation by transpedicular system. A similar surgical treatment of spine fractures following ankylosing spondylitis makes it possible to achieve early activation of patients and reduce rehabilitation period.