Management of spinal fractures in patients with ankylosing spondylitis

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.

Case series: O-arm navigation assisted by the Wiltse approach improves the accuracy of pedicle screw placement in ankylosing spondylitis combined with thoracolumbar fractures

Here we assessed the accuracy of O-arm navigation assisted by Wiltse approach to improve based pedicle screw insertion in ankylosing spondylitis combined with thoracolumbar fractures. We then compared it with the freehand pedicle screw insertion technique. The study sample included 32 patients with ankylosing spondylitis combined with thoracolumbar fractures. Pedicle screw reduction and internal fixation was performed under an O-arm navigation system assisted by a Wiltse approach-combined osteotomy ("navigation group," n = 17) and posterior pedicle screw reduction and internal fixation was performed using freehand technique combined osteotomy ("freehand group," n = 15). We then compared the operation time and bleeding volume between the 2 groups. The visual analog scale (VAS) and Oswestry disability index (ODI) were then used to evaluate the clinical efficacy and the kyphosis Cobb angle was used to evaluate the radiological efficacy before operation, 3 days after operation and after the last follow-up. All complications were noted when detected. Finally, classification of screw positions as proposed by Neo et al was used to evaluate the relationship of the position between the screw, the bone cortex, and the incidence of screw penetration. All patients were followed up for 18 to 36 months (i.e., 24.2 ± 3.5 months). The operation time and intraoperative bleeding volume of the navigation group were significantly shorter (lower) than those of the freehand group (P < .05). In addition, Both groups showed significantly decreased VAS, ODI, and Cobb angle 3 days after the operation and at the last follow-up when compared to values recorded pre-operation. However, we found no significant difference in VAS, ODI, and Cobb angle between the 2 groups (P > .05). We identified no complications (e.g., infection, VTE/PE, or nerve injury). Moreover, the pedicle screw placement position of the navigation group was better than that of the freehand group (P < .05), and the screw cortical penetration rate was lower than the freehand group (P < .05). During the process of posterior pedicle screw placement, O-arm navigation assisted by the Wiltse approach can significantly reduce operation time, minimize the amount of bleeding volume, and enhance the accuracy of pedicle screw implantation.

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.

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 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.

Clinical Efficacy of Large-Channel Percutaneous Lumbar Endoscopic Decompression in the Treatment of Lumbar Spinal Stenosis Secondary to Old Compression Fractures

OBJECTIVE

We sought to explore the clinical efficacy of lumbar spinal stenosis (LSS) secondary to old vertebral compression fractures (OVCF) treatment by large-channel percutaneous endoscopic lumbar decompression.

METHODS

Medical data for a total of 17 patients diagnosed with LSS secondary to OVCF and treated with large-channel percutaneous endoscopic lumbar decompression in our institution from January 2019 to January 2021 were collected. The dural sac cross-sectional area and morphologic grading of the magnetic resonance imaging cross-sectional area were recorded. Lumbar spine stability was assessed using the White-Panjabi scoring system. Visual analog scale and Japanese Orthopaedic Association scores were used to evaluate the surgical efficacy, and the SF-36 health questionnaire was used to evaluate the quality of life of patients. Type and probability of complications were also recorded.

RESULTS

The operative segments of the enrolled patients were all in the lower lumbar spine. One-year follow-up post operation showed that the dural sac cross-sectional area was significantly enlarged compared with preoperation, and the morphologic grade was significantly improved (P < 0.05). There was no difference in White-Panjabi score between preoperation and postoperation (P > 0.05). Visual analog scale and Japanese Orthopaedic Association scores at each follow-up time point after operation were higher than those before operation and were significantly improved (P < 0.05). The SF-36 health survey score at 1 year after operation was significantly higher than that before operation (P < 0.05). The complication rate was 6%.

CONCLUSIONS

Large-channel percutaneous lumbar endoscopic decompression has an evident clinical effect in the treatment of LSS secondary to OVCF and has little effect on the stability of the lumbar spine, which is worthy of clinical application.

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.

Posterior Cervical Fusion of Occiput-T3 for Unstable Complex Odontoid Fracture in an 80-Year-Old Male With C2-Sacrum Synostosis From Ankylosing Spondylitis: A Case Report

Ankylosing spondylitis (AS) is an autoimmune arthritic condition that presents with inflammation of the axial skeleton and oligoarthritis of the peripheral joints. While its pathophysiology is not fully understood, the condition can lead to kyphosis and spontaneous intervertebral synostosis of the spine. AS is managed through both non-operative and operative means, but fractures in patients with AS are more complicated in those with synostosis. We present a case of a patient who is a tribal elder and Salish language instructor, with kyphotic AS with synostosis of C2-sacrum, and mobility confined to occiput-C1 and C1-C2. The patient suffered a low-energy fall backward from bed and presented to the orthopedic clinic approximately a month after his injury complaining of torticollis and neck pain. He was diagnosed to have a dens fracture, a right C2 pars/facet fracture, and a right lateral mass fracture with C1-C2 stenosis and cervical myelopathy. After the failure of conservative management, the patient required a full occiput-T3 fusion due to the osteoporosis and fragile AS synostosis of the spine, to mitigate transitional zone stresses that can occur with a shorter fusion. The fusion was successful, and it minimized the pain, corrected the torticollis, and allowed the patient to resume his tribal roles.

Percutaneous kyphoplasty for the treatment of diffuse idiopathic skeletal hyperostosis with vertebral fractures: A case report and treatment review

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic metabolic condition characterized by new bone formation mainly at the anterolateral spine. Surgery such as screw fixation is commonly used for DISH patients who also suffer from vertebral fractures. In this case report, we share a DISH case with lumbar vertebral fracture and osteoporosis who underwent percutaneous kyphoplasty plus braces and medication. Percutaneous kyphoplasty, considered as minimally invasive surgery, may be another treatment option with the advantages of less trauma and faster recovery. The clinical information and radiological findings are described and treatments for DISH with vertebral fractures are then briefly reviewed.

The impact of the lateral decubitus position in the perioperative period on posterior fixation for thoracolumbar fracture with ankylosing spinal disorder

OBJECTIVE

Patients with ankylosing spinal disorders (ASDs), such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, often have rigid kyphosis of the spine. The fracture site is sometimes unintentionally displaced when surgery is conducted with the patient prone. To prevent this incident, the authors adopted the lateral decubitus position for patients intraoperatively for this pathology. The aim of this study was to retrospectively assess the impact of the lateral decubitus position in the perioperative period on posterior fixation for thoracolumbar fractures with ASD.

METHODS

Thirty-seven consecutive patients who underwent posterior instrumentation for thoracolumbar fracture with ASD at the authors' institute were divided into 15 lateral decubitus positions (group L) and 22 prone positions (group P). Surgical time, estimated blood loss (EBL), number of levels fused, perioperative complications, length of stay (LOS), ratio of fracture voids, and ratio of anterior wall height were investigated. The ratio of fracture void and the ratio of anterior wall height were the radiological assessments showing a degree of reduction in vertebral fracture on CT.

RESULTS

Age, sex, BMI, fracture level, and LOS were similar between the groups. Levels fused and EBL were significantly shorter and less in group L (p < 0.001 and p = 0.04), but there was no significant difference in surgical time. The complication rate was similar, but 1 death within 90 days after surgery was found in group P. The ratio of fracture voids was 85.4% ± 12.8% for group L and 117.5% ± 37.3% for group P. A significantly larger number of patients with a fracture void ratio of 100% or less was found in group L (86.7% vs 36.4%, p = 0.002). The ratio of anterior wall height was 107.5% ± 12.3% for group L and 116.9% ± 18.8% for group P. A significantly larger number of patients with the anterior wall height ratio of 100% or less was also found in group L (60.0% vs 27.3%, p = 0.046).

CONCLUSIONS

The results of this study suggest that the lateral decubitus position can be expected to have an effect on closing or maintaining the fracture void or a preventive effect of intraoperative unintentional extension displacement of the fractured site, which is often seen in the prone position during surgery for thoracolumbar fractures involving ASD.

Classification and Treatment for Cervical Spine Fracture with Ankylosing Spondylitis: A Clinical Nomogram Prediction Study

Objective

Through the follow-up analysis of cervical spine fracture cases with ankylosing spondylitis (AS), a treatment-oriented fracture classification method is introduced to evaluate the clinical efficacy guided by this classification method.

Method

A retrospective analysis was performed on 128 AS patients who underwent comprehensive treatment in the Spine Surgery Department of Qingdao University Hospital from January 2009 to May 2018. Statistics of patient demographic data, distribution of different fractures corresponding to surgical methods, 3-year follow-up outcomes, and summary of objective fracture classification methods were analyzed. A prospective 5-year follow-up study of 90 patients with AS cervical spine fractures from June 2015 to August 2020 was also included. Statistical differences on the distribution of factors such as case information, cervical spine sagittal sequence parameters, and fracture classification were assessed. Correlations between surgical information, American Spinal Injuries Association grade (ASIA), modified Japanese Orthopaedic Association scores (mJOA), and other factors were analyzed to establish a nomogram predictive model for curative effect outcomes. Overall, three major types and the four subtypes of AS cervical spine fractures were evaluated based on the clinical efficacy of the classification and the selection of surgical treatment methods.

Result

The most common type of fracture was type II (30 cases, 33.33%), most of the subtypes were A (37 cases), followed by B (36 cases) and C (17 cases). Twenty-four of 28 patients with type I underwent anterior surgery, and 47 of 62 patients with type II and III underwent posterior surgery. The average follow-up time was 25.76 ± 11.80 months. The results of predicting clinical variables are different but include factors such as fracture type and subtype, type of operation, and age. The predictor variables include the above-mentioned similar variables, but survival is more affected by the fracture type of the patient.

Conclusion

This predictive model based on follow-up information delineation points out the impact of ankylosing spondylitis cervical spine fracture classification on surgical selection and clinical efficacy.

Posterior pedicle screw fixation combined with transpedicular bone grafting for treatment of single-level thoracolumbar fractures with the aid of a vertebroplasty tool

OBJECTIVE

This study was performed to assess the efficacy of a novel tool to assist transpedicular bone grafting in short-segment pedicle screw fixation combined with pedicle fixation at the level of the fractured vertebra (six-screw fixation).

METHODS

We retrospectively analyzed 80 patients (40 in the control group and 40 in the tool-aided group) with single-level thoracolumbar fractures. Patients in the control group underwent traditional six-screw fixation combined with transpedicular bone grafting. In the tool-aided group, we introduced a novel vertebroplasty tool to assist transpedicular bone grafting. Basic information and related indicators were recorded.

RESULTS

There were no significant differences in the patients' baseline characteristics or surgical outcomes between the control group and tool-aided group. Both traditional surgery and tool-aided surgery restored the height of the fractured vertebrae and decreased the Cobb angle, visual analog scale score, and Oswestry Disability Index. However, tool-aided surgery more effectively restored the height of the fractured vertebrae and reduced the visual analog scale score and Oswestry Disability Index than did traditional surgery.

CONCLUSION

Vertebroplasty tool-aided surgery facilitated more precise and successful grafting of bone into damaged vertebrae than did traditional surgery and therefore might be recommended for treating single-level thoracolumbar fractures.

Case Report: Identifying Andersson-Like Lesions in Diffuse Idiopathic Skeletal Hyperostosis

Andersson lesions (ALs) in ankylosing spondylitis (AS) pose a severe risk to the stability of ankylosed spine, which might result in significant deterioration of spinal cord function after traumatic or inflammatory causes. Herein, erosive discovertebral lesions in diffuse idiopathic skeletal hyperostosis (DISH) presented important clinical similarities to AL in AS, but failed to completely recognize unstable spinal lesions. Therefore, we pioneered to identify spinal discovertebral lesions similar to Andersson-like lesions (ALLs) in DISH, followed by the characterization and summarization of the etiology, radiology, laboratory results, clinical symptoms, and treatment strategies for AL in AS with ALL in DISH. By characterizing the ALL in DISH cases, we showed that the ALL was mainly traumatic and established at the junction of focal stress between two adjacent ossified level arms. Erosive discovertebral ALLs were formed after trivial stress of direct impact and could be subdivided into transdiscal, transvertebral, and discovertebral types radiologically. Patients who presented with ALL frequently suffered from consistent back pain clinically and experienced a decrease in motion ability that could reflect skeletal stability, which received treatment effectiveness after conservative external spinal immobilization or further surgical internal fixation, indicating the significance of recognizing ALL in the ankylosed DISH spine to further maintain spinal stability in order to prevent catastrophic neurologic sequelae. Our work highlighted the clinical relevance of ALL in DISH in comparison with AL in AS, which provided broader insight to identify ALL in DISH, thus facilitating early intervention against DISH deterioration.

Spontaneous intraoperative lumbar fracture leading to an unexpected correction in ankylosing spondylitis corrective surgery - a case report

Severe kyphotic deformity in patients with ankylosing spondylitis can be corrected surgically to achieve a better spinal alignment and an improved visual axis. Different surgical techniques are used today depending on the extent of ossification and the degree of kyphosis. It is well known that the underlying disease leads to distinct biomechanical changes of the spinal column causing an increased fracture risk especially in case of minor trauma. This includes manipulations during surgical procedures as well as during the required perioperative measures.

We present the case of a 45-year-old patient with severe global kyphotic deformity due to ankylosing spondylitis. During the elective corrective surgery (pedicle subtraction osteotomy at the level of L3) the patient sustained a spontaneous fracture at L2/3. This fortunately nondisplaced wedge-shaped fracture in the sense of a Smith-Peterson osteotomy led to a spontaneous correction of the kyphosis. The described unexpected event required a change in the surgical strategy. Correction could be achieved using a two-stage surgical procedure without further drawbacks for the patient.

This case report stresses the need of particular attention regarding the increased susceptibility of the spinal column in case of ankylosing spondylitis.

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.

SURGICAL TREATMENT OF FRACTURES OF THE ANKYLOSED SPINE

ABSTRACT Objective We aim to identify retrospectively surgically treated patients with an ankylosed spine who sustained a vertebral fracture. Our goal is to evaluate the main outcomes and complications. Methods We selected patients through the database of surgical interventions in the setting of fractures of an ankylosed spine segment between January 1st 2008 and June 30th 2018. We collected data from digital medical records. The parameters analyzed include hospital length of stay, Intensive Care Unit (ICU) admission, perioperative and postoperative complications as well as neurological evolution. Results Fractures occurred in 14 patients with ankylosing spondylitis (82%) and 3 patients with diffuse idiopathic skeletal hyperostosis (18%). All patients were male and the mean age was 69 years. Fourteen fractures occurred after minor trauma (83%), of which 11 were due to falls from standing height or lower (65%). The cervical spine represents the majority of the levels involved (65%). Seven patients were admitted to the ICU (41%) and 11 suffered neurological damage. There was improvement of neurological status in less than 50% and there were high percentages of post-operative complications. Conclusion Patients with ankylosed spine diseases are at higher risk for vertebral fracture, even after minor trauma, and these are located predominantly in the cervical spine. The surgical treatment of these conditions is effective as it allows improvement of the patient’s neurological status. However, they still present higher morbidity and mortality, as well as increased post-op complications. Prevention of falls may drastically change patients’ outcome, neurological function and independence in activities of daily living. Level of evidence IV; A case series therapeutic study.

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.

The surgical treatment strategies for thoracolumbar spine fractures with ankylosing spondylitis: a case report

Background

Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects spine and paraspinal soft tissue. Ankylosing spondylitis is one of the causes of osteoporosis and patients with ankylosing spondylitis tend to have spinal fractures due to limited mobility and osteoporosis. In recent years, due to the increase in the number of patients with AS, patients with AS and thoracolumbar spine fractures have gradually increased. In the past 1 year, we have treated 3 cases of AS with thoracolumbar spine fractures via simple posterior internal fixation and this paper aims to report its clinic effect.

Case presentation

All the three patients selected had a history of ankylosing spondylitis for nearly 30 years, and one of them developed a thoracolumbar spine fracture after falling when he walked, and the other two developed a thoracolumbar spine fracture without any reason. They were hospitalized for “low back pain” and were diagnosed as fractures after careful physical examination and imaging examinations such as X-ray, CT, and MRI. After the preoperative preparation was completed, all the three patients underwent surgery with simple posterior internal fixation-reduction of the fracture and pedicle screw fixation via posterior approach. All the implants-pedicle screws and connecting rods-are made of titanium alloy. For postoperative management, we asked all the patients to stay in bed for 3 weeks after the operation, and then slowly move down with the help of crutches. Fracture healing and neurological function recovery were observed postoperatively. All the three patients recovered satisfactorily after surgery, and the follow-up confirmed that the fracture healed successfully after 3 months.

Conclusions

The 3 patients included 2 men and 1 women. All the 3 patients recovered well after surgery, and the follow-up confirmed that the fracture healed successfully after 3 months. One man developed urination dysfunction after operation and recovered to normal 3 months after rehabilitation exercise.

Lateral position and utility of navigation for posterior fixation of unstable cervical fracture with ankylosing spondylitis

Background:

Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy within the spectrum of rheumatologic diseases. The systemic inflammation that characterizes AS leads to bone resorption and reformation. Pathologic remodeling may include kyphosis, osteoporosis, and multi-segment auto-fusion. Cervical fractures account for 53–78% of spinal trauma seen with AS. Surgical planning is often challenging owing to spinal deformity, medical comorbidities, the cervicothoracic foci of injury, and gross instability of these fracture.

Case Description:

A 55-year-old male with AS was presented with a three-column injury at the C6 level. The C6 vertebra was fractured, minimally displaced, and there was a focal kyphotic deformity. Attempted posterior fixation 2 days after presentation was aborted; the patient could not tolerate prone positioning, and there were further technical limitations to a posterior approach. Cervicothoracic fixation from C2 to T2 was then performed using the right lateral decubitus position employing the Mayfield head holder, a beanbag, and spinal neuronavigation.

Conclusion:

In this study, we presented a unique approach to posterior fixation of an unstable cervicothoracic fracture in a patient with AS utilizing the lateral position and neural navigation under intraoperative physiological monitoring.

Surgical management of spinal fractures in ankylosing spondylitis

Background

Ankylosing spondylitis (AS) is a rheumatologic condition that affects the axial skeleton. Structural changes render the spine susceptible to fractures, which can be treated operatively or non-operatively. The preferred surgical approach is not well established. The objective of this study is to evaluate trends in the surgical treatment of AS patients with cervical and thoracolumbar spine fractures.

Methods

Using the nationwide inpatient sample (NIS) database, we identified 961 (4,683 weighted) AS patients from 2003 to 2014 who had fusion surgery for vertebral fractures. Our primary outcome was the national trend in use of posterior (PSF), anterior posterior (APSF), and anterior fusion (ASF) surgeries. In addition, we examined patient demographics, complications, institutional characteristics, and hospitalization lengths and costs.

Results

The number of fusions performed in AS patients with fractures increased significantly (P<0.01). The proportion of cervical fractures receiving fusions stayed consistent, whereas that of thoracolumbar fractures increased significantly (P<0.01). Patients undergoing APSF had higher hospitalization lengths in cervical and thoracolumbar fractures (P<0.01). There was significant association between pulmonary complications and cervical fusions (P<0.01).

Conclusions

Surgical treatment has been growing in popularity for thoracolumbar fractures but staying consistent for cervical fractures in AS patients. Surgical approach has shifted for cervical fractures with APSF transitioning from most to least popular approach from 2003 to 2014. For thoracolumbar fractures, PSF has remained the preferred approach. APSF had significantly higher pulmonary complication rates with cervical fractures. This finding can help surgeons in treating fractures in AS patients with underlying pulmonary disease.

Radiographic and Neurological Outcome After Surgical Treatment of Traumatic Fractures of the Ankylotic Thoracic Spine: A Retrospective Case Series

BACKGROUND

Spontaneous thoracic ankylosis is a progressive degenerative process that predisposes patients to potentially highly unstable traumatic injuries. Acute hyperextension fractures result in dynamic instability putting the spinal cord at risk.

OBJECTIVE

To describe preoperative radiographic characteristics of fractures of the ankylotic thoracic spine and relate findings to early postoperative radiographic and clinical outcomes.

METHODS

A single center, retrospective review was performed of 28 surgically treated patients with fractures of the ankylotic thoracic spine. Radiographic assessment included preoperative fracture angulation (FA) and fracture displacement (FD), and postoperative change in sagittal alignment. Early clinical outcomes included preoperative and postoperative American Spinal Injury Association (ASIA) grade and perioperative complications.

RESULTS

Seven patients (25%) presented with poor neurological grade (ASIA A-C) compared to 21 (75%) with good grade (ASIA D, E). At presentation, poor grade patients had a mean FA of 16.4° (range 0°-34.5°), and FD of 7.76 mm (range 0.8-9.2). Good grade patients had a mean FA of 18.2° (range 0°-43.3°), and FD of 4.77 mm (range 0-25.1). There was no statistically significant difference in FA or FD between groups (P = .70 and .20 respectively). All underwent posterior pedicle screw fixation for stabilization. Fifty per cent of patients presenting with ASIA C or D spinal cord injury improved 1 or more ASIA grades. There were no perioperative complications. Early postoperative sagittal alignment was maintained with a mean change of -2.6°.

CONCLUSION

Presenting fracture alignment does not significantly correlate with pre- or postoperative neurological status. Early posterior stabilization preserved neurological function, with neurological recovery occurring in a portion of individuals.

Double non-contiguous fractures in a patient with spondylo-epiphyseal dysplasia with spinal ankylosis treated with open and percutaneous spinal fixation technique: a case report

Background

Patients with ankylosing spines are susceptible to developing spinal fractures even with minor trauma and can develop early or late neurological injuries. These fractures require early and aggressive surgical management to enable spinal stability and/or neural decompression. Being highly unstable by nature, they require relatively long segment instrumentation and fusion, which can increase paravertebral soft tissue damage and perioperative bleeding. The purpose of this report is to describe a rare case of traumatic double fractures at the cervico-thoracic and thoraco-lumbar transition zones in ankylosing spine with spondylo-epiphyseal dysplasia (SED) of unknown cause, which were successfully treated with a combined open and percutaneous spinal fusion procedure.

Case presentation

A 46-year-old woman who was diagnosed with non-contiguous fractures in cervico-thoracic and thoraco-lumbar junction zones among multiple injuries sustained in a traffic accident was treated with hybrid techniques for posterior instrumentation with an open approach using a computed tomography (CT)-based navigation system and percutaneous pedicle-screwing method. She regained mobility to pre-admission levels and started walking on crutches 3 months postoperatively. Genetic testing for the cause of SED revealed no mutation in the COL2A1 or TRPVR4 genes. The union of fractured spine was confirmed on CT scan 1 year postoperatively.

Conclusion

This is the first report of double spinal fractures in an ankylosing spine with genetically undetermined spondyloepiphyseal dysplasia. A long-segment posterior instrumentation procedure incorporating the invasive treatment of spinal fractures in ankylosing spondylitis or diffuse idiopathic hyperostosis was effective.

Successful Nonoperative Treatment of a Lumbar Spine Extension Injury with Disruption of all Three Bony Columns in a Patient with Ankylosing Spondylitis - A Case Report

STUDY DESIGN

A case report.

BACKGROUND

Patients with ankylosing spondylitis have altered spinal biomechanics putting them at increased risk of spinal fractures that are unstable. As a result there is an increasing trend to treat these fractures with surgical stabilization. We hypothesize that the fracture pattern is also an important factor in patients with this disease and that those with an extension injury in the lumbar spine can be treated with brace immobilization.

OBJECTIVE

Report on the non-operative management of an elderly patient, with ankylosing spondylitis, who sustained an extension injury of all three bony columns of the lumbar spine.

METHODS

A case report of a 70-year-old man who fell from a standing height, sustaining a three-column fracture at L1-2, who did not want surgical stabilization.

RESULTS

External brace immobilization was used and the patient was closely monitored. At his final 13 month follow-up, the patient had no clinical evidence of spinal instability or neurologic compromise and radiologically we could see callous formation anteriorly and laterally between the L1 and L2 vertebral bodies.These bridged the trebeculae across the middle and posterior columns at L1 and L2 on the lateral view, and there was no change in the sagittal or coronal alignment" to "There was mature bridging bone across the middle and posterior columns at L1 and L2 on the lateral view, and there was no change in the sagittal or coronal alignment.

CONCLUSION

This case supports our hypothesis that the fracture pattern is an important factor in patients with ankylosing spondylitis and adds to the body of knowledge in the scientific literature concerning non-operative treatment of fractures in patients with ankylosed spines. Further study is required to determine whether ours is an isolated case or whether this applies to a wider population of ankylosing spondylitis patients.

Spine and Spinal Cord Injury Associated with a Fracture in Elderly Patients with Ankylosing Spondylitis

There are few cases of spinal cord injury with ankylosing spondylitis (AS). This study investigated the clinical results of a spinal cord injury with a fracture in elderly patients with AS. Nine patients who had sustained a spinal cord injury with vertebral fractures in ankylosed spines were included in this study. The mean age was 79.3 years; two were male and seven were female. The mechanism of injury, the level of vertebral fractures, clinical methods, the follow-up period, and treatment outcomes were investigated. The mechanism of injury of six cases was a fall and in the others was a slip. The levels of vertebral fractures were a cervical lesion (n = 5), a thoracic lesion (n = 3), and a lumbar lesion (n = 1). Six cases underwent a surgical procedure with posterior fusion and decompression, two cases were treated only with a brace, and one case was treated with a halo vest. The mean follow-up period was 4.3 years. The neurological deficit treatment outcomes were improved or no change in four cases each and one case had died. There was not much difference in treatment outcomes between a surgical treatment and a conservative treatment. Computed tomography imaging to evaluate the entire spine is required in all patients with AS with a possible spinal fracture. A surgical treatment and early rising and rehabilitation should be recommended for patients with fractures and AS to avoid further complications, not from the standpoint of improving the neurological status.

Fractures in Spinal Ankylosing Disorders: A Narrative Review of Disease and Injury Types, Treatment Techniques, and Outcomes

INTRODUCTION

Spinal ankylosing disorders encompass ankylosing spondylitis (AS), disseminated hyperostosis of the spine, and end-stage spondylosis. All these result in a stiffened and frequently deformed spinal column. This makes the spinal column highly susceptible to severe injuries that are commonly associated with unfavorable outcomes. Improved understanding of the underlying disease processes and clinical comorbidities may alter the poor injury related morbidity and mortality outcomes.

METHODS

A systematic review of the MEDLINE and PubMed databases was performed using the following key words to identify articles published between 2001 and 2016: "ankylosing spondylitis," "epidemiology," "DISH," "treatment," "outcome," and/or "fracture." Articles were read for data on methodology (retrospective vs. prospective), type of treatment, number of patients, mean patient age, and mean follow-up.

RESULTS

Twenty-one identified articles were analyzed. Average age was 63.4 years. Most patients were men. Ground level fall or low energy trauma caused most injuries. Diagnosis was delayed in 15%-41% cases. Hyperextension fracture patterns were most common. Cervical spine fractures were more common than thoracolumbar fractures, with the highest prevalence between C5 and C7. Neurologic deficits were encountered in 21%-100% of patients. Operative fixation and fusion were performed in 40%-100% of patients. Mortality was reported between 0% and 32% at 1 year postinjury. Complications were encountered in 84% of patients, mostly in the form of pneumonia, respiratory failure, and pseudoarthrosis. Neurologic deterioration has been reported in 16% of patients. Fusion was successful in 87%-100% of patients. Neurologic deficits improved in function in 6%-66% at the final follow-up.

CONCLUSIONS

Because of the stiffening of the spinal column, patients with spinal ankylosing disorders are preferably evaluated for spinal fractures and ligamentous injuries after even trivial trauma. Spinal injuries in patients with AS are difficult to diagnose on plain radiographs; computed tomography and magnetic resonance imaging are recommended instead. The entire spine should be scanned for multilevel involvement. Although osteoporosis makes fixation of spine implants a significant concern, the literature has reported that most patients with AS treated surgically had good outcomes. Numerous studies have reported risks associated with conservative management.

[Comparative study of decompression and non-decompression surgeries in treatment of thoracolumbar fractures with intraspinal occupying and without neurological symptoms]

Objective

To investigate the effectiveness of posterior non-decompression surgery in the treatment of thoracolumbar fractures without neurological symptoms by comparing with the conventional posterior decompression surgery.

Methods

Between October 2008 and October 2015, a total of 97 patients with thoracolumbar fractures with intraspinal occupying 1/3-1/2 and without neurological symptoms were divided into the decompression surgery group (51 cases) and the non-decompression surgery group (46 cases). There was no significant difference in gender, age, cause of injury, injury segment, the thoracolumbar injury severity score (TLICS), combined injury, disease duration, and preoperative relative anterior vertebral height, kyphosis Cobb angle, intraspinal occupying percentage, visual analogue scale (VAS), Oswestry disability index (ODI), and Japanese Orthopaedic Association (JOA) score between 2 groups ( P>0.05). The operation time, intraoperative blood loss volume, postoperative drainage, bed rest time, hospitalization time, and relative anterior vertebral height, kyphosis Cobb angle, intraspinal occupying percentage, and VAS score, ODI, JOA score at preoperative and postoperative 3 days and 1 year were recorded and compared.

Results

The operation time, intraoperative blood loss volume, and postoperative drainage in non-decompression surgery group were significantly less than those in decompression surgery group ( P<0.05). There was no significant difference in the postoperative bed rest time and hospitalization time between 2 groups ( P>0.05). In decompression surgery group, 4 cases had cerebrospinal fluid leakage and healed after conservative treatment. All incisions healed by first intention, and no nerve injury or infection of incision occurred. All patients were followed up 10-18 months (mean, 11.7 months). The recovery of vertebral body height was satisfactory in 2 groups, without secondary kyphosis and secondary nerve symptoms. The imaging indexes and effectiveness scores of 2 groups at 3 days and 1 year after operation were significantly improved when compared with preoperative ones ( P<0.05). The intraspinal occupying percentage, VAS score, and ODI at 1 year after operation were significantly lower than those at 3 days after operation in 2 groups ( P<0.05), and JOA score at 1 year after operation was significantly higher than that at 3 days after operation ( P<0.05). Relative anterior vertebral height at 1 year after operation was significantly higher than that at 3 days after operation in non-decompression surgery group ( P<0.05); and there was no significant difference in decompression surgery group ( P>0.05). At 3 days, the intraspinal occupying percentage and JOA score in non-decompression surgery group were higher than those in decompression surgery group ( P<0.05), and VAS score and ODI at 3 days in non-decompression surgery group were lower than those in decompression surgery group ( P<0.05). No significant difference was found in the other indexes between 2 groups at 3 days and 1 year after operation ( P>0.05).

Conclusion

Compared with the posterior decompression surgery, posterior non-decompression surgery has the advantages of less bleeding, less trauma, less postoperative pain, and so on. It is an ideal choice for the treatment of thoracolumbar fractures with intraspinal occupying 1/3-1/2 and without neurological symptoms under the condition of strict indication of operation.

Genome-wide DNA methylation profile analysis identifies differentially methylated loci associated with ankylosis spondylitis

Background

Ankylosing spondylitis (AS) is a chronic rheumatic and autoimmune disease. Little is known about the potential role of DNA methylation in the pathogenesis of AS. This study was undertaken to explore the potential role of DNA methylation in the genetic mechanism of AS.

Methods

In this study, we compared the genome-wide DNA methylation profiles of peripheral blood mononuclear cells (PBMCs) between five AS patients and five healthy subjects, using the Illumina Infinium HumanMethylation450 BeadChip. Quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR) was performed to validate the relevance of the identified differentially methylated genes for AS, using another independent sample of five AS patients and five healthy subjects.

Results

Compared with healthy controls, we detected 1915 differentially methylated CpG sites mapped to 1214 genes. The HLA-DQB1 gene achieved the most significant signal (cg14323910, adjusted P = 1.84 × 10^–6, β difference = 0.5634) for AS. Additionally, the CpG site cg04777551 of HLA-DQB1 presented a suggestive association with AS (adjusted P = 1.46 × 10^–3, β difference = 0.3594). qRT-PCR observed that the mRNA expression level of HLA-DQB1 in AS PBMCs was significantly lower than that in healthy control PBMCs (ratio = 0.48 ± 0.10, P < 0.001). Gene Ontology (GO) and KEGG pathway enrichment analysis of differentially methylated genes identified four GO terms and 10 pathways for AS, functionally related to antigen dynamics and function.

Conclusions

Our results demonstrated the altered DNA methylation profile of AS and implicated HLA-DQB1 in the development of AS.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1382-1) contains supplementary material, which is available to authorized users.

One-stage surgical treatment of cervical spine fracture-dislocation in patients with ankylosing spondylitis via the combined anterior-posterior approach

The aim of the article is to investigate the efficacy and safety of 1-stage surgical therapy via combined anterior-posterior approach on cervical spine fracture in patients with ankylosing spondylitis (AS).We retrospectively analyzed profiles of 12 AS patients with severe fracture-dislocation of cervical spine received 1-stage combined anterior-posterior surgery in our hospital from October, 2013, to October, 2015, including clinical characteristics, follow-up data, and imaging records. We compared the parameters before and after surgery on the basis of neurological function, bone fusion, Cobb angles of operation segment, Barthel index (BI) score, and incidence rate of complications.A total of 12 patients received 1-stage surgery via combined anterior-posterior approach within 3 days after injury. No severe complications and death occurred. All patients received the successfully anatomical reduction of fracture-dislocation, in which 9 achieved function restoration. The latest follow-up showed the neurological function status of patients was improved. The Cobb angles of operation segments were recovered; the rate of bone fusion was 66.7% at 3 months and 100% at 6 months post-operation. The BI score was improved, 4 cases of moderate dependence and 8 of slight dependence at the latest follow-up compared to 10 of severe dependence and 2 of moderate dependence preoperation. In no cases did severe complications from implanted instrumentation occur.It was high efficacy and safety that the surgical therapy was performed on cervical fracture-dislocation in AS patients by the 1-stage combined anterior-posterior approach. The key of the surgery is the robust stabilization and full decompression of fracture spine at early stage. In addition, if spinal anatomical reduction of fracture segments is difficult to be achieved, the functional restoration should be adopted during the surgery.

Safety of tumor necrosis factor-alpha inhibitors for treatment of ankylosing spondylitis: A meta-analysis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic immune-mediated disease affecting the sacroiliac joints and the spine, manifesting with new bone formation and osteopenia. Five tumor necrosis factor-alpha (TNF-α) inhibitors (infliximab, etanercept, adalimumab, certolizumab, and golimumab) are available for the treatment of AS, however, the results for the safety of TNF-α inhibitors in the treatment of AS are not consistent.

METHODS

In this study, we conducted a meta-analysis to determine the safety of TNF-α inhibitors compared with placebo in reducing pain, swelling, and inflammation of AS patients. Eight relevant articles including 2049 patients were included for this meta-analysis study. We observed that the incidence of adverse events (RR  =  1.22, 95% CI: 1.12-1.33; P  =  .501, I  =  0%) and injection-site reaction (RR  =  2.93, 95% CI: 2.02-4.23; P  =  .691, I  =  0%) in AS patients' treatment with TNF-α inhibitors was significantly higher than that with placebo.

RESULTS

However, there was no significant difference in the incidence of serious adverse event, infection, serious infection, and discontinuations due to adverse event. TNF-α inhibitors may be a promising treatment for AS, but carries an increased incidence rate of adverse events and injection-site reaction.

CONCLUSION

Due to the existence of the unstable factors, further studies need to be done to verify the result of this study.