Percutaneous surgery for thoraco-lumbar fractures in ankylosing spondylitis: Study of 31 patients

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.

Mono-segmental percutaneous screw fixation in the management of AoSpine thoracolumbar type B fracture in patients with ankylosing spondylitis: A new treatment

PURPOSE

To assess the viability and effectiveness of mono-segmental percutaneous screw fixation in the treatment of unstable type B thoracolumbar fracture due to ankylosing spondylitis.

METHODS

We report here all 40 patients treated by mono-segmental screw fixation in this indication, between January 2018 and January 2022, with follow-up at 3 and 9 months. Study variables comprised operating time, length of stay, fusion, stabilization quality, and peri-operative morbidity and mortality.

RESULTS

One patient showed early displacement of rods caused by technical error. None of the others showed secondary displacement of rods or screws. Mean age was 73 years (range 18-93), mean hospital stay 4.8 days (range 2-15), mean operative time 52minutes (range 26-95minutes) and mean estimated blood loss 40ml. There were 2 deaths caused by intensive care unit complications. All patients except those in intensive care were verticalized within 24hours after surgery. Parker score was unchanged for each patient before and after surgery and during follow-up.

CONCLUSION

Mono-segmental percutaneous screw fixation in the treatment of unstable type B thoracolumbar fracture due to ankylosing spondylitis was safe and effective. This study showed that this surgery reduced length of hospital stay, operative time, blood loss and complications compared to open or extended percutaneous surgery, and allowed fast rehabilitation in this vulnerable population.

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.

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.

An updated management algorithm for incorporating minimally invasive techniques to treat thoracolumbar trauma

OBJECTIVE

Minimally invasive surgery (MIS) techniques can effectively stabilize and decompress many thoracolumbar injuries with decreased morbidity and tissue destruction compared with open approaches. Nonetheless, there is limited direction regarding the breadth and limitations of MIS techniques for thoracolumbar injuries. Consequently, the objectives of this study were to 1) identify the range of current practice patterns for thoracolumbar trauma and 2) integrate expert opinion and literature review to develop an updated treatment algorithm.

METHODS

A survey describing 10 clinical cases with a range of thoracolumbar injuries was sent to 12 surgeons with expertise in spine trauma. The survey results were summarized using descriptive statistics, along with the Fleiss kappa statistic of interrater agreement. To develop an updated treatment algorithm, the authors used a modified Delphi technique that incorporated a literature review, the survey results, and iterative feedback from a group of 14 spine trauma experts. The final algorithm represented the consensus opinion of that expert group.

RESULTS

Eleven of 12 surgeons contacted completed the case survey, including 8 (73%) neurosurgeons and 3 (27%) orthopedic surgeons. For the 4 cases involving patients with neurological deficits, nearly all respondents recommended decompression and fusion, and the proportion recommending open surgery ranged from 55% to 100% by case. Recommendations for the remaining cases were heterogeneous. Among the neurologically intact patients, MIS techniques were typically recommended more often than open techniques. The overall interrater agreement in recommendations was 0.23, indicating fair agreement. Considering both literature review and expert opinion, the updated algorithm indicated that MIS techniques could be used to treat most thoracolumbar injuries. Among neurologically intact patients, percutaneous instrumentation without arthrodesis was recommended for those with AO Spine Thoracolumbar Classification System subtype A3/A4 (Thoracolumbar Injury Classification and Severity Score [TLICS] 4) injuries, but MIS posterior arthrodesis was recommended for most patients with AO Spine subtype B2/B3 (TLICS > 4) injuries. Depending on vertebral body integrity, anterolateral corpectomy or mini-open decompression could be used for patients with neurological deficits.

CONCLUSIONS

Spine trauma experts endorsed a range of strategies for treating thoracolumbar injuries but felt that MIS techniques were an option for most patients. The updated treatment algorithm may provide a foundation for surgeons interested in safe approaches for using MIS techniques to treat thoracolumbar trauma.

Posterior Percutaneous Screw Fixation to Treat Vertebral Fracture Non-union in Diffuse Idiopathic Skeletal Hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH) alters the biomechanical properties of the spine, rendering it highly prone to fracture, following even minor trauma. Risk of delayed diagnosis of vertebral fractures is particularly high in this cohort of patients since radiographs are notoriously difficult to interpret and presentation is late, due to difficulty distinguishing new from pre-existing back pain. Our case describes a gentleman in his late sixties with a six-month delay in presentation to our services with a T12 fracture, secondary to previously undiagnosed DISH, which had progressed to non-union. He underwent T9-L3 thoracolumbar posterior percutaneous stabilisation and fusion. At eighteen months follow-up, there was evidence of union, significant improvement in his pain, no focal neurology signs, and the patient had returned to his activities of daily living (ADLs).

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.

Open versus minimally invasive fixation of thoracic and lumbar spine fractures in patients with ankylosing spinal diseases

Purpose

Posterior multilevel fixation of traumatic instability in ankylosing spinal disease (ASD) can be performed by open surgery (OS) or minimally invasive surgery (MIS). We investigated whether both methods differ based on the reduction results and perioperative parameters.

Methods

In this retrospective cohort study, OS and MIS groups were investigated. The bisegmental Cobb angles and dislocation angles were measured using pre- and postoperative CT images, and the initial malalignment and achieved reduction were calculated. Cut-seam time, calculated blood loss, transfusion number, fluoroscopy time, pedicle screw placement accuracy, duration of ICU stay, in-patient stay, and complications (bleeding, postoperative thrombosis and embolism, and postoperative mortality) were recorded.

Results

Seventy-five ASD patients with spine fractures (Ø 75 ± 11 years, male: 52, female: 23) (MIS: 48; OS: 27) were included in this study. The extent of reduction did not differ in the OS and MIS groups (p = 0.465; MIS:− 1 ± 3°, OS:−2 ± 6°). The residual postoperative malalignment angle was not significantly different (p = 0.283). Seventy-eight of the implanted screws (11%) showed malpositioning. No difference was found between OS and MIS (MIS, 37 [7%]; OS, 41 [16%]; p = 0.095). MIS was associated with less blood loss (OS: 1.28 ± 0.78 l, MIS: 0.71 ± 0.57 l, p = 0.001), cut-seam time (MIS: 98 ± 44 min, OS: 166 ± 69 min, p < 0.001), and hospital stay (MIS: Ø14 ± 16 d, OS: Ø38 ± 49 d, p = 0.02) than OS.

Conclusion

OS and MIS show equally limited performance in terms of the fracture reduction achieved. The MIS technique was superior to OS based on the perioperative outcome. Therefore, MIS should be preferred over OS for unstable spinal injuries, excluding C-type fractures, in ASD patients without neurological impairment.

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.

Efficacy of computed tomography-assisted limited decompression in the surgical management of thoracolumbar fractures with neurological deficit

Objective

To investigate the effect of CT-assisted limited decompression in managing single segment A3 lumbar burst fracture.

Method

A retrospective study (January 2015–June, 2019). One hundred six cases with single-level Magerl type A3 lumbar burst fractures treated with short-segment posterior internal fixation and limited decompression. Patients were divided into two groups: CT-assisted group and non-CT-assisted group. Perioperative factors, clinical outcomes, post-operative complications, imaging parameters, and health-related quality of life (HRQoL) were evaluated.

Results

Kyphosis, loss of anterior and posterior vertebral body heights, operative time, and post-operative complications were not significantly different between the two groups. The visual analog score (VAS) and spinal canal encroachment in the CT-assisted group were lower compared with the non-CT-assisted group (p < 0.05). The Japanese Orthopaedic Association (JOA) score, the simplified HRQoL scale, and the American Spinal Injury Association (ASIA) Spinal Cord Injury Grade in the CT-assisted group were significantly higher compared with the non-CT-assisted group (p < 0.05).

Conclusion

CT-assisted limited decompression in the treatment of single-segment A3 lumbar burst fracture can achieve better fracture reduction and surgical results and improve the long-term recovery of the patients’ neurological function and quality of life.

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 Percutaneous Modified Iliac Screw Placement Using Intraoperative Navigation: A Technical Note

OBJECTIVE

The modified iliac screw fixation technique was proposed to be an interesting alternative option for spinopelvic fixation. In this study, we describe a new minimally invasive technique for percutaneous placement of modified iliac screws.

METHODS

A 64-year-old man with ankylosing spondylitis suffered from a 3-column fracture at the L5 vertebra without any neurologic deficit. We performed percutaneous pedicle screw fixation from L2 to S1 with additional modified iliac screws augmentation using an intraoperative navigation. We inserted both S1 pedicle screw and modified iliac screw within a stab incision on each side of the patient's back without using rod connector.

RESULTS

The patient's severe low back pain subsided on the day following the operation. There was no clinical low back pain at 2-week follow-up. The 1-year follow-up x-ray showed that the fracture was healed successfully without signs of screw loosening or breakage.

CONCLUSIONS

The modified iliac screws can be placed safely via percutaneous approach with an intraoperative image guidance. By using this new technique, surgeons can easily adjust the screw head to align with S1 pedicle screw via the same small incision. The rod connectors are not necessary for this technique. This method also prevents the acute angle that can develop between the screw head and shaft of the screw, which is typically found in S2 alar-iliac screw technique.

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.

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.