Spinal Fractures in Ankylosing Spondylitis: Patterns, Management, and Complications in the United States - Analysis of Latest Nationwide Inpatient Sample Data

Surgical management and outcomes of ankylosing spondylitis fractures in adults: a systematic review and meta-analysis

INTRODUCTION

Ankylosing spondylitis (AS) is a chronic inflammatory condition affecting the vertebral column. Surgical management of traumatic spinal fractures in patients with AS is often the first line treatment, however it has a high risk of perioperative complications. This systematic review explored current operative techniques and their outcomes in patients with AS sustaining traumatic spinal fractures.

METHODS

A PRISMA-compliant systematic review was conducted, and databases Embase, Pubmed/Medline and Cochrane were searched from inception to April 2024. Studies were included if they had complete individual patient data. Data was synthesized qualitatively and quantitatively. Univariate and multivariate logistic regression and ordinal regression was performed on R, to evaluate the relationship between surgical outcomes and independent patient and operative factors.

RESULTS

Seven studies with complete individual patient data were included, involving 150 patients. Increasing age was a significant predictor of mortality (OR 1.08, 95% CI 1.04-1.13, p < 0.001) and post-operative complications (OR 1.07, 95% CI 1.04-1.10, p < 0.001). Fixation and decompression of the thoracic level was also strongly associated with higher complications (OR 6.4, 95% CI 1.28-40.14, p < 0.05). Single level compression improved post-operative ASIA outcomes (OR 0.43, 95% CI 0.17-0.97, p < 0.05). A higher pre-operative ASIA score (C, D or E) was related with improved post-operative neurological recovery.

CONCLUSION

This study emphasizes the impact of age, level of spinal involvement, and surgical approach on surgical outcomes of traumatic spine fractures in AS. Future randomised controlled trials in the field can help further refine surgical strategies and improve patient care.

Spine surgery and readmission: Risk factors in lumbar corpectomy patients

Background

A corpectomy of the lumbar spine is a widely performed surgical procedure with numerous indications. Previous research predominantly focused on various surgical techniques and their outcomes, lacking a general and comprehensive analysis of factors affecting this procedure. With this study, we aimed to assess the all-cause 90-day readmission rate and identify risk factors for adverse events following a lumbar corpectomy.

Methods

Utilizing the 2020 Nationwide Readmissions Database adults (>18 years) were selected by ICD-10 procedure category codes for lumbar corpectomy. Patients with adult deformity or degenerative conditions were excluded due to coding inconsistencies. Demographic information and clinical data, including comorbidities, was extracted. Patients were categorized by their readmission status. The primary outcome was readmission, with multivariable logistic regression analysis used to identify independent risk factors.

Results

A total of 3,238 patients were included, with 20.8% readmitted. The readmission group was significantly older and had higher comorbidity burdens. Malignancy had the greatest odds of readmission (OR 3.172, p=.002), with spondylodiscitis also showing significant association (OR 2.177, p=.030). Fractures were significantly more frequent in the single admission group and not associated with readmission (OR 1.235, p=.551). Medical comorbidities differed significantly between the groups with a variety of them being identified as risk factors.

Conclusions

We established an all-cause 90-day readmission rate of 20.8%, which is in range of other procedures in spine surgery but underscores the severity of lumbar corpectomy. Underlying pathologies have a greater impact on the readmission rate compared to medical comorbidities. These findings highlight the importance of preoperative patient selection, especially when performing more invasive procedures. However, the study's limitations may limit the generalizability of the findings.

Ankylosing spondylitis: special considerations and clinical outcomes in surgical management of spinal fractures, case series and analysis of twenty patients

Ankylosing Spondylitis (AS) is a systemic inflammatory disease that involves the axial skeleton the most. It causes ascending inflammation and, thus, rigidity in the spinal column, from the sacroiliac joint to the cervical region. Spinal column deformities, besides vulnerability to trauma, alter the patients' quality of life and put their neural elements a great risk. In this study, we reviewed data of twenty AS patients who underwent spinal surgery due to trauma and spinal deformity due to AS, over 12 years in our center. Spinal radiologic indices, besides clinical evaluation of quality of life and neurologic status, were reviewed and mentioned. AS patients who were operated due to severe deformity and instability, correction of spinopelvic indices correlated with significant improvement in their quality of life and pain scores. Among those who were operated due to fracture and/or neurologic damage, clinical and neurologic improvement was significant. Spinal trauma and mal-alignment is AS, correlates with neurological compromise, and clinical symptoms such as pain and gait disturbance. Near complete correction of these indices improves patients' quality of life. Traumatic spinal fractures in AS, should be considered unstable unless otherwise proved. Meticulous surgical stabilization in such cases usually indicates.

Osteoporosis in axial radiographic spondyloarthritis: diagnostic limitations of bone mineral density and the need for comprehensive fracture risk assessment

Axial radiographic spondyloarthritis (r-axSpA) is a chronic inflammatory joint disease that leads to a considerable decline in the quality of life of patients by impairment of function and mobility, which, in turn, brings about a deterioration of both physical and mental health. Osteoporosis (OP) is a significant issue in the course of r-axSpA. Fractures resulting from OP complicate the treatment of the underlying disease and reduce the quality of life of patients. The aim of this paper is to discuss currently available diagnostic methods for OP and highlight why the gold standard for diagnosis - the assessment of bone mineral density via dual-energy X-ray absorptiometry - is not sufficient for patients with r-axSpA.

Thoracic Vertebra Chance Fracture Resulting from Mechanical CPR

Chest compressions, used in cardiopulmonary resuscitation (CPR), cause rib and sternum fractures in around 79% and 54% of patients, respectively. Spinal fractures resulting from CPR are far rarer. We present the case of a 70-year-old man who underwent mechanical CPR after choking whilst eating. The patient received a cerebral and thoracic CT scan upon arrival to the hospital. The cerebral scan was normal, but the chest CT scan revealed signs of ankylosing spondylitis and an unstable Chance fracture of the 12th thoracic vertebra. The patient was hospitalised but passed away. This case highlights the need for awareness of uncommon spine fractures due to the high associated morbidity. Teaching point: In patients who have undergone thoracic compressions, one should not only search for rib fractures but also for spine fractures, which, though uncommon, have a far greater impact on the patient's morbidity, especially in patients with predisposing spine conditions.

Implications of Frailty on Postoperative Health Care Resource Utilization in Ankylosing Spondylitis Patients Undergoing Spine Surgery for Spinal Fractures

OBJECTIVE

The rise of spinal surgery for ankylosing spondylitis (AS) necessitates balancing health care costs with quality patient care. Frailty has been independently associated with adverse outcomes and increased costs. This study investigates whether frailty is an independent predictor of poor outcomes after elective surgery for AS.

METHODS

Using the National Inpatient Sample (NIS) database, a retrospective study was conducted on adult patients with AS who underwent posterior spinal fusion for fracture between 2016 and 2019. Each patient was assigned a modified frailty index (mFI) score and categorized as prefrail (mFI = 0 or 1), moderately frail (mFI = 2), and highly frail (mFI≥3). Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay, non-routine discharge (NRD), and exorbitant admission costs.

RESULTS

Of the 1910 patients, 35.3% were prefrail, 31.2% moderately frail, and 33.5% highly frail. Age was significantly different across groups (P < 0.001), and frailty was associated with increased comorbidities (P < 0.001). Mean length of stay (P = 0.007), NRD rate (P < 0.001), and mean cost of admission (P = 0.002) all significantly increased with increasing frailty. However, frailty was not an independent predictor of extended hospital stay, NRD, or higher costs on multivariate analysis. Instead, predictors included multiple adverse events, number of comorbidities, and race.

CONCLUSIONS

While frailty in patients with AS is associated with older age, greater comorbidities, and increased adverse events, it was not an independent predictor of extended hospital stay, NRD, or higher hospital costs. Further research is required to understand the full impact of frailty on surgical outcomes and develop effective interventions.

Korean treatment recommendations for patients with axial spondyloarthritis

We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and Kmbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5-12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13-16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.

Korean treatment recommendations for patients with axial spondyloarthritis

We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and KMbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5~12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13~16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.

Ankylosing spondylitis substantially increases health-care costs and length of hospital stay following total hip arthroplasty - National in-patient database study

Introduction

The outcome following major arthroplasty surgeries in patients with ankylosing spondylitis (AS) has tremendously improved over the past decades, due to substantial amelioration in the medical therapies and sophistication of available surgical modalities. Although various studies have already demonstrated the complication rates and challenges faced in AS patients undergoing THA, there is a substantial paucity of data on the actual healthcare burden associated with this disease, and the diverse factors which may affect it.

Methods

Using the National Inpatient Sample (NIS) database (on the basis of ICD-10 CMP codes), patients undergoing THA between the years 2016 and 2019 were identified. These patients were then classified into two categories: group A: patients with a known diagnosis of AS; and group N: those without. The details regarding demographical information, associated co-morbidities, data pertaining to patients' hospital admissions including expenditure incurred, length of stay and complications encountered, were compared. In addition, propensity-score matching was performed to identify a 1:1 matched sample of THA patients without AS.

Results

Overall, 367,890 patients underwent THA; among whom, 501 (0.14%) were known AS patients (group A). Group A included a substantially higher proportion of patients belonging to younger age group (58.6 ± 13.4 versus 65.9 ± 11.4 years; p < 0.001), male sex (67.1% in group A vs 44.1% in group N; p < 0.001), and Asian ethnicity (p < 0.001). Group A patients had a substantially higher risk for longer duration of hospital stay (p < 0.03) and higher overall healthcare expenditure incurred (p < 0.001). As compared to group N, AS patients had a significantly higher risk for developing post-operative anemia [21.8% (group A) vs 11.8% (group N); p < 0.02]; and higher rate of periprosthetic infections [2.4% (group A) vs 1.0% (group N); p < 0.007].

Conclusion

Patients with AS require a significantly longer duration of hospital stay and higher admission-related expenditure following THA, as compared to the general population. These enhanced early health care-associated costs can be attributed to higher complication rates in AS patients. AS patients are prone to higher rates of anemia and peri-prosthetic infections during the early post-THA period.