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

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.

Combined anterior and posterior approach in treatment of ankylosing spondylitis-associated cervical fractures: a systematic review and meta-analysis

OBJECTIVE

Cervical fractures with ankylosing spondylitis (CAS) are a specific type of spinal fracture with poor stability, low healing rate, and high disability rate. Its treatment is mainly surgical, predominantly through the anterior approach, posterior approach, and the anterior-posterior approach. Although many clinical studies have been conducted on various surgical approaches, controversy still exists concerning the choice of these surgical approaches by surgeons. The authors present here a systematic evaluation and meta-analysis exploring the utility of the anterior-posterior approach versus the anterior approach and the posterior approach.

METHODS

After a comprehensive literature search of PubMed, Cochrane, Web of Science, and Embase databases, 12 clinical studies were included in the final qualitative analysis and 8 in the final quantitative analysis. Of these studies, 11 conducted a comparison between the anterior-posterior approach and the anterior approach and posterior approaches, while one examined only the anterior-posterior approach. Where appropriate, statistical advantage ratios and 95% confidence intervals were calculated.

RESULTS

The present meta-analysis of postoperative neurological improvement showed no statistical difference in the overall neurological improvement rate between the anterior-posterior approach and anterior approach (OR 1.70, 95% CI 0.61 to 4.75; p = 0.31). However, the mean change in postoperative neurological function was lower in patients who received the anterior approach than in those who received the anterior-posterior approach (MD 0.17, 95% CI -0.02 to 0.36; p = 0.08). There was an identical trend between the anterior-posterior approach and posterior approach, with no statistically significant difference in the overall rate of neurological improvement (OR 1.37, 95% CI 0.70 to 2.56; p = 0.38). Nevertheless, the mean change in neurological function was smaller in patients receiving the anterior-posterior approach compared with the posterior approach, but there was no statistically significant difference between the two (MD 0.17, 95% CI -0.02 to 0.36; p = 0.08).

CONCLUSIONS

The results of this review and meta-analysis suggest that the benefits of the anterior-posterior approach are different from those of the anterior and posterior approaches in the treatment of ankylosing spondylitis-related cervical fractures. In a word, there is no significant difference between the cervical surgical approach and the neurological functional improvement. Therefore, surgeons should pay more attention to the type of cervical fracture, the displacement degree of cervical fracture, the spinal cord injury, the balance of cervical spine and other aspects to comprehensively consider the selection of appropriate surgical methods.

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.

The Efficacy and Safety of Epsilon-Aminocaproic Acid for Perioperative Blood Management in Spinal Fusion Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Perioperative blood loss is a major concern in spinal fusion surgery and often requires blood transfusion. A large amount of perioperative blood loss might increase the risks of various perioperative complications. Recent clinical studies have focused on the perioperative administration of epsilon-aminocaproic acid (EACA) in spinal fusion surgery. The aim of this review was to evaluate the efficacy and safety of EACA in spinal fusion surgery.

METHODS

Electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials) were systematically searched up to April 2021. Data on perioperative blood loss, blood transfusion, and complications were extracted and analyzed by RevMan software.

RESULTS

Six randomized controlled studies comprising 398 patients undergoing spinal fusion surgery were included in this systematic review. Compared with the control group, the EACA group had significantly lower total perioperative blood loss, postoperative blood loss, postoperative hemoglobin, postoperative blood transfusion units, total blood transfusion units, and postoperative red blood cell transfusion units. Additionally, no significant differences were observed between the EACA and control groups in intraoperative blood loss, intraoperative blood transfusion units, intraoperative crystalloid administered, hospital stays, operative time, perioperative respiratory complications, and wound bleeding.

CONCLUSIONS

EACA in patients undergoing spinal fusion surgery is effective in perioperative hemostasis without increasing the incidence of postoperative complications. However, more large-scale trials are needed to examine the long-term adverse side effects of EACA in spinal fusion surgery.