Clinical Study
Perioperative complications in open versus percutaneous treatment of spinal fractures in patients with an ankylosed spine

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Highlights

  • Patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis and vertebral fracture were studied.

  • We compared open stabilization of vertebral fractures to percutaneous spinal fixation techniques.

  • Cohorts had similar mechanisms of injury, Injury Severity Scale scores, AO grade, number of vertebral fractures and additional injuries.

  • Percutaneous stabilization was associated with lower blood loss, shorter operative times and decreased need for transfusion.

  • Percutaneous stabilization was associated with shorter hospitalization time and a lower perioperative complication rate.

Abstract

We compared open stabilization of vertebral fractures to percutaneous spinal fixation techniques in patients with a diagnosis of either ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH). A retrospective review of patients known to have AS or DISH treated for spinal column fracture at a single institution between 1995 and 2011 was performed. Patients were analyzed by the type of fixation, divided into either a percutaneous group (PG) or an open group (OG). There were 41 patients identified with a spinal column fracture and history of AS or DISH who received surgical intervention. There were 17 (42%) patients with AS and 24 (58%) with DISH. Patients in the PG and OG cohorts presented with similar mechanisms of injury, Injury Severity Scale, number of vertebral fractures, number of additional injuries, and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification scores. Mean operative time (254.76 minutes versus 334.67 minutes, p = 0.040), estimated blood loss (166.8 versus 1240.36 mL, p < 0.001), blood transfusion volume (178.32 versus 848.69 mL, p < 0.001), and time to discharge (9.58 days versus 16.73 days, p = 0.008) were significantly less in the PG cohort. The rate of blood transfusion (36% versus 87.5%, p = 0.001) and complications (56% versus 87%, p = 0.045) were significantly less in the PG cohort. Percutaneous stabilization of fractures in patients with AS or DISH was associated with lower blood loss, shorter operative times and decreased need for transfusion, shorter hospitalization time and a lower perioperative complication rate.

Introduction

Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are two disease entities with distinct pathophysiology characterized by ankylosis and osteoporosis of the spinal column [1]. Patients with an ankylosed spine are predisposed to spinal fractures even after minor trauma [2] leading to instability and devastating neurologic injuries [3], [4]. Patients with AS have a four-fold increased fracture risk during their lifetime compared to normal individuals [5]. These fractures are very challenging because of the high morbidity and mortality rates, ranging from 8–75% [6], [7], [8], [9].

Traditional surgical treatment of these fractures may contribute to the high complication and mortality rates due to increased blood loss and extensive surgical exposure. We hypothesize that percutaneous instrumentation may be associated with improved patient outcomes in this cohort. In this study we investigated the rates of perioperative morbidity and mortality as a function of open surgical approaches versus percutaneous fixation techniques in patients with ankylosed spines.

Section snippets

Inclusion and exclusion criteria

After approval from the Institutional Review Board, we conducted a retrospective cohort study of patients with AS or DISH who were treated for spinal fractures at our level I trauma and tertiary care referral center. Our computerized database was scanned from 1995 to 2011 to retrospectively identify any individual with a recorded diagnosis of either AS or DISH who was surgically treated for a spinal fracture. The diagnosis of AS and DISH was made upon clinical, biological and radiological

Demographics and comorbidities

There were 41 patients included in this analysis with a diagnosis of AS (n = 17; 42%) or DISH (n = 24; 58%) and a surgically managed spinal fracture (Table 1). There were 16 patients (39%) in the OG cohort and 25 patients (61%) in the PG cohort. The mean age of all patients was 75.56 years.

The OG and PG cohorts were similar with regard to most patient demographic characteristics and comorbidities (Table 1). The OG cohort consisted of proportionally more males relative to the PG cohort (100% versus

Discussion

AS is a chronic inflammatory disease that mainly affects the axial skeleton and sacroiliac joints, which can lead to enthesopathy and ossification [12]. In contrast, DISH, also known as Forestier’s disease, is a non-inflammatory disorder characterized by spinal hyperostosis [1], [13]. Both conditions share similar clinical manifestations, including spinal stiffness, decreased range of motion and increased fragility which results in a relatively high propensity for fracture. Most fractures of

Conclusion

Patients with an ankylosed spine secondary to AS or DISH have increased spinal fracture risk even after minor trauma. The results from this study demonstrate reduced blood loss, blood transfusion, operative time, complication rates, and time to discharge in patients with AS or DISH who received percutaneous instrumentation compared to open instrumentation for a spinal column fracture. Future prospective studies should be used to validate these findings.

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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