Clinical StudyPerioperative complications in open versus percutaneous treatment of spinal fractures in patients with an ankylosed spine
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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Spine trauma management issues: Thoracic and lumbar
2022, Neural Repair and Regeneration after Spinal Cord Injury and Spine TraumaEffect of bisphosphonates on ankylosing spondylitis: A meta-analysis
2021, Journal of Clinical NeuroscienceCitation Excerpt :Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease characterized by inflammatory back pain due to sacroiliitis and spondylitis, and the formation of syndesmophytes leads to ankylosis [1–4].
Spinal trauma in DISH and AS: is MRI essential following the detection of vertebral fractures on CT?
2021, Spine JournalCitation Excerpt :This is comparable to other studies in which low energy mechanisms have been reported in 64% to 78% of cases [11,17,18,20–24]. Males made up over 80% of both the AS and DISH cohorts in our study, also consistent with prior literature [2,11,14,17,21–23,25]. The cervical spine is a common site of injury in both, which is seen in our study as well [2,11,14,17,18,20,25,26].
Diffuse idiopathic skeletal hyperostosis: Etiology and clinical relevance
2020, Best Practice and Research: Clinical RheumatologyCitation Excerpt :The intubation process could be compromised by the stiff and deformed cervical ankylosed spine, positioning/manipulation of the patient should be performed with utmost care and posterior stabilization is currently the preferred method with fixation of at least three levels above and three levels below the fracture. Compared with percutaneous pedicle screw fixation techniques, open stabilization is associated with more complications, longer hospital stay, more blood loss, and a higher mortality rate in several small retrospective studies [94,95]. Percutaneous pedicle screw-based fixation techniques are therefore the favored method for thoracolumbar B3 or C type fractures without neurological deficit [96–98].
Percutaneous surgery for thoraco-lumbar fractures in ankylosing spondylitis: Study of 31 patients
2017, Orthopaedics and Traumatology: Surgery and ResearchCitation Excerpt :Our findings support these previous results by showing that percutaneous internal fixation reliably ensures healing of thoraco-lumbar fractures in patients with AS. Minimally invasive surgery is associated with better functional recovery during the early post-operative period [20–23]. A meta-analysis by McAnany et al. [24] found no difference in clinical or radiological outcomes between open and percutaneous surgery.