Surgical Approach to Cervical Fractures in Ankylosing Spondylitis Patients: Rationale and Surgical Strategy

Abstract

Current literature lacks an objective criteria to decide on the surgical management in ankylosing spondylitis patients with cervical fractures. The purpose of our study was to analyze the determinants for stratifying surgical approach, evaluate the outcome in these groups of patients and postulate a management strategy. This is a retrospective study of patients with ankylosing spondylitis(AS) who underwent surgery for cervical spine injury having a minimum follow-up of 2 years. The patient's neurological recovery, fractrure pattern including translation and angulation, surgical duration, blood loss and postoperative complications were recorded and a comparative analysis of these factors with anterior, posterior and combined surgical approaches was performed. Forty-three males with a mean age of 57 years were included. Forty-nine percent underwent anterior only, 16% posterior only, and 35% combined stabilization. Mean operative time was significantly lower in anterior only(81.4 minutes,p<0.05), and posterior only(124 minutes, p<0.05) approaches as compared to combined antero-posterior approaches(266.6 minutes). The mean blood loss was significantly lower in the anterior only(87.5 ml, p<0.05) as compared to posterior only(714.7ml) and the combined(912.7 ml) approaches. The mean translation was 1.8mm; 1.7mm and 3.7mm in the anterior, posterior and combined approaches(p<0.05) respectively. Our study provides insights into the management of cervical spine fractures in AS patients. A fracture displacement ≤ 2 mm, may be successfully managed by an anterior approach while the posterior approach may be beneficial in similar fractures warranting instrumentation extending to the thoracic spine. All other fractures warrant a combined surgical approach.