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Background
Ankylosing spondylitis (AS) is a rheumatoid disease leading to progressive ossification of the spinal column. Patients suffering from AS are highly susceptible to unstable vertebral fractures and often require surgical stabilisation due to long lever arms. Medical treatment of these patients improved during the last decades, but until no...
Citations
... Dr. Palmowski's work was supported by a research grant from the Deutsche Autoimmun-Stiftung ("German Autoimmune Foundation"). 1 Individuals with axial SpA are hypothesized to have a higher risk of fracture compared with the general population through multiple mechanisms, including chronic inflammation and resulting osteoproliferation and osteoporosis. [3][4][5][6][7] Osteoproliferation, new bone formation, is a key feature of axial SpA. It includes the development of syndesmophytes, ankylosis, and ligamentous ossification of the spine. ...
... 12 Thus, there is a need to generate contemporary US data about fractures in AS to inform health interventions that aim to reduce the risk of fractures. 6 In this study, we examined patients with AS using the Rheumatology Informatics System for Effectiveness (RISE) registry, a national electronic health record (EHR)-enabled rheumatology registry that contains data recorded during routine outpatient clinical care in participating rheumatology practices across the United States, 13 and linked Medicare data. The advantage of this approach is that rheumatic disease diagnoses are more specific in RISE because they are assigned by rheumatologists, whereas Medicare claims permit examination of clinical events across patients' entire spectrum of inpatient and outpatient care. ...
Objective
We evaluated the incidence rate and factors associated with fractures among adults with ankylosing spondylitis (AS).
Methods
We performed a retrospective cohort study with data from the Rheumatology Informatics System for Effectiveness registry linked to Medicare claims from 2016 to 2018. Patients were required to have two AS International Classification of Diseases codes 30 or more days apart and a subsequent Medicare claim. Then, 1 year of baseline characteristics were included, after which patients were observed for fractures. First, we calculated the incidence rate of fractures. Second, we constructed logistic regression models to identify factors associated with the fracture, including age, sex, race and ethnicity, body mass index, Medicare/Medicaid dual eligibility, area deprivation index, Charlson comorbidity index, smoking status, osteoporosis, historical fracture, and use of osteoporosis treatment, glucocorticoids, and opioids.
Results
We identified 1,426 adults with prevalent AS. Mean ± SD age was 69.4 ± 9.8 years, 44.3% were female, and 77.3% were non‐Hispanic White. Fractures occurred in 197 adults with AS. The overall incidence rate of fractures was 76.7 (95% confidence interval [CI] 66.4–88.6) per 1,000 person‐years. Older age (odds ratio [OR] 2.8, 95% CI 1.39–5.65), historical fracture (OR 5.24, 95% CI 3.44–7.99), and use of more than 30 mg morphine equivalent (OR 1.86, 95% CI 1.08–3.19) conferred increased odds of fracture.
Conclusions
In this large sample of Medicare beneficiaries with AS, increasing age, historical fracture, and use of opioids had higher odds of fracture. Men and women were equally likely to have a fracture. Because opioid use was associated with fracture in AS, this high‐risk population should be considered for interventions to mitigate risk.
... There is a paucity of literature on whether the increased use of TNFi is protective against fractures. To our knowledge, only 2 earlier studies have evaluated fracture risk in AS in relation to TNFi use (21,30). An Australian population-based observational study looked at 2,321 patients with AS and found significantly increased risk of vertebral fracture in AS compared to matched non-AS comparators, but the risk did not change following the introduction of TNFi (21). ...
... An Australian population-based observational study looked at 2,321 patients with AS and found significantly increased risk of vertebral fracture in AS compared to matched non-AS comparators, but the risk did not change following the introduction of TNFi (21). A Swedish longitudinal cohort spanning 22 years found that the proportion of spinal fractures in hospitalized AS patients increased from 0.82% in 1987 up to 11.3% in 2008; however, this study could not account for predisposing factors for fractures such as age, sex, or osteoporosis (30). The increased fracture rates in AS patients in the Swedish study could be explained by greater clinical awareness of fractures, and the availability of advanced imaging modalities and resources. ...
... Certain limitations of our study must be acknowledged. We cannot fully exclude the possibility of misclassification of AS cases or fracture outcomes determined from ICD and CPT codes alone, although these definitions have been previously validated (18,19,21,(30)(31)(32). Further, we were unable to account for the magnitude of bias from changes in diagnostic coding accuracy over time. ...
Objective
There is an increased risk of fracture in individuals with ankylosing spondylitis (AS) compared to the general population, possibly due to systemic inflammatory effects. The use of tumor necrosis factor inhibitors (TNFi) may reduce fracture risk by inhibiting inflammation. We assessed fracture rates in AS versus non‐AS comparators and whether these rates have changed since the introduction of TNFi.
Methods
We used the national Veterans Affairs database to identify adults ≥18 years old with ≥1 International Classification of Diseases, Ninth Revision (ICD‐9)/ICD‐10 code for AS and at least 1 disease‐modifying antirheumatic drug prescription. As comparators, we selected a random sample of adults without AS diagnosis codes. We calculated fracture incidence rates for AS and comparators, with direct standardization to the cohort structure in 2017. To compare fracture rates from 2000 to 2002 (pre‐TNFi) versus 2004–2020 (TNFi era), we performed an interrupted time series analysis.
Results
We included 3,794 individuals with AS (mean age 53 years, 92% male) and 1,152,805 comparators (mean age 60 years, 89% male). For AS, the incidence rate of fractures increased from 7.9/1,000 person‐years in 2000 to 21.6/1,000 person‐years in 2020. The rate also increased among comparators, although the ratio of fracture rates (AS/comparators) remained relatively stable. In the interrupted time series, the fracture rate for AS patients in the TNFi era was nonsignificantly increased compared to the pre‐TNFi era.
Conclusion
Fracture rates have increased over time for both AS and non‐AS comparators. The fracture rate in individuals with AS did not decrease after TNFi introduction in 2003.
... This improvement is associated with increased life expectancy. Robinson et al. showed that the incidence of complicated spinal fractures among these patients could be expected to rise dramatically [9]. The cervical spine is the region that is most susceptible to these fractures. ...
... This is consistent with our findings. The cervical fractures of patients with AS mostly occur in the lower segment, and the incidence rate at the cervical-thoracic junction (C7-T1) is the most significant [9,10]. This is related to the unique physiological structure and biomechanical transmission. ...
... Only in a few situations an anterior approach may be sufficient. This strategy for the surgical approach is in coherence with the most published literature dealing with cervical spine fractures in ankylosing spondylitis patients [9,[19][20][21]. Due to the difficulty encountered during the positioning of the patients, some authors recommended that utilizing the sitting position for the posterior cervicothoracic fusion portion of a combined anterior-posterior approach can overcome complicationspurring positioning difficulties and provide proper surgical management of an unstable cervical spine fracture in a patient with ankylosing spondylitis. ...
Purpose
In this work, a two-center study was performed to study the clinical presentation of cervical spine fractures in ankylosing spondylitis (AS) patients and assess the surgical management of these fractures.
Methods
A retrospective analysis of prospectively collected data in two level-1 spine surgery centers was performed. Both spine centers have a standard database for all admitted patients. Inclusion criteria were surgically treated AS with cervical spine fracture diagnosis (from C1 to Th3) and postoperative follow-up minimum of 12 months.
Results
One hundred ten patients (105 male/5 female) were included. The mean age was 62 ± 10 years. The mean time between trauma and surgery was 49 ± 42 days. There was a history of mild trauma in 72 patients (65.4%). The clinical presentation was a pain in all patients. Twenty-seven (24.6%) had a neurological deficit at admission. The most common fracture level was C6/7 in 63 patients (57.23%). The VAS was 7 ± 1, and NDI was 34 ± 8 in the preoperative assessment. The mean preoperative kyphosis angle was 48 ± 26° between C2 and C7.
Positioning and preparing of the patients on the operation table took a mean of 57 ± 28 min. The surgical approach was dorsal in 59 patients (53.6%), combined in 45 patients (40.9%), and ventral in 6 patients (6,5%). The mean number of the fixed levels was 6 ± 2 levels.
Intraoperative complications occurred in 9 patients (8.2%). Postoperative Cobb angle improved to a mean of 17 ± 9 degrees. Neurological improvement occurred in 20/27 patients. In 12 patients, the recovery was complete. The mean postoperative follow-up was 46 ± 18 months. VAS improved to 3 ± 1, and NDI improved to 14 ± 6 at the last postoperative visit. The improvement was clinically significant (p = 0.01 and 0.00, respectively).
Conclusion
High suspicion of cervical spine fractures is necessary for patients with AS. CT and MRI images are necessary to rule out cervical spine fractures in AS patients, especially to detect occult fractures. Surgical treatment is safe, and the posterior approach with long-segment fusion is the approach of choice in this group of patients.
... Cervical spinal injuries are common, occurring in 3% of major trauma patients [1]. Cervical trauma in AS 28:97 patients requires particular attention in the acute shock room setting, as the risk of severe neurological complications due to spinal stenosis is greatly elevated [2,3]. ...
Introduction
Cervical spinal instability can be difficult to detect in the shock room setting even with the utilization of computed tomography (CT) scans. This may be especially true in patients with cervical degenerative disease, such as ankylosing spondylitis (AS). The purpose of this study was to investigate the influence AS has on various radiologic parameters used to detect traumatic and degenerative instability of the cervical spine, to assess if CT imaging in the shock room is diagnostically appropriate in this patient population.
Methods
A matched, case–control retrospective analysis of patients with AS and controls without AS admitted at two level-1 trauma centers was performed. All patients were admitted via shock room and received a polytrauma CT. Twenty-four CT parameters of atlanto-occipital dislocation/instability, traumatic and degenerative spondylolisthesis, basilar invagination, and prevertebral soft tissue swelling were assessed. Since the study was assessing normal values, study patients were included if they had no injury to the cervical spine. Study patients were matched by age and sex.
Results
A total of 78 patients were included (AS group, n = 39; control group, n = 39). The evaluated cervical radiologic parameters were largely within normal limits and showed no significant clinical or morphologic differences between the two groups.
Conclusion
In this analysis, CT measurements pertaining to various cervical pathologies were not different between patients with and without AS. Parameters to assess for atlanto-occipital dislocation/instability, spondylolisthesis, or basilar invagination in the trauma setting may reliably be used in patients with AS.
... [33,34] These patients may sustain fractures even from minor, low-energy trauma, including trivial falls from a standing or sitting position. [34][35][36][37][38] Previous case reports describe the decompensations and lethal consequences of cervical immobilization for these patients. [20,21] Some problems highlighted in these studies are as follows: 1) unlike young patients, these patients do not have a neutral position; and 2) these orthoses force the patient into hyperextension, thus compromising the spine cord. ...
Research question: Are the currently used cervical orthoses suitable for immobilizing the cervical spine for patients with preexisting ankylosing spondylitis, an anatomically short neck, or obesity?
Materials and Methods: Tools, immobilization methods, completion time, sagittal displacement, and feedback on result were compared for one control and two severe case scenarios simulated on appropriately built manikins. Scenario 1 simulated a young patient who sustained a bicycle fall with no fracture. Scenario 2 simulated a short-necked middle-aged patient who met a vehicle accident and showed C7/T1 bilateral facet dislocation fracture. Scenario 3 simulated an elderly patient with preexisting ankylosing spondylitis who fell down stairs and sustained a C6/C7 non-displaced fracture.
Results: For scenarios 1 and 2, the immobilization rate with the collar was 100% vs. 86%, average completion time was 90 s vs. 175 s, rate of attempts involving tool changes was 16% vs. 49%, rate of attempts with the collar forced in position was 0% vs. 32%, and proportion of cases with satisfactory results was 100% vs. 5%. For scenarios 1 and 3, the immobilization rate with the collar was 100% vs. 16%. For scenario 3, the rates of critical and highly critical sagittal deviation were 54% and 13.5%, respectively, while the efficiency of immobilization was 0%.
Discussion and conclusion: Currently used rigid collars can increase the time on-scene and tamper with spinal alignment. They cannot be easily and safely applied to elderly, overweight patients and those with an anatomically short neck and can diminish the outcomes for these patients.
... Due to the reduced vertebral bone quality and amplified forces from the rigid spine, the risk of spinal fractures in patients with AS is higher than in the general population, especially after minor trauma (4). The data extracted from the Swedish National Hospital Discharge Registry showed that 724 patients were suffering from spinal fractures of 17,764 patients with AS during 22 years, of which 398 patients (1.4%) sustained cervical fractures (55.0%) and 302 patients sustained thoracolumbar fractures (41.7%) (5). According to statistical results from the National Inpatient Sample in 498 patients with AS, spinal fractures are present in the cervical spine (53%), thoracic spine (41.9%), lumbar spine (18.2%), and sacrum (1.5%). ...
Background
Intravertebral vacuum phenomenon (IVP) is a special sign after vertebral fractures, which is common in patients with ankylosing spondylitis (AS) and may indicate pseudarthrosis and bone nonunion that lead to spinal instability. The objective of this study is to evaluate the efficacy and safety of kyphoplasty (KP) in treating such types of vertebral fractures with AS.Methods
Sixteen patients with AS suffering from thoracic or lumbar fractures with IVP received KP from 2015 to 2020 and were monitored for more than 1 year. The visual analog scale (VAS) score was used to evaluate back pain relief. The Oswestry Disability Index (ODI) questionnaire was used to assess the improvement of the patients' living quality. The anterior and middle vertebral height restoration ratio (AVH, MVH) and the kyphotic angle (KA) were used to evaluate the radiographic results.ResultsThe mean follow-up period was 20.8 months (12–28 months). The VAS and ODI significantly reduced at 3 days, 3 months after surgery, and at the last follow-up compared with the preoperative outcomes (p < 0.05). The AVH and MVH were significantly increased compared with the preoperative outcomes (p < 0.05). There was a significant correction in the KA between pre- and postoperative assessments (p < 0.05). Asymptomatic intradiscal polymethylmethacrylate (PMMA) cement leakage was found in two patients.Conclusions
For thoracic or lumbar fractures with IVP in AS patients, KP may be safe and effective, which achieves pain relief and satisfying functional improvement, restores the anterior and middle height, and corrects the kyphotic angle of the fractured vertebra.
... Cervical involvement in AS patients requires particular attention, as the risk of fractures and severe neurological complications due to spinal stenosis is greatly elevated [3,6]. ...
Introduction: Cervical ligamentous injuries in patients with ankylosing spondylitis (AS) may be difficult to detect, even with the utilization of computed tomography (CT) scans. The purpose of this study was to investigate the influence AS has on various radiologic parameters used to detect traumatic and degenerative pathologies of the cervical spine.
Methods: A matched, case-control retrospective analysis of patients with AS and controls without AS admitted at two level-1 trauma centers was performed. All patients were admitted via shock room and received a polytrauma CT. Study patients were included if they had no injury to the cervical spine. Twenty-four CT parameters of atlanto-occipital dislocation/ instability, traumatic and degenerative spondylolisthesis, basilar invagination, and prevertebral soft-tissue swelling were assessed. Study patients were matched by age and sex.
Results: A total of 78 patients were included (AS group, n=39; control group, n=39). The evaluated cervical radiologic parameters were largely within normal limits and showed no significant clinical or morphologic differences between the two groups.
Conclusion: In this analysis, CT measurements pertaining to various cervical pathologies were not different between patients with and without ankylosing spondylitis. Parameters to assess for atlanto-occipital dislocation/ instability, spondylolisthesis, or basilar invagination may reliably be used in patients with AS.
... The need to know how bisphosphonates (and by extension, denosumab, a RANK ligand inhibitor) might affect all axSpA-related bone lesions in the spine over the short and long term, has been emphasised by data suggesting that by reducing bone turnover, bisphosphonates might promote osteoproliferation; 133 a worry given that progressive ankylosis may be the most important change in the spine dictating spinal fracture risk. 134 An additional theoretical concern would be if bisphosphonates were to be given at the time of development of osteoproliferation. We know nothing of the structural integrity of ossified spinal entheses and syndesmophytes that have incorporated bisphosphonate into their structure. ...
The breadth of bone lesion types seen in spondyloarthritis is unprecedented in medicine and includes increased bone turnover, bone loss and fragility, osteitis, osteolysis and erosion, osteosclerosis, osteoproliferation of soft tissues adjacent to bone and spinal skeletal structure weakness. Remarkably, these effects can be present simultaneously in the same patient. The search for a potential unifying cause of effects on the skeleton necessarily focuses on inflammation arising from the dysregulation of immune response to microorganisms, particularly dysregulation of T H 17 lymphocytes, and the dysbiosis of established gut and other microbiota. The compelling notion that a common antecedent pathological mechanism affects existing bone and tissues with bone-forming potential (entheses), simultaneously with variable effect in the former but bone-forming in the latter, drives basic research forward and focuses our awareness on the effects on these bone mechanisms of the increasing portfolio of targeted immunotherapies used in the clinic.
... The majority of fractures are located in the cervical spine, particularly the lower cervical spine or the cervicothoracic junction. [6][7][8][9][10][11][12][13][14][15][16][17][18] The fractures of the ankylosed spine often involve through the anterior column to the posterior column, along with the fractures of ossified anterior and posterior ligamentous complexes and the surrounding tissue. For such cervical instability that lack of the usual stabilizing ligamentous support increases the demand of mechanical stabilization with fixation devices. ...
The ankylosed spine is prone to fracture even as a result of minor trauma due to its changed biomechanical properties. Fractures in ankylosing spondylitis (AS) patients are highly unstable and surgical intervention for fixation is warranted. Implant failure rates are high and combined anterior and posterior fixation is required to enhance the fixation outcome. For fusion, anterior interbody fusion or posterior bone graft fusion is often adopted. Here, we introduce a new method which combines vertebroplasty with anterior and posterior approaches to improve pain control, facilitate the long-term fixation outcome and mechanics, and decrease perioperative risks with prompt stabilization, especially in patients with spine curve deformity. Here, we present two AS cases with cervical spine fracture treated with this new method.
... Downloaded on January 17, 2021 from Only two earlier studies, to our knowledge, have also compared long-term outcomes of VFs in AS patients and controls. A Swedish longitudinal cohort spanning 22 years, including a pre-and post-TNFi era, found 4% of 17,764 AS patients to have had a VF, and the proportion admitted to hospital increased from 0.8% in 1987 to 11.3% in 2008 (22). While this confirms that long-term observations are important to accurately estimate VF prevalence and risk, the study did not adjust for predisposing factors such as age, sex and diagnosis of osteoporosis as performed here, thereby complicating comparisons. ...
Objective
To compare the long-term prevalence, incidence and outcomes of vertebral fracture (VF) between ankylosing spondylitis (AS) patients and matched controls, including the role of extra-articular manifestations (EAM) and osteoporosis.
Methods
State-wide observational study using linked health data for 2,321 AS patients and 22,976 controls presenting to hospital from 1980-2015. Data were analysed using incidence rates (per 1000 person-years) and ratios (IRR), multivariable Cox-proportional hazard regression and Kaplan-Meier survival curves.
Results
Over a median 13.92 (IQR 7.58, 21.67) years of follow-up, AS patients had a greater VF prevalence and incidence of developing a new VF compared to controls (9.3% vs 2.5%, 6.8% vs 1.9%, respectively, all p<0.001). AS patients had an increased risk of developing a VF after adjustment for age, sex and osteoporosis (HR=2.55; 95%CI: 2.11, 3.09) compared to controls, and remained throughout the study period. AS patients were 5-years younger at time of first VF (p=0.008) and had a greater likelihood of a re-current VF (IRR=4.64; 95%CI: 4.54, 4.75) compared to respective controls. Mortality overall was comparable between AS patients and controls after adjustment for age, sex, osteoporosis and VF status (HR=0.90; 95%CI: 0.80, 1.01).
Conclusion
The significantly increased risk for VF in AS patients has not altered following the introduction of TNFi treatment. While AS patients experience a first VF at a younger age than controls, this does not lead to an increased risk of death.
