- Design
- Systematic review and meta-analysis of 18 retrospective studies
- Population
- 1,441 patients with ankylosing spondylitis and surgically treated cervical fractures
- Primary outcome
- Complications, neurological recovery and mortality by approach
- Effect
- Complications anterior vs posterior OR 2.97 (1.23-7.19); no difference in recovery or mortality
A meta-analysis in Neurosurgical Review (17 October 2026) pooled 18 retrospective studies of 1,441 patients with ankylosing spondylitis who had surgery for a cervical fracture, comparing anterior, posterior and combined approaches across nine pairwise comparisons.
The one statistically significant finding was a higher complication rate with anterior than posterior surgery (OR 2.97, 95% CI 1.23-7.19). Neurological recovery and mortality did not differ in any comparison; combined versus posterior surgery showed a non-significant trend toward fewer complications with posterior alone (OR 1.48, 0.98-2.25). Methodological quality was uniformly poor and heterogeneity often very high.
These fractures behave like long-bone fractures in a rigid spine: unstable, often through all three columns, and in patients with stiff chests and frequent cardiorespiratory disease. Long posterior constructs spanning several levels above and below are widely favoured for that reason. This analysis is consistent with that preference on complications, while giving no reason to think neurological outcome depends on the approach.
- Consider a posterior approach first for ankylosing spondylitis cervical fractures when morphology allows
- Weigh cardiopulmonary comorbidity heavily - anterior surgery carried more complications
- Do not expect approach choice alone to change neurological recovery
- Plan multilevel fixation; the ankylosed spine behaves like a long bone
Why it matters
It gives some pooled support to the approach most surgeons already lean towards in a high-risk fracture.
Don't overread it
Low-certainty retrospective evidence; fracture morphology and neurology should still drive the choice.
The statistics, in plain English
An odds ratio of 2.97 means complications were roughly three times as likely with anterior surgery, but the interval (1.23-7.19) is wide and I² of 66% shows the studies disagreed. With nine comparisons tested, one significant result could partly reflect chance, and all the underlying studies were retrospective.
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