Ankylosing spondylitis cervical fractures: anterior fixation linked to more complications

Design

Systematic review and meta-analysis of retrospective studies

Population

1441 patients with ankylosing spondylitis cervical fractures, 18 studies

Primary outcome

Complications, neurological recovery and mortality by approach

Effect

Complications anterior vs posterior OR 2.97 (95% CI 1.23 to 7.19)

This meta-analysis pooled 18 retrospective studies (1441 patients, almost 90% men) comparing anterior, posterior and combined surgical approaches for cervical fractures in ankylosing spondylitis. Methodological quality was uniformly poor.

Across nine pairwise comparisons, the only significant difference was a higher complication rate with anterior than posterior fixation (OR 2.97, 95% CI 1.23 to 7.19; I² = 66%). Neurological recovery and mortality did not differ significantly between any approaches, though heterogeneity for neurological recovery was very high.

The fused ankylosed spine behaves like a long bone, and anterior-only constructs have to resist long lever arms. The finding fits that biomechanical reasoning, but it is low-certainty and selection bias is likely, since approach was chosen by surgeons on fracture pattern and patient fitness. It is a reason to favour posterior or combined fixation when the choice is otherwise balanced, not a rule.

• Consider a posterior or combined approach for ankylosing spondylitis cervical fractures when fracture pattern allows a choice.
• Weigh cardiopulmonary fitness, fracture morphology and neurological status in the choice of approach.
• Expect similar neurological recovery across approaches, based on current low-certainty evidence.
• Plan multisegment fixation, since the ankylosed spine transmits long lever-arm forces.

Why it matters

These fractures are unstable, often missed and carry high mortality, so even weak comparative evidence on approach helps planning.

Don't overread it

Retrospective studies with surgeon-chosen approaches cannot show that one approach causes fewer complications.

The statistics, in plain English

An odds ratio of 2.97 means roughly three times the odds of a complication with an anterior approach. The wide interval, 1.23 to 7.19, and heterogeneity of 66% show the size is very uncertain. Neurological comparisons had heterogeneity near 90%, meaning the studies disagreed too much to give a useful pooled answer.

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