Risk-stratified management of ankylosing spondylitis-related spinal fractures—a meta-synthesis of contemporary surgical and nonsurgical strategies: a narrative review

Introduction

Ankylosing spondylitis (AS) is a debilitating, chronic inflammatory rheumatic disease primarily affecting the axial skeleton (1). Distinguishing features of AS include inflammation of the sacroiliac joint and entheses, accompanied by syndesmophyte formation, kyphosis, and peripheral joint arthritis (2-4). AS carries a rising prevalence of 32 per 10,000 individuals in North America, with a male-to-female ratio of 4:1 and a peak onset between 20–40 years of age (3,5,6). The incidence of spinal fractures in patients with AS ranges from 10% to 15%, with the cervical spine being particularly vulnerable due to its mobility and structural features (2,7). AS imposes significant morbidity, with profound mental health and physical health burdens to the individual and a substantial economic cost globally (8,9).

AS leads to the progressive fusion of spinal vertebrae, resulting in a rigid spine significantly prone to fractures and severe complications despite minimal trauma (10,11). In addition, diagnosis and treatment of AS fractures have been historically difficult as fracture pain is often mistaken for the inflammatory cascade present in AS, leading to delayed diagnoses and further complications of nonunion, malunion, neurological deficits, and spinal cord injuries (12,13). AS-related fractures lead to significant functional impairment, decreased quality of life, reduced productivity, chronic pain, and reduced mobility (2,14,15). Early management is crucial for improving long-term outcomes and minimizing the risk of progressive kyphotic deformity and recurrent fractures (16). Given recent advancements in both non-surgical and surgical treatments for AS, such as Janus kinase (JAK) inhibitors and minimally invasive spine surgery, the development of standardized guidelines for managing AS fractures has become increasingly critical for optimizing therapeutic outcomes. No studies have comprehensively reviewed the latest advancements in AS management and no universal consensus on optimal management strategies exists, hence the need for updated guidelines for the management of frequent AS-related fractures is of paramount clinical importance. The current paper aims to summarize contemporary advances and challenges in treating AS fractures in adults, evaluate existing surgical and non-surgical management strategies, and propose clinical guidelines for the management of frequent AS-related fractures in adults.

Pathophysiology of AS fractures

AS is caused by a disruption in the balance between innate and adaptive immune responses, leading to the progressive fusion of the axial skeleton (17). As a historically difficult disease to diagnose and manage, the pathophysiology of AS fractures is complex, involving several aberrant processes that increase susceptibility to these fractures. First, persistent inflammation of the entheses and intervertebral joints, driven by upregulation of proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-17 (IL-17), and interleukin-23 (IL-23), results in progressive stiffness, swelling, and chronic pain (18-20). As the disease progresses, this chronic inflammation disrupts normal bone remodeling, leading to syndesmophyte formation and eventual spinal segment fusion (21). Prolonged use of corticosteroids in managing chronic inflammation can exacerbate and amplify the pathogenicity by reducing bone density and elevating the risk of osteoporosis and vertebral fractures (22). The resulting fusion, often referred to as “bamboo spine”, severely limits spinal flexibility and mobility (13,23). Despite excessive bone formation and spinal fusion, the remodeled bone is biomechanically weak, predisposing AS patients to unstable fractures even from low-energy trauma and increased risk of spinal cord injury (SCI).

In recent years, numerous studies have aimed to elucidate the underlying immunological triggers of AS through high-throughput techniques such as ribonucleic acid sequencing (RNA-Seq), whole genome sequencing (WGS), and cytokine profiling. The most significant genetic factor associated with AS is the human leukocyte antigen B27 (HLA-B27), present in approximately 90–95% of patients (24,25). Furthermore, a recent genome-wide association study (GWAS) revealed a genetic association between increased interleukin-6 (IL-6) signaling during chronic inflammation and increased risk of AS (25). This led to a more comprehensive meta-analysis, which further elucidated the pathogenesis of AS, revealing that the disease involves an imbalance between Th17 and Tregs, as well as between Th1 and Th2 cells. This imbalance further recapitulates that AS chronic inflammation is caused by disruption in both the innate and adaptive immune system (17,26).

Diagnostic criteria and clinical presentation

The diagnostic criteria for AS are based on the modified New York Criteria established in 1984. According to these criteria, a definitive diagnosis requires the presence of sacroiliitis on X-ray and at least one additional radiographic or clinical indicator (27). Radiographic indicators include X-ray evidence of grade two or higher bilateral sacroiliitis or grade three or four unilateral sacroiliitis. Furthermore, plain radiography may show ligamentous calcification, vertebral squaring, sclerosis, and joint space narrowing. In addition, a defining feature of end-stage disease in AS is the presence of an ankylosed “bamboo spine” on X-rays. Clinical indicators include (I) a history of inflammatory back pain and morning stiffness lasting at least three months, which improves with exertion and is not relieved by rest; (II) notable restriction in lumbar spine movement in bending forward-backward and side-to-side directions; and (III) significantly reduced chest expansion compared to normal values for age and gender (27-29). It is important to note that radiological signs of sacroiliitis may not be present early in the disease onset (30). Hence, the reliance on comprehensive patient history and physical exam, as well as alternative imaging modalities such as magnetic resonance imaging (MRI), allows for confirmation at early stages of the disease (Table 1). MRI is particularly valuable for early-stage disease detection, since radiographic sacroiliitis is not present in all patients at presentation.

Clinical presentation of AS can be categorized into axial symptoms, peripheral arthritis, dactylitis, enthesitis, systemic symptoms, and extra-articular manifestations. Axial symptoms include chronic back pain, prolonged morning stiffness, and reduced spinal mobility corresponding to the ascending involvement of the spine (30,31). As disease activity progresses from the sacroiliac joints upward, patients experience chronic dull pain and stiffness in the lower back, often with a stooped posture developing as kyphosis increases (32,33). Although AS predominantly affects the axial skeleton, the progression of the disease leads to peripheral joint arthritis, swelling, and reduced mobility of the shoulder, hips, knees, and ankles. Unlike rheumatoid arthritis, peripheral arthritis in AS typically carries an asymmetrical presentation (34).

Enthesitis, or inflammation at tendon and ligament insertions, can cause significant pain and tenderness at sites such as the costosternal junctions, plantar fascia, and Achilles tendon. Dactylitis, characterized by diffuse swelling of an entire finger or toe, reflects severe tenosynovitis and is another manifestation of the disease’s inflammatory burden (35,36). Systemic symptoms include chronic fatigue, significant weight loss, recurrent fevers caused by disrupted immune signaling pathways, and chronic sleep disturbances due to pain (37). Extra-articular manifestations often include anterior uveitis, which affects 25–40% of patients (38). In addition, aortic root dilation, aortic insufficiency, upper lobe pulmonary fibrosis, inflammatory bowel disease, and ulcerative colitis can also present in AS patients due to the sustained pro-inflammatory response characteristic of the disease (39).

The persistent clinical features of AS can lead to ossification of the spinal joints, reduced bone density, worsening ankylosis, and diminished shock absorption, which contribute to a significant increase in the risk of vertebral fractures in adults (36). In fact, spinal fractures are four times more frequent in AS patients than in the general population, with a lifetime incidence of 10–15% (40). These fractures can lead to serious neurologic complications, including SCI, radiculopathy, myelopathy, epidural hematomas, and cauda equina syndrome (CES) in cases of severe nerve root compression or extensive syndesmophyte formation (41). SCI is the most frequent complication, presenting in nearly 60% of patients with AS fractures. In cases of traumatic fractures, SCI can present in more than two-thirds of AS patients upon fractures (42). SCI injuries in fractured patients can be due to numerous causes, such as disc herniation, epidural hematoma, dislocation, and ossification of the ligamentum flavum (43).

Fracture classification and patterns in AS

The subaxial cervical spine is the most common site of fractures in AS patients, followed by the thoracolumbar junction (42,43). The predilection for cervical fractures is attributed to the high mobility of the neck, the small size of the cervical vertebrae, their oblique articular facets, and the lever-arm effect between the mobile skull and the fused thoracic spine. Cervical fractures are extremely unstable and carry a high risk of mortality and permanent neurological deficits. Fractures in an ankylosed spine often behave like long-bone fractures: they frequently traverse all three spinal columns, either through the vertebral body (transvertebral) or through the intervertebral disc and adjacent ossified ligaments (transdiscal) (42-45). In fact, most AS-related fractures occur through the intervertebral disc space, the biomechanically weakest point in the fused spine, due to calcification and brittleness of the annulus fibrosus and nucleus pulposus. As a result, transdiscal fractures represent the majority of fracture patterns observed in AS patients less commonly, a fracture line may pass through a vertebral body or posterior elements (transvertebral fracture), but even these often extend across the disk or adjacent vertebra because of the rigid fusion (46,47).

Mechanistically, injuries typically occur via hyperextension or flexion forces, corresponding to distraction-type patterns. Hyperextension injuries (e.g., a fall causing the head or torso to forcefully extend over a fused segment) are very common, especially at the cervicothoracic junction, and are classified as distraction injuries (AO Spine type B3) in the context of a stiff spine (46,48). Flexion-distraction injuries, analogous to Chance fractures, can also occur, leading to horizontal “jackknifing” fracture lines through the ossified disc or vertebra. Notably, one series of thoracolumbar fractures in ankylosed spines found the majority were extension-type injuries. Overall, according to contemporary classifications, most fractures in ankylosed spines fall into highly unstable categories (AO type B or type C injuries) (48). For instance, a recent imaging study reported that 43.8% of fractures in AS patients were hyperextension-type (AO B3) and 27.4% were translational injuries (AO type C) (48). Recognizing the diverse fracture patterns present in AS patients is critical to their effective management, as these patients are highly susceptible to both primary and secondary neurological deficits.

The overwhelming prevalence of complications associated with AS-related spinal fractures significantly raises mortality rates compared to the general population (41). Delayed diagnosis of AS fractures exacerbates this issue, further increasing the risk for neurological deterioration and secondary complications (40,41). Factors contributing to delayed diagnosis include several reasons. First, chronic pain frequently experienced by AS patients makes it challenging to detect the onset of new pain due to recent fractures. Second, radiographic findings of early fractures are often difficult to detect due to pre-existing spinal fusions, calcifications, and syndesmophyte formation. Third, AS fractures carry significant overlap in symptomatology to the initial disease, preventing patients from attributing the onset of new symptoms to a recent fracture (46,48). In addition, cervical fractures are often missed on initial plain radiographs due to kyphotic deformities and high-riding shoulders that can hinder imaging of the lower cervical spine (48,49). An emergent retrospective review revealed that 60% of cervical fracture-dislocations were not visible on initial radiographs, underscoring the need for advanced imaging modalities such as MRI and computed tomography (CT) upon initial presentation in suspected cases (46,50). Improving early diagnosis and developing high-resolution imaging modalities are critical avenues for increasing contemporary management strategies for AS patients.

From a clinical decision-making standpoint, most fractures through an ankylosed spine should be considered unstable unless proven otherwise. Even fractures that appear nondisplaced can destabilize due to the long lever arms above and below the injury. As such, classification of the fracture helps confirm the need for surgical stabilization in most cases. Only in exceedingly rare scenarios, such as a truly isolated anterior column (wedge) fracture without disruption of the posterior elements, might nonoperative management be appropriate. In practice, however, simple compression fractures are uncommon in AS. In one series, only 1 of 70 fractures was a minor compression injury (48).

Rationale for the current review: clarifying clinical uncertainty through evidence-based synthesis

Despite an increasing literature on AS-related spinal fractures, contemporary management is hindered by several unsettled issues: underrepresentation of elderly and medically compromised patients in primary research; operative technique and reporting heterogeneity; and absence of stratified, evidence-based framework with which to inform surgical decision-making. Despite advances in diagnostic imaging and stabilization methods in recent years, no synthesis has yet integrated biomechanical considerations, patient-specific risk factors, and real-world outcomes across surgical techniques. The result is a disjointed clinical landscape in which treatment remains highly variable, and consensus on best practices is lacking, particularly in high-risk groups where operative morbidity is a concern.

To address these limitations, we conducted a focused narrative review and meta-synthesis of adult AS-related spinal fracture studies with an emphasis on outcomes according to fracture type, neurologic involvement, surgical approach (posterior-only, anterior, or combined), and comorbidity profile. Our approach combines mechanistic insight with clinical pragmatism, with the aim of elucidating clinically informative patterns from heterogeneous data. By combining evidence across numerous large-scale studies spanning 11,262 patients and delineating predictors of neurologic recovery, fusion success, and complication risk, this review not only clarifies current patterns of practice variation but also offers data-driven guardrails to inform future surgical algorithms and prospective clinical research. We present this article in accordance with the Narrative Review reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-119/rc).

Methods

We conducted a focused meta-synthesis of retrospective and cohort studies examining surgical outcomes in patients with AS-related spinal fractures. A systematic search of PubMed was conducted. The meta-synthesis used keyword combinations including, but not limited to, “ankylosing spondylitis”, “spinal fractures”, “surgery”, “outcomes”, and a variety of terms indicating older or comorbid patients. The full search query is included in Appendix 1. The search was restricted to retrospective or cohort studies, excluding reports and reviews. Eligible studies met the following inclusion criteria: (I) elderly (>70 years) or medically comorbid patient population; (II) spinal fractures related to AS; (III) surgical intervention (posterior, anterior, combined, or minimally invasive); and (IV) reporting of at least one outcome of interest (neurologic recovery, fusion success, complication rates, or mortality). The initial search yielded 104 articles. Following title and abstract screening, 12 full texts were assessed against the inclusion criteria, resulting in 9 articles that met all eligibility and inclusion criteria. Figure 1 illustrates the selection process in a PRISMA-style flow diagram. Data were extracted and synthesized, shown in Table 2. Two reviewers independently extracted data from the included studies and cross-checked them for accuracy. Extracted variables included study year, sample size, fracture level and type, surgical approach (combined, posterior-only, anterior-only, or minimally invasive), American Spinal Injury Association (ASIA) grade improvement rates, fusion success rates, complication rates, and in-hospital mortality. Due to heterogeneity of study designs, patient populations, and outcome definitions, results were synthesized descriptively rather than being pooled quantitatively. Trends in neurologic recovery, fusion rates, and complication profiles were compared qualitatively among surgical approaches, with particular interest in outcomes in elderly or comorbid patients. All included studies were retrospective cohorts or case series, by inclusion criteria, and their methodological shortcomings were considered when interpreting results. The search and reporting process followed PRISMA guidelines where applicable to promote transparency and reproducibility. Table 3 further recapitulates the meta-synthesis search strategy of the current manuscript.

Figure 1 PRISMA diagram of screening for surgical outcomes in AS fracture patients. AS, ankylosing spondylitis.

Current management strategies

The management of AS fractures in adults is an evolving field, as there are currently no formalized guidelines from major bodies such as the American College of Rheumatology or European Alliance of Associations for Rheumatology (EULAR). Patients with AS fractures often present with a range of co-morbidities, including cardiac, pulmonary, and gastrointestinal conditions, which can be exacerbated by the chronic inflammatory cascade characteristic of the disease. Hence, despite the versatility of management strategies in the treatment of AS fractures, it is vital to recognize that the course of management depends on numerous factors, such as the severity of the fracture pattern, the presence of primary and secondary neurological deficits, and the patient’s overall medical history. Treatment approaches encompass both non-surgical to surgical strategies.

Non-surgical management

Non-surgical management of AS fractures typically begins with pain control through nonsteroidal anti-inflammatory drugs (NSAIDs) to alleviate pain and inflammation (54). Corticosteroids and disease-modifying antirheumatic drugs (DMARDs) are used to address the underlying pro-inflammatory cascade and disease activity (46,54-56). In cases of minor, stable fractures, defined by AO spine classification as subtype A0, with “no concern for mechanical instability or neurological deficit” (57) or when surgery is contraindicated due to medical comorbidities, external immobilization can be utilized to stabilize the spine and prevent further injury (58,59). Rigid cervical collars or thoracolumbosacral braces (TLSO) are applied to immobilize the injured segment, particularly if surgical stabilization must be delayed or avoided. Once the acute phase has passed, and if the patient remains neurologically intact, a guided rehabilitation program is recommended to improve mobility, strength, posture, and overall function. Studies of focused 8-week rehabilitation programs in AS patients have shown significant improvements in pain, fatigue, and quality of life measures (46,60,61). The advancement of anti-inflammatory interventions, such as JAK inhibitors, has demonstrated symptomatic relief in patients with AS as reported by multiple functional scores [ankylosing spondylitis quality of life (ASQL), bath ankylosing spondylitis functional index (BASFI), bath ankylosing spondylitis metrology index (BASMI), functional assessment of chronic illness therapy (FACIT)-F, etc.] (62) and can be ceased within 3 days prior to operation for surgical fixation for AS and due to their short life, should be resumed within 3–5 days post-operatively (63).

Non-surgical management strategies can be further categorized into traction, external orthoses, and halo vest placement (40,41,46). Skeletal traction involves applying a longitudinal pulling force to align and stabilize fracture fragments, and it is sometimes used acutely for unstable cervical fractures to restore alignment prior to definitive treatment. In the past, traction was occasionally employed as a definitive treatment for cervical fractures, but this approach has largely been abandoned due to poor long-term results. External orthoses help stabilize the spine in AS patients with sustained fractures to restrict movement and promote healing in post-operative care (48,59,64). Cervical collars and TLSO are used to manage minor cervical spine injuries and thoracolumbar compression fractures, respectively (64-66). However, care must be taken in patients with pre-existing kyphosis, as poorly fitted orthoses can exacerbate respiratory issues due to restricted chest expansion (46,67,68). Halo vests are used for immobilizing the cervical spine, particularly in cases of high cervical spine fractures (69). A halo vest can temporize an unstable cervical injury if the patient is not an immediate surgical candidate, but halo immobilization in AS also carries risks including pin loosening or infection, and difficulty managing the device on a kyphotic torso.

Non-surgical management requires extremely careful and frequent follow-up. Even when initial alignment is achieved in a brace or halo, fracture displacements can quickly worsen with minimal stress because of the brittle, fused spine. Recent small cohort data suggest that in patients with spinal ankylosing diseases presenting with an extension type fracture (AO spine B3), presenting with a fracture which does not involve the posterior vertebral wall or annulus, is of an osseous or osseous-discal pattern and opens anteriorly up to 6 mm, non-operative management may be sufficient (70). Most studies, however, suggest that outcomes of purely conservative treatment in AS patients with unstable fractures have historically been poor. High rates of fracture nonunion and progressive deformity have been reported when operative stabilization is not performed (46,48). Prolonged bed rest, which may be required for those managed in traction or a cast, is associated with a high incidence of pulmonary complications such as pneumonia and even a risk of fatal outcomes in this patient population. For this reason, nonoperative management is typically reserved for selective cases, typically fractures that are nondisplaced/stable or in patients who are poor surgical candidates. Any signs of fracture displacement, neurological decline, or inability to tolerate immobilization should prompt a reassessment and likely transition to surgical management.

Surgical management

Definitive indications for the surgical management of fractures in AS patients are warranted when any one of the following is present: (I) deteriorating neurological status; (II) severe deformity; (III) significant spinal instability; (IV) spinal cord injuries; or (V) intractable pain (49,70,71). Surgical management is generally preferred over non-surgical interventions due to its effectiveness in reducing mortality rates and complications (46,72). The surgical management should be individually tailored to the patient’s needs and involve significant multidisciplinary team consultations. Important clinical phenotypes to consider are the patient’s overall medical history, age, comorbidities, fracture location (cervical, thoracic, lumbar), degree of displacement, and the presence of spinal cord compression and kyphosis (49,51). Multidisciplinary input is often valuable: for example, preoperative clearance and optimization by cardiopulmonary specialists is advisable, given that many AS patients have restrictive lung disease (due to kyphosis) and cardiac conduction abnormalities (due to chronic inflammation) (67,73). In elderly patients or in those with co-morbidities [e.g., 80-year-old with chronic obstructive pulmonary disease (COPD)], the posterior-only approach with long-segment fixation and ideally minimally invasive approach can be used to reduce blood loss, operative time, and wound morbidity. We recommend avoiding routine anterior or staged anteroposterior procedures given their higher cardiopulmonary burden and higher mortality in this group (74). Use cement augmentation when bone stock is poor and prioritize pulmonary optimization (pre-op clearance, lung-protective anesthesia) and early mobilization. For younger or healthier patients, the posterior-only approach remains first-line for most injuries; consider anteroposterior reconstruction selectively (e.g., profound anterior column loss/pseudoarthrosis) when the patient can tolerate longer anesthesia and higher physiologic stress (74). It is also important to assess bone density, as osteoporosis is common in AS; if osteoporosis is present, medical management (e.g., bisphosphonates or teriparatide) may be initiated to improve fusion success (75,76). In osteoporotic AS fractures, we recommend adherence to the Congress of Neurological Surgeons guidelines to assess/optimize bone health and preferentially use teriparatide peri-operatively to support fusion (77), while continuing or initiating bisphosphonates to reduce implant-related failures (78); fixation is reinforced with long-segment constructs and cement augmentation when bone stock is poor (77,79). Perioperative planning should include attention to the patient’s rigid spinal posture, positioning on the operating table must maintain their baseline alignment to avoid iatrogenic neurologic injury during anesthesia and transfers (80,81). In summary, surgical management in AS fracture patients requires careful preoperative evaluation and planning to mitigate the elevated risks of complications in this complex population (46,49,82).

The fundamental goals of surgery are to achieve solid internal fixation across the fracture, decompress the neural elements if needed, and restore or maintain acceptable alignment of the spinal column. Stabilization may involve instrumentation via anterior, posterior, or a combined anteroposterior approach, depending on the fracture characteristics and patient factors. Recent comparative studies confirm that no single fixation strategy (anterior-only, posterior-only, or combined anteroposterior) confers a clear advantage in neurologic recovery or survival for ankylosing-spine fractures. A 2023 meta-analysis of 12 cervical cohorts showed equivalent rates of postoperative ASIA grade improvement and in-hospital mortality across the three approaches, although anterior-only constructs required the most late re-operations for hardware failure, whereas posterior fusion offered the shortest operative time and least blood loss (74,83). Single posterior long-segment fixation therefore remains the work-horse: it spans at least two healthy levels above and below the injury, allows concomitant laminectomy for decompression, and avoids the cardiopulmonary stress of a second stage. Hence, a single posterior approach is often preferred as it allows direct access to the spinal canal and efficient correction of kyphosis. Conversely, anteroposterior fixation may be more suitable for highly unstable fractures in patients with fewer comorbidities (43,84,85) (Table 4).

For thoracolumbar fractures, a 2022 series comparing percutaneous posterior screws with open long-segment fusion documented identical solid-fusion and pain-relief rates but significantly lower blood loss, operative time, and wound morbidity with the minimally invasive technique, making it attractive for frail AS patients. Similar benefits were reported with robot-assisted percutaneous fixation, which achieved 100% union while further improving screw-placement accuracy in a 2024 cohort (53). A long-term follow-up study (median follow-up: 38 months; range, 12–75 months) reported on a series of 43 AS patients with thoracolumbar fractures treated by percutaneous pedicle screw fixation (86). They reported 97% of patients achieved bony fusion by 12 months on CT with the authors concluding that minimally invasive surgery (MIS) provides stable fracture healing with an acceptable complication rate, making it a suitable option for AS-related fractures (86).

Decompressive laminectomies are performed to relieve spinal cord or nerve root compression and are indicated in cases with severe spinal stenosis, ossification of the posterior longitudinal ligament (OPLL), and other spinal pathologies (87). For unstable fractures in high-risk patients, minimally invasive fixation techniques, such as percutaneous screw fixation, may be used to provide immediate stability, followed by open fusion to minimize surgical time and complications (46,88). Studies evaluating thoracolumbar fractures have demonstrated that percutaneous instrumentation reduces surgical invasiveness, thereby reducing the risk of infection and bleeding due to minimal tissue disruption (89) (Table 5).

Surgical deformity correction across the cervical, thoracic, and lumbar regions in AS has matured in the last decade with numerous studies guiding best practices.

Population-level data highlight how age and comorbidity profoundly modulate risk. In a Nationwide Inpatient Sample analysis of 8,526 surgically-treated AS fractures, patients ≥70 years had a 57% complication rate and 10% in-hospital mortality, more than triple the risk seen in younger cohorts; anterior or combined approaches amplified that mortality compared with posterior-only fusion (14). Population-level data highlight how age and comorbidity profoundly modulate risk. In a Nationwide Inpatient Sample analysis of 8,526 surgically-treated AS fractures, patients ≥70 years had a 57% complication rate and 10% in-hospital mortality, more than triple the risk seen in younger cohorts; anterior or combined approaches amplified that mortality compared with posterior-only fusion (52). Collectively, contemporary evidence supports early posterior stabilization, preferably with minimally invasive, cement-augmented screws when bone quality is poor, as the default strategy, reserving anterior or dual-column reconstruction for severe anterior column loss or frank pseudo-arthrosis in physiologically robust patients.

Surgical management offers several advantages over non-operative management, including superior deformity correction, early mobilization, immediate stability, spinal decompression, prevention of secondary neurological insults, and more favorable long-term outcomes (88,89). Furthermore, surgical intervention allows for an increasingly patient-stratified treatment strategy that encapsulates enduring co-morbidities in AS-fractured patients. Nonetheless, it also presents challenges such as postoperative complications, increased mortality rates, potential deterioration of existing co-morbidities, extended recovery time, and the risk of adjacent segment disease, particularly in single-position lumbar fusions (88,90). Thus, the management of AS fractures requires a multidisciplinary approach that addresses the unique challenges of spinal rigidity and fracture propensity inherent to the disease.

Results

Systematic search of PubMed resulted in 104 records, with 12 full-text articles being screened for eligibility and 9 studies being identified as meeting all inclusion criteria (Figure 1). The entire search query is provided to allow reproducibility. The studies in Table 2 constituted a combined sample of 11,262 patients with spinal fractures caused by AS. Sample sizes were extremely heterogeneous between studies, ranging from small single-center cohorts of fewer than 20 patients to enormous national registries of more than 8,000 patients. Fracture patterns differed between studies but the cervical spine was more highly represented in institutional series, whereas population-based series had a more even distribution between cervical and thoracolumbar injuries. The posterior-only fixation was used in 50% to 85% of cases, and combined anterior–posterior in 13–41%, and anterior-only fixation in 6–19% (Table 2).

Functional recovery and success of fusion were not uniformly reported across the studies, but such data that were reported showed significant gain in function as well as high union rates, particularly with posterior-only techniques (2,51). Published ASIA grade improvement rates were 55% in anterior-only constructs to 74% in posterior-dominant cohorts, and success of fusion was uniformly reported as 100% in series that included this assessment (2,51). Furthermore, in a recent single-center cohort, robotic-assisted percutaneous posterior fixation in elderly patients was associated with no wound complications, no perioperative mortality, and 100% radiographic fusion at final follow-up (53).

Complication rates were extremely variable depending on study design and patient population, ranging from 8% to 20% for posterior approaches by institutional series and to a high of 50% in mixed approaches (Table 2). In-hospital mortality showed a clear age and approach-related gradient: in a national cohort, mortality was 7.4% in old patients with posterior-only fixation but rose to 15.6% and 19.5% with combined and anterior-only approaches, respectively (13,14). These preventable deaths were largely caused by pulmonary events, which underlines the vital clinical importance of respiratory prophylaxis and monitoring (52).

Together, these outcomes confirm posterior-only long-segment fixation as the most dependably useful method in elderly or medically compromised AS patients, offering outstanding fusion and neurologic improvement rates at less morbidity and mortality than more invasive techniques (2,51). Minimally invasive posterior fixation, when feasible, was associated with fewer wound complications and operative time, and is particularly attractive in high-risk populations (53). Furthermore, combined reconstruction or anterior plating may be advisable in a chosen subset of patients with three-column instability or compromise of the anterior column, provided they have sufficient physiological reserve to tolerate a more extensive procedure (16,64). During all procedures, careful attention to pulmonary management, early mobilization, and vigilant monitoring remains essential to prevent the out-of-proportion respiratory morbidity and mortality hazard for this subset of patients. These observations form the basis for a risk-stratified, patient-tailored surgical decision-making in AS-related spinal fractures.

Strengths and limitations

This review presents an in-depth synthesis of emerging evidence concerning AS-related spinal fractures, combining recent data on imaging modalities, surgical techniques, and patient-level variables influencing outcomes. One of the significant merits of this review is its multidisciplinary approach, uniting rheumatologic, radiologic, and surgical perspectives to inform decision-making in a range of clinical settings. By stratification of fracture patterns, surgical plans, and comorbidities, this review demonstrates a patient-level, comprehensive strategy available to clinicians in managing a high-risk and heterogeneous population. Further, the discussion is comprehensive of new findings from large cohort studies, novel uses of imaging, and minimally invasive technologies for surgery, thereby commenting on the evolving landscape of AS fracture treatment.

However, there are important limitations that need to be addressed. Since it is a narrative and not a systematic review, there is inevitable selection bias in literature inclusion, although a thorough and comprehensive meta-synthesis is present. While we emphasize practical recommendations and clinical acumen, heterogeneity of practice within institutions and lack of randomized trials in this specialty subgroup limit the generalizability of some recommendations. Second, phenotypic heterogeneity of AS and fracture biomechanics, and variability in terminology used to describe each across studies, means standardization of protocols for treatment is challenging. Additionally, the 32 primary studies we examined as part of our meta-analysis were retrospective cohort designs, which leads to possible selection bias and confounding residuals. At the time of manuscript composition, we did not have access to prospective registries but future work would benefit from incorporating prospective registries to help mitigate these limitations. Furthermore, we acknowledge that although minimally invasive (including robot-assisted) approaches are promising, our review did not assess their cost-effectiveness or practical feasibility in low-resource settings, which merits dedicated future study. Despite these limitations, we hope that the current review contributes to the literature by describing current practice, highlighting emerging approaches, and identifying evidence gaps that can be resolved through a prospective study and formal guideline development.

Future directions

Advanced imaging models and artificial intelligence (AI) have substantial potential in furthering our elucidation of the clinical neurosciences and surgical interventions, such as AI-aided imaging for trigeminal neuralgia, MRI classification of Alzheimer’s disease using ConvNeXt-based, and ASNet framework for detection of AS at early stages (91-95), provides examples of how deep learning can improve diagnostic accuracy and prognostication. Applying similar methodologies in AS would enable the automatic identification of occult fractures, comprehensive classification of instability, and prediction of long-term outcomes such as fusion success, reoperation rate, and recovery of function. Developing large, multi-institutional imaging repositories, along with radiomic features and clinical parameter integration, will be critical to develop validated predictive models. Last, such approaches could facilitate a future era of precision medicine in which both surgical and nonsurgical treatments are guided not only by clinical acumen, but also by patient-specific risk profiles that are reflected in AI-created imaging biomarkers.

Conclusions

AS is a chronic, disabling, rheumatic disease with a high prevalence in the United States, leading to significant physical and mental health morbidities and substantial global economic burdens. There are currently no unified guidelines for the management of AS and its associated fractures in adults, largely because conventional antirheumatic therapies have limited efficacy in reducing underlying inflammation and sacroiliitis. AS patients are at a significantly higher risk of spinal fractures compared to the general population, due to factors such as substantial osteoporosis, spinal rigidity, kyphosis, and gait disturbances. The most common fracture sites in AS patients are the cervical spine and the thoracolumbar junction. Furthermore, delays in diagnosis are frequent, which exacerbates the risk of neurological deterioration and complications related to pre-existing co-morbidities.

AS-related fractures are inherently unstable, with significantly elevated mortality risks and complication rates in this patient population. Consequently, contemporary management strategies must focus on early intervention and minimize diagnostic delays. It is critical that AS patients with even minor trauma are thoroughly evaluated for acute spinal fractures using advanced imaging techniques, such as CT and MRI. Furthermore, substantial consideration must be maintained in the transfer and positioning of AS patients in the hospital setting to preserve pre-existing kyphotic alignment and minimize the risk of secondary neurological injuries. Non-surgical management, including traction, external orthoses, and halo vest placement, is particularly beneficial for minor cervical spine injuries and thoracolumbar compression fractures, offering the most clinically promising outcomes (Table 6).

Surgical management is indicated for unstable fractures, significant neurological deficits, progressive kyphosis, and intractable pain. Surgical stabilization often involves posterior instrumentation or a combination of anteroposterior fixation, followed by osteotomies and laminectomies for deformity correction and spinal decompression, respectively. While surgical management generally improves recovery from neurological injuries, it also carries risks of postoperative complications, such as infection, cardiopulmonary issues, delayed healing, and nonunion. Contemporary approaches to managing AS-related fractures must increasingly incorporate enhanced diagnostic techniques, such as high-resolution imaging, to detect subtle fractures frequently missed in AS patients. Furthermore, guideline-specific expansion and emphasizing minimally invasive fixation methods, such as percutaneous instrumentation, are paramount in improving overall outcomes, enhancing recovery, and reducing postoperative complications in patients with AS-related fractures.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-25-119/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-119/prf

Funding: None.

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