Qian Bang-ping, Qiu Yong, Wang Bin, Yu Yang, Zhu Ze-zhang
Department of Spine Surgery, Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China.
Zhonghua Yi Xue Za Zhi. 2007 Nov 6;87(41):2893-8.
To explore the clinical features and strategies for treatment of spinal fracture complicating ankylosing spondylitis (AS).
The clinical data of 15 patients with spinal fracture in AS, 13 males and 2 females, aged 49.8 (10 - 45), with the average history of AS of 24.6 years, were studied. Fractures were found in the cervical spine in 6 patients and in the thoracolumbar spine in 9. Of the 6 cervical spine fracture patients, 2 were treated with conservative therapy, 2 underwent anterior internal fixation and fusion, 1 was stabilized with posterior fixation and fusion, and 1 underwent decompression, posterior fixation and fusion. Seven of the 9 thoracolumbar fracture patients developed thoracolumbar kyphosis with a mean Cobb angle of 64 degrees (46 - 106 degrees). Three techniques were used in thoracolumbar fracture: posterior transpedicular vertebral osteotomy coupled with internal fixation and autogenous bone grafting was performed in 3 patients; anterior interbody fusion and internal fixation was performed for 2 patients; and combined anterior and posterior surgery (using posterior osteotomy with instrumentation and autogenous bone grafting in stage 1, and anterior focal debridement and autogenous bone grafting in stage 2) was performed on 4 patients.
Of the patients with cervical fracture, three had the fracture lines through the disc spaces; the other 3 had their fracture lines through the vertebral bodies near the end plate. Both the two patients treated with conservative therapy died of severe pulmonary infection. One patient with incomplete neurological deficit undergoing posterior decompression and fixation could independently ambulate with the help of walking device at the final follow-up. Radiographic evidence of fusion was observed in the four patients with cervical fracture who underwent anterior or posterior fixation in the final follow-up. Of the patients with thoracolumbar fracture, three had the fracture lines through the vertebral bodies near the end plate; the other 6 patients had their fracture lines through the disc spaces with the formation of pesudoarthrosis. Postoperatively, the thoracolumbar kyphosis ranged 26 degrees (22 - 42 degrees) and the correction of the kyphotic angle was 38 degrees. In the latest follow-up, the range of thoracolumbar kyphosis was 28 degrees (24 - 44 degrees) with 2 degrees loss of correction. At the final follow-up, solid bony fusion had been achieved in all patients.
The cervical fracture in AS patient tends to be unstable, and conservative treatment cannot get better outcome. Prompt anterior or posterior stabilization can achieve reconstruction of spinal stability and fracture union. Thoracolumbar fracture patients without kyphosis deformity can be treated with anterior debridement and fusion with autogenous bone grafting. The transpedicular osteotomy technique can be used in patients with fracture or pseudoarthrosis with kyphotic deformity in AS, which can not only correct the kyphosis deformity, but also facilitate the union of fracture simultaneously. After posterior osteotomy, in order to prevent the intervertebral disc space anteriorly opening, which may result in deficiency of anterior column, anterior fusion with autogenous bone grafting is needed to strut anterior column and to prevent failure of correction.
探讨强直性脊柱炎（AS）合并脊柱骨折的临床特点及治疗策略。
研究15例AS合并脊柱骨折患者的临床资料，其中男性13例，女性2例，年龄49.8岁（10 - 45岁），AS平均病程24.6年。颈椎骨折6例，胸腰椎骨折9例。6例颈椎骨折患者中，2例行保守治疗，2例行前路内固定融合术，1例行后路固定融合术稳定脊柱，1例行减压、后路固定融合术。9例胸腰椎骨折患者中，7例发生胸腰椎后凸畸形，平均Cobb角为64度（46 - 106度）。胸腰椎骨折采用了三种技术：3例患者行后路经椎弓根椎体截骨术联合内固定及自体骨移植；2例患者行前路椎间融合及内固定；4例患者行前后联合手术（第1阶段采用后路截骨内固定及自体骨移植，第2阶段行前路病灶清除及自体骨移植）。
颈椎骨折患者中，3例骨折线通过椎间盘间隙；另外3例骨折线通过终板附近的椎体。2例保守治疗患者均死于严重肺部感染。1例不完全神经功能缺损患者行后路减压固定，末次随访时借助步行器可独立行走。4例颈椎骨折行前路或后路固定的患者在末次随访时可见融合的影像学证据。胸腰椎骨折患者中，3例骨折线通过终板附近的椎体；另外6例骨折线通过椎间盘间隙并形成假关节。术后胸腰椎后凸畸形角度为26度（22 - 42度），后凸角矫正38度。在最近一次随访时，胸腰椎后凸畸形角度为28度（24 - 44度），矫正丢失2度。末次随访时，所有患者均实现了牢固的骨融合。
AS患者颈椎骨折往往不稳定，保守治疗效果不佳。及时行前路或后路稳定手术可实现脊柱稳定性重建及骨折愈合。无后凸畸形的胸腰椎骨折患者可采用前路病灶清除及自体骨移植融合术治疗。经椎弓根截骨技术可用于AS合并骨折或假关节伴后凸畸形的患者，该技术不仅可矫正后凸畸形，还可促进骨折愈合。后路截骨后，为防止椎间盘间隙前方张开导致前柱缺损，需行前路自体骨移植融合术支撑前柱并防止矫正失败。
