Surgical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with ankylosing spondylitis

Surgical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with ankylosing spondylitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with ankylosing spondylitis Zhi-Yuan Ye, Jin-Yu Bai, Zhi-Min Ye, Xu-Shen Zhao, Fang-Long Song, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4241368/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Jun, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 12 You are reading this latest preprint version Abstract Background: Spinal fractures in patients with ankylosing spondylitis (AS) mainly present as instability, involving all three columns of the spine, and surgical intervention is often considered necessary. However, in AS patients, the significant alterations in bony structure and anatomy result in a lack of identifiable landmarks, which increases the difficulty of pedicle screw implantation. Therefore, we present the clinical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with AS. Methods: A retrospective review was conducted on a series of 12 patients diagnosed with AS. All patients sustained thoracolumbar fractures between October 2018 and October 2022 and underwent posterior robotic-assisted percutaneous fixation procedures. Outcomes of interest included operative time, intra-operative blood loss, complications, duration of hospital stay and fracture union. The clinical outcomes were assessed using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). To investigate the achieved operative correction, pre- and postoperative radiographs in the lateral plane were analyzed by measuring the Cobb angle. Results: The 12 patients had a mean age of 62.8±13.0 years and a mean follow-up duration of 32.7±18.9 months. Mean hospital stay duration was 15±8.0 days. The mean operative time was 119.6±32.2 min, and the median blood loss was 50 (50, 250) ml. The VAS value improved from 6.8±0.9 preoperatively to 1.3±1.0 at the final follow-up (P<0.05). The ODI value improved from 83.6±6.1% preoperatively to 11.8±6.6% at the latest follow-up (P<0.05). The average Cobb angle changed from 15.2±11.0 pre-operatively to 8.3±7.1 at final follow-up (P<0.05). Bone healing was consistently achieved. Of the 108 screws implanted, 2 (1.9%) were improperly positioned. One patient experienced delayed nerve injury after the operation, but the nerve function returned to normal upon discharge. Conclusion: Posterior robotic-assisted percutaneous internal fixation can be used as an ideal surgical treatment for thoracolumbar fractures in AS patients. However, while robot-assisted pedicle screw placement can enhance the accuracy of pedicle screw insertion, it should not be relied upon solely. Ankylosing spondylitis thoracolumbar fractures surgical outcomes percutaneous techniques robot Figures Figure 1 Figure 2 Figure 3 Background Ankylosing Spondylitis (AS) is a chronic inflammatory disease which is characterized by pain and progressive stiffness[ 1 ]. Considering the unique characteristics of spinal fusion, osteoporosis, and spinal deformities in AS patients, individuals affected by these conditions are more prone to experiencing fractures even with minimal force impact[ 2 – 4 ]. The prevalence of spinal fractures in patients with AS is believed to be four times higher than that in healthy individuals[ 5 ]. Because these fractures often occur after minor trauma and in individuals with pre-existing chronic back pain, reaching a diagnosis is often challenging and may result in secondary neurological deficits[ 2 ]. The spinal fractures in patients with AS are predominantly unstable, involving all three columns of the spine, which require effective treatment in the early stage[ 5 ]. Due to the prevalence of unstable injuries and a higher occurrence of neurological symptoms, surgical intervention is often considered essential[ 6 , 7 ]. The traditional posterior open surgery is the classic treatment for AS, which achieves good clinical results[ 8 , 9 ]. However, due to the inflammatory reaction and osteoporosis of the disease itself, extensive dissection of paraspinal muscles during the operation will leads to increased bleeding, prolonged operation time, and an increased risk of postoperative infection[ 9 ]. In recent years, there has been an increasing inclination towards the utilization of percutaneous techniques for spinal fracture instrumentation. This approach offers advantages such as reduced surgical duration, minimal blood loss, and shorter hospital stays for individuals with AS who have thoracolumbar fractures[ 9 – 12 ]. However, in patients with AS, the significant alterations in bony structure and anatomy result in a lack of identifiable landmarks, which increases the difficulty of pedicle screw implantation and imposes demanding technical requirements on the operator[ 9 ]. Therefore, robot-assisted surgical fixation for AS combined with thoracolumbar fractures has become possible, because it has been confirmed to have the advantages of minimizing radiation exposure and improving the accuracy of screw placement in the treatment of common spinal fractures[ 13 – 15 ]. In addition, by utilizing robotic assistance, surgeons have the flexibility to select screws with a larger diameter and increased length[ 16 ]. This theoretically provides a more stable healing environment for thoracolumbar fractures in patients with AS. Here, we present a study on patients with AS who underwent robotic-assisted percutaneous fixation for thoracolumbar fractures. To the best of our knowledge, this is the first case series investigating the clinical effect of robotic-assisted percutaneous fixation in treating thoracolumbar fractures in AS patients, which may provide a new treatment option. We thoroughly analyze our results, focusing on outcomes and complications, and compare them to previously published data. Materials and methods Patients This study was approved by the Institutional Review Board of the Second Affiliated Hospital of Soochow University, and all patients understood and completing a consent form. filled in an informed consent form. A retrospective review was conducted on all patients diagnosed with thoracolumbar fractures in AS who underwent robotic-assisted percutaneous fixation at our institution from October 2018 to October 2022. All patients received plain radiography, computed tomography (CT), magnetic resonance imaging, and a physical examination by a spinal surgeon upon their admission to the hospital. Patients who had a delay of over 24 hours in receiving a diagnosis for their fractures were classified as having experienced a delayed identification. Diagnosis was made based on clinical and radiographic assessment. The AO Spine Thoracolumbar Spine Injury Classification System was utilized for the categorization of spinal fractures. Neurological impairments were evaluated using the American Spinal Injury Association (ASIA) grading system. Age, gender, trauma history, fracture level, delayed diagnosis, duration between diagnosis and operation, body mass index and C-reactive protein levels were recorded (Table 1). Table 1 Patient demographics and case details Case Gender (F/M) Age (years) Trauma history Fracture level AO classification (fracture type) ASIA grade preoperatively Delayed diagnosis Days between diagnosis and operation CRP (mg/L) BMI (kg/m 2 ) 1 F 65 No L2 B2 ASIA E Yes 3 6.1 32.87 2 M 57 Fall from ladder (high impact) T5 B2 ASIA E NO 20 171.2 24.80 3 M 48 No L1、L2 B2 ASIA D Yes 4 25.8 23.53 4 M 83 Fall from standing (low impact) L3 B3 ASIA E Yes 5 100.1 25.39 5 M 68 No T10、T11 B3 ASIA E Yes 6 51.6 27.24 6 M 69 Fall from standing (low impact) T12 B3 ASIA E Yes 3 57.4 25.95 7 M 79 Fall from standing (low impact) T12 B3 ASIA E NO 3 60.9 26.81 8 M 66 No L1、L2 B3 ASIA E Yes 1 7.0 25.71 9 M 49 Fall from ladder (high impact) T10 B3 ASIA E Yes 4 7.3 23.74 10 M 41 Fall from standing (low impact) L2 B3 ASIA E NO 4 110.5 24.8 11 M 54 Fall from standing (low impact) L2 B3 ASIA E NO 5 98.6 20.3 12 M 74 Fall from standing (low impact) T11 B3 ASIA E No 4 43.3 19.59 F, female; M, male; L, lumbar; T, thoracic; BMI, body mass index; CRP, C-reactive protein; ASIA, American Spinal Injury Association Inclusion and exclusion criteria The inclusion criteria were as follows: 1. AS was diagnosed based on the modified New York criteria; 2. the imaging findings were thoracolumbar fracture; 3. the patient underwent posterior robotic-assisted percutaneous fixation for treatment. The exclusion criteria were as follows: 1. The patient was treated conservatively or with other procedures without robotic assistance; 2. the patient has thoracolumbar fracture combined with multiple concomitant fractures; 3. the patient is unable to tolerate surgery for personal reasons; 4. the incompleteness of radiological information, treatment details, and follow-up data. Surgical technique All surgical procedures were performed on a specially designed flexible operating bed with the patient in a prone position and under general anesthesia. Sufficient cushioning was applied to accommodate the kyphotic deformity and minimize the risk of spinal cord injury. The CT scan of the surgical area was sent to the workstation prior to the operation (Renaissance; Mazor Robotics Ltd., Caesarea, Israel). The surgeon's requests for precise vertebral trajectories and screw dimensions were meticulously planned one day prior to the surgery (Figure 1A-C). During the preparation surgery, registration was performed using anteroposterior and oblique plane images in order to automatically merge them with the preoperative CT. The next step involved positioning a compact robotic manipulator (400 g, 9 cm tall, 5 cm diameter) onto the bone-mounted platform, ensuring that it was precisely aligned with the planned trajectory, following the surgeon's instructions (Figure 1D). After tapping the screw paths with a thread tap through the expanded channels, the screw was manually inserted following the guide wire. The rods were percutaneously inserted from the upper side to the lower side, with the assistance of a screw extender. Clinical evaluation Follow-up evaluations were conducted at 1, 3, 6, and 12-month intervals after the surgical procedure, with additional yearly assessments if necessary. The effectiveness of the treatment was assessed using the Visual Analogue Scale (VAS) for quantifying back pain severity, the Oswestry Disability Index (ODI) for evaluating disability, and the modified MacNab score to determine postoperative results during the most recent follow-up period. Neurological status was evaluated using the ASIA classification system. The collection of complications was conducted during both the intraoperative and postoperative periods. Radiographical assessment Radiographic assessment included the evaluation of the sagittal Cobb angle, bone fusion status and pedicle screw placement. The sagittal Cobb angle is used to assess the achieved operative correction. It is defined as the angular measurement between a line parallel to the superior end plate of the vertebra located above the fracture and another line parallel to the inferior end plate of the vertebra positioned one level below the fracture[17]. Bone fusion is defined as the blurring of the fracture line on radiographs, the formation of bridging bone (Figure 2), or the appearance of a trabecular pattern across the fracture site on CT imaging[12, 18]. The placement of the pedicle screws was assessed by utilizing axial CT scans and categorized according to the grading system of Gertzbein and Robbins[19]. The criteria for implant failure include screw breakage, screw pullout, peri-implant loosening, and rod breakage. Statistical analysis Qualitative variables were presented using numerical values and percentages, while quantitative variables were expressed as the mean ± standard deviation or median. Paired sample t-tests were utilized to compare preoperative and postoperative measurements, with statistical significance defined as P<0.05. The statistical analyses were conducted using IBM SPSS Statistics 27.0 software. Results Surgical results All patients, including 11 males and one female, underwent posterior robotic-assisted percutaneous fixation. The average age was 62.8 ± 13.0 years, and the average duration of postoperative follow-up was 32.7 ± 18.9 months. The mechanism of injury was identified as low energy or no trauma history in 83% (n = 10), while a high energy injury was noted in 17% (n = 2). Fractures classified by the AO classification were B2 in 25% (n = 3) and B3 in 75% (n = 9) patients. Delayed diagnosis was present in 58% (n = 7) of patients, including 1 (14%) patient who experienced neurologic deterioration and 3 (43%) patients with secondary pseudarthrosis. Delay of surgery (> 72 hours) occurred in 8 (67%) patients. The mean operative time was 119.6 ± 32.2 min, and the median blood loss was 50 (50, 250) ml. The average change in hemoglobin concentration before and after surgery was 1.6 ± 8.6 g/dl. Mean hospital stay duration was 15.0 ± 8.0 days. One patient experienced delayed neurologic deficit after surgery, resulting in a change of grade from ASIA E to ASIA C. The patient underwent emergency spinal canal decompression with the assistance of a microscope, as it was determined that the cause was compression caused by a hematoma, and the neurological status returned to normal after 2 weeks. The remaining patients did not experience any postoperative complications, and there were no deaths during the follow-up period (Table 2 ). Table 2 Surgical treatment and outcomes Case Internal stabilization Operation time (min) Hemorrhage (ml) Perioperative complications Death during FU Length of hospital stay (day) Time of bony union (mon) 1 T10-L4 180 400 No No 14 7 2 T3-8 180 300 No No 26 12 3 T12-L3 130 50 No No 11 4 4 L1-5 120 300 No No 12 6 5 T9-12 100 100 No No 20 8 6 T10-L2 110 50 Yes (neurological deficit) No 32 7 7 T10-L2 95 100 No No 14 6 8 T12-L3 120 50 No No 7 5 9 T9-T12 90 30 No No 6 6 10 T12-L4 130 40 No No 7 6 11 T12-L4 100 50 No No 12 5 12 T9-L1 80 50 No No 19 6 L, lumbar; T, thoracic; FU, follow-up. Clinical results All patients expressed satisfaction with the outcome of the surgery and reported a reduction in their back discomfort. The preoperative VAS value showed a significant improvement, decreasing from 6.8 ± 0.9 to 1.3 ± 1.0 the final follow-up (P < 0.05). Similarly, the ODI value demonstrated a remarkable enhancement, reducing from 83.6 ± 6.1% before surgery to 11.8 ± 6.6% at the most recent follow-up (P < 0.05) (Table 3 ). Based on the modified Macnab criteria, clinical efficacy was assessed as excellent in 10 cases and good in 2 cases during the most recent follow-up evaluation. One patient who had ASIA D neurologic deficit before surgery improved to ASIA E, and the internal fixation was removed 2 years after the operation. Table 3 Preoperative and Last Follow-up Patient Data Preoperative Last follow-up P value VAS 6.8 ± 0.9 1.3 ± 1.0 < 0.001 ODI (%) 83.6 ± 6.1 11.8 ± 6.6 < 0.001 Cobb angle (°) 15.2 ± 11.0 8.3 ± 7.1 0.002 VAS, visual analogue scale; ODI, oswestry disability index. Radiologic findings All patients achieved successful fracture healing, and no patient experienced implant failure. Out of the 108 screws implanted, 2 (1.9%) were improperly positioned, and both screws were located outside the lateral wall of the pedicle (Fig. 3 ). One patient did not have any clinical manifestations, so we did not perform further revision. Another patient experienced delayed neurologic deficit one day after surgery and underwent emergency spinal canal decompression. Although the cause was determined to be compression caused by a hematoma, we still repositioned the screw. The Cobb angle changed from 15.2 ± 11.0 preoperatively to 8.3 ± 7.1 at the final follow-up (P < 0.05) (Table 3 ). Discussion Spinal fractures can occur in patients with AS even under low-energy impact, predominantly resulting in instability and involving all three columns of the spine, which presents a challenge for surgeons in terms of treatment[ 2 , 4 , 5 ]. However, fractures such as these may frequently go undetected on plain radiography and be masked by common symptoms in AS, leading to a delay in diagnosis[ 5 ]. It has been reported that delayed diagnosis was observed in 17.1–65.4% of cases with AS vertebral fractures[ 5 , 20 ], and one-third of patients developed neurologic deficits[ 2 ]. Furthermore, this delay in diagnosis may result in non-union of the fracture, leading to thoracolumbar pseudarthrosis[ 21 ]. In our series, delayed diagnosis was present in 58% (n = 7) of patients, including 1 (14%) patient who experienced neurologic deterioration and 3 (43%) patients with secondary pseudarthrosis. The findings were consistent with those of previous studies. As previous studies have shown, there was a presence of both doctor's delay and patient's delay in the diagnostic process[ 5 ]. None of our patients experienced a delay in diagnosis due to the physician, which may be because we have been aware of the concealment and harmfulness with these spinal fractures and remained vigilant. However, there is still a need for improvement in the understanding of AS combined with spinal fractures. Especially for patients themselves, it is necessary to promptly seek medical advice when the nature of pain changes. The effectiveness of conservative treatment is limited and often results in suboptimal outcomes, which may include the use of braces, rest, and anti-inflammatory drugs[ 22 – 24 ]. Due to the frequent occurrence of unstable injuries and a higher probability of encountering neurological symptoms, internal fixation is often considered necessary. The study conducted by Robinson et al.[ 25 ] demonstrated that surgical treatment could significantly improve patients' survival rates. Additionally, Westerveld et al.[ 26 ] discovered that surgical treatment can enhance patients' neurological function to some extent. Therefore, we recommend surgery in the absence of any surgical contraindications. The traditional posterior open surgery is a classic treatment method that also yields favorable clinical outcomes[ 27 ]. However, the surgical trauma is significant and there are more postoperative complications[ 9 ]. Nugent et al.[ 28 ] and Nakao et al.[ 22 ] reported surgical complications with incidences of 64% and 30.8%, respectively. In recent years, minimally invasive surgery has been recognized by the majority of doctors, especially for elderly AS patients with more underlying diseases. It can achieve better clinical results and reduce the occurrence of surgical complications[ 9 , 10 , 29 , 30 ]. Ye et al.[ 9 ] demonstrated that minimally invasive surgery can achieve effects similar to those of traditional open surgery, while reducing bleeding, trauma, and postoperative complications. Additionally, bone cement was used to enhance the screw holding force and prevent screw loosening in patients with severe osteoporosis[ 12 , 31 ]. However, in patients with AS, the significant alterations in bony structure and anatomy result in a lack of identifiable landmarks, especially in the upper thoracic spine[ 32 ]. Therefore, acquiring high-quality intra-operative images can present challenges and impose rigorous technical demands on the operator, especially in minimally invasive surgery[ 9 ]. Bredin et al.[ 31 ] used a percutaneous technique to implant 228 pedicle screws, 6 (2.6%) of which were poorly positioned, including 1 within the spinal canal. According to a meta-analysis, Tian et al.[ 33 ] found that the incidence of screw malposition ranged from 10–31% when conventional techniques were used for pedicle screw insertion. In our series, the pedicle screw was implanted with the assistance of a robot and the accuracy rate was 98.1%, which surpasses the outcomes documented in previous studies[ 31 , 33 ]. This finding also demonstrates the benefits of robot-assisted screw placement precision, thereby enhancing the safety of surgical treatment for patients with AS combined with thoracolumbar fractures. However, two pedicle screws remained positioned outside the lateral wall of the pedicle, and one underwent revision. The possible reason could be that the robot is not securely fixed, leading to guide pin slippage upon insertion due to bone sclerosis. Therefore, based on our experiential learning, we recommend slowly inserting the guide pin into the bone upon contact with the bone surface at maximum rotation speed. Fluoroscopy should be performed again after all screws placement to evaluate the position of the screw. The repeated use of intraoperative fluoroscopy is essential for achieving more precise screw positioning, particularly in minimally invasive procedures performed on patients with AS[ 9 ]. Brooks et al.[ 34 ] demonstrated that minimally invasive surgery significantly increased intraoperative radiation exposure compared to traditional open surgery. Additionally, Kai et al.[ 11 ] identified radiation exposure as the only drawback of minimally invasive surgery in AS patients due to the increased difficulty in obtaining high-quality intraoperative images in the spine. The latest findings also indicate that prolonged exposure to low levels of radiation significantly increases the risk of mortality from solid tumors, causes damage to DNA and death of leukocytes, and has been classified as a "known human carcinogen" by the World Health Organization[ 35 , 36 ]. Therefore, it is necessary to enhance occupational protection measures and reduce medical radiation exposure. In our study, the use of robot-assisted screw placement eliminates the need for repeated fluoroscopy during surgery, thereby significantly reducing radiation exposure. This finding has also been observed in other studies[ 13 , 15 , 37 ]. In the future, we will continue to closely monitor intraoperative radiation exposure, further present radiation-related data, and conduct controlled studies. The clinical outcomes of our robot-assisted percutaneous fixation technique are consistent with previous studies on minimally invasive surgery, demonstrating consistently favorable results[ 12 , 30 , 31 ]. The VAS and ODI values were 1.3 ± 1.0 and 11.8 ± 6.6%, respectively, at the most recent follow-up. All patients successfully achieved union of the fracture, and there were no occurrences of implant failure. This is probably because we applied a robot-assisted technique to plan the trajectory of the screw and select a larger-sized screw in advance, achieving maximum fixation strength while maintaining the structural integrity of the vertebral pedicles[ 38 ]. Barkay et al.[ 39 ] demonstrated that postponing surgical intervention (> 72 hours) in elderly patients with spinal ankylosing disorders may lead to an increase in medical complications and mortality. In our study, surgery was delayed in 8 (67%) patients; however, no patients died, and the incidence of postoperative complications was 8.3%, which was lower than that reported in other studies[ 12 , 30 , 39 ]. This could potentially be attributed to the limited sample size of participants in our research or the use of robot-assisted technology, which improves work efficiency and promotes early rehabilitation. One patient experienced delayed neurological deficits due to hematoma compression after surgery; fortunately, the neurological status returned to normal following spinal canal decompression surgery. From this, it can be inferred that robot-assisted surgery has the potential to enhance operational efficiency and mitigate complications. However, it is imperative not to disregard the limitations of minimally invasive surgery in terms of detecting deep tissue hemorrhage and ensuring prompt and effective hemostasis. There were several limitations in our study. First, it was a retrospective study. Secondly, the study's limited sample size emphasizes the need for future research with larger sample sizes to replicate these findings. Thirdly, we did not present data such as intraoperative fluoroscopy and specific screw size. Controlled studies with large samples are needed to further clarify the advantages of robot-assisted technology in the treatment of thoracolumbar fractures with AS. Finally, the relatively high cost of robot-assisted treatment necessitates a comprehensive evaluation of the need for such technology. Conclusions Posterior robotic-assisted percutaneous internal fixation can achieve satisfactory outcomes for thoracolumbar fractures in patients with AS. However, while robot-assisted pedicle screw placement can enhance the accuracy of pedicle screw insertion, it should not be relied upon solely. Abbreviations CT: Computed tomography AS: Ankylosing spondylitis VAS: Visual analogue scale ODI: Oswestry disability index ASIA: American Spinal Injury Association Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board of the Second Affiliated Hospital of Soochow University. Consent for publication Not applicable. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was sponsored by the National Natural Science Foundation of China (81873995, 82172425), the Project for Suzhou Orthopedic Clinical Center (Szlcyxzxj202104), and the Social Development Key Programs of Jiangsu Province (JSDW202223). Authors' contributions XZZ contributed to the study conception and design. ZYY, XSZ, FLS, and ZTZ contributed to clinical data collection; JYB, ZMY, and BCS contributed to radiological data analysis; ZYY contributed to statistical analysis; ZYY, JYB, and ZMY contributed to the writing and editing. All authors have read and approved the final manuscript. Acknowledgements None. References Schiefer TK, Milligan BD, Bracken CD, Jacob JT, Krauss WE, Pichelmann MA, et al. In-hospital neurologic deterioration following fractures of the ankylosed spine: a single-institution experience. World Neurosurg. 2015; 83(5):775-83. Tu PH, Liu ZH, Yeap MC, Liu YT, Li YC, Huang YC, et al. Spinal cord injury and spinal fracture in patients with ankylosing spondylitis. BMC Emerg Med. 2022; 22(1):73. Alhashash M, Shousha M, Heyde CE, von der Hoh NH. Cervical spine fractures in ankylosing spondylitis patients: an analysis of the presentation and clinical results of 110 surgically managed patients in two spine centers. Eur Spine J. 2023; 32(6):2131-9. Tang Z, Chen T, Tan J, Zhang H. Surgical Outcomes and Prognostic Factors for Cervical Spine Fractures in Patients with Ankylosing Spondylitis. World Neurosurg. 2022; 166:e278-e84. Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J. 2009; 18(2):145-56. Ren C, Zhu Q, Yuan H. Imaging features of spinal fractures in ankylosing spondylitis and the diagnostic value of different imaging methods. Quant Imaging Med Surg. 2021; 11(6):2499-508. Lu AY, Blitstein JS, Talbott JF, Chan AK, Dhall SS, El Naga AN, et al. Single versus dual operative spine fractures in ankylosing spondylitis. Neurosurg Focus. 2021; 51(4):E6. Rustagi T, Drazin D, Oner C, York J, Schroeder GD, Vaccaro AR, et al. Fractures in Spinal Ankylosing Disorders: A Narrative Review of Disease and Injury Types, Treatment Techniques, and Outcomes. J Orthop Trauma. 2017; 31 Suppl 4:S57-S74. Ye J, Jiang P, Guan H, Wei C, Li S, Jia M, et al. Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques. J Orthop Surg Res. 2022; 17(1):504. Kohler FC, Schenk P, Bechstedt-Schimske M, Ullrich BW, Klauke F, Hofmann GO, et al. Open versus minimally invasive fixation of thoracic and lumbar spine fractures in patients with ankylosing spinal diseases. Eur J Trauma Emerg Surg. 2022; 48(3):2297-307. Kai K, Ikuta K, Masuda K, Kitamura T, Senba H, Shidahara S. Surgical Outcomes of Minimally Invasive Stabilization for Spinal Fractures in Patients with Ankylosing Spinal Disorders. Asian Spine J. 2018; 12(3):434-41. Trungu S, Ricciardi L, Forcato S, Miscusi M, Raco A. Percutaneous instrumentation with cement augmentation for traumatic hyperextension thoracic and lumbar fractures in ankylosing spondylitis: a single-institution experience. Neurosurg Focus. 2021; 51(4):E8. Du SY, Dai J, Zhou ZT, Shan BC, Jiang FX, Yang JY, et al. Size selection and placement of pedicle screws using robot-assisted versus fluoroscopy-guided techniques for thoracolumbar fractures: possible implications for the screw loosening rate. BMC Surg. 2022; 22(1):365. Al Saiegh F, Leibold A, Mouchtouris N, Sabourin V, Stefanelli A, Franco D, et al. Robot-Assisted Instrumented Fusion of a T8-9 Extension Distraction Fracture and Epidural Hematoma Evacuation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown). 2020; 19(4):E420-E1. Suliman A, Wollstein R, Bernfeld B, Bruskin A. Robotic-assisted device in posterior spinal fusion for a high risk thoraculombar fracture in ankylosing spondylitis. Asian Spine J. 2014; 8(1):64-8. Shafi KA, Pompeu YA, Vaishnav AS, Mai E, Sivaganesan A, Shahi P, et al. Does robot-assisted navigation influence pedicle screw selection and accuracy in minimally invasive spine surgery? Neurosurg Focus. 2022; 52(1):E4. Keynan O, Fisher CG, Vaccaro A, Fehlings MG, Oner FC, Dietz J, et al. Radiographic measurement parameters in thoracolumbar fractures: a systematic review and consensus statement of the spine trauma study group. Spine (Phila Pa 1976). 2006; 31(5):E156-65. Ling T, Zhou B, Zhu C, Yang X, Song Y, Qiang Z, et al. One-stage posterior grade 4 osteotomy and bone graft fusion at pseudarthrosis for the treatment of kyphotic deformity with Andersson lesions in ankylosing spondylitis. Clin Neurol Neurosurg. 2017; 159:19-24. Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976). 1990; 15(1):11-4. Teunissen FR, Verbeek BM, Cha TD, Schwab JH. Spinal cord injury after traumatic spine fracture in patients with ankylosing spinal disorders. J Neurosurg Spine. 2017; 27(6):709-16. Wu M, Yan F, Ping A, Lei J. Effects of Andersson lesion treatment in ankylosing spondylitis: A medical record review study focused on medium- to long-term outcomes. Int J Rheum Dis. 2020; 23(6):753-62. Nakao Y, Sakuraba K, Harimaya K, Terada K, Kobara N, Kawaguchi KI, et al. Clinical features and outcomes of spine surgery in patients with ankylosing spondylitis. Mod Rheumatol. Published online December 5, 2022. Sapkas G, Kateros K, Papadakis SA, Galanakos S, Brilakis E, Machairas G, et al. Surgical outcome after spinal fractures in patients with ankylosing spondylitis. BMC Musculoskelet Disord. 2009; 10:96. Nayak NR, Pisapia JM, Abdullah KG, Schuster JM. Minimally Invasive Surgery for Traumatic Fractures in Ankylosing Spinal Diseases. Global Spine J. 2015; 5(4):266-73. Robinson Y, Willander J, Olerud C. Surgical Stabilization Improves Survival of Spinal Fractures Related to Ankylosing Spondylitis. Spine (Phila Pa 1976). 2015; 40(21):1697-702. Westerveld LA, van Bemmel JC, Dhert WJ, Oner FC, Verlaan JJ. Clinical outcome after traumatic spinal fractures in patients with ankylosing spinal disorders compared with control patients. Spine J. 2014; 14(5):729-40. Whang PG, Goldberg G, Lawrence JP, Hong J, Harrop JS, Anderson DG, et al. The management of spinal injuries in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis: a comparison of treatment methods and clinical outcomes. J Spinal Disord Tech. 2009; 22(2):77-85. Nugent M, Berney MJ, Morris S. Clinical outcomes following spinal fracture in patients with ankylosing spondylitis. Ir J Med Sci. 2017; 186(3):677-81. McCarty S, Bruckner JJ, Camacho JE, Jauregui JJ, Thomson AE, Ye I, et al. Comparison of Outcomes in Percutaneous Fixation of Traumatic Fractures between Ankylosing Spondylitis and Diffuse Idiopathic Skeletal Hyperostosis. Global Spine J. 2023;13(7): 1821-1828. Buxbaum RE, Shani A, Mulla H, Rod A, Rahamimov N. Percutaneous, PMMA-augmented, pedicle screw instrumentation of thoracolumbar ankylotic spine fractures. J Orthop Surg Res. 2021; 16(1):317. Bredin S, Fabre-Aubrespy M, Blondel B, Falguieres J, Schuller S, Walter A, et al. Percutaneous surgery for thoraco-lumbar fractures in ankylosing spondylitis: Study of 31 patients. Orthop Traumatol Surg Res. 2017; 103(8):1235-9. Yeoh D, Moffatt T, Karmani S. Good outcomes of percutaneous fixation of spinal fractures in ankylosing spinal disorders. Injury. 2014; 45(10):1534-8. Tian NF, Huang QS, Zhou P, Zhou Y, Wu RK, Lou Y, et al. Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies. Eur Spine J. 2011; 20(6):846-59. Brooks F, Rackham M, Williams B, Roy D, Lee YC, Selby M. Minimally invasive stabilization of the fractured ankylosed spine: a comparative case series study. J Spine Surg. 2018; 4(2):168-72. Richardson DB, Leuraud K, Laurier D, Gillies M, Haylock R, Kelly-Reif K, et al. Cancer mortality after low dose exposure to ionising radiation in workers in France, the United Kingdom, and the United States (INWORKS): cohort study. BMJ. 2023; 382:e074520. Mi C, Zhang X, Yang C, Wu J, Chen X, Ma C, et al. Bone disease imaging through the near-infrared-II window. Nat Commun. 2023; 14(1):6287. Burke JF, Tadepalli V, Chi J, Li XJ. Reduction and Stabilization of an Extension-Distraction Injury in a Patient with Ankylosing Spondylitis: A Case Report. JBJS Case Connect. 2022; 12(4). Huang JC, Xuan WB, Qian BP, Qiu Y, Wang B, Yu Y, et al. Pedicle Morphology of Lower Thoracic and Lumbar Spine in Ankylosing Spondylitis Patients with Thoracolumbar Kyphosis: A Comparison with Fracture Patients. Orthop Surg. 2022; 14(9):2188-94. Barkay G, Apterman S, Ackshota N, Shtewe AH, Sissman E, Friedlander A. Early surgery for thoracolumbar extension-type fractures in geriatric patients with ankylosing disorders reduces patient complications and mortality. Spine J. 2023; 23(1):157-62. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Jun, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 14 May, 2024 Reviews received at journal 08 May, 2024 Reviewers agreed at journal 05 May, 2024 Reviews received at journal 30 Apr, 2024 Reviews received at journal 21 Apr, 2024 Reviewers agreed at journal 15 Apr, 2024 Reviewers agreed at journal 11 Apr, 2024 Reviewers invited by journal 11 Apr, 2024 Editor assigned by journal 11 Apr, 2024 Editor invited by journal 10 Apr, 2024 Submission checks completed at journal 10 Apr, 2024 First submitted to journal 09 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4241368","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":290761391,"identity":"6660d587-1ecd-46f0-8ce8-df1a1cac785f","order_by":0,"name":"Zhi-Yuan Ye","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhi-Yuan","middleName":"","lastName":"Ye","suffix":""},{"id":290761392,"identity":"bdbdef5a-928b-43ca-8742-1ef2ab6b9382","order_by":1,"name":"Jin-Yu Bai","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jin-Yu","middleName":"","lastName":"Bai","suffix":""},{"id":290761393,"identity":"73c8b29c-85bc-4e24-8189-6613f25f4b4f","order_by":2,"name":"Zhi-Min Ye","email":"","orcid":"","institution":"Sihong Geriatric Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhi-Min","middleName":"","lastName":"Ye","suffix":""},{"id":290761394,"identity":"e87793c6-fb6d-4fc7-826f-9a0d39ea7dcc","order_by":3,"name":"Xu-Shen Zhao","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xu-Shen","middleName":"","lastName":"Zhao","suffix":""},{"id":290761395,"identity":"5195d5cd-cd0e-4498-b485-126feb1f14a2","order_by":4,"name":"Fang-Long Song","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fang-Long","middleName":"","lastName":"Song","suffix":""},{"id":290761396,"identity":"a0cb7a15-cb53-4562-91b6-1c5d09b84f53","order_by":5,"name":"Zhen-Tao Zhou","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhen-Tao","middleName":"","lastName":"Zhou","suffix":""},{"id":290761397,"identity":"256713cb-dfa2-4a5a-b3b5-4548bdf2acf1","order_by":6,"name":"Bing-Chen Shan","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bing-Chen","middleName":"","lastName":"Shan","suffix":""},{"id":290761398,"identity":"f2388a6d-0da0-4b7d-8f59-2af26be7851b","order_by":7,"name":"Xiao-Zhong Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYDACCTBpA8QJQMxGvJY00rUcJkGL/OzmY9I8f87bGxxPfsDwoewwA//sBvxaGOccS5OcwXM7ccOZZwaMM84dZpC4cwC/FmaJHDOJDxK3EwxuJBgw87YdZjCQSMCvhQ2kJcHgnL3BjfQPzH+J0cIDtiXhAOOGGzkGzIzEaJGQSEu2nHEgOXHmmTcFB3vOpfNI3CCgRX5G8sHbPH/s7PmOp2988KPMWo5/BgEtKOAAyKUkqB8Fo2AUjIJRgAsAAMgMQOCPp4+XAAAAAElFTkSuQmCC","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Xiao-Zhong","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2024-04-09 11:00:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4241368/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4241368/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-024-07597-6","type":"published","date":"2024-06-20T15:49:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55174821,"identity":"445e4253-01b2-44a8-b83b-ee3b2e928758","added_by":"auto","created_at":"2024-04-23 16:06:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":773165,"visible":true,"origin":"","legend":"\u003cp\u003eA 41-year-old man, who was diagnosed with an L2 fracture, had a history of low-impact trauma. (A-C) The preoperative planning involves determining the optimal trajectory for screw placement and selecting the appropriate size of pedicle screw. (D) The robotic manipulator was positioned on the bone-mounted platform, and the appropriate pedicle screws were inserted. Postoperative anteroposterior (E) and lateral radiographs (F), as well as transverse computed tomography scans (G-H), demonstrate satisfactory screw placement and sizing.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4241368/v1/9a373112f2d7cc6c5e71b1e7.jpg"},{"id":55174823,"identity":"647237ec-949e-41db-8e77-3b017bdd106c","added_by":"auto","created_at":"2024-04-23 16:06:39","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":738714,"visible":true,"origin":"","legend":"\u003cp\u003eA 51-year-old man was diagnosed with a T11 fracture after sustaining an injury from a fall. Lateral radiography (A) reveals morphological changes in the T11 vertebral body (arrow). Preoperative computed tomography (B-C) demonstrated a fracture traversing the T11 vertebral body, pedicle, and articular process (arrow). Preoperative magnetic resonance imaging (D) showing a 3-column injury at T11 (arrow). Postoperative plain radiographs (E-F) demonstrate satisfactory screw placement. Lateral radiography (G-H) showed that the fracture had healed two years after the operation, and the internal fixation had been removed.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4241368/v1/0e4ebc528e6a15fd4409d5bd.jpg"},{"id":55174822,"identity":"b1f45bc2-04b0-4053-b71f-306b94633168","added_by":"auto","created_at":"2024-04-23 16:06:38","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":179077,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative computed tomography (A-B) revealed that the screws were positioned outside the lateral wall of the pedicle.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4241368/v1/5b981a1b75ea76525212b80c.jpg"},{"id":58823689,"identity":"9a366bee-1582-4d29-b949-96084835d05b","added_by":"auto","created_at":"2024-06-21 17:05:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2330982,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4241368/v1/62915654-4555-46ac-b1d0-a5e120cce584.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with ankylosing spondylitis","fulltext":[{"header":"Background","content":"\u003cp\u003eAnkylosing Spondylitis (AS) is a chronic inflammatory disease which is characterized by pain and progressive stiffness[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Considering the unique characteristics of spinal fusion, osteoporosis, and spinal deformities in AS patients, individuals affected by these conditions are more prone to experiencing fractures even with minimal force impact[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The prevalence of spinal fractures in patients with AS is believed to be four times higher than that in healthy individuals[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Because these fractures often occur after minor trauma and in individuals with pre-existing chronic back pain, reaching a diagnosis is often challenging and may result in secondary neurological deficits[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe spinal fractures in patients with AS are predominantly unstable, involving all three columns of the spine, which require effective treatment in the early stage[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Due to the prevalence of unstable injuries and a higher occurrence of neurological symptoms, surgical intervention is often considered essential[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The traditional posterior open surgery is the classic treatment for AS, which achieves good clinical results[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, due to the inflammatory reaction and osteoporosis of the disease itself, extensive dissection of paraspinal muscles during the operation will leads to increased bleeding, prolonged operation time, and an increased risk of postoperative infection[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, there has been an increasing inclination towards the utilization of percutaneous techniques for spinal fracture instrumentation. This approach offers advantages such as reduced surgical duration, minimal blood loss, and shorter hospital stays for individuals with AS who have thoracolumbar fractures[\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, in patients with AS, the significant alterations in bony structure and anatomy result in a lack of identifiable landmarks, which increases the difficulty of pedicle screw implantation and imposes demanding technical requirements on the operator[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, robot-assisted surgical fixation for AS combined with thoracolumbar fractures has become possible, because it has been confirmed to have the advantages of minimizing radiation exposure and improving the accuracy of screw placement in the treatment of common spinal fractures[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In addition, by utilizing robotic assistance, surgeons have the flexibility to select screws with a larger diameter and increased length[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This theoretically provides a more stable healing environment for thoracolumbar fractures in patients with AS.\u003c/p\u003e \u003cp\u003eHere, we present a study on patients with AS who underwent robotic-assisted percutaneous fixation for thoracolumbar fractures. To the best of our knowledge, this is the first case series investigating the clinical effect of robotic-assisted percutaneous fixation in treating thoracolumbar fractures in AS patients, which may provide a new treatment option. We thoroughly analyze our results, focusing on outcomes and complications, and compare them to previously published data.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Second Affiliated Hospital of Soochow University, and all patients understood and completing a consent form. filled in an informed consent form. A retrospective review was conducted on all patients diagnosed with thoracolumbar fractures in AS who underwent robotic-assisted percutaneous fixation at our institution from October 2018 to October 2022. All patients received plain radiography, computed tomography (CT), magnetic resonance imaging, and a physical examination by a spinal surgeon upon their admission to the hospital. Patients who had a delay of over 24 hours in receiving a diagnosis for their fractures were classified as having experienced a delayed identification. Diagnosis was made based on clinical and radiographic assessment. The AO Spine Thoracolumbar Spine Injury Classification System was utilized for the categorization of spinal fractures. Neurological impairments were evaluated using the American Spinal Injury Association (ASIA) grading system. Age, gender, trauma history, fracture level, delayed diagnosis, duration between diagnosis and operation, body mass index and C-reactive protein levels were recorded (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e \u003cstrong\u003ePatient demographics and case details\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eGender (F/M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eTrauma history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eFracture level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eAO classification\u003c/p\u003e\n \u003cp\u003e(fracture type)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA grade\u003c/p\u003e\n \u003cp\u003epreoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eDelayed\u003c/p\u003e\n \u003cp\u003ediagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003eDays between\u003c/p\u003e\n \u003cp\u003ediagnosis and operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eCRP (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eL2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e32.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eFall from ladder\u003c/p\u003e\n \u003cp\u003e(high impact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eT5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e171.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e24.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eL1、L2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e25.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e23.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eFall from standing\u003c/p\u003e\n \u003cp\u003e(low impact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eL3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e100.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e25.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eT10、T11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e51.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e27.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eFall from standing\u003c/p\u003e\n \u003cp\u003e(low impact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eT12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e57.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e25.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eFall from standing\u003c/p\u003e\n \u003cp\u003e(low impact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eT12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e60.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e26.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eL1、L2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e25.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eFall from ladder\u003c/p\u003e\n \u003cp\u003e(high impact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eT10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e23.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eFall from standing\u003c/p\u003e\n \u003cp\u003e(low impact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eL2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e110.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e24.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eFall from standing\u003c/p\u003e\n \u003cp\u003e(low impact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eL2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e98.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e20.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.319148936170213%\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eFall from standing\u003c/p\u003e\n \u003cp\u003e(low impact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eT11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.638297872340425%\"\u003e\n \u003cp\u003eASIA E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e43.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\n \u003cp\u003e19.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eF, female; M, male; L, lumbar; T, thoracic; BMI, body mass index; CRP, C-reactive protein; ASIA, American Spinal Injury Association\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows: 1. AS was diagnosed based on the modified New York criteria; 2. the imaging findings were thoracolumbar fracture; 3. the patient underwent posterior robotic-assisted percutaneous fixation for treatment. The exclusion criteria were as follows: 1. The patient was treated conservatively or with other procedures without robotic assistance; 2. the patient has thoracolumbar fracture combined with multiple concomitant fractures; 3. the patient is unable to tolerate surgery for personal reasons; 4. the incompleteness of radiological information, treatment details, and follow-up data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgical procedures were performed on a specially designed flexible operating bed with the patient in a prone position and under general anesthesia. Sufficient cushioning was applied to accommodate the kyphotic deformity and minimize the risk of spinal cord injury. The CT scan of the surgical area was sent to the workstation prior to the operation (Renaissance; Mazor Robotics Ltd., Caesarea, Israel). The surgeon\u0026apos;s requests for precise vertebral trajectories and screw dimensions were meticulously planned one day prior to the surgery (Figure 1A-C). During the preparation surgery, registration was performed using anteroposterior and oblique plane images in order to automatically merge them with the preoperative CT. The next step involved positioning a compact robotic manipulator (400 g, 9 cm tall, 5 cm diameter) onto the bone-mounted platform, ensuring that it was precisely aligned with the planned trajectory, following the surgeon\u0026apos;s instructions (Figure 1D). After tapping the screw paths with a thread tap through the expanded channels, the screw was manually inserted following the guide wire. The rods were percutaneously inserted from the upper side to the lower side, with the assistance of a screw extender.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollow-up evaluations were conducted at 1, 3, 6, and 12-month intervals after the surgical procedure, with additional yearly assessments if necessary. The effectiveness of the treatment was assessed using the Visual Analogue Scale (VAS) for quantifying back pain severity, the Oswestry Disability Index (ODI) for evaluating disability, and the modified MacNab score to determine postoperative results during the most recent follow-up period. Neurological status was evaluated using the ASIA classification system. The collection of complications was conducted during both the intraoperative and postoperative periods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRadiographical assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRadiographic assessment included the evaluation of the sagittal Cobb angle, bone fusion status and pedicle screw placement. The sagittal Cobb angle is used to assess the achieved operative correction. It is defined as the angular measurement between a line parallel to the superior end plate of the vertebra located above the fracture and another line parallel to the inferior end plate of the vertebra positioned one level below the fracture[17]. Bone fusion is defined as the blurring of the fracture line on radiographs, the formation of bridging bone (Figure 2), or the appearance of a trabecular pattern across the fracture site on CT imaging[12, 18]. The placement of the pedicle screws was assessed by utilizing axial CT scans and categorized according to the grading system of Gertzbein and Robbins[19]. The criteria for implant failure include screw breakage, screw pullout, peri-implant loosening, and rod breakage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative variables were presented using numerical values and percentages, while quantitative variables were expressed as the mean \u0026plusmn; standard deviation or median. Paired sample t-tests were utilized to compare preoperative and postoperative measurements, with statistical significance defined as P\u0026lt;0.05. The statistical analyses were conducted using IBM SPSS Statistics 27.0 software.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSurgical results\u003c/h2\u003e \u003cp\u003eAll patients, including 11 males and one female, underwent posterior robotic-assisted percutaneous fixation. The average age was 62.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.0 years, and the average duration of postoperative follow-up was 32.7\u0026thinsp;\u0026plusmn;\u0026thinsp;18.9 months. The mechanism of injury was identified as low energy or no trauma history in 83% (n\u0026thinsp;=\u0026thinsp;10), while a high energy injury was noted in 17% (n\u0026thinsp;=\u0026thinsp;2). Fractures classified by the AO classification were B2 in 25% (n\u0026thinsp;=\u0026thinsp;3) and B3 in 75% (n\u0026thinsp;=\u0026thinsp;9) patients. Delayed diagnosis was present in 58% (n\u0026thinsp;=\u0026thinsp;7) of patients, including 1 (14%) patient who experienced neurologic deterioration and 3 (43%) patients with secondary pseudarthrosis. Delay of surgery (\u0026gt;\u0026thinsp;72 hours) occurred in 8 (67%) patients. The mean operative time was 119.6\u0026thinsp;\u0026plusmn;\u0026thinsp;32.2 min, and the median blood loss was 50 (50, 250) ml. The average change in hemoglobin concentration before and after surgery was 1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 g/dl. Mean hospital stay duration was 15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0 days. One patient experienced delayed neurologic deficit after surgery, resulting in a change of grade from ASIA E to ASIA C. The patient underwent emergency spinal canal decompression with the assistance of a microscope, as it was determined that the cause was compression caused by a hematoma, and the neurological status returned to normal after 2 weeks. The remaining patients did not experience any postoperative complications, and there were no deaths during the follow-up period (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical treatment and outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternal\u003c/p\u003e \u003cp\u003estabilization\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003cp\u003etime (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHemorrhage\u003c/p\u003e \u003cp\u003e(ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePerioperative\u003c/p\u003e \u003cp\u003ecomplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003cp\u003eduring FU\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLength of\u003c/p\u003e \u003cp\u003ehospital stay (day)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTime of bony union (mon)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT10-L4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT3-8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT12-L3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL1-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT9-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT10-L2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes (neurological deficit)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT10-L2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT12-L3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT9-T12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT12-L4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT12-L4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT9-L1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eL, lumbar; T, thoracic; FU, follow-up.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eClinical results\u003c/h2\u003e \u003cp\u003eAll patients expressed satisfaction with the outcome of the surgery and reported a reduction in their back discomfort. The preoperative VAS value showed a significant improvement, decreasing from 6.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9 to 1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 the final follow-up (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Similarly, the ODI value demonstrated a remarkable enhancement, reducing from 83.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1% before surgery to 11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6% at the most recent follow-up (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Based on the modified Macnab criteria, clinical efficacy was assessed as excellent in 10 cases and good in 2 cases during the most recent follow-up evaluation. One patient who had ASIA D neurologic deficit before surgery improved to ASIA E, and the internal fixation was removed 2 years after the operation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative and Last Follow-up Patient Data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast follow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eODI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e83.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCobb angle (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eVAS, visual analogue scale; ODI, oswestry disability index.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRadiologic findings\u003c/h2\u003e \u003cp\u003eAll patients achieved successful fracture healing, and no patient experienced implant failure. Out of the 108 screws implanted, 2 (1.9%) were improperly positioned, and both screws were located outside the lateral wall of the pedicle (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). One patient did not have any clinical manifestations, so we did not perform further revision. Another patient experienced delayed neurologic deficit one day after surgery and underwent emergency spinal canal decompression. Although the cause was determined to be compression caused by a hematoma, we still repositioned the screw. The Cobb angle changed from 15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0 preoperatively to 8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 at the final follow-up (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSpinal fractures can occur in patients with AS even under low-energy impact, predominantly resulting in instability and involving all three columns of the spine, which presents a challenge for surgeons in terms of treatment[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, fractures such as these may frequently go undetected on plain radiography and be masked by common symptoms in AS, leading to a delay in diagnosis[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It has been reported that delayed diagnosis was observed in 17.1\u0026ndash;65.4% of cases with AS vertebral fractures[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and one-third of patients developed neurologic deficits[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Furthermore, this delay in diagnosis may result in non-union of the fracture, leading to thoracolumbar pseudarthrosis[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our series, delayed diagnosis was present in 58% (n\u0026thinsp;=\u0026thinsp;7) of patients, including 1 (14%) patient who experienced neurologic deterioration and 3 (43%) patients with secondary pseudarthrosis. The findings were consistent with those of previous studies. As previous studies have shown, there was a presence of both doctor's delay and patient's delay in the diagnostic process[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. None of our patients experienced a delay in diagnosis due to the physician, which may be because we have been aware of the concealment and harmfulness with these spinal fractures and remained vigilant. However, there is still a need for improvement in the understanding of AS combined with spinal fractures. Especially for patients themselves, it is necessary to promptly seek medical advice when the nature of pain changes.\u003c/p\u003e \u003cp\u003eThe effectiveness of conservative treatment is limited and often results in suboptimal outcomes, which may include the use of braces, rest, and anti-inflammatory drugs[\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Due to the frequent occurrence of unstable injuries and a higher probability of encountering neurological symptoms, internal fixation is often considered necessary.\u003c/p\u003e \u003cp\u003eThe study conducted by Robinson et al.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] demonstrated that surgical treatment could significantly improve patients' survival rates. Additionally, Westerveld et al.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] discovered that surgical treatment can enhance patients' neurological function to some extent. Therefore, we recommend surgery in the absence of any surgical contraindications. The traditional posterior open surgery is a classic treatment method that also yields favorable clinical outcomes[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, the surgical trauma is significant and there are more postoperative complications[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Nugent et al.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and Nakao et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported surgical complications with incidences of 64% and 30.8%, respectively.\u003c/p\u003e \u003cp\u003eIn recent years, minimally invasive surgery has been recognized by the majority of doctors, especially for elderly AS patients with more underlying diseases. It can achieve better clinical results and reduce the occurrence of surgical complications[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Ye et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] demonstrated that minimally invasive surgery can achieve effects similar to those of traditional open surgery, while reducing bleeding, trauma, and postoperative complications. Additionally, bone cement was used to enhance the screw holding force and prevent screw loosening in patients with severe osteoporosis[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, in patients with AS, the significant alterations in bony structure and anatomy result in a lack of identifiable landmarks, especially in the upper thoracic spine[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Therefore, acquiring high-quality intra-operative images can present challenges and impose rigorous technical demands on the operator, especially in minimally invasive surgery[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Bredin et al.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] used a percutaneous technique to implant 228 pedicle screws, 6 (2.6%) of which were poorly positioned, including 1 within the spinal canal. According to a meta-analysis, Tian et al.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] found that the incidence of screw malposition ranged from 10\u0026ndash;31% when conventional techniques were used for pedicle screw insertion. In our series, the pedicle screw was implanted with the assistance of a robot and the accuracy rate was 98.1%, which surpasses the outcomes documented in previous studies[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This finding also demonstrates the benefits of robot-assisted screw placement precision, thereby enhancing the safety of surgical treatment for patients with AS combined with thoracolumbar fractures. However, two pedicle screws remained positioned outside the lateral wall of the pedicle, and one underwent revision. The possible reason could be that the robot is not securely fixed, leading to guide pin slippage upon insertion due to bone sclerosis. Therefore, based on our experiential learning, we recommend slowly inserting the guide pin into the bone upon contact with the bone surface at maximum rotation speed. Fluoroscopy should be performed again after all screws placement to evaluate the position of the screw.\u003c/p\u003e \u003cp\u003eThe repeated use of intraoperative fluoroscopy is essential for achieving more precise screw positioning, particularly in minimally invasive procedures performed on patients with AS[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Brooks et al.[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] demonstrated that minimally invasive surgery significantly increased intraoperative radiation exposure compared to traditional open surgery. Additionally, Kai et al.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] identified radiation exposure as the only drawback of minimally invasive surgery in AS patients due to the increased difficulty in obtaining high-quality intraoperative images in the spine. The latest findings also indicate that prolonged exposure to low levels of radiation significantly increases the risk of mortality from solid tumors, causes damage to DNA and death of leukocytes, and has been classified as a \"known human carcinogen\" by the World Health Organization[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Therefore, it is necessary to enhance occupational protection measures and reduce medical radiation exposure. In our study, the use of robot-assisted screw placement eliminates the need for repeated fluoroscopy during surgery, thereby significantly reducing radiation exposure. This finding has also been observed in other studies[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In the future, we will continue to closely monitor intraoperative radiation exposure, further present radiation-related data, and conduct controlled studies.\u003c/p\u003e \u003cp\u003eThe clinical outcomes of our robot-assisted percutaneous fixation technique are consistent with previous studies on minimally invasive surgery, demonstrating consistently favorable results[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The VAS and ODI values were 1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 and 11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6%, respectively, at the most recent follow-up. All patients successfully achieved union of the fracture, and there were no occurrences of implant failure. This is probably because we applied a robot-assisted technique to plan the trajectory of the screw and select a larger-sized screw in advance, achieving maximum fixation strength while maintaining the structural integrity of the vertebral pedicles[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Barkay et al.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] demonstrated that postponing surgical intervention (\u0026gt;\u0026thinsp;72 hours) in elderly patients with spinal ankylosing disorders may lead to an increase in medical complications and mortality. In our study, surgery was delayed in 8 (67%) patients; however, no patients died, and the incidence of postoperative complications was 8.3%, which was lower than that reported in other studies[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This could potentially be attributed to the limited sample size of participants in our research or the use of robot-assisted technology, which improves work efficiency and promotes early rehabilitation. One patient experienced delayed neurological deficits due to hematoma compression after surgery; fortunately, the neurological status returned to normal following spinal canal decompression surgery. From this, it can be inferred that robot-assisted surgery has the potential to enhance operational efficiency and mitigate complications. However, it is imperative not to disregard the limitations of minimally invasive surgery in terms of detecting deep tissue hemorrhage and ensuring prompt and effective hemostasis.\u003c/p\u003e \u003cp\u003eThere were several limitations in our study. First, it was a retrospective study. Secondly, the study's limited sample size emphasizes the need for future research with larger sample sizes to replicate these findings. Thirdly, we did not present data such as intraoperative fluoroscopy and specific screw size. Controlled studies with large samples are needed to further clarify the advantages of robot-assisted technology in the treatment of thoracolumbar fractures with AS. Finally, the relatively high cost of robot-assisted treatment necessitates a comprehensive evaluation of the need for such technology.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePosterior robotic-assisted percutaneous internal fixation can achieve satisfactory outcomes for thoracolumbar fractures in patients with AS. However, while robot-assisted pedicle screw placement can enhance the accuracy of pedicle screw insertion, it should not be relied upon solely.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT: Computed tomography\u003c/p\u003e\n\u003cp\u003eAS: Ankylosing spondylitis\u003c/p\u003e\n\u003cp\u003eVAS: Visual analogue scale\u003c/p\u003e\n\u003cp\u003eODI: Oswestry disability index\u003c/p\u003e\n\u003cp\u003eASIA: American Spinal Injury Association\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Second Affiliated Hospital of Soochow University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was sponsored by the National Natural Science Foundation of China (81873995, 82172425), the Project for Suzhou Orthopedic Clinical Center (Szlcyxzxj202104), and the Social Development Key Programs of Jiangsu Province (JSDW202223).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXZZ contributed to the study conception and design. ZYY, XSZ, FLS, and ZTZ contributed to clinical data collection; JYB, ZMY, and BCS contributed to radiological data analysis; ZYY contributed to statistical analysis; ZYY, JYB, and ZMY contributed to the writing and editing. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSchiefer TK, Milligan BD, Bracken CD, Jacob JT, Krauss WE, Pichelmann MA, et al. In-hospital neurologic deterioration following fractures of the ankylosed spine: a single-institution experience. World Neurosurg.\u003cem\u003e \u003c/em\u003e2015; 83(5):775-83.\u003c/li\u003e\n\u003cli\u003eTu PH, Liu ZH, Yeap MC, Liu YT, Li YC, Huang YC, et al. Spinal cord injury and spinal fracture in patients with ankylosing spondylitis. BMC Emerg Med.\u003cem\u003e \u003c/em\u003e2022; 22(1):73.\u003c/li\u003e\n\u003cli\u003eAlhashash M, Shousha M, Heyde CE, von der Hoh NH. Cervical spine fractures in ankylosing spondylitis patients: an analysis of the presentation and clinical results of 110 surgically managed patients in two spine centers. Eur Spine J.\u003cem\u003e \u003c/em\u003e2023; 32(6):2131-9.\u003c/li\u003e\n\u003cli\u003eTang Z, Chen T, Tan J, Zhang H. Surgical Outcomes and Prognostic Factors for Cervical Spine Fractures in Patients with Ankylosing Spondylitis. World Neurosurg.\u003cem\u003e \u003c/em\u003e2022; 166:e278-e84.\u003c/li\u003e\n\u003cli\u003eWesterveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J.\u003cem\u003e \u003c/em\u003e2009; 18(2):145-56.\u003c/li\u003e\n\u003cli\u003eRen C, Zhu Q, Yuan H. Imaging features of spinal fractures in ankylosing spondylitis and the diagnostic value of different imaging methods. Quant Imaging Med Surg.\u003cem\u003e \u003c/em\u003e2021; 11(6):2499-508.\u003c/li\u003e\n\u003cli\u003eLu AY, Blitstein JS, Talbott JF, Chan AK, Dhall SS, El Naga AN, et al. Single versus dual operative spine fractures in ankylosing spondylitis. Neurosurg Focus.\u003cem\u003e \u003c/em\u003e2021; 51(4):E6.\u003c/li\u003e\n\u003cli\u003eRustagi T, Drazin D, Oner C, York J, Schroeder GD, Vaccaro AR, et al. Fractures in Spinal Ankylosing Disorders: A Narrative Review of Disease and Injury Types, Treatment Techniques, and Outcomes. J Orthop Trauma.\u003cem\u003e \u003c/em\u003e2017; 31 Suppl 4:S57-S74.\u003c/li\u003e\n\u003cli\u003eYe J, Jiang P, Guan H, Wei C, Li S, Jia M, et al. Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques. J Orthop Surg Res.\u003cem\u003e \u003c/em\u003e2022; 17(1):504.\u003c/li\u003e\n\u003cli\u003eKohler FC, Schenk P, Bechstedt-Schimske M, Ullrich BW, Klauke F, Hofmann GO, et al. Open versus minimally invasive fixation of thoracic and lumbar spine fractures in patients with ankylosing spinal diseases. Eur J Trauma Emerg Surg.\u003cem\u003e \u003c/em\u003e2022; 48(3):2297-307.\u003c/li\u003e\n\u003cli\u003eKai K, Ikuta K, Masuda K, Kitamura T, Senba H, Shidahara S. Surgical Outcomes of Minimally Invasive Stabilization for Spinal Fractures in Patients with Ankylosing Spinal Disorders. Asian Spine J.\u003cem\u003e \u003c/em\u003e2018; 12(3):434-41.\u003c/li\u003e\n\u003cli\u003eTrungu S, Ricciardi L, Forcato S, Miscusi M, Raco A. Percutaneous instrumentation with cement augmentation for traumatic hyperextension thoracic and lumbar fractures in ankylosing spondylitis: a single-institution experience. Neurosurg Focus.\u003cem\u003e \u003c/em\u003e2021; 51(4):E8.\u003c/li\u003e\n\u003cli\u003eDu SY, Dai J, Zhou ZT, Shan BC, Jiang FX, Yang JY, et al. Size selection and placement of pedicle screws using robot-assisted versus fluoroscopy-guided techniques for thoracolumbar fractures: possible implications for the screw loosening rate. BMC Surg.\u003cem\u003e \u003c/em\u003e2022; 22(1):365.\u003c/li\u003e\n\u003cli\u003eAl Saiegh F, Leibold A, Mouchtouris N, Sabourin V, Stefanelli A, Franco D, et al. Robot-Assisted Instrumented Fusion of a T8-9 Extension Distraction Fracture and Epidural Hematoma Evacuation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown).\u003cem\u003e \u003c/em\u003e2020; 19(4):E420-E1.\u003c/li\u003e\n\u003cli\u003eSuliman A, Wollstein R, Bernfeld B, Bruskin A. Robotic-assisted device in posterior spinal fusion for a high risk thoraculombar fracture in ankylosing spondylitis. Asian Spine J.\u003cem\u003e \u003c/em\u003e2014; 8(1):64-8.\u003c/li\u003e\n\u003cli\u003eShafi KA, Pompeu YA, Vaishnav AS, Mai E, Sivaganesan A, Shahi P, et al. Does robot-assisted navigation influence pedicle screw selection and accuracy in minimally invasive spine surgery? Neurosurg Focus.\u003cem\u003e \u003c/em\u003e2022; 52(1):E4.\u003c/li\u003e\n\u003cli\u003eKeynan O, Fisher CG, Vaccaro A, Fehlings MG, Oner FC, Dietz J, et al. Radiographic measurement parameters in thoracolumbar fractures: a systematic review and consensus statement of the spine trauma study group. Spine (Phila Pa 1976).\u003cem\u003e \u003c/em\u003e2006; 31(5):E156-65.\u003c/li\u003e\n\u003cli\u003eLing T, Zhou B, Zhu C, Yang X, Song Y, Qiang Z, et al. One-stage posterior grade 4 osteotomy and bone graft fusion at pseudarthrosis for the treatment of kyphotic deformity with Andersson lesions in ankylosing spondylitis. Clin Neurol Neurosurg.\u003cem\u003e \u003c/em\u003e2017; 159:19-24.\u003c/li\u003e\n\u003cli\u003eGertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976).\u003cem\u003e \u003c/em\u003e1990; 15(1):11-4.\u003c/li\u003e\n\u003cli\u003eTeunissen FR, Verbeek BM, Cha TD, Schwab JH. Spinal cord injury after traumatic spine fracture in patients with ankylosing spinal disorders. J Neurosurg Spine.\u003cem\u003e \u003c/em\u003e2017; 27(6):709-16.\u003c/li\u003e\n\u003cli\u003eWu M, Yan F, Ping A, Lei J. Effects of Andersson lesion treatment in ankylosing spondylitis: A medical record review study focused on medium- to long-term outcomes. Int J Rheum Dis.\u003cem\u003e \u003c/em\u003e2020; 23(6):753-62.\u003c/li\u003e\n\u003cli\u003eNakao Y, Sakuraba K, Harimaya K, Terada K, Kobara N, Kawaguchi KI, et al. Clinical features and outcomes of spine surgery in patients with ankylosing spondylitis. Mod Rheumatol.\u003cem\u003e \u003c/em\u003ePublished online December 5, 2022.\u003c/li\u003e\n\u003cli\u003eSapkas G, Kateros K, Papadakis SA, Galanakos S, Brilakis E, Machairas G, et al. Surgical outcome after spinal fractures in patients with ankylosing spondylitis. BMC Musculoskelet Disord.\u003cem\u003e \u003c/em\u003e2009; 10:96.\u003c/li\u003e\n\u003cli\u003eNayak NR, Pisapia JM, Abdullah KG, Schuster JM. Minimally Invasive Surgery for Traumatic Fractures in Ankylosing Spinal Diseases. Global Spine J.\u003cem\u003e \u003c/em\u003e2015; 5(4):266-73.\u003c/li\u003e\n\u003cli\u003eRobinson Y, Willander J, Olerud C. Surgical Stabilization Improves Survival of Spinal Fractures Related to Ankylosing Spondylitis. Spine (Phila Pa 1976).\u003cem\u003e \u003c/em\u003e2015; 40(21):1697-702.\u003c/li\u003e\n\u003cli\u003eWesterveld LA, van Bemmel JC, Dhert WJ, Oner FC, Verlaan JJ. Clinical outcome after traumatic spinal fractures in patients with ankylosing spinal disorders compared with control patients. Spine J.\u003cem\u003e \u003c/em\u003e2014; 14(5):729-40.\u003c/li\u003e\n\u003cli\u003eWhang PG, Goldberg G, Lawrence JP, Hong J, Harrop JS, Anderson DG, et al. The management of spinal injuries in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis: a comparison of treatment methods and clinical outcomes. J Spinal Disord Tech.\u003cem\u003e \u003c/em\u003e2009; 22(2):77-85.\u003c/li\u003e\n\u003cli\u003eNugent M, Berney MJ, Morris S. Clinical outcomes following spinal fracture in patients with ankylosing spondylitis. Ir J Med Sci.\u003cem\u003e \u003c/em\u003e2017; 186(3):677-81.\u003c/li\u003e\n\u003cli\u003eMcCarty S, Bruckner JJ, Camacho JE, Jauregui JJ, Thomson AE, Ye I, et al. Comparison of Outcomes in Percutaneous Fixation of Traumatic Fractures between Ankylosing Spondylitis and Diffuse Idiopathic Skeletal Hyperostosis. Global Spine J.\u003cem\u003e \u003c/em\u003e2023;13(7): 1821-1828.\u003c/li\u003e\n\u003cli\u003eBuxbaum RE, Shani A, Mulla H, Rod A, Rahamimov N. Percutaneous, PMMA-augmented, pedicle screw instrumentation of thoracolumbar ankylotic spine fractures. J Orthop Surg Res.\u003cem\u003e \u003c/em\u003e2021; 16(1):317.\u003c/li\u003e\n\u003cli\u003eBredin S, Fabre-Aubrespy M, Blondel B, Falguieres J, Schuller S, Walter A, et al. Percutaneous surgery for thoraco-lumbar fractures in ankylosing spondylitis: Study of 31 patients. Orthop Traumatol Surg Res.\u003cem\u003e \u003c/em\u003e2017; 103(8):1235-9.\u003c/li\u003e\n\u003cli\u003eYeoh D, Moffatt T, Karmani S. Good outcomes of percutaneous fixation of spinal fractures in ankylosing spinal disorders. Injury.\u003cem\u003e \u003c/em\u003e2014; 45(10):1534-8.\u003c/li\u003e\n\u003cli\u003eTian NF, Huang QS, Zhou P, Zhou Y, Wu RK, Lou Y, et al. Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies. Eur Spine J.\u003cem\u003e \u003c/em\u003e2011; 20(6):846-59.\u003c/li\u003e\n\u003cli\u003eBrooks F, Rackham M, Williams B, Roy D, Lee YC, Selby M. Minimally invasive stabilization of the fractured ankylosed spine: a comparative case series study. J Spine Surg.\u003cem\u003e \u003c/em\u003e2018; 4(2):168-72.\u003c/li\u003e\n\u003cli\u003eRichardson DB, Leuraud K, Laurier D, Gillies M, Haylock R, Kelly-Reif K, et al. Cancer mortality after low dose exposure to ionising radiation in workers in France, the United Kingdom, and the United States (INWORKS): cohort study. BMJ.\u003cem\u003e \u003c/em\u003e2023; 382:e074520.\u003c/li\u003e\n\u003cli\u003eMi C, Zhang X, Yang C, Wu J, Chen X, Ma C, et al. Bone disease imaging through the near-infrared-II window. Nat Commun.\u003cem\u003e \u003c/em\u003e2023; 14(1):6287.\u003c/li\u003e\n\u003cli\u003eBurke JF, Tadepalli V, Chi J, Li XJ. Reduction and Stabilization of an Extension-Distraction Injury in a Patient with Ankylosing Spondylitis: A Case Report. JBJS Case Connect.\u003cem\u003e \u003c/em\u003e2022; 12(4).\u003c/li\u003e\n\u003cli\u003eHuang JC, Xuan WB, Qian BP, Qiu Y, Wang B, Yu Y, et al. Pedicle Morphology of Lower Thoracic and Lumbar Spine in Ankylosing Spondylitis Patients with Thoracolumbar Kyphosis: A Comparison with Fracture Patients. Orthop Surg.\u003cem\u003e \u003c/em\u003e2022; 14(9):2188-94.\u003c/li\u003e\n\u003cli\u003eBarkay G, Apterman S, Ackshota N, Shtewe AH, Sissman E, Friedlander A. Early surgery for thoracolumbar extension-type fractures in geriatric patients with ankylosing disorders reduces patient complications and mortality. Spine J.\u003cem\u003e \u003c/em\u003e2023; 23(1):157-62.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ankylosing spondylitis, thoracolumbar fractures, surgical outcomes, percutaneous techniques, robot","lastPublishedDoi":"10.21203/rs.3.rs-4241368/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4241368/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSpinal fractures in patients with ankylosing spondylitis (AS) mainly present as instability, involving all three columns of the spine, and surgical intervention is often considered necessary. However, in AS patients, the significant alterations in bony structure and anatomy result in a lack of identifiable landmarks, which increases the difficulty of pedicle screw implantation. Therefore, we present the clinical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with AS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA retrospective review was conducted on a series of 12 patients diagnosed with AS. All patients sustained thoracolumbar fractures between October 2018 and October 2022 and underwent posterior robotic-assisted percutaneous fixation procedures. Outcomes of interest included operative time, intra-operative blood loss, complications, duration of hospital stay and fracture union. The clinical outcomes were assessed using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). To investigate the achieved operative correction, pre- and postoperative radiographs in the lateral plane were analyzed by measuring the Cobb angle.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe 12 patients had a mean age of 62.8±13.0 years and a mean follow-up duration of 32.7±18.9 months. Mean hospital stay duration was 15±8.0 days. The mean operative time was 119.6±32.2 min, and the median blood loss was 50 (50, 250) ml. The VAS value improved from 6.8±0.9 preoperatively to 1.3±1.0 at the final follow-up (P\u0026lt;0.05). The ODI value improved from 83.6±6.1% preoperatively to 11.8±6.6% at the latest follow-up (P\u0026lt;0.05). The average Cobb angle changed from 15.2±11.0 pre-operatively to 8.3±7.1 at final follow-up (P\u0026lt;0.05). Bone healing was consistently achieved. Of the 108 screws implanted, 2 (1.9%) were improperly positioned. One patient experienced delayed nerve injury after the operation, but the nerve function returned to normal upon discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Posterior robotic-assisted percutaneous internal fixation can be used as an ideal surgical treatment for thoracolumbar fractures in AS patients. However, while robot-assisted pedicle screw placement can enhance the accuracy of pedicle screw insertion, it should not be relied upon solely.\u003c/p\u003e","manuscriptTitle":"Surgical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with ankylosing spondylitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-23 16:06:33","doi":"10.21203/rs.3.rs-4241368/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-14T14:59:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-08T05:41:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95932601208228321573441049807003041943","date":"2024-05-05T12:56:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-30T11:18:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-21T15:05:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13ace37f-5240-49ea-84fb-c0a74f0c15fe","date":"2024-04-15T10:09:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"c1ad99ce-7c1c-4ec4-8078-5c90b1ce662b","date":"2024-04-11T10:51:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-11T08:01:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-11T07:57:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-11T03:58:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-11T03:57:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-04-09T10:58:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bca67444-176b-472a-afd2-ee82efdaf2d3","owner":[],"postedDate":"April 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T15:49:06+00:00","versionOfRecord":{"articleIdentity":"rs-4241368","link":"https://doi.org/10.1186/s12891-024-07597-6","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2024-06-20 15:49:06","publishedOnDateReadable":"June 20th, 2024"},"versionCreatedAt":"2024-04-23 16:06:33","video":"","vorDoi":"10.1186/s12891-024-07597-6","vorDoiUrl":"https://doi.org/10.1186/s12891-024-07597-6","workflowStages":[]},"version":"v1","identity":"rs-4241368","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4241368","identity":"rs-4241368","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}