Ankylosing Spondylitis: Special Considerations and Clinical Outcomes in Surgical Management of Spinal Fractures, Case Series and Analysis of Twenty Patients

Ankylosing Spondylitis: Special Considerations and Clinical Outcomes in Surgical Management of Spinal Fractures, Case Series and Analysis of Twenty Patients | 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 Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ankylosing Spondylitis: Special Considerations and Clinical Outcomes in Surgical Management of Spinal Fractures, Case Series and Analysis of Twenty Patients Majid Reza Farrokhi, Keyvan Eghbal, Hormoz Nouraei, Alireza Liaghat, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4405137/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Ankylosing Spondylitis (AS) is a systemic inflammatory disease that involves axial skeleton the most. It causes ascending inflammation and thus rigidity in spinal column, from sacroiliac joint to the cervical region. Spinal column deformities beside vulnerability to trauma, alters the patients’ quality of life and put their neural elements to a great risk. Material and method: In this study, we reviewed data of twenty AS patients who underwent spinal surgery due to trauma, over 12 years in our center. Spinal radiologic indices beside clinical evaluation of quality of life and neurologic status were reviewed and mentioned. Results AS patients who were operated due to severe deformity and instability, correction of spinopelvic indices correlated with significant improvement in their quality of life and pain scores. Among those who were operated due to fracture and/or neurologic damage, clinical and neurologic improvement was significant. Conclusion Spinal trauma and mal-alignment in AS, correlates with neurological compromise and clinical symptoms such as pain and gate disturbance. Near complete correction of these indices improves patients’ quality of life. Traumatic spinal fractures in AS, should be considered unstable unless otherwise proved. Meticulous surgical stabilization in such cases usually indicates. Ankylosing Spondylitis spinal deformity spine fracture quality of life Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction AS is a chronic inflammatory disease, affecting mostly and primarily the axial skeleton [ 1 ]. It is more common in men and is mostly seen in the third and fourth decades of life [ 2 ]. AS usually starts with the involvement of the sacroiliac joint, extends to the spinal column, and may involve peripheral joints and other organs [ 3 ]. Human leukocyte antigen (HLA)-B27, which also varies between races, is the most common positive serologic marker in AS patients [ 1 – 7 ]. So far, the most acceptable diagnostic system for AS is modified New York (mNY) criteria [ 8 ]. One or more clinical symptoms besides one or more radiologic findings are considered a definite AS diagnosis [ 7 , 8 ]. Inflammatory lower back pain, which is maximum after resting or sleeping and diminishes by motion, is the most common presentation [ 1 – 3 ]. Spinal column involvement causes calcification of the bone-ligament interface and, thus, the fusion of vertebral bodies; this is called the” bamboo spine” [ 4 ]. As a result, the spinal column acts like a single large bone and becomes vulnerable to minor trauma [ 5 ]. Progressive kyphosis also alters patients' gate, the axis of vision, and thus the quality of life [ 6 ]. Spinal surgery is regarded as a challenge in this group of patients, which is considered in those affected with trauma or deformities presenting with noticeable instability or neurologic deficit. Spinal surgery in AS has many specific perioperative considerations, including anesthetic implications [ 2 , 7 , 11 ]. Spinal surgery is indicated in AS mostly when instability or neurologic deficit happens following minor or major trauma [ 9 , 10 ]. It is also a solution for deformity correction for life quality improvement [ 11 , 12 ]. In this study, we review surgical indications, perioperative considerations, and clinical outcomes of spinal surgery in 20 cases of AS who underwent spinal surgery in our center between 2010–2022. Materials and Methods The current study represents the characteristics of 20 AS patients who underwent spinal surgical procedures in the Chamran hospital, a tertiary center affiliated with the Shiraz University of Medical Science, between 2010–2022. Adult patients with ages less than 70 years who were definitely diagnosed with AS according to the modified New York (mNY) criteria and underwent spinal surgery were included. Patients with any endocrine or metabolic disorders and those with a previous history of spinal surgery in the newly affected region were excluded from this study. The information on demographics, initial spinal issues, hospitalization course, surgical interventions, and imaging of the patients was extracted from the hospital database and Picture Archiving and Communication System (PACS). Prior to the surgical interventions, all patients had a careful neurological assessment and an MRI of the affected region to evaluate the nervous system elements. Regarding the patients’ condition, the bones of the involved spinal region were assessed using a CT scan and X-ray imaging. Bone mineral densitometry (BMD) was also required to assess the feasibility of surgical intervention. Fractures were classified based on the AO-spinal fractures system [ 13 ] and managed with acceptable surgical interventions based on the symptoms and the affected regions. The purpose of surgical intervention was to fix the affected level in order to resolve any compression effect on the neural elements. Neurologic status was also assessed using the Frankel classifications [ 14 ]. Patients who had altered state of gate, vision, respiration, etc., due to spinal deformity following traumatic spinal column injury underwent corrective surgery. Spine profile indices, such as sacral slope، pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis, and sagittal vertical axis, were measured in the pre-and post-operative state. The quality of life by means of the Oswestry Disability Index (ODI) was investigated in the deformity group. In all patients, quantitative pain scores using the Visual Analogue Scale (VAS). Surgical Intervention The surgical procedures were performed after careful clinical and radiological assessments. Following the preparation of the patients, interventions were conducted with patients positioned prone, with the affected region placed in the most accessible site. All surgical approaches were taking as posterior-only for the patients. After ethical consent, all patients were admitted and prepared for surgery, days before intervention. Investigation with intraoperative neuromonitoring(IONM), using motor evoked potential(MEP) and somatosensory evoked potential(SSEP), was performed in every procedure prior to positioning till repositioning to supine, after surgical intervention. The surgical approach was chosen based on different factors, such as the level of fracture and the extent of involvement etc. in each patient. The purpose of the surgery was to realign spinal column, restore stabilization and subside the neurological deficits. Beside these, the corrective surgery in those patients with spinal deformity was aimed at resolving the regional deformities and alleviating symptoms caused by vertebral imbalance. Based on the severity of the deformity and involved levels, the pedicle subtraction osteotomy and posterior fixation were conducted. All complications, such as surgical-related adverse events or hospitalization complications, were documented. The post-operation characteristics of the patients were recorded at a one-year follow-up of patients. Ethical Consideration The informed consent was obtained from all the patients prior to the surgical intervention. This study was also approved by the ethics committee of Shiraz University of Medical Sciences with an ethics code of IR.SUMS.REC. 1401.503. Statistical Analysis The continuous variables are presented as mean ± SD, and the categorical ones as number and percentage. In order to compare VAS and deformity indices before and after the surgery, paired T-test or Wilcoxon test were used, where appropriate. Considering the significance level of P-Value < 0.05, the analyses were performed using Statistical Package for the Social Sciences (SPSS, version 26, Chicago, US). Results Since the early 2010s, twenty spine surgeries have been performed on 20 AS patients in our center. Of 20 patients, 4 (25%) were women, 16 (75%) were men, and the mean age was 49.5 ± 9.73 years. The duration between the initial diagnosis of AS and the surgery ranged from 5–17 years, with a mean of 9.95 ± 3.77 years. Nine surgeries were performed in acute post traumatic phase for management of gross instability and/or neurological deficit due to trauma, out of which three were caused by falls, and the rest were consequences of motor-vehicle accident. Other patients were surgery candidates due to the progressive disabling kyphotic deformity as a result of subacute or old traumatic spinal column injury. The mean T-score for the neck of the femur was 2.46 ± 0.56, and for the vertebral body was − 2.2 ± 0.27. Evaluation of the subjective pain, using the VAS scale, revealed a significant decrease from 7.70 ± 0.97 before the surgery to 3.20 ± 1.19 one year after the surgery (P-value < 0.05). Among patients with gross instability following acute spinal trauma(n = 9), the site of the main fracture was the cervical region in five patients, and the proper surgical procedure was chosen considering the clinical and radiological status of the patients. In the other four patients, the lower thoracic levels were affected. Neurological status was examined and compared with the Frankel scale. Of the nine patients with instability, the exam was completely intact in 5 patients, which remained unchanged after the surgery. Of the other four patients who had a deficit in the pre-operation evaluation, 3 had improvement after the surgical intervention, and only one patient with initial Frankel-A remained unchanged. Disability was assessed with ODI for the deformity group and showed significant improvement with surgery (46.6 ± 1.7 vs. 17.22 ± 1.9, P-value < 0.05). Osteotomy in all patients of the deformity group was single-level pedicle subtraction osteotomy (PSO), and the posterior spinal fixation (PSF) was performed in multiple levels based on the condition of the patients. The characteristics of the patients are presented in Table-1. Radiologic evaluation of fusion was also performed for all patients utilizing plane X-rays, Computed Tomography (CT) scans, and Magnetic Resonance Imaging (MRI) both before and after the surgery. The spinal alignment indices such as sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), and thoracic kyphosis(TK) were measured in every patient with deformity. The details of these indices are presented in Table-2. The comparison of the pre-and post-operation indices revealed a significant correction, which was comparable to the normal population. The details of the changes in parameters are presented in Table-3. Durotomy was the most common complication, with 11 cases of 20 (55%). During the surgical procedure, the mean estimated blood loss was 751 ± 460 ml, and the average duration of the hospital stay was 6 ± 3.67 days. Figures 1 and 2 illustrate patients with progressive kyphotic deformity following traumatic spinal column injury and acute instability due to trauma before and after the surgery, respectly. Discussion Trauma AS is an inflammatory disease described in the literature by primary involvement of sacroiliacjoint(SIJ), followed by ascending enthesopathy and ectopic calcification of anterior and posterior spinal ligament [ 17 , 18 ]. Thus, spinal column is vulnerable to trauma. Some facts about spinal trauma in AS are: Minor trauma can cause instability and spinal cord injury Cervical spine is involved in later phase Thoracolumbar region is the most common site of spinal fracture followed by cervical region Trauma mostly cause three-column injury to the spinal column[ 10 , 20 – 24 ] The prevalence of spinal cord injury(SCI) in AS patients following trauma is very different in the literature, ranging between 15 to almost 60 percent [ 20 – 22 ]. It is investigated in the literature with ASIA score [ 22 ]. Although ASIA-A showed improvement in Ull et al. study [ 22 ], In our study we didn’t notice any change in ASIA score. But, Frankle scales showed significant improvement after surgical decompression and stabilization. Management of spinal fractures in AS can be either surgical or non-surgical. Non-surgical management is traction with immobilization [ 10 , 23 ]. Surgical management was associated with great risk of mortality and morbidity in the past [ 10 , 22 – 24 ]. With advances in surgical techniques and failure in non-surgical treatments, surgery got more attention for majority of cases recently [ 22 ]. Surgical approaches have been compared in details by many authors. Considering future risks for proximal junctional disease, spinal biomechanics of thoracolumbar junction and maximum stabilization; three levels above and below the fractured vertebra is acceptable for extent of construct recently [ 22 , 30 ]. Three column spinal fusion has many advantages because spinal fractures in AS are associated with three-column injury and circumferential fixation brings about maximum stability; but, it is associated with great risk of mortality and complications [ 10 ]. Risk of complications is also greater in posterior fixation in comparison to anterior approach for surgery [ 10 , 22 ]. As a result, anterior approach and minimal invasive techniques have least risk for mortality and complications [ 22 ]. In our study, we utilized posterior approach for majority of cases as the only approach. We reached good results in fusion and least complications beside any device failure or revision surgeries. Deformity Patients with AS develop kyphotic spinal deformity in time following minor insults or as the natural course of the disease [ 4 ]. Kyphotic deformity is the most common deformity in this disease. It is mainly presented in imaging with positive SVA, which is anterior displacement of C7-plumb line from posterior-superior edge of S1 vertebra, in midsagittal plane standing spinal X-ray(figure-1). In fact, positive SVA means anterior displacement of C7 in related to S1 vertebra in sagittal plane. As the result, it leads to alteration of axis of vision, balance and gait [ 1 , 4 ]. As PI = PT + SS, compensations in spinal column starts with increasing PT up to the amount of PI with cost of decreasing SS to near zero degrees. Further compensation results in knee flexion and hip retroversion [ 1 , 4 , 25 , 26 ]. In many studies, spinopelvic parameters have been discussed in order to reach a standard guideline for correction and their relation to symptom improvements [ 1 , 30 , 31 ]. It is generally accepted that sagittal imbalance has the most correlation with pain and quality of life. The most related parameters of sagittal imbalance to the patients’ symptoms is PT and SVA [ 1 , 30 , 31 ]]. The most common and effective osteotomy for kyphosis correction in AS patients, are Smith-Petersen osteotomy (SPO) and PSO(figure-3[ 27 ]). Each level SPO can correct up to 10 degrees of kyphosis and each level PSO, 30–40 degrees [ 11 , 25 ]. PSO has six subclassifications, each has its own indications and considerations. The latest revision of Schwab’s PSO classification presented in the literature in detail by Bourghli et al. in 2020[ 29 ]. Of all eleven PSOs, 7 was grade 4A according to Schwab’s classification [ 29 ]. This type of PSO, which includes resection of proximal disc and partial resection of pedicle and lamina, allows 25° of correction along with closure of middle and posterior column [ 29 ]. The other four PSOs were performed matched with type 3C Schwab’s classification, which opens the anterior column and closes the middle column by means of resecting the whole pedicle and lamina. This type, brings about 40° of correction at maximum [ 29 ]. In our center, we chose posterior approach for multilevel SPO and one level PSO for patients with thoracolumbar kyphosis and alterations in quality of life. We reached significant decrease in SVA (pre-op: 109.5 ± 12.03 Vs. post-op: 63.47 ± 8.79) and thus VAS score beside remarkable clinical improvement in standing and gait. Outcome In numbers of similar studies, quality of life in patients with AS, has been investigated with numerical parameters. In traumatic patients, improvement of neurological deficit has been shown with ASIA/Frankle scales [ 20 – 24 ]. In cases of thoracolumbar kyphotic deformity, ODI - evaluating multiple parameters in daily activities- is widely acceptable to investigate and follow quality of life [ 6 , 25 , 28 ]. The results of our experience with AS patients is remarkable in this aspect. We had improvement in neurological deficit back to normal status in all but one traumatic patients. Also, ODI and VAS score improved in our study significantly. Special Considerations Disease Control and Perioperative States AS starts with a cascade of ascending inflammation in spinal column as well as other organs; therefore, we face a systemic disease affecting the spine [ 1 – 7 ]. Although the beginning of disease is before the age of 40 and severe cervicothoracic deformities commonly occurs above 60s; some factors such as medical control of systemic inflammation may disturb this concept [ 3 , 4 ]. The mean age of deformity group in our study is about 15 years lower than similar series. The logical implication might be poor control of AS due to low socioeconomic condition and poor compliance of the patients beside weakness in health care facilities following up such patients. Complete medical attention is mandatory before any spinal surgery if there is no urgency. DMARD (disease modifying anti-rheumatoid drugs) and anti-TNF (tumor necrosis factor) alpha adjustment, BMD evaluations and osteoporosis management, evaluating cardiopulmonary and renal function are important tasks of a practiced rheumatologist in AS management team [ 11 ]. Anesthesia Many pre, intra and post-operative anesthetic considerations have been listed in the literature. Among those, intubation and airway management needs special attention. Although laryngeal mask is an option, awake fiber optic intubation is gold-standard and retrograde tracheal intubation would be suitable for severe cervical deformity (chin to chest) and temporomandibular involvement [ 7 , 11 ]. Positioning and Neuromonitoring All AS patients need careful positioning. Spinal trauma causes highly instability in three columns [ 22 – 24 ] and spinal deformity-specially cervicothoracic kyphosis- puts patients in great risk of neurovascular damage during positioning [ 1 , 2 , 4 ]. Thus, neurophysiologic monitoring before anesthesia to the end of procedure is highly emphasized in the literature [ 4 , 7 , 11 ]. We performed neurophysiologic study for all deformity groups and majority of traumatic patients for whom full-emergency surgical intervention was not indicated and facilities were accessible. Complications Spinal fractures and their management in AS patients coincide with many complications. The most common of which in previous studies, is pulmonary complications, including pneumonia and tracheostomy due to inability to wean from ventilator [ 22 ]. Other complications with different prevalence are urinary tract infection(UTI), surgical site infection(SSI), kidney injury, cardiac problems, thromboembolism and death [ 23 ]. In our study we had only one case of SSI who was completely recovered with medications. Thromboembolism was not seen in our cases due to pre- and post-op medical and physical prophylaxis. We also had no new neurological deficit during hospitalization or in follow-up visits. Revision spinal surgery and failed construct or fusion was not seen in our series. Traumatic or iatrogenic durotomy is very common in spinal surgery in AS with mean prevalence of 50–60%. We had nearly 60% durotomy overall without any desperate outcome such as CSF fistula, meningitis and etc. Conclusion Spinal trauma in AS patients can cause gross instability and neural tissue damage even with a minor trauma in the acute phase. Thus, spinal fractures in these cases should be considered highly unstable. Besides, progressive spinal deformity in patients who are treated with early non-operative management, is also a problem. It can lead to axial pain, alteration in gait, axis of vision and quality of life. Altogether, sufficient neural tissue decompression and maximum surgical stabilization for acute phase, and correction of spinopelvic alignment indices for progressive deformity, is widely acceptable as standard management in such situations. Declarations Consent for publication : The authors provide consent for publication. Conflict of Interest : None declared. Funding : None declared. Authors’ Contributions: MRF: study concept, data gathering, revision of the manuscript; SRM: revision of the manuscript; KE: preparation of the manuscript; HN: preparation of the manuscript; AL: data gathering; MASHM: revision of the manuscript; OY: preparation of the manuscript; Acknowledgment: The authors would like to thank Ms. Hosseini, in Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran, References Lee JS, Suh KT, Kim JI, Goh TS. Analysis of sagittal balance of ankylosing spondylitis using spinopelvic parameters. Clin Spine Surg. 2014;27(3):E94–8. Britto NMF, Renor BS, Ghizoni E, Tedeschi H, Joaquim AF. Spine surgery in patients with ankylosing spondylitis. Revista da Associação Médica Brasileira. 2018;64:379–83. Zhu W, He X, Cheng K, Zhang L, Chen D, Wang X, Weng X. Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone Res. 2019;7(1):22. Lazennec JY, d’Astorg H, Rousseau MA. 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Tables Case No. Age/Sex Fracture site/ Osteotomy Pre-op Duration (years) Pre-op VAS Preop Frankel /ODI surgery (Fixation levels/ osteotomy) Post-op Frankel /ODI Post-op VAS Spine T-score 1 M-60 T11-T12 fx (AO-B) 8 8 Frankel-E T10:L1 PSF E 5 -1.9 2 M-59 T12- Kyphosis 14 9 ODI- 46 T12 PSO T10:L4 PSF 16 4 -2.3 3 M-65 C2 odontoid fx (type-III) 16 7 Frankel-C C1:C3 PCF E 3 -2.4 4 M-47 C1-C2 subluxation 12 6 Frankel-E C1:C3 PCF E 4 -2.1 5 M-40 L3-kyphosis 6 6 ODI-49 L3 PSO T12:L5 PSF 17 4 -2 6 M-45 L2- kyphosis T12-L1 fx 8 9 ODI-44 L2 PSO T7:L4 PSF 15 5 -2.2 7 M-45 C2 odontoid fx (type-II) 7 8 Frankel-E Harm’s procedure E 5 -2.3 8 F-59 L4-kyphosis 17 8 ODI-48 L4 PSO L3-L4 TLIF L2:S1 PSF 17 4 -2.4 9 M-62 T12 fx (AO-C) 12 8 Frankel-A T10:L2 PSF A 3 -2 10 M-44 T11-T12 fx (AO-C) 9 6 Frankel-D T9:L2 PSF E 4 -2.1 11 M-57 L2-kyphosis 15 7 ODI-46 L2 PSO T8:L5 PSF 19 2 -2.3 12 M-44 C5-C6 traumatic subluxation 5 7 Frankel-E AP approach for C5-C6, C6-C7 ACDFP C5-C7 PCF E 1 -1.8 13 M-56 L2-kyphosis 13 8 ODI-47 L2 PSO T8:L5 PSF 21 1 -1.9 14 M-45 L3 kyphosis 10 8 ODI-48 L3 PSO T12:L5 PSF 17 3 -2.2 15 F- 37 T12-Kyphosis 3 8 ODI-46 T12 PSO T10:L4 PSF 15 3 -1.9 16 M-55 T11 Kyphosis 10 7 ODI- 44 T11 PSO T6:L4 PSF 18 2 -2.4 17 M-53 C2 odontoid fx (type-II) 8 9 Frankel-E Anterior odontoid screw E 3 -2.5 18 F-27 T10-kyphosis 6 8 ODI-48 T10 PSO T3:L3 PSF - 3 -2 19 F-40 L2-kyphosis 10 9 - L2-PSO T10:L5 PSF - 2 -3 20 M-50 T10 fx (AO-B) 10 8 Frankel-A T8:L1 PSF B 3 -2.3 Table 1. ACDFP: anterior cervical discectomy and fusion with plate, F: female, M: male, PCF: posterior cervical fusion, PSF: posterior spinal fixation, PSO: pedicular subtraction osteotomy, TLIF: transforaminal lumbar interbody fusion Case no. Pre-op SVA (mm) Post-op SVA (mm) PI Pre-op PT Post-op PT Pre-op SS Post-op SS Pre-op LL Post-op LL Pre-op TK Post-op TK 2 135 75 51.4 29 20 20.4 26.4 31 39 58 39 5 110 80 44.5 23.5 20 21 25 16 36 62 41 6 100 65 46 26 18.6 20 24 28 40 58 43 8 90 62 55 31 21 22 27 12 43 56 40 11 103 51.2 53 34.6 29.4 18.7 23.7 10 48 57.5 10 13 115 70 50 26 19.32 24 30.6 44 56 65.3 40.9 14 100 55 51 30 17 20 32 18 44 55 38 15 106 60 47 28 20 19 26.5 20 36 52 42 16 120 60 52 30 21 20 28 17 42 75 44 18 110 55 50 31 22 19 26 18 36 65 50 19 116 65 49 31 22 20 27 24 36 58 48 Table 2. Spinal alignment indices; LL: lumbar lordosis, PI: pelvic incidence, PT: pelvic tilt, SS: sacral slope, SVA: sagittal vertical axis, TK: thoracic kyphosis Variable Pre Post P-value ODI 46.60±1.7 17.22±1.9 0.001 SVA 109.5±12.03 63.47 ± 8.79 0.001 PT 29.1± 3.07 20.93 ± 3.16 0.000 SS 20.37 ± 1.52 26.92±2.53 0.000 LL 21.64 ± 9.74 41.45 ± 6.25 0.008 Thoracic Kyphosis 60.16 ± 6.36 39.62 ± 10.47 0.008 Table-3. Pre- and post-operational spinal indices; LL: lumbar lordosis, PT: pelvic tilt, SS: sacral slope, SVA: sagittal vertical axis Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board 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-4405137","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":304327632,"identity":"428daf40-50ed-49b3-9dd4-5b7d3371d10b","order_by":0,"name":"Majid Reza Farrokhi","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Majid","middleName":"Reza","lastName":"Farrokhi","suffix":""},{"id":304327633,"identity":"1b7a603d-4c37-4109-a085-1efe8e956f45","order_by":1,"name":"Keyvan Eghbal","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Keyvan","middleName":"","lastName":"Eghbal","suffix":""},{"id":304327634,"identity":"c2363812-4e7b-46bd-8848-ac8eba9af0dd","order_by":2,"name":"Hormoz Nouraei","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hormoz","middleName":"","lastName":"Nouraei","suffix":""},{"id":304327635,"identity":"9cffb56e-a39c-44bf-a698-70dc4ece304f","order_by":3,"name":"Alireza Liaghat","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Alireza","middleName":"","lastName":"Liaghat","suffix":""},{"id":304327636,"identity":"093c00ea-e7d4-4416-bc2d-a6225225b624","order_by":4,"name":"Mohammad hadi Amir Shahpari Motlagh","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"hadi Amir Shahpari","lastName":"Motlagh","suffix":""},{"id":304327637,"identity":"24fd2b3b-02c4-45bb-9403-fcb5089ce566","order_by":5,"name":"Omid yousefi","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Omid","middleName":"","lastName":"yousefi","suffix":""},{"id":304327638,"identity":"ae231d66-c22a-430a-b625-60d0e6bd3517","order_by":6,"name":"Seyed Reza Mousavi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYHADxgYgYQNiNB4gRUsamEGsFjA4DCbxajFvb3/46UbFYXv+GckNzAV/ztutbT8MtKXGJhqXFpkzB5Klc84cTpxxI7GBeWbb7eRtZxKBWo6l5Tbg0CIhkXBAOrftcALDmYMNzLwNt5PNDgC1MDYcxq1F/mHzb6AWe3mQFp4/55LNzj8koEWCmQ1kC+OG441ALWwH7MxuELKFJ43NOudMeuJGoJbDvG3JCWY3gLYk4PML+/HHt3MqrO3lDrM/fMzzx87e7Hz6wwcfamxwakEBB4A4EawygRjlMGBPiuJRMApGwSgYGQAApCtj8vjjWRsAAAAASUVORK5CYII=","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Seyed","middleName":"Reza","lastName":"Mousavi","suffix":""}],"badges":[],"createdAt":"2024-05-11 11:24:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4405137/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4405137/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57292563,"identity":"2d90a957-49de-4656-89f4-16ebc0d63390","added_by":"auto","created_at":"2024-05-28 18:06:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":91328,"visible":true,"origin":"","legend":"\u003cp\u003ePre-op evaluation of a 54 y/o man with 10 years history of AS, presenting with gate and axis of vision disturbance. Here is AP and lateral standing gross pictures and radiogram, measuring thoracolumbar kyphosis angle and SVA.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4405137/v1/26bfaeb205804cd08843c03f.jpg"},{"id":57291020,"identity":"0f93dfd6-0ac5-4f29-ba2a-a9db4f56891c","added_by":"auto","created_at":"2024-05-28 17:58:33","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58372,"visible":true,"origin":"","legend":"\u003cp\u003ePost-op evaluation of the same patient.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4405137/v1/cb6fd2f6a46b07079f421249.jpg"},{"id":57291024,"identity":"b30e4b27-ea06-48a8-9750-322889064081","added_by":"auto","created_at":"2024-05-28 17:58:33","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":29791,"visible":true,"origin":"","legend":"\u003cp\u003eSPO and PSO as the main osteotomy procedures to correct the deformity in AS patients[27].\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4405137/v1/035980a86ae9bbb5b9787a72.jpg"},{"id":57292828,"identity":"be4c3e11-3b4c-434b-bb50-3d7f861bd5fb","added_by":"auto","created_at":"2024-05-28 18:14:33","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":67250,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal and coronal spinal CT-scan in 1-year post-op follow-up in a patient with severe thoracolumbar kyphosis who went under surgical intervention correcting the deformity.\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4405137/v1/29020414c30af2513040c756.jpg"},{"id":57796523,"identity":"bac712fe-6b97-424c-8053-499deed6730b","added_by":"auto","created_at":"2024-06-05 19:31:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":983231,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4405137/v1/065700dd-05a6-468a-bd5e-7f7a9ef6ece5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ankylosing Spondylitis: Special Considerations and Clinical Outcomes in Surgical Management of Spinal Fractures, Case Series and Analysis of Twenty Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAS is a chronic inflammatory disease, affecting mostly and primarily the axial skeleton [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is more common in men and is mostly seen in the third and fourth decades of life [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. AS usually starts with the involvement of the sacroiliac joint, extends to the spinal column, and may involve peripheral joints and other organs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Human leukocyte antigen (HLA)-B27, which also varies between races, is the most common positive serologic marker in AS patients [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. So far, the most acceptable diagnostic system for AS is modified New York (mNY) criteria [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. One or more clinical symptoms besides one or more radiologic findings are considered a definite AS diagnosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInflammatory lower back pain, which is maximum after resting or sleeping and diminishes by motion, is the most common presentation [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Spinal column involvement causes calcification of the bone-ligament interface and, thus, the fusion of vertebral bodies; this is called the\u0026rdquo; bamboo spine\u0026rdquo; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As a result, the spinal column acts like a single large bone and becomes vulnerable to minor trauma [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Progressive kyphosis also alters patients' gate, the axis of vision, and thus the quality of life [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSpinal surgery is regarded as a challenge in this group of patients, which is considered in those affected with trauma or deformities presenting with noticeable instability or neurologic deficit. Spinal surgery in AS has many specific perioperative considerations, including anesthetic implications [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSpinal surgery is indicated in AS mostly when instability or neurologic deficit happens following minor or major trauma [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. It is also a solution for deformity correction for life quality improvement [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, we review surgical indications, perioperative considerations, and clinical outcomes of spinal surgery in 20 cases of AS who underwent spinal surgery in our center between 2010\u0026ndash;2022.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThe current study represents the characteristics of 20 AS patients who underwent spinal surgical procedures in the Chamran hospital, a tertiary center affiliated with the Shiraz University of Medical Science, between 2010\u0026ndash;2022.\u003c/p\u003e \u003cp\u003eAdult patients with ages less than 70 years who were definitely diagnosed with AS according to the modified New York (mNY) criteria and underwent spinal surgery were included. Patients with any endocrine or metabolic disorders and those with a previous history of spinal surgery in the newly affected region were excluded from this study.\u003c/p\u003e \u003cp\u003eThe information on demographics, initial spinal issues, hospitalization course, surgical interventions, and imaging of the patients was extracted from the hospital database and Picture Archiving and Communication System (PACS).\u003c/p\u003e \u003cp\u003ePrior to the surgical interventions, all patients had a careful neurological assessment and an MRI of the affected region to evaluate the nervous system elements. Regarding the patients\u0026rsquo; condition, the bones of the involved spinal region were assessed using a CT scan and X-ray imaging. Bone mineral densitometry (BMD) was also required to assess the feasibility of surgical intervention.\u003c/p\u003e \u003cp\u003eFractures were classified based on the AO-spinal fractures system [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and managed with acceptable surgical interventions based on the symptoms and the affected regions. The purpose of surgical intervention was to fix the affected level in order to resolve any compression effect on the neural elements. Neurologic status was also assessed using the Frankel classifications [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients who had altered state of gate, vision, respiration, etc., due to spinal deformity following traumatic spinal column injury underwent corrective surgery. Spine profile indices, such as sacral slope، pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis, and sagittal vertical axis, were measured in the pre-and post-operative state. The quality of life by means of the Oswestry Disability Index (ODI) was investigated in the deformity group.\u003c/p\u003e \u003cp\u003eIn all patients, quantitative pain scores using the Visual Analogue Scale (VAS).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Intervention\u003c/h2\u003e \u003cp\u003eThe surgical procedures were performed after careful clinical and radiological assessments. Following the preparation of the patients, interventions were conducted with patients positioned prone, with the affected region placed in the most accessible site.\u003c/p\u003e \u003cp\u003eAll surgical approaches were taking as posterior-only for the patients. After ethical consent, all patients were admitted and prepared for surgery, days before intervention. Investigation with intraoperative neuromonitoring(IONM), using motor evoked potential(MEP) and somatosensory evoked potential(SSEP), was performed in every procedure prior to positioning till repositioning to supine, after surgical intervention.\u003c/p\u003e \u003cp\u003eThe surgical approach was chosen based on different factors, such as the level of fracture and the extent of involvement etc. in each patient. The purpose of the surgery was to realign spinal column, restore stabilization and subside the neurological deficits. Beside these, the corrective surgery in those patients with spinal deformity was aimed at resolving the regional deformities and alleviating symptoms caused by vertebral imbalance. Based on the severity of the deformity and involved levels, the pedicle subtraction osteotomy and posterior fixation were conducted. All complications, such as surgical-related adverse events or hospitalization complications, were documented. The post-operation characteristics of the patients were recorded at a one-year follow-up of patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEthical Consideration\u003c/h2\u003e \u003cp\u003e The informed consent was obtained from all the patients prior to the surgical intervention. This study was also approved by the ethics committee of Shiraz University of Medical Sciences with an ethics code of IR.SUMS.REC. 1401.503.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, and the categorical ones as number and percentage. In order to compare VAS and deformity indices before and after the surgery, paired T-test or Wilcoxon test were used, where appropriate. Considering the significance level of P-Value\u0026thinsp;\u0026lt;\u0026thinsp;0.05, the analyses were performed using Statistical Package for the Social Sciences (SPSS, version 26, Chicago, US).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSince the early 2010s, twenty spine surgeries have been performed on 20 AS patients in our center. Of 20 patients, 4 (25%) were women, 16 (75%) were men, and the mean age was 49.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.73 years.\u003c/p\u003e \u003cp\u003eThe duration between the initial diagnosis of AS and the surgery ranged from 5\u0026ndash;17 years, with a mean of 9.95\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77 years.\u003c/p\u003e \u003cp\u003eNine surgeries were performed in acute post traumatic phase for management of gross instability and/or neurological deficit due to trauma, out of which three were caused by falls, and the rest were consequences of motor-vehicle accident.\u003c/p\u003e \u003cp\u003eOther patients were surgery candidates due to the progressive disabling kyphotic deformity as a result of subacute or old traumatic spinal column injury.\u003c/p\u003e \u003cp\u003eThe mean T-score for the neck of the femur was 2.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56, and for the vertebral body was \u0026minus;\u0026thinsp;2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27.\u003c/p\u003e \u003cp\u003eEvaluation of the subjective pain, using the VAS scale, revealed a significant decrease from 7.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97 before the surgery to 3.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19 one year after the surgery (P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eAmong patients with gross instability following acute spinal trauma(n\u0026thinsp;=\u0026thinsp;9), the site of the main fracture was the cervical region in five patients, and the proper surgical procedure was chosen considering the clinical and radiological status of the patients. In the other four patients, the lower thoracic levels were affected.\u003c/p\u003e \u003cp\u003eNeurological status was examined and compared with the Frankel scale. Of the nine patients with instability, the exam was completely intact in 5 patients, which remained unchanged after the surgery. Of the other four patients who had a deficit in the pre-operation evaluation, 3 had improvement after the surgical intervention, and only one patient with initial Frankel-A remained unchanged.\u003c/p\u003e \u003cp\u003eDisability was assessed with ODI for the deformity group and showed significant improvement with surgery (46.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 vs. 17.22\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9, P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eOsteotomy in all patients of the deformity group was single-level pedicle subtraction osteotomy (PSO), and the posterior spinal fixation (PSF) was performed in multiple levels based on the condition of the patients. The characteristics of the patients are presented in Table-1.\u003c/p\u003e \u003cp\u003eRadiologic evaluation of fusion was also performed for all patients utilizing plane X-rays, Computed Tomography (CT) scans, and Magnetic Resonance Imaging (MRI) both before and after the surgery. The spinal alignment indices such as sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), and thoracic kyphosis(TK) were measured in every patient with deformity. The details of these indices are presented in Table-2.\u003c/p\u003e \u003cp\u003eThe comparison of the pre-and post-operation indices revealed a significant correction, which was comparable to the normal population. The details of the changes in parameters are presented in Table-3.\u003c/p\u003e \u003cp\u003eDurotomy was the most common complication, with 11 cases of 20 (55%). During the surgical procedure, the mean estimated blood loss was 751\u0026thinsp;\u0026plusmn;\u0026thinsp;460 ml, and the average duration of the hospital stay was 6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.67 days.\u003c/p\u003e \u003cp\u003eFigures \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrate patients with progressive kyphotic deformity following traumatic spinal column injury and acute instability due to trauma before and after the surgery, respectly.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTrauma\u003c/h2\u003e \u003cp\u003eAS is an inflammatory disease described in the literature by primary involvement of sacroiliacjoint(SIJ), followed by ascending enthesopathy and ectopic calcification of anterior and posterior spinal ligament [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Thus, spinal column is vulnerable to trauma. Some facts about spinal trauma in AS are:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMinor trauma can cause instability and spinal cord injury\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCervical spine is involved in later phase\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThoracolumbar region is the most common site of spinal fracture followed by cervical region\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTrauma mostly cause three-column injury to the spinal column[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe prevalence of spinal cord injury(SCI) in AS patients following trauma is very different in the literature, ranging between 15 to almost 60 percent [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. It is investigated in the literature with ASIA score [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Although ASIA-A showed improvement in Ull et al. study [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], In our study we didn\u0026rsquo;t notice any change in ASIA score. But, Frankle scales showed significant improvement after surgical decompression and stabilization.\u003c/p\u003e \u003cp\u003eManagement of spinal fractures in AS can be either surgical or non-surgical. Non-surgical management is traction with immobilization [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Surgical management was associated with great risk of mortality and morbidity in the past [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. With advances in surgical techniques and failure in non-surgical treatments, surgery got more attention for majority of cases recently [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Surgical approaches have been compared in details by many authors. Considering future risks for proximal junctional disease, spinal biomechanics of thoracolumbar junction and maximum stabilization; three levels above and below the fractured vertebra is acceptable for extent of construct recently [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Three column spinal fusion has many advantages because spinal fractures in AS are associated with three-column injury and circumferential fixation brings about maximum stability; but, it is associated with great risk of mortality and complications [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Risk of complications is also greater in posterior fixation in comparison to anterior approach for surgery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. As a result, anterior approach and minimal invasive techniques have least risk for mortality and complications [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our study, we utilized posterior approach for majority of cases as the only approach. We reached good results in fusion and least complications beside any device failure or revision surgeries.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDeformity\u003c/h2\u003e \u003cp\u003ePatients with AS develop kyphotic spinal deformity in time following minor insults or as the natural course of the disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Kyphotic deformity is the most common deformity in this disease. It is mainly presented in imaging with positive SVA, which is anterior displacement of C7-plumb line from posterior-superior edge of S1 vertebra, in midsagittal plane standing spinal X-ray(figure-1). In fact, positive SVA means anterior displacement of C7 in related to S1 vertebra in sagittal plane. As the result, it leads to alteration of axis of vision, balance and gait [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As PI\u0026thinsp;=\u0026thinsp;PT\u0026thinsp;+\u0026thinsp;SS, compensations in spinal column starts with increasing PT up to the amount of PI with cost of decreasing SS to near zero degrees. Further compensation results in knee flexion and hip retroversion [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn many studies, spinopelvic parameters have been discussed in order to reach a standard guideline for correction and their relation to symptom improvements [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. It is generally accepted that sagittal imbalance has the most correlation with pain and quality of life. The most related parameters of sagittal imbalance to the patients\u0026rsquo; symptoms is PT and SVA [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]]. The most common and effective osteotomy for kyphosis correction in AS patients, are Smith-Petersen osteotomy (SPO) and PSO(figure-3[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]). Each level SPO can correct up to 10 degrees of kyphosis and each level PSO, 30\u0026ndash;40 degrees [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. PSO has six subclassifications, each has its own indications and considerations. The latest revision of Schwab\u0026rsquo;s PSO classification presented in the literature in detail by Bourghli et al. in 2020[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOf all eleven PSOs, 7 was grade 4A according to Schwab\u0026rsquo;s classification [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This type of PSO, which includes resection of proximal disc and partial resection of pedicle and lamina, allows 25\u0026deg; of correction along with closure of middle and posterior column [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The other four PSOs were performed matched with type 3C Schwab\u0026rsquo;s classification, which opens the anterior column and closes the middle column by means of resecting the whole pedicle and lamina. This type, brings about 40\u0026deg; of correction at maximum [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our center, we chose posterior approach for multilevel SPO and one level PSO for patients with thoracolumbar kyphosis and alterations in quality of life. We reached significant decrease in SVA (pre-op: 109.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.03 Vs. post-op: 63.47\u0026thinsp;\u0026plusmn;\u0026thinsp;8.79) and thus VAS score beside remarkable clinical improvement in standing and gait.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcome\u003c/h3\u003e\n\u003cp\u003eIn numbers of similar studies, quality of life in patients with AS, has been investigated with numerical parameters. In traumatic patients, improvement of neurological deficit has been shown with ASIA/Frankle scales [\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In cases of thoracolumbar kyphotic deformity, ODI - evaluating multiple parameters in daily activities- is widely acceptable to investigate and follow quality of life [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results of our experience with AS patients is remarkable in this aspect. We had improvement in neurological deficit back to normal status in all but one traumatic patients. Also, ODI and VAS score improved in our study significantly.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSpecial Considerations\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eDisease Control and Perioperative States\u003c/h2\u003e \u003cp\u003eAS starts with a cascade of ascending inflammation in spinal column as well as other organs; therefore, we face a systemic disease affecting the spine [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although the beginning of disease is before the age of 40 and severe cervicothoracic deformities commonly occurs above 60s; some factors such as medical control of systemic inflammation may disturb this concept [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The mean age of deformity group in our study is about 15 years lower than similar series. The logical implication might be poor control of AS due to low socioeconomic condition and poor compliance of the patients beside weakness in health care facilities following up such patients.\u003c/p\u003e \u003cp\u003eComplete medical attention is mandatory before any spinal surgery if there is no urgency. DMARD (disease modifying anti-rheumatoid drugs) and anti-TNF (tumor necrosis factor) alpha adjustment, BMD evaluations and osteoporosis management, evaluating cardiopulmonary and renal function are important tasks of a practiced rheumatologist in AS management team [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAnesthesia\u003c/h2\u003e \u003cp\u003eMany pre, intra and post-operative anesthetic considerations have been listed in the literature. Among those, intubation and airway management needs special attention. Although laryngeal mask is an option, awake fiber optic intubation is gold-standard and retrograde tracheal intubation would be suitable for severe cervical deformity (chin to chest) and temporomandibular involvement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePositioning and Neuromonitoring\u003c/h2\u003e \u003cp\u003eAll AS patients need careful positioning. Spinal trauma causes highly instability in three columns [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and spinal deformity-specially cervicothoracic kyphosis- puts patients in great risk of neurovascular damage during positioning [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Thus, neurophysiologic monitoring before anesthesia to the end of procedure is highly emphasized in the literature [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. We performed neurophysiologic study for all deformity groups and majority of traumatic patients for whom full-emergency surgical intervention was not indicated and facilities were accessible.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eComplications\u003c/h2\u003e \u003cp\u003eSpinal fractures and their management in AS patients coincide with many complications. The most common of which in previous studies, is pulmonary complications, including pneumonia and tracheostomy due to inability to wean from ventilator [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Other complications with different prevalence are urinary tract infection(UTI), surgical site infection(SSI), kidney injury, cardiac problems, thromboembolism and death [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In our study we had only one case of SSI who was completely recovered with medications.\u003c/p\u003e \u003cp\u003eThromboembolism was not seen in our cases due to pre- and post-op medical and physical prophylaxis.\u003c/p\u003e \u003cp\u003eWe also had no new neurological deficit during hospitalization or in follow-up visits.\u003c/p\u003e \u003cp\u003eRevision spinal surgery and failed construct or fusion was not seen in our series.\u003c/p\u003e \u003cp\u003eTraumatic or iatrogenic durotomy is very common in spinal surgery in AS with mean prevalence of 50\u0026ndash;60%. We had nearly 60% durotomy overall without any desperate outcome such as CSF fistula, meningitis and etc.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSpinal trauma in AS patients can cause gross instability and neural tissue damage even with a minor trauma in the acute phase. Thus, spinal fractures in these cases should be considered highly unstable.\u003c/p\u003e \u003cp\u003eBesides, progressive spinal deformity in patients who are treated with early non-operative management, is also a problem. It can lead to axial pain, alteration in gait, axis of vision and quality of life.\u003c/p\u003e \u003cp\u003eAltogether, sufficient neural tissue decompression and maximum surgical stabilization for acute phase, and correction of spinopelvic alignment indices for progressive deformity, is widely acceptable as standard management in such situations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: The authors provide consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e: None declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: None declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u003c/strong\u003e MRF: study concept, data gathering, revision of the manuscript; SRM: revision of the manuscript; KE: preparation of the manuscript; HN: preparation of the manuscript; AL: data gathering; MASHM: revision of the manuscript; OY: preparation of the manuscript;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Ms. Hosseini, in Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee JS, Suh KT, Kim JI, Goh TS. Analysis of sagittal balance of ankylosing spondylitis using spinopelvic parameters. Clin Spine Surg. 2014;27(3):E94\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBritto NMF, Renor BS, Ghizoni E, Tedeschi H, Joaquim AF. Spine surgery in patients with ankylosing spondylitis. Revista da Associa\u0026ccedil;\u0026atilde;o M\u0026eacute;dica Brasileira. 2018;64:379\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu W, He X, Cheng K, Zhang L, Chen D, Wang X, Weng X. Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone Res. 2019;7(1):22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLazennec JY, d\u0026rsquo;Astorg H, Rousseau MA. Cervical spine surgery in ankylosing spondylitis: review and current concept. Orthop Traumatology: Surg Res. 2015;101(4):507\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurucan E, Bernstein DN, Mesfin A. Surgical management of spinal fractures in ankylosing spondylitis. J Spine Surg. 2018;4(3):501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee JS, Youn MS, Shin JK, Goh TS, Kang SS. Relationship between cervical sagittal alignment and quality of life in ankylosing spondylitis. Eur Spine J. 2015;24:1199\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoodward LJ, Kam PCA. Ankylosing spondylitis: recent developments and anaesthetic implications. Anaesthesia. 2009;64(5):540\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLinden SVD, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. Arthr Rhuem. 1984;27(4):361\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurgery: Spine. 2002;97(2):218\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurucan E, Bernstein DN, Mesfin A. Surgical management of spinal fractures in ankylosing spondylitis. J Spine Surg. 2018;4(3):501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoaquim AF, De Oliveira SA, Appenzeller S, Patel AA. Spine surgery and ankylosing spondylitis: optimizing perioperative management. Clin spine Surg. 2023;36(1):8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaddas R, Belanger T. (2017). Clinical gait analysis on a patient undergoing surgical correction of kyphosis from severe ankylosing spondylitis. Int J Spine Surg, \u003cem\u003e11\u003c/em\u003e(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchnake KJ, Schroeder GD, Vaccaro AR, Oner C. AOSpine classification systems (subaxial, thoracolumbar). 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Comparison of radiological characteristics between diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis: a multicenter study. Sci Rep. 2023;13(1):1849.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamiro S, Nikiphorou E, Sepriano A, Ortolan A, Webers C, Baraliakos X, Van Der Heijde D. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis. 2023;82(1):19\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLakra C, Desai M. Heterotopic ossification in a patient with cervical spinal cord injury and ankylosing spondylitis: The consequences of the late diagnosis. J Int Soc Phys Rehabilitation Med. 2020;3(3):97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTu PH, Liu ZH, Yeap MC, Liu YT, Li YC, Huang YC, Chen CC. Spinal cord injury and spinal fracture in patients with ankylosing spondylitis. BMC Emerg Med. 2022;22(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKandregula S, Birk HS, Savardekar A, Newman WC, Beyl R, Trosclair K, Sin A. Spinal Fractures in Ankylosing Spondylitis: Patterns, Management, and Complications in the United States\u0026ndash;Analysis of Latest Nationwide Inpatient Sample Data. Neurospine. 2021;18(4):786.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUll C, Yilmaz E, Hoffmann MF, Reinke C, Aach M, Schildhauer TA, Kruppa C. Factors associated with major complications and mortality during hospitalization in patients with ankylosing spondylitis undergoing surgical management for a spine fracture. Global Spine J. 2022;12(7):1380\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwendner M, Seule M, Meyer B, Krieg SM. Management of spine fractures in ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis: a challenge. NeuroSurg Focus. 2021;51(4):E2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly A, Younus A, Lekgwara P. Surgical management of spinal fractures in ankylosing spondylitis: A case series and literature review. East Afr Orthop J. 2020;14(1):36\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDebarge R, Demey G, Roussouly P. Sagittal balance analysis after pedicle subtraction osteotomy in ankylosing spondylitis. Eur Spine J. 2011;20:619\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShin JK, Lee JS, Goh TS, Son SM. Correlation between clinical outcome and spinopelvic parameters in ankylosing spondylitis. Eur Spine J. 2014;23:242\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZebala LP, Bridwel KH. Smith-petersen osteotomy and pedicle subtraction osteotomy. Operative Techniques in Spine Surgery. Wolters Kluwer Health Adis (ESP); 2014. pp. 234\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? Eur Spine J. 2018;27:70\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBourghli, A., Boissi\u0026egrave;re, L., Konbaz, F., Al Eissa, S., Al-Habib, A., Qian, B. P.,\u0026hellip; Obeid, I. (2021). On the pedicle subtraction osteotomy technique and its modifications during the past two decades: a complementary classification to the Schwab\u0026rsquo;s spinal osteotomy classification. \u003cem\u003eSpine Deformity, 9, 515\u0026ndash;528.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarrokhi MR, Jamali M, Gholami M, Farrokhi F, Hosseini K. Clinical and radiological outcomes after decompression and posterior fusion in patients with degenerative scoliosis. Br J Neurosurg. 2017;31(5):514\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarrokhi MR, Haghnegahdar A, Rezaee H, Rad MRS. Spinal sagittal balance and spinopelvic parameters in patients with degenerative lumbar spinal stenosis; a comparative study. Clin Neurol Neurosurg. 2016;151:136\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"906\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase No.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge/Sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFracture site/\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOsteotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDuration\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreop Frankel /ODI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003e\u003cstrong\u003esurgery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Fixation levels/\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eosteotomy)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-op Frankel /ODI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-op VAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpine\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eT-score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eM-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eT11-T12 fx (AO-B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eFrankel-E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n 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width=\"14.56953642384106%\"\u003e\n \u003cp\u003eL2- kyphosis\u003c/p\u003e\n \u003cp\u003eT12-L1 fx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eODI-44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eL2 PSO\u003c/p\u003e\n \u003cp\u003eT7:L4 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n 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width=\"10.706401766004415%\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eM-44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eT11-T12 fx (AO-C)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eFrankel-D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eT9:L2 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eM-57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eL2-kyphosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eODI-46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eL2 PSO\u003c/p\u003e\n \u003cp\u003eT8:L5 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eM-44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eC5-C6 traumatic subluxation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eFrankel-E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eAP approach for\u003c/p\u003e\n \u003cp\u003eC5-C6, C6-C7 ACDFP\u003c/p\u003e\n \u003cp\u003eC5-C7 PCF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eM-56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eL2-kyphosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eODI-47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eL2 PSO\u003c/p\u003e\n \u003cp\u003eT8:L5 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eM-45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eL3 kyphosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eODI-48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eL3 PSO\u003c/p\u003e\n \u003cp\u003eT12:L5 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eF- 37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eT12-Kyphosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eODI-46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eT12 PSO\u003c/p\u003e\n \u003cp\u003eT10:L4 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eM-55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eT11 Kyphosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eODI- 44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eT11 PSO\u003c/p\u003e\n \u003cp\u003eT6:L4 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eM-53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eC2 odontoid fx\u003c/p\u003e\n \u003cp\u003e(type-II)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eFrankel-E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eAnterior odontoid screw\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eF-27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eT10-kyphosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eODI-48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eT10 PSO\u003c/p\u003e\n \u003cp\u003eT3:L3 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eF-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eL2-kyphosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eL2-PSO\u003c/p\u003e\n \u003cp\u003eT10:L5 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.28476821192053%\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.298013245033113%\"\u003e\n \u003cp\u003eM-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.56953642384106%\"\u003e\n \u003cp\u003eT10 fx (AO-B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.609271523178808%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.596026490066226%\"\u003e\n \u003cp\u003eFrankel-A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.335540838852097%\"\u003e\n \u003cp\u003eT8:L1 PSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.706401766004415%\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.05739514348786%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.947019867549669%\"\u003e\n \u003cp\u003e-2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1. ACDFP: anterior cervical discectomy and fusion with plate, F: female, M: male, PCF: posterior cervical fusion, PSF: posterior spinal fixation, PSO: pedicular subtraction osteotomy, TLIF: transforaminal lumbar interbody fusion\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"866\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase no.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSVA (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-op\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSVA (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-op\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-op\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-op LL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op TK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-op TK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e51.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e44.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e51.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e34.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e23.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e57.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e19.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e65.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e40.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.664739884393064%\"\u003e\n \u003cp\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.514450867052023%\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.710982658959537%\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.745664739884393%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.017341040462428%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.323699421965317%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.630057803468208%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.092485549132949%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.520231213872833%\"\u003e\n \u003cp\u003e48\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\u003e\u0026nbsp;Table 2. Spinal alignment indices; LL: lumbar lordosis, PI: pelvic incidence, PT: pelvic tilt, SS: sacral slope, SVA: sagittal vertical axis, TK: thoracic kyphosis\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"638\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.17554858934169%\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.764890282131663%\"\u003e\n \u003cp\u003ePre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.078369905956112%\"\u003e\n \u003cp\u003ePost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.981191222570533%\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.17554858934169%\"\u003e\n \u003cp\u003eODI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.764890282131663%\"\u003e\n \u003cp\u003e46.60\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.078369905956112%\"\u003e\n \u003cp\u003e17.22\u0026plusmn;1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.981191222570533%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.17554858934169%\"\u003e\n \u003cp\u003eSVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.764890282131663%\"\u003e\n \u003cp\u003e109.5\u0026plusmn;12.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.078369905956112%\"\u003e\n \u003cp\u003e63.47 \u0026plusmn; 8.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.981191222570533%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.17554858934169%\"\u003e\n \u003cp\u003ePT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.764890282131663%\"\u003e\n \u003cp\u003e29.1\u0026plusmn; 3.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.078369905956112%\"\u003e\n \u003cp\u003e20.93 \u0026plusmn; 3.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.981191222570533%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.17554858934169%\"\u003e\n \u003cp\u003eSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.764890282131663%\"\u003e\n \u003cp\u003e20.37 \u0026plusmn; 1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.078369905956112%\"\u003e\n \u003cp\u003e26.92\u0026plusmn;2.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.981191222570533%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.17554858934169%\"\u003e\n \u003cp\u003eLL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.764890282131663%\"\u003e\n \u003cp\u003e21.64 \u0026plusmn; 9.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.078369905956112%\"\u003e\n \u003cp\u003e41.45 \u0026plusmn; 6.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.981191222570533%\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.17554858934169%\"\u003e\n \u003cp\u003eThoracic Kyphosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.764890282131663%\"\u003e\n \u003cp\u003e60.16 \u0026plusmn; 6.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.078369905956112%\"\u003e\n \u003cp\u003e39.62 \u0026plusmn; 10.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.981191222570533%\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable-3. Pre- and post-operational spinal indices; LL: lumbar lordosis, PT: pelvic tilt, SS: sacral slope, SVA: sagittal vertical axis\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ankylosing Spondylitis, spinal deformity, spine fracture, quality of life","lastPublishedDoi":"10.21203/rs.3.rs-4405137/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4405137/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAnkylosing Spondylitis (AS) is a systemic inflammatory disease that involves axial skeleton the most. It causes ascending inflammation and thus rigidity in spinal column, from sacroiliac joint to the cervical region. Spinal column deformities beside vulnerability to trauma, alters the patients\u0026rsquo; quality of life and put their neural elements to a great risk.\u003c/p\u003e\u003ch2\u003eMaterial and method:\u003c/h2\u003e \u003cp\u003eIn this study, we reviewed data of twenty AS patients who underwent spinal surgery due to trauma, over 12 years in our center. Spinal radiologic indices beside clinical evaluation of quality of life and neurologic status were reviewed and mentioned.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAS patients who were operated due to severe deformity and instability, correction of spinopelvic indices correlated with significant improvement in their quality of life and pain scores. Among those who were operated due to fracture and/or neurologic damage, clinical and neurologic improvement was significant.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSpinal trauma and mal-alignment in AS, correlates with neurological compromise and clinical symptoms such as pain and gate disturbance. Near complete correction of these indices improves patients\u0026rsquo; quality of life. Traumatic spinal fractures in AS, should be considered unstable unless otherwise proved. Meticulous surgical stabilization in such cases usually indicates.\u003c/p\u003e","manuscriptTitle":"Ankylosing Spondylitis: Special Considerations and Clinical Outcomes in Surgical Management of Spinal Fractures, Case Series and Analysis of Twenty Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-28 17:58:29","doi":"10.21203/rs.3.rs-4405137/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"876abd3b-1a99-4a21-a88a-6b3f18cf9e56","owner":[],"postedDate":"May 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-05T19:23:49+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-28 17:58:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4405137","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4405137","identity":"rs-4405137","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}