Ankylosing spondylitis (AS) combined with lower cervical fracture is often categorized into unstable fracture, with a high incidence of neurological injury and a high rate of disability and morbidity. As factors such as shoulder occlusion may affect the accuracy of X-ray imaging diagnosis, it is often easily misdiagnosed at the primary diagnosis. Non-operative treatment has complications such as bone nonunion and the possibility of secondary neurological damage, while the timing, access and choice of surgical treatment are still controversial. Currently, there are no clinical practice guidelines for the treatment of AS combined with lower cervical fracture with or without dislocation. To this end, the Spinal Trauma Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate Clinical guidelines for the treatment of ankylosing spondylitis combined with lower cervical fracture in adults ( version 2024) in accordance with the principles of evidence-based medicine, scientificity and practicality, in which 11 recommendations were put forward in terms of the diagnosis, imaging evaluation, typing and treatment, etc, to provide guidance for the diagnosis and treatment of AS combined with lower cervical fracture.

Ankylosing spondylitis (AS) combined with spinal fractures with thoracic and lumbar fracture as the most common type shows characteristics of unstable fracture, high incidence of nerve injury, high mortality and high disability rate. The diagnosis may be missed because it is mostly caused by low-energy injury, when spinal rigidity and osteoporosis have a great impact on the accuracy of imaging examination. At the same time, the treatment choices are controversial, with no relevant specifications. Non-operative treatments can easily lead to bone nonunion, pseudoarthrosis and delayed nerve injury, while surgeries may be failed due to internal fixation failure. At present, there are no evidence-based guidelines for the diagnosis and treatment of AS combined with thoracic and lumbar fracture. In this context, the Spinal Trauma Academic Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate the Clinical guideline for the diagnosis and treatment of adult ankylosing spondylitis combined with thoracolumbar fracture ( version 2023) by following the principles of evidence-based medicine and systematically review related literatures. Ten recommendations on the diagnosis, imaging evaluation, classification and treatment of AS combined with thoracic and lumbar fracture were put forward, aiming to standardize the clinical diagnosis and treatment of such disorder.

The acute combination fractures of the atlas and axis in adults have a higher rate of neurological injury and early death compared with atlas or axial fractures alone. Currently, the diagnosis and treatment choices of acute combination fractures of the atlas and axis in adults are controversial because of the lack of standards for implementation. Non-operative treatments have a high incidence of bone nonunion and complications, while surgeries may easily lead to the injury of the vertebral artery, spinal cord and nerve root. At present, there are no evidence-based Chinese guidelines for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults. To provide orthopedic surgeons with the most up-to-date and effective information in treating acute combination fractures of the atlas and axis in adults, the Spinal Trauma Group of Orthopedic Branch of Chinese Medical Doctor Association organized experts in the field of spinal trauma to develop the Evidence-based guideline for clinical diagnosis and treatment of acute combination fractures of the atlas and axis in adults ( version 2023) by referring to the "Management of acute combination fractures of the atlas and axis in adults" published by American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) in 2013 and the relevant Chinese and English literatures. Ten recommendations were made concerning the radiological diagnosis, stability judgment, treatment rules, treatment options and complications based on medical evidence, aiming to provide a reference for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults.

Objective:To explore the correlation between cervical curve and ossification of ligaments in cranio-cervical junction and cervical spine in patients with cervical degenerative diseases.Methods:A retrospective study was conducted among 458 patients with cervical degenerative disease who underwent cervical spine X-ray and CT examinations at the Orthopedics Department of Beijing Tiantan Hospital, Capital Medical University between January 2016 and July 2020. There were 265 males and 193 females, with an average age of 57.02±10.41 years (range, 22-87 years). Patients were divided into 5 types (lordosis, straight, S-type degenerative kyphosis, R-type degenerative kyphosis and C-type degenerative kyphosis). Cervical lordosis was defined as C 2-C 7 curve <-4°, cervical kyphosis was defined as >4°, cervical straight was defined as -4° to 4°. C 2-C 7 curve, C 0-C 2 curve were measured respectively, and correlations among these imaging parameters were analyzed. CT images were used to assess the presence of ossification of ligaments in cranio-cervical and cervical spine, including ossification of the posterior longitudinal ligament, nuchal ligament, ligamentum flavum, transverse ligament, apical ligament, diffuse idiopathic skeletal hyperostosis (DISH), as well as capped dens sign (CDS), and correlations between these cervical curve and presence of ossification of ligaments were analyzed. The different grades were based on the length of the ossification of interest with respect to the distance from the posterosuperior rim of the anterior arch of the atlas to the inferior margin of the foramen magnum on mid-sagittal cervical spine CT images, Grade 3 CDS was determined when the length was more than two-thirds. Results:There were 245 patients with cervical lordosis, 114 patients with straight, 53 patients with S-type degenerative cervical kyphosis, 36 patients with R-type degenerative cervical kyphosis and 10 patients with C-type degenerative cervical kyphosis. C 0-C 2 curve showed a negative correlation with C 2-C 7 curve in all enrolled patients ( r=-0.45, P<0.001) and R-type degenerative kyphosis group ( r=-0.58, P<0.001); C 0-C 2 curve showed no correlation with C 2-C 7 curve in lordosis ( r=-0.10, P=0.124), straight ( r=-0.11, P=0.233), S-type degenerative kyphosis ( r=-0.01, P=0.943) or C-type degenerative kyphosis groups ( r=0.03, P=0.946). CDS was detected in 38.4% (176/458) of patients, and Grade 3 was detected in 17.9% (82/458) of patients. The prevalence of CDS was correlated with R-type degenerative cervical kyphosis ( r=0.10, P=0.030). Cervical kyphosis, S-type degenerative kyphosis, C-type degenerative kyphosis, C 2-C 7 curve and C 0-C 2 curve showed no correlation with ossification of the posterior longitudinal ligament, nuchal ligament, ligamentum flavum, transverse ligament, apical ligament, diffuse idiopathic skeletal hyperostosis (DISH) or different grades CDS ( P>0.05). Conclusion:R-type degenerative cervical kyphosis are more likely to correlate with the cranio-cervical curve and CDS, which is an ossification of ligament in cranio-cervical junction.

Objective:To identify the potential impact of cervical spine kyphosis on muscle parameters, the correlation between life quality score and muscle parameters, the correlation between cervical sagittal parameters and muscle parameters.Methods:From September 30, 2019 to September 30, 2020, 30 patients diagnosed with cervical kyphosis and 34 volunteers with normal cervical curvature were enrolled in this case control study. Kyphosis group and control group were matched with sex (χ 2=0.23, P=0.75), age ( t=0.13, P=0.73), BMI ( t=0.26, P=0.20) and neck pain duration time ( t=4.67, P=0.68). Visual analogue scale (VAS) and the neck disability index (NDI) were applied. Cervical sagittal parameters and cervical range of motion (ROM) were measured on lateral radiographs of cervical spine, which included C 2-C 7 lordosis (CL), cervical sagittal vertical axis (C 2-C 7 SVA), T 1-slope (T 1S) and spinal canal angle (SCA). To evaluate muscle functions, Co-contraction ratio (CCR) was measured by surface electromyography (SEMG). Spearman method was used to analyze the correlation between life quality score, cervical sagittal parameters and CCR. Results:VAS in control group 1.4±0.9 was lower than that in kyphosis group (2.3±0.7), and therewasno statistically significant difference ( t=3.71, P=0.30). NDI in control group (4.3%±2.5%) was significantly lower than that in kyphosis group (5.8%±1.7%), and the difference was statistically significant ( t=2.60, P=0.04). CL in control group (-18.76°±2.43°) was significantly lower than that in kyphosis group (13.80°±7.59°) ( t=3.43, P<0.01). SCA in control group (85.94°±4.52°) was significantly higher than that in kyphosis group (84.07°±10.44°) ( t=0.95, P<0.01). T 1S in control group (24.00°±2.85°) was significantly higher than that of kyphosis group (15.47°±11.33°) ( t=4.25, P<0.01), and C 2-C 7 SVA of control group (30.35±6.59 mm) was significantly higher than that in kyphosis group (19.08±14.47 mm) ( t=4.09, P<0.01). ROM in control group (50.23°±3.07°) was significantly higher than that in kyphosis group (45.63°±11.73°) ( t=2.21, P<0.01). CCR from neutral to flexion movement (CCRNF) was significantly lower in control group (0.46±0.20) than kyphosis group (0.84±0.13)( t=12.61, P=0.005), CCR from extension to neutral movement (CCREN) was significantly lower in control group (0.55±0.21) than in kyphosis group (0.79±0.16) ( t=7.10, P=0.042). CCRNF was significantly correlated with VAS ( r=0.504), NDI ( r=0.322), CL ( r=-0.240), T 1S ( r=-0.591), C 2-C 7 SVA ( r=-0.474) and ROM ( r=-0.303, P<0.05). There were significant correlations between CCREN and VAS ( r=0.339), NDI ( r=0.243), CL ( r=-0.347), T 1S ( r=-0.341), C 2-C 7 SVA ( r=-0.346) and ROM ( r=-0.065) ( P<0.05). However, there was no significant difference between CCR and SCA ( P>0.05). Conclusion:SEMG canbe an objective tool to evaluate the degree of neck pain and neck disability index. During cervical flexion movement, patients with cervical kyphosis had more tensional cervical extensor muscle and worse muscle function.

Objective:To explore sagittal parameters change of upper cervical spine after anterior cervical decompression and fusion (ACDF) and analyze the influential factors by comparison between single-, double- and multi-level surgery.Methods:In this retrospective study, 126 patients (include 60 patients with radiculopathy, 41 patients with myelopathy and 25 patients with myeloradiculopathy) who underwent ACDF between December 2016 and December 2018, were followed up at least 1year ranged from14 to 38 months, with the average of 25.6±7.2 months. 20 patients were operated by single-level ACDF, 45 patients were operated by double-level ACDF and 61 patients were operated by 3- or 4-level ACDF. Standing radiographs of cervical spine and the flexion and extension cervical X-rays were obtained in all patients at 1week before, 3 months after and 1year after operation. The Japanese Orthopaedic Association (JOA) Scores, visual analogue scale (VAS) and neck disability index (NDI) were used to evaluate the clinical effectiveness. Cervical sagittal parameters were assessed with the following parameters: the platform angle of axis (C2Slope), the cobb angle and the range of motion (ROM) of C2-7, C0-1 and C1-2.Results:All the patients obtained satisfactory clinical effects. The mean operative time of single-, double- and multi-level group were 86.4±15.5 min, 117.6±15.6 min and 170.2±28.7 min, respectively. The intraoperative blood loss of 3 groups were 16.5±5.2 ml, 37.2±30.5 ml and 63.4±41.5 ml, respectively. There was statistically significant difference between the 3 groups ( P<0.05). In the single- and double-level groups, the changes of the cobb angle and ROM of upper cervical spine between 1 week before operation and 1 year after operation was no significant difference ( P>0.05). In the multi-level group, the ROM of atlantooccipital joint (C0-1) increased significantly from 11.5°±6.1° before operation to 16.1°±13.9° 3 months and 15.3°±4.8° 1 year after operation ( P<0.05). The cobb angle of upper cervical spine and C2Slpoe was decreased significantly from 21.0°±7.6°, 6.1°±6.7° before operation to 18.6°±7.7°, 4.3°±6.9° 3 months and 19.7°±7.2°, 5.6°±6.3° 1 year after operation respectively ( P<0.05). However, there was no significant difference of cobb angle ofatlantooccipital joint between 1 week before operation and 1 year after operation ( P>0.05). Conclusion:Single- and double-level surgery makes a better ability of preserving the restoration of cervical lordosis, with little impact on the upper cervical spine, meanwhile multi-level fusion shows a negative influence on the restoration and limits the range of motion, also increases risk of surgical operation and degeneration of the atlantooccipital joint, with the increased stress distribution and range of motion.

Objective To investigate the middle-term clinical and radiological outcomes of self-locking and zero-profile cages for the treatment of multi-segmental cervical spondylosis in elderly patients through anterior decompression and fusion approach.Methods A total of 39 old patients with multi-segmental cervical spondylosis who received anterior cervical decompression and internal fixation with self-locking and zero-profile cages from January 2013 to January 2015 were retrospectively analyzed.The operation time,intraoperative bleeding volume and post-operational complications were recorded.The functions of cervical spine before and 1-month,1-year,the last follow-up after treatment were evaluated by using the neck pain visual analogue scale(VAS) score,the Japanese orthopedic association (JOA)score and neck disability index (NDI)score.The subjective satisfaction at the final follow-up was evaluated by using Odom's criteria.The whole cervical spine curvature,the range of motion of cervical spine,the height of fused segment,Cobb angle of fused segment,C2～C7 line of force at sagittal view,Cage sedimentation rate and fusion rate before and 1-month and 1-year and the last follow-up after treatment were evaluated by using X-ray and CT and compared between the two groups.Results All patients were followed up,and the mean follow-up time was(35.0±5.3)months(24-48 months).The average operation time was(110.0±21.3)min(85-180 min).The average intraoperative bleeding volum was (50.3 ± 10.6)ml (20-150 ml).There were significant differences in JOA and NDI scores before versus at 1-month,1-year and the final follow-up after treatment(F=9.93 and 28.21,P=0.001 and 0.001).The VAS score of neck pain was lower at 1-month,1-year follow-up than at pre-treatment(P＜0.05),while there were no significant differences in VAS score before treatment versus at the final treatment(P＞0.05).The fineness rate by the Odom criteria was 84.6 ％ (33/39 cases)at the final follow-up.The whole cervical spine curvature,the height of fused segment,the Cobb angle of fused segment and C2-C7 line of force at sagittal view were significantly improved at 1-month,1-year and the final follow-up versus pre-treatment(P＜0.05).The improvements in whole cervical spine curvature and the height of fused segment were lost in some degree with the time extension of follow-up,and the degree of improvements losing was higher at the final follow-up than at 1-year follow-up.At last follow up and in all of patients,the rate of segment fusion were 87.2 ％ (102/117 cases) and Cage sedimentation rate was still 21.4 ％ (25/117 cases).Conclusions Self-locking and zero-profile cages can shorten the operation time,reduce the incidence of postoperative dysphagia,and have good clinical efficacy and fusion rate.But the improvements in cervical spine curvature and the height of fused segement are gradually lost,and the cage has a subsidence in some degree in the middle-term follow-up.Thus,a comprehensive consideration is still needed when choosing self-locking and zero-profile cages for clinical application.

Objective To investigate clinical effect of surgical treatment for spinal stenosis with lumbar degenerative de novo scoliosis with spinal stenosis.To discuss selection of operation methods and ranges of fusion.Methods 27 patients of degenerative scoliosis with spinal stenosis were treated by oper-ation.We performed posterior decompression on the segments and selected fusion,then performed correc-tion deformity.Measured Cobb 's angle,lumbar lordosis angle,the distance between C7 plumb line (C7PL),upper edge of S1 vertebral body(SVA),and the distance between C7PL and center sacral verti-cal line(CVA)after operation and final follow up were compared with preoperative data.JOA score system were used to evaluate clinical effects.The SF-36 questionary was used to evaluate the patients'life quality before and after operation as well.Results All patients were followed up with an average of 20 months. Preoperative,postoperative and final follow up,Cobb's angle was(22.1 ±10.5 )°,(10.2 ±7.3)°and (10.4 ±4.8)°,respectively;lumbar lordosis angle was(21.2 ±10.3)°,(25.7 ±12.2)°and(25.3 ± 12.3)°,respectively;SVA was(7.5 ±6.1)cm,(0.6 ±3.1)cm and(0.5 ±2.4)cm,respectively;CVA was(6.9 ±5.3)cm,(2.8 ±1.3)cm and(2.9 ±1.2)cm,respectively.There was significant difference in data before and after operation(P >0.05).JOA score was 10.8 ±1.4,21.3 ±2.4 and 23.5 ±2.3,re-spectively;All domains of SF-36 score were significantly improved postoperatively(P <0.05).Conclu-sion For surgical treatment with limited decompression,pedicle screw fixation and fusion will be effective methods for degenerative scoliosis with spinal stenosis,individualized surgery design should be made ac-cording to clinical symptoms,signs and imaging features.

OBJECTIVETo analyze the percutaneous kyphoplasty (PKP) data statistically to predict the bone cement volume (CV).

METHODSRetrospective analysis of 93 patients with 154 vertebrae of osteoporotic vertebra compressed fracture, who received PKP from January 2012 to December 2013 in Beijing Tian Tan Hospital, Capital Medical University. All procedures were bilateral and non-high-pressure polymethyl methacrylate injection. The balloon volume (BV), balloon peak pressure (Pmax), CV and the ratio of Pmax to BV (P/BV) were documented. The data was analyzed by correlation analysis and linear regression analysis to reveal the correlation between BV and CV.

RESULTSSeven vertebrae had bone cement leakage, no intraspinal leakage, no neuro-deficit. Visual analogue scale was 0-2 of all patients on 3 d postoperation. The data of 147 vertebrae without leakage: BV was 2.1-6.3 ml, Pmax was 130-359 psi, CV was 2.8-8.5 ml, and the ratio of Pmax to BV (P/BV) was 25-263 psi/ml. The data analysis showed there was no high correlation between BV and CV as one group (R<0.75). However if divided the data into three groups by the value of P/BV, group A (P/BV<100), group B (100≤P/BV<200), group C (P/BV≥200), there was high correlation and linear relationship between BV and CV in each group (R>0.75, P<0.01). CV was 0.9-1.1 times of BV in group A; CV was 1.4-1.6 times of BV in group B; and CV was 2.0-2.2 times of BV in group C.

CONCLUSIONCV is predictable by the BV and the ratio of Pmax to BV. It can reduce the rate of the leakage, and also can prevent the unsatisfactory results by insufficient bone cement volume.

Beijing ; Bone Cements ; Fractures, Compression ; surgery ; Humans ; Injections ; Kyphoplasty ; Pain Measurement ; Postoperative Period ; Pressure ; Retrospective Studies ; Spinal Fractures ; surgery

Objective To establish standard parameters of cervical alignment and cervical range of motion(ROM) in asymptomatic population,and to explore the influential factors such as age,sex and cervical disc degeneration.Methods The cervical standard lateral,flexion and extension plain radiographs of 212 asymptomatic volunteers were analyzed retrospectively.The volunteers,including 128 females and 84 males with ages ranging from 20 to 79 years,were divided into 6 groups from 3rd to 8th decade of life and were divided into 4 groups based on the scoring system of cervical disc degeneration.These plain films were blindly measured by 3 spine surgeons with Mimics software,and each spine surgeon mcasured them for 3 times.Several parameters,including C2-C7 cervical alignment,total ROM,flexion ROM,extension ROM and segmental ROM were measured.The score of disc degeneration were assessed from C2-C3 to C6-C7.Pearson correlation analyses was used to quantify the relation between cervical alignment and total ROM.Multiple linear regression analyses were required to account for influential factors.Inter-and intrarater correlation coefficient was analyzed.Results The C2-C7 cervical alignment was 21.40°± 12.15°,and the total ROM was 63.59°± 15.37°.Sex had a significant impact on the cervical alignment (regression coefficient was-2.472,P ＜ 0.05).Both sex and age had significant impacts on the total ROM (regression coefficient was 3.863 and-6.463 respectively,P ＜ 0.05).Sex had a significant impact on C2,3 and C5,6 segmental ROM; age had a significant impact on all of the five segmental ROM from C2,3 to C6,7; cervical disc degeneration had a significant impact on the C4-5,C5-6 and C6-7 segmental ROM.The cervical alignment had no significant association with both of the extension and total ROM (r=-0.106 and 0.215,respectively,P ＞ 0.05),but had a significantly negative association with flexion angle (r=-0.401,P＜ 0.05).The measurement of cervical alignment,total ROM and segmental ROM showed excellent intra-rater agreement and excellent inter-rater agreement.Conclusion Sex is an influential factor of the cervical alignment.Sex and age are two influential factors of the total ROM.Sex,age and cervical disc degeneration are influential factors of the segmental ROM.The cervical alignments do not have an impact on total ROM.