A Systematic Review Evaluating the Surgical Management of Cervical Spine Fractures in Patients With Ankylosing Spondylitis

Patients with ankylosing spondylitis (AS) are vulnerable to cervical spinal fractures despite minute trauma. As there is a lack of consensus on which surgical approach is the most efficacious in treating cervical spinal fractures in AS patients, we sought to compare the posterior-only and combined (anterior-posterior) approach regarding intraoperative and postoperative complications. This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (ID: CRD42024284877). Studies published up to May 20, 2025, were searched in PubMed, MEDLINE, and CENTRAL (Cochrane Central Register of Controlled Trials) with predetermined terms. Studies reporting outcomes, including intraoperative and postoperative complications and mortality rate, were evaluated. Included studies underwent a risk of bias assessment. Seventeen studies (one prospective, 16 retrospective) involving 858 patients (with AS and cervical spine fractures) with an average age of 59.9 years were included. The most common mechanism of injury was minor trauma (173, 66%), and C6-7 was the most common level injured (185, 50.6%). Although the posterior-only approach yielded fewer intraoperative complications (4 (4.8%) vs. 2 (15%); p>0.05), postoperative complications (17 (7.5%) vs. 16 (22.6%); p>0.05), and instrument-related complications (1 (2.8%) vs. 3 (12.5%); p>0.05) compared to the combined approach, the difference was not statistically significant. However, the combined approach recorded a significantly lower mortality rate (3 (9.2%) vs. 13 (24.5%); p>0.05) when compared with the posterior-only approach. The results of this systematic review suggest that both the combined and posterior-only approaches have advantages and disadvantages and approach selection should be done on a case-by-case basis. Future randomized controlled trials directly evaluating the efficacy of surgical approaches in such patients are needed to form a consensus.