From circumferential to posterior-only fixation: evolving strategies for cervical fractures in ankylosing spinal disorders

Cervical fractures in patients with ankylosing spinal disorders are highly unstable injuries associated with substantial morbidity and mortality. While surgical stabilization is widely accepted, the optimal surgical strategy remains debated.

To evaluate surgical strategies, neurological outcomes, morbidity, and mortality following surgical treatment of cervical fractures in patients with spinal ankylosis.

We retrospectively analyzed 91 consecutive patients with ankylosing spinal disorders who sustained cervical spine fractures and were treated surgically between 2008 and 2025. Demographic characteristics, fracture morphology, neurological status, surgical approach, perioperative outcomes, complications, and mortality were assessed.

The cohort comprised 91 patients with a median age of 78 years. Low-energy trauma accounted for most injuries. Neurological deficits were present in 28.6% of patients and were significantly associated with AO type C fractures and epidural hematoma. Surgical treatment consisted predominantly of posterior fixation, with a temporal shift from combined anterior-posterior stabilization toward posterior-only navigated pedicle screw constructs. Overall complication and in-hospital mortality rates were 52.7% and 9.9%, respectively. In multivariable Firth regression, higher Charlson Comorbidity Index remained associated with in-hospital mortality, whereas age did not.

AO type C morphology and concomitant epidural hematoma were associated with neurological compromise. Posterior long-segment fixation using navigated pedicle screws became the predominant treatment strategy, with no mechanical failures requiring revision observed in this group during the available follow-up. Additional anterior stabilization remained important when direct anterior decompression or structural anterior column reconstruction was required.