Surgical vs. non-surgical management of cervical spine fractures associated with ankylosing spinal disorders: a matched retrospective comparison assessing mortality

Background Ankylosing spinal disorders (ASD) increase the risk of unstable cervical spine fractures, posing a significant mortality risk. Surgery is recommended for patients with neurological deficits, but the effectiveness of non-surgical treatment in those without deficits remains unclear. This study aimed to compare survival rates between surgical and non-surgical treatments of ASD-related cervical fractures in a matched cohort. Methods The study analyzed data from the Swedish Fracture Registry (SFR) on adult patients treated for ASD-related cervical spine fractures between January 2015 and December 2021. Preoperative variables included age, sex, trauma type, neurological function, fracture morphology, and treatment method. Propensity score matching was conducted to compare outcomes between treatment groups, ensuring balanced comparison groups regarding age, sex, type of trauma, time from injury to admission, fracture type, level of injury, and neurological function. Results In total, 357 adult patients with ASD-related cervical spine fractures were analyzed. Among them, 186 were treated surgically and 171 non-surgically. Treatment failure and conversion so surgical treatment was seen in 3.4% of the non-surgically treated patients. Most patients were male (80%), with a median age of 75 years. Fractures were mainly caused by low-energy trauma (69%). Most patients (92%) were ambulatory (Frankel grade D or E). In the unmatched analysis, surgically treated patients had significantly lower 1-year mortality rates (13% vs. 22%; p < 0.001), but after matching, there were no longer any difference between the two groups (16% vs. 22%; p = 0.44). These findings were also validated on Kaplan-Meier analysis. Multivariable logistic regression analysis identified high age as the only predictor for 30-day mortality (OR 1.14 [95% CI 1.09-1.22], p < 0.001). Conclusion Following propensity score matching, surgical and conservative management result in similar mortality outcomes for neurologically intact patients with ASD fractures. Age, rather than treatment approach, emerged as a stronger predictor of overall mortality. Nonetheless, treatment decisions should also consider other clinical outcomes beyond mortality, emphasizing the need for an individualized approach until more robust evidence is available.