Can a Nomogram Predict Survival After Treatment for an Ankylosing Spondylitis Cervical Fracture in a Patient With Neurologic Impairment? A National, Multicenter Study

Author:

Bai Hao1,Li Yaobin1,Huang Xinyi1,Tan Quanchang1,Ma Xuexiao2,Wang Qingde3,Wang Linfeng4,Chen Xiongsheng5,Wang Bing6,Xiang Liangbi7,Liu Hao8,Ma Xiaomin9,Liu Xinyu10,Jiang Zhensong11,Wu Aimin12,Cai Weidong13,Liu Peng14,Mao Ningfang15,Lu Ming16,Wan Yong17,Zang Xiaofang18,Li Songkai19,Liao Bo20,Zhao Shuai21,Fu Suochao22,Xie Youzhuan23,Yu Haiyang24,Song Ruoxian25,Ma Zhensheng1,Yan Ming1,Chu Jianjun26,Sun Jiangbo27,Liu Xiang28,Feng Yafei1,Dong Yuan29,Hao Dingjun30,Lei Wei1,Wu Zixiang1

Affiliation:

1. Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, Xi’an, PR China

2. Department of Spine Surgery, the Affiliated Hospital of Qingdao University, Qingdao, PR China

3. Department of Spine Surgery, Zhengzhou Orthopaedic Hospital, Zhengzhou, PR China

4. Department of Orthopedics, The Third Hospital of Hebei Medical University, The Key Laboratory of Orthopedic Biomechanics of Hebei Province, Shijiazhuang, PR China

5. Spine Center, Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, PR China

6. The Second Xiangya Hospital of Central South University, Changsha, PR China

7. Department of Orthopaedics, the General Hospital of Northern Theater Command, Shenyang, PR China

8. Department of Orthopedic Surgery, West China Hospital, Sichuan University, Sichuan, PR China

9. General Hospital of Ningxia Medical University, Yinchuan, PR China

10. Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Jinan, PR China

11. Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, PR China

12. Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, PR China

13. The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China

14. Department of Orthopedics, Daping Hospital, Army Medical University, Chongqing, PR China

15. Department of Spinal Surgery, Changhai Hospital, Second Military Medical University, Shanghai, PR China

16. Department of Orthopaedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China

17. The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China

18. The Third Xiangya Hospital of Central South University, Changsha, PR China

19. Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, PR China

20. Department of Orthopaedics, Tangdu Hospital, The Fourth Military Medical University, Xi'an, PR China

21. Guangdong Province Hospital of Traditional Chinese Medicine, Guangzhou, PR China

22. Department of Orthopedics, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou, PR China

23. Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China

24. Department of Orthopaedic Surgery, Fuyang People's Hospital, Fuyang Clinical College of Anhui Medical University, Fuyang, PR China

25. Department of Orthopedics, PLA 960th Hospital, Jinan, PR China

26. Department of Spine Surgery, Hefei Orthopaedics Hospital, Hefei, PR China

27. Shaoyang Zhenggu Hospital, Shaoyang, PR China

28. Hebei Aidebao Hospital, Zhengzhou, Langfang, PR China

29. Department of Cardiology, Xijing Hospital, The Air Force Medical University, Xi’an, PR China

30. Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, PR China

Abstract

Abstract Background Ankylosing spondylitis–related cervical spine fracture with neurologic impairment (ASCF-NI) is a rare but often lethal injury. Factors independently associated with survival after treatment remain poorly defined, and identifying patients who are likely to survive the injury remains challenging. Questions/purposes (1) What factors are independently associated with survival after treatment among patients with ASCF-NI? (2) Can a nomogram be developed that is sufficiently simple for clinicians to use that can identify patients who are the most likely to survive after injury? Methods This retrospective study was conducted based on a multi-institutional group of patients admitted and treated at one of 29 tertiary hospitals in China between March 1, 2003, and July 31, 2019. A total of 363 patients with a mean age of 53 ± 12 years were eventually included, 343 of whom were male. According to the National Household Registration Management System, 17% (61 of 363) died within 5 years of injury. Patients were treated using nonsurgical treatment or surgery, including procedures using the anterior approach, posterior approach, or combined anterior and posterior approaches. Indications for surgery included three-column injury, unstable fracture displacement, neurologic impairment or continuous progress, and intervertebral disc incarceration. By contrast, patients generally received nonsurgical treatment when they had a relatively stable fracture or medical conditions that did not tolerate surgery. Demographic, clinical, and treatment data were collected. The primary study goal was to identify which factors are independently associated with death within 5 years of injury, and the secondary goal was the development of a clinically applicable nomogram. We developed a multivariable Cox hazards regression model, and independent risk factors were defined by backward stepwise selection with the Akaike information criterion. We used these factors to create a nomogram using a multivariate Cox proportional hazards regression analysis. Results After controlling for potentially confounding variables, we found the following factors were independently associated with a lower likelihood of survival after injury: lower fracture site, more-severe peri-injury complications, poorer American Spinal Injury Association (ASIA) Impairment Scale, and treatment methods. We found that a C5 to C7 or T1 fracture (ref: C1 to C4 and 5; hazard ratio 1.7 [95% confidence interval 0.9 to 3.5]; p = 0.12), moderate peri-injury complications (ref: absence of or mild complications; HR 6.0 [95% CI 2.3 to 16.0]; p < 0.001), severe peri-injury complications (ref: absence of or mild complications; HR 30.0 [95% CI 11.5 to 78.3]; p < 0.001), ASIA Grade A (ref: ASIA Grade D; HR 2.8 [95% CI 1.1 to 7.0]; p = 0.03), anterior approach (ref: nonsurgical treatment; HR 0.5 [95% CI 0.2 to 1.0]; p = 0.04), posterior approach (ref: nonsurgical treatment; HR 0.4 [95% CI 0.2 to 0.8]; p = 0.006), and combined anterior and posterior approach (ref: nonsurgical treatment; HR 0.4 [95% CI 0.2 to 0.9]; p = 0.02) were associated with survival. Based on these factors, a nomogram was developed to predict the survival of patients with ASCF-NI after treatment. Tests revealed that the developed nomogram had good performance (C statistic of 0.91). Conclusion The nomogram developed in this study will allow us to classify patients with different mortality risk levels into groups. This, coupled with the factors we identified, was independently associated with survival, and can be used to guide more appropriate treatment and care strategies for patients with ASCF-NI. Level of Evidence Level III, therapeutic study

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Orthopedics and Sports Medicine,General Medicine,Surgery

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