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Numrering	Referens	Omslagsbild	Hitta
1.	Anderberg, Leif, et al. (författare) Pisksnärtsskada ingen indikation för kraniocervikal fusion 2004 Ingår i: Läkartidningen. - 0023-7205. ; 101:9, s. 7-806 Tidskriftsartikel (refereegranskat)
2.	Anderberg, L., et al. (författare) [Whiplash injury is not an indication for craniocervical fusion] 2004 Ingår i: Lakartidningen. - 0023-7205. ; 101:9 Tidskriftsartikel (refereegranskat)
3.	Andersson, Susanna, et al. (författare) Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly 2000 Ingår i: Eur Spine J. ; 9, s. 56- Tidskriftsartikel (refereegranskat)
4.	Berg, Svante, 1953- (författare) On Total Disc Replacement 2010 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Low back pain consumes a large part of the community’s resources dedicated to health care and sick leave. Back disorders also negatively affect the individual leading to pain suffering, decreased quality-of-life and disability. Chronic low back pain (CLBP) due to degenerative disc disease (DDD) is today often treated with fusion when conservative treatment has failed and symptoms are severe. This treatment is as successful as arthroplasty is for hip arthritis in restoring the patient’s quality of life and reducing disability. Even so, there are some problems with this treatment, one of these being recurrent CLBP from an adjacent segment (ASD) after primarily successful surgery. This has led to the development of alternative surgical treatments and devices that maintain or restore mobility, in order to reduce the risk for ASD. Of these new devices, the most frequently used are the disc prostheses used in Total Disc Replacement (TDR).This thesis is based on four studies comparing total disc replacement with posterior fusion. The studies are all based on a material of 152 patients with DDD in one or two segments, aged 20-55 years that were randomly treated with either posterior fusion or TDR.The first study concerned clinical outcome and complications. Follow-up was 100% at both one and two years. It revealed that both treatment groups had a clear benefit from treatment and that patients with TDR were better in almost all outcome scores at one-year follow-up. Fusion patients continued to improve during the second year. At two-year follow-up there was a remaining difference in favour of TDR for back pain. 73% in the TDR group and 63% in the fusion group were much better or totally pain-free (n.s.), while twice as many patients in the TDR group were totally pain free (30%) compared to the fusion group (15%).Time of surgery and total time in hospital were shorter in the TDR group.There was no difference in complications and reoperations, except that seventeen of the patients in the fusion group were re-operated for removal of their implants.The second study concerned sex life and sexual function. TDR is performed via an anterior approach, an approach that has been used for a long time for various procedures on the lumbar spine. A frequent complication reported in males when this approach is used is persistent retrograde ejaculation. The TDR group in this material was operated via an extra-peritoneal approach to the retroperitoneal space, and there were no cases of persistent retrograde ejaculation. There was a surprisingly high frequency of men in the fusion group reporting deterioration in ability to have an orgasm postoperatively.Preoperative sex life was severely hampered in the majority of patients in the entire material, but sex life underwent a marked improvement in both treatment groups by the two-year follow-up that correlated with reduction in back pain.The third study was on mobility in the lumbar spinal segments, where X-rays were taken in full extension and flexion prior to surgery and at two-year follow-up. Analysis of the films showed that 78% of the patients in the fusion group reached the surgical goal (non-mobility) and that 89% of the TDR patients maintained mobility.Preoperative disc height was lower than in a normative database in both groups, and remained lower in the fusion group, while it became higher in the TDR group. Mobility in the operated segment increased in the TDR group postoperatively. Mobility at the rest of the lumbar spine increased in both treatment groups. Mobility in adjacent segments was within the norm postoperatively, but slightly larger in the fusion group.In the fourth study the health economics of TDR vs Fusion was analysed. The hospital costs for the procedure were higher for patients in the fusion group compared to the TDR group, and the TDR patients were on sick-leave two months less.In all, these studies showed that the results in the TDR group were as good as in the fusion group. Patients are more likely to be totally pain-free when treated with TDR compared to fusion. Treatment with this new procedure seems justified in selected patients at least in the short-term perspective. Long-term follow-up is underway and results will be published in due course.
5.	Berg, Svante, et al. (författare) Total disc replacement compared to lumbar fusion : a randomised controlled trial with 2-year follow-up 2009 Ingår i: EUROPEAN SPINE JOURNAL. - : Springer Science and Business Media LLC. - 0940-6719 .- 1432-0932. ; 18:10, s. 1512-1519 Tidskriftsartikel (refereegranskat)abstract The study design includes a prospective, randomised controlled study comparing total disc replacement (TDR) with posterior fusion. The main objective of this study is to compare TDR with lumbar spinal fusion, in terms of clinical outcome, in patients referred to a spine clinic for surgical evaluation. Fusion is effective for treating chronic low back pain (LBP), but has drawbacks, such as stiffness and possibly adjacent level degradation. Motion-preserving options have emerged, of which TDR is frequently used because of these drawbacks. How the results of TDR compare to fusion, however, is uncertain. One hundred and fifty-two patients with a mean age of 40 years (21-55) were included: 90 were women, and 80 underwent TDR. The patients had not responded to a conservative treatment programme and suffered from predominantly LBP, with varying degrees of leg pain. Diagnosis was based on clinical examination, radiographs, MRI, and in unclear cases, diagnostic injections. Outcome measures were global assessment (GA), VAS for back and leg pain, Oswestry Disability Index, SF36 and EQ5D at 1 and 2 years. Follow-up rate was 100%, at both 1 and 2 years. All outcome variables improved in both groups between preoperative and follow-up assessment. The primary outcome measure, GA, revealed that 30% in the TDR group and 15% in the fusion group were totally pain-free at 2 years (P = 0.031). TDR patients had reached maximum recovery in virtually all variables at 1 year, with significant differences compared to the fusion group. The fusion patients continued to improve and at 2 years had results similar to TDR patients apart from numbers of pain-free. Complications and reoperations were similar in both groups, but pedicle screw removal as additive surgery, was frequent in the fusion group. One year after surgery, TDR was superior to spinal fusion in clinical outcome, but this difference had diminished by 2 years, apart from (VAS for back pain and) numbers of pain-free. The long-term benefits have yet to be examined.
6.	Bodon, Gergely, et al. (författare) Anatomical changes in occipitalization : is there an increased risk during the standard posterior approach? 2013 Ingår i: European spine journal. - : Springer Science and Business Media LLC. - 0940-6719 .- 1432-0932. ; 22:3 suppl., s. 512-516 Tidskriftsartikel (refereegranskat)abstract PURPOSE:The purpose of this study was to examine the anatomic changes in a case of occipitalization of the atlas.METHODS:Occipitalization of the atlas was found accidentally in a 64-year-old male cadaver. Anatomic dissection was carried out to examine the posterior aspect of the upper cervical region and craniocervical junction. The occipitalized atlas was then harvested and macerated to study the bony anomaly.RESULTS:In this case of occipitalization, fusion was observed at both lateral masses and at the left posterior hemiarch of the atlas. We found the following soft tissue changes: the rectus capitis posterior minor muscle was lacking on the left side and was atrophic on the right, the obliquus capitis superior muscle was present on both sides showing moderate atrophy and fatty changes. The posterior atlanto-axial membrane was thinner and asymmetric, had a free edge on the right side. Lateral to this edge the dura was lying free. We believe that these changes of the posterior atlanto-axial membrane together with the increased distance between the fused posterior arch of the atlas and the lamina of the axis could cause the observed "dura bulge" at this level. The vertebral artery was entering the skull through a canal on the left side.CONCLUSIONS:In our case, occipitalization considerably changed the anatomy of the upper cervical spine and craniocervical junction. Special care must be taken when using the posterior approach to avoid neurovascular injury in cases with occipitalization.
7.	Bodon, Gergely, et al. (författare) Applied anatomy of a minimally invasive muscle-splitting approach to posterior C1-C2 fusion : an anatomical feasibility study 2014 Ingår i: Surgical and Radiologic Anatomy. - : Springer Science and Business Media LLC. - 0930-1038 .- 1279-8517. ; 36:10, s. 1063-1069 Tidskriftsartikel (refereegranskat)abstract PURPOSE:To describe the applied anatomy of a minimally invasive muscle-splitting approach used to reach the posterior aspect of the C1-C2 complex.SUMMARY OF BACKGROUND DATA:Atlantoaxial fusion using a midline posterior approach and polyaxial screw and rod system is widely used. Although minimally invasive variations of this technique have been recently reported, the complex applied anatomy of these approaches has not been described. The C1-C2 complex represents an unique challenge because of its bony and vascular anatomy. In this study, the applied anatomy and feasibility of this technique are examined on cadavers.METHODS:The microsurgical anatomy of the upper cervical spine is examined on a formalin-fixed and on a fresh cadaver. The muscle-splitting approach is performed on 12 fresh cadavers using this technique.RESULTS:The minimally invasive muscle-splitting approach is described in detail. Relevant anatomy and bony landmarks that aid screw placement in C1 and C2 could be well visualized. Using this approach, we were able to reach the lateral mass of the atlas and the inferior articular process and pars interarticularis of the axis in all of the nine cadavers. We placed mini polyaxial screws in C1 lateral mass and C2 pars interarticularis in four cadavers according to the technique described by Harms and Melcher.CONCLUSIONS:Using this approach, it was possible to reach the posterior aspect of C1 and C2; the relevant anatomy needed to perform a C1-C2 fusion could be well visualized.
8.	Carrwik, Christian, et al. (författare) Does knowledge of the primary tumour affect survival after surgery for spinal metastatic disease? : A retrospective longitudinal cohort study 2021 Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 11:8 Tidskriftsartikel (refereegranskat)abstract OBJECTIVES: To compare survival after surgery for patients with spinal metastatic disease with known primary tumour (KPT) versus patients with unknown primary tumour (UPT).PARTICIPANTS: 393 patients 18 years or older (270 men and 123 women, mean age 67.3 years) undergoing surgery at Uppsala University Hospital in Swedenbetween 2006 and 2016due to spinal metastatic disease . 271 patients (69%) had a KPT at the time of surgery and 122 (31%) had an UPT.INTERVENTIONS: Decompressive and/or stabilising spine surgery due to spinal metastatic disease.PRIMARY OUTCOME: Survival (median and mean) after surgery.RESULTS: The estimated median survival time after surgery for patients with KPT was 7.4 months (95% CI 6.0 to 8.7) and mean survival time was 21.6 months (95% CI 17.2 to 26.0). For patients with UPT, the median estimated survival time after surgery was 15.6 months (95% CI 7.5 to 23.7) and the mean survival time was 48.1 months (95% CI 37.3 to 59.0) (Breslow, p=0.001). Unknown primary cancer was a positive predictor of survival after surgery (Cox regression, HR=0.58, 95% CI 0.46 to 0.73).CONCLUSION: In this study, patients with spinal metastasis and UPT had a longer expected survival after surgery compared with patients with KPT. This suggests that patients with UPT and spinal metastasis should not be withheld from surgery only based on the fact that the primary tumour is unknown.
9.	Carrwik, Christian, et al. (författare) Predictive Scores Underestimate Survival of Patients With Metastatic Spine Disease : A Retrospective Study of 315 Patients in Sweden 2020 Ingår i: Spine. - 0362-2436 .- 1528-1159. ; 45:6, s. 414-419 Tidskriftsartikel (refereegranskat)abstract STUDY DESIGN: Retrospective cohort study.OBJECTIVE: To validate the precision of four predictive scoring systems for spinal metastatic disease and evaluate whether they underestimate or overestimate survival.SUMMARY OF BACKGROUND DATA: Metastatic spine disease is a common complication to malignancies. Several scoring systems are available to predict survival and to help the clinician to select surgical or nonsurgical treatment.METHODS: Three hundred fifteen adult patients (213 men, 102 women, mean age 67 yr) undergoing spinal surgery at Uppsala University Hospital, Sweden, due to metastatic spine disease 2006 to 2012 were included. Data were collected prospectively for the Swedish Spine Register and retrospectively from the medical records. Tokuhashi scores, Revised Tokuhashi Scores, Tomita scores, and Modified Bauer Scores were calculated and compared with actual survival data from the Swedish Population Register.RESULTS: The mean estimated survival time after surgery for all patients included was 12.4 months (confidence interval 10.6-14.2) and median 5.9 months (confidence interval 4.5-7.3). All four scores had significant correlation to survival (P < 0.0001) but tended to underestimate rather than overestimate survival. Modified Bauer Score was the best of the four scores to predict short survival, both regarding median and mean survival. Tokuhashi score was found to be the best of the scores to predict long survival, even though the predictions were inaccurate in 42% of the cases.CONCLUSION: Predictive scores underestimate survival for the patients which might affect important clinical decisions.LEVEL OF EVIDENCE: 3.
10.	Carrwik, Christian, 1977-, et al. (författare) Survival after surgery for spinal metastatic disease: a nationwide multiregistry cohort study. 2021 Ingår i: BMJ open. - : BMJ. - 2044-6055. ; 11:11 Tidskriftsartikel (refereegranskat)abstract To evaluate survival after surgery and indications for surgery due to spinal metastatic disease.A retrospective longitudinal multiregistry nationwide cohort study.19 public hospitals in Sweden with spine surgery service, where 6 university hospitals account for over 90% of the cases.1820 patients 18 years or older undergoing surgery due to spinal metastatic disease 2006-2018 and registered in Swespine, the Swedish national spine surgery registry.Decompressive and/or stabilising spine surgery due to spinal metastatic disease.Survival (median and mean) after surgery.Indications for surgery, types of surgery and causes of death.The median estimated survival after surgery was 6.2 months (95% CI: 5.6 to 6.8) and the mean estimated survival time was 12.2 months (95% CI: 11.4 to 13.1). Neurologic deficit was the most common indication for surgery and posterior stabilisation was performed in 70.5% of the cases. A neoplasm was stated as the main cause of death for 97% of the patients.Both median and mean survival times were well above the generally accepted thresholds for surgical treatment for spinal metastases, suggesting that patient selection for surgical treatment on a national level is adequate. Further research on quality of life after surgery and prognostication is needed.
11.	Cornefjord, Michael, et al. (författare) Posterior atlanto-axial fusion with the Olerud cervical fixation system for odontoid fractures and C1-C2 instability in reumathoid arthritis 2003 Ingår i: European spine journal. - : Springer Science and Business Media LLC. - 0940-6719 .- 1432-0932. ; 12:1, s. 91-96 Tidskriftsartikel (refereegranskat)abstract In posterior C1-C2 fusion, traditional wire fixation gives poor stability. The bone quality is often insufficient to provide the competent structural bone graft that is required, and the introduction of sublaminar wires is somewhat dangerous. The stability is markedly improved by adding transarticular screws, but the drawbacks of structural bone graft and sublaminar wires remain. The C1 claw of the Olerud Cervical Fixation System improves C1-C2 fixation without relying on structural bone graft or compromising the spinal canal. The aim of this study was to evaluate radiological healing and possible complications in a consecutive series of C1-C2 fusions from our department operated with the C1 claw device. Twenty-six patients (14 women) with a mean age of 73 (range 37-93) years were included. The diagnoses were odontoid fracture in 18 patients, rheumatoid instability in 6, and odontoid non-union and os odontoideum in 1 each. The patients were followed clinically and with plain radiographs for an average of 15 (range 3-27) months. There were no neurological or vascular complications, and no secondary displacements or reoperations in the series. Twenty patients followed for 6-27 months were radiographically healed. Six patients died from unrelated causes 1-38 months postoperatively. Three of these patients had no radiographs later than the postoperative control, one had a healed odontoid fracture but resorbed bone graft at 8 months, while the remaining two patients were not healed, but showed no signs of healing disturbance at the time of death. On the basis of the findings of this study, posterior C1-C2 fusion with the Olerud Cervical Fixation System seems promising. No serious complications related to the surgical procedure were encountered. The stability of the implant obviates the use of a solid bone block as a graft and still allows a high frequency of fusion healing.
12.	Cornefjord, Michael, et al. (författare) Posterior fixation of subaxial cervical spine fractures in patients with ankylosing spondylitis. 2004 Ingår i: Eur Spine J. - 0940-6719. Tidskriftsartikel (refereegranskat)
13.	Covaro, Augusto Atilio, et al. (författare) The importance of the occipitocervical area in patients with ankylosing spondylitis : analysis of a cohort of 86 cervical fractures in surgically treated patients. 2017 Ingår i: Journal of Craniovertebral Junction and Spine. - : Wolters Kluwer. - 0974-8237 .- 0976-9285. ; 8:4, s. 374-377 Tidskriftsartikel (refereegranskat)abstract Study Design: This was a retrospective analysis of prospectively collected data.Objective: The effect of C0-C1-C2 cervical ankylosis in patients with ankylosing spondylitis (AS) is not documented. The objective of this study is to describe the radiological characteristics of the occipitocervical junction in patients with AS operated for a cervical fracture and to correlate them with their clinical evolution.Materials and Methods: Analysis of patients with ankylosing spondylitis (AS) treated in a single institution of a cervical vertebral fracture between 2007 and 2014 who were prospectively followed through the SWESPINE registry. The integrity of the C0-C1-C2 joints was determined and classified into fused and nonfused joints. By determining the angle between C0-C1 and C1-C2 joints in the coronal view of the computed tomography scan (X-angle), the progressive degeneration of these joints was described. Intra- and inter-observer reliability of this test was determined. The instruments of health-related quality of life (QOL) and disability were EQ5D and Oswestry disability index (ODI), respectively.Results: A total of 86 patients with AS treated surgically for cervical fracture had complete facet ankylosis between C3 and T1 due to their pathology. Mean age 69.2 years (standard deviation [SD]: 11.7). The most common level of fracture was in C5-C6. In 24 patients, the C0-C1 joint was fused, and in 15 patients, C1-C2 joint was fused. The intra- and inter-class reliabilities for X-angle measurement were very high (intraclass correlation coefficients = 0.94; 0.92). The mean X-angle was 125° (SD: 12) in nonfused patients and 136° (SD: 14) in fused patients (P < 0.001). There were no differences in QOL and disability at 2 years between the two groups: EQ5D-index of 0.54 and 0.55 (P = 0.5), ODI of 26.4 and 24, (P = 0.35) respectively.Conclusions: X-angle is a reliable measure for joint integrity C0-C1-C2 in patients with AS. Total cervical ankylosis including the C0-C1-C2 segments is not related to poorer QOL and disability in these patients.
14.	Eriksson, Thomas, et al. (författare) Low-dose CT of postoperative pelvic fractures : a comparison with radiography 2019 Ingår i: Acta Radiologica. - : SAGE Publications. - 0284-1851 .- 1600-0455. ; 60:1, s. 85-91 Tidskriftsartikel (refereegranskat)abstract Background Computed tomography (CT) is superior to conventional radiography (CR) for assessing internal fixation of pelvic fractures, but with a higher radiation exposure. Low-dose CT (LDCT) could possibly have a sufficient diagnostic accuracy but with a lower radiation dose. Purpose To compare postoperative diagnostic accuracy of LDCT and CR after open reduction and internal fixation of pelvic fracture. Material and Methods Twenty-one patients were examined with LDCT and CR 0-9 days after surgery. The examinations were reviewed by two musculoskeletal radiologists. Hardware, degree of fracture reduction, image quality, and reviewing time were assessed, and effective radiation dose was calculated. Inter-reader agreement was calculated. Results LDCT was significantly better than CR in determining whether hardware positioning was assessable ( P < 0.001). Acetabular congruence was assessable in all fractured patients with LDCT. In 12 of the 32 assessments with CR of patients with an acetabular fracture, joint congruence was not assessable due to overlapping hardware ( P = 0.001). Image quality was significantly higher for LDCT. Median time to review was 240 s for LDCT compared to 180 s for CR. Effective dose was 0.79 mSv for LDCT compared to 0.32 mSv for CR ( P < 0.001). Conclusion LDCT is more reliable than CR in assessing hardware position and fracture reduction. Joint congruency is sometimes not possible to assess with CR, due to overlapping hardware. The image quality is higher, but also the effective dose, with LDCT than with CR.
15.	Gulle, Eva, et al. (författare) Pharmacological strategies to reduce pruritus during postoperative epidural analgesia after lumbar fusion surgery - a prospective randomized trial in 150 patients. 2011 Ingår i: Patient safety in surgery. - : Springer Science and Business Media LLC. - 1754-9493. ; 5:1 Tidskriftsartikel (refereegranskat)abstract Epidural analgesia with bupivacain, epinephrine and fentanyl provides excellent pain control after lumbar fusion surgery, but pruritus and motor block are frequent side effects. Theoretically epidural ropivacain combined with oral oxycodone could decrease the incidence of these side effects. The two regimens were compared in a prospective randomized trial.150 patients (87 women) treated with posterior instrumented lumbar fusion were included. The mean age was 51 +/- 11 years. 76 were randomized to bupivacain, epinephrine and fentanyl (group B) and 74 to ropivacain and oxycodone (group R). Pruritus, motor block and pain were measured 6 hours after surgery, thereafter 6 times per day for 5 days. Any pain breakthrough episode was registered whenever it occurred.The epidural treatment could be performed in 143 patients (72 in group B and 71 in group R). Disturbing pruritus occurred in 53 patients in group B compared to 12 in group R (p < 0.0001). Motor blockade was most frequent on day 1, occurring in 45% of the patients with no difference between the groups. Both regimes gave good pain control with average VAS under 40, but the pain relief was statistically better in group B. The number of pain breakthrough episodes did not differ between the groups.Pruritus could be reduced with a combination of epidural ropivacain and oral oxycodone, at the price of a slightly higher pain level. Ropivacaine was not found to be superior to bupivacaine with regard to motor blocks.
16.	Henriques, Thomas, et al. (författare) Adjacent level motion, a human cadaveric study of the cervical spine before and after one segment fixation Ingår i: Spine. Tidskriftsartikel (refereegranskat)
17.	Henriques, Thomas, 1957- (författare) Biomechanical and Clinical Aspects on Fixation Techniques in the Cervical Spine 2003 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract The present work is analyzing the general biomechanical aspects of fixation techniques in the upper and lower cervical spine along with clinical implications.The in vitro biomechanical properties of five different posterior atlanto-axial fixation techniques are compared. They provided for either a one, two or three-point fixation between atlas and axes. A new device, the C1 claw was biomechanically tested, which allow for fixation without the need for a structural bone graft. The three-point reconstructions indicated superior biomechanical properties compared to all others.The new C1 claw device was clinically evaluated in a series of 26 patients treated with a posterior C1-C2 fusion. There were no clinical or radiological failures in the series, Twenty-one patients out of twenty-three with any length of follow up either showed a solidly healed fusion or a healed fracture. Distractive flexion (DF) injuries in the lower cervical spine treated with anterior plate alone were analyzed with respect to healing rate and complications in a consecutive series of 36 patients. Results indicated that DF injury stage 1 and 2 according to Allen and Ferguson healed without complication, whereas DF injuries stage 3 had a high frequency of failure, needing an additional posterior fixation. The in vitro biomechanical properties of four different fixation techniques for a distractive flexion injury stage 3 were analyzed. The result indicated that anterior plate alone for fixation of a DF injury stage 3 is insufficient supporting the clinical finding in the previous study.Adjacent level motion was analyzed following a one segment fusion in the lower cervical spine. Motion was found to increase in adjacent levels possibly contributing to accelerated degeneration.
18.	Henriques, Thomas, et al. (författare) Biomechanical comparison of five different atlantoaxial posterior fixation techhniques 2000 Ingår i: Spine. - 0362-2436 .- 1528-1159. ; 25:22, s. 2877-2883 Tidskriftsartikel (refereegranskat)abstract STUDY DESIGN:Five different reconstructions of the atlantoaxial complex were biomechanically compared in vitro in a nondestructive test.OBJECTIVES:To determine whether non-bone graft-dependent one-point fixation affords stability levels equivalent to three-point reconstructions.SUMMARY OF BACKGROUND DATA:Previous investigations have demonstrated that three-point fixation, using bilateral transarticular screws in combination with posterior wiring, provide the most effective resistance to minimize motion around C1-C2. However, placement of transarticular screws is technically demanding. Posterior wiring techniques affording one-point fixation have failure rates of approximately 15%, with failure considered to be secondary to structural bone graft failures. One-point, non-bone graft-dependent fixations have not been tested.METHODS:Eight human cervical specimens, C0-C3 were loaded nondestructively. Unconstrained three-dimensional segmental motion was measured. The reconstructions tested were two one-point fixations, one two-point fixation, and two three-point fixations.RESULTS:Under axial rotation two and three-point reconstructions provided better stiffness than the one-point reconstructions (P < 0.05). During flexion-extension, higher stiffness levels were observed in one- and three-point fixations when compared with the intact spine (P < 0.05). In lateral bending no significant differences were observed among the six groups, although the trend was that reconstructions including transarticular screws provided greater stability than one-point fixations.CONCLUSION:The current findings substantiate the use of three-point fixation as the treatment of choice for C1-C2 instability. [l: atlantoaxial fixation, biomechanics, cervical spine, instability, spinal instrumentation, transarticular screws]
19.	Henriques, Thomas, et al. (författare) Biomechanical evaluation of four different fixation techniques for a distractive flexion injury stage 3 of the cervical spine An in vitro human cadaveric model Ingår i: Spine. Tidskriftsartikel (refereegranskat)
20.	Henriques, Thomas, et al. (författare) Distractive flexion injuries of the subaxial cervical spine treated with anterior plate alone 2004 Ingår i: Journal of Spinal Disorders & Techniques. - 1536-0652 .- 1539-2465. ; 17:1, s. 1-7 Tidskriftsartikel (refereegranskat)abstract The clinical and radiographic effect of anterior plate fixation alone was evaluated in 36 consecutive patients with distractive flexion (DF) injuries in the lower cervical spine. Mean follow-up time was 15 months. The aim of the present study was to determine whether anterior plate fixation alone provides sufficient stability when treating DF injuries in the cervical spine. Solid union was seen in 6 of 6 patients with stage 1 injury and in 15 of 17 patients with stage 2 injury. In the patients with stage 3 injury, 7 of 13 of the anterior fixations failed. These failures occurred mainly among the patients with severe neurologic injuries. We believe these findings substantiate the use of anterior plate alone for DF injuries at stage 1 and 2 but disqualify anterior plate fixation alone for DF injuries at stage 3, with neurologic injury present.
21.	Henriques, Thomas, et al. (författare) In vitro biomechanical evaluation of four fixation techniques for distractive-flexion injury stage 3 of the cervical spine 2015 Ingår i: Upsala Journal of Medical Sciences. - : Uppsala Medical Society. - 0300-9734 .- 2000-1967. ; 120:3, s. 198-206 Tidskriftsartikel (refereegranskat)abstract Purpose. Anterior plate fixation has been reported to provide satisfactory results in cervical spine distractive flexion (DF) injuries stages 1 and 2, but will result in a substantial failure rate in more unstable stage 3 and above. The aim of this investigation was to determine the biomechanical properties of different fixation techniques in a DF-3 injury model where all structures responsible for the posterior tension band mechanism are torn. Methods. The multidirectional three-dimensional stiffness of the subaxial cervical spine was measured in eight cadaveric specimens with a simulated DF-3 injury at C5-C6, stabilized with four different fixation techniques: anterior plate alone, anterior plate combined with posterior wire, transarticular facet screws, and a pedicle screw-rod construct, respectively. Results. The anterior plate alone did not improve stability compared to the intact spine condition, thus allowing considerable range of motion around all three cardinal axes (p > 0.05). The anterior plate combined with posterior wire technique improved flexion-extension stiffness (p = 0.023), but not in axial rotation and lateral bending. When the anterior plate was combined with transarticular facet screws or with a pedicle screws-rod instrumentation, the stability improved in flexion-extension, lateral bending, and in axial rotation (p < 0.05). Conclusions. These findings imply that the use of anterior fixation alone is insufficient for fixation of the highly unstable DF-3 injury. In these situations, the use of anterior fixation combined with a competent posterior tension band reconstruction (e.g. transarticular screws or a posterior pedicle screws-rod device) improves segmental stability.
22.	Henriques, Thomas, et al. (författare) Letter to the editor 2001 Ingår i: Spine. - 0362-2436 .- 1528-1159. ; 26:21, s. 2405- Tidskriftsartikel (populärvet., debatt m.m.)
23.	Hirasawa, Atsuhiko, et al. (författare) Regional Differences in Diffuse Idiopathic Skeletal Hyperostosis : A Retrospective Cohort Study from Sweden and Japan 2018 Ingår i: Spine. - 0362-2436 .- 1528-1159. ; 43:24, s. E1474-E1478 Tidskriftsartikel (refereegranskat)abstract Study Design: We retrospectively reviewed computed tomography (CT) records of patients in Japan and Sweden, which are both aging populations. Objective. To research the influence of ethnicity and region on diffuse idiopathic skeletal hyperostosis (DISH) prevalence.Summary of Background Data_ DISH can complicate nonsurgical treatment of spinal fractures and often requires surgical intervention. We previously reported a prevalence of DISH in Japan that was higher than that reported in other studies.Methods: We retrospectively reviewed CT records of patients in Japan and Sweden, which have both aging populations. Patients undergoing whole body CT during trauma examinations at an acute outpatient clinic in Uppsala University Hospital in a 1-year period were eligible for inclusion. Excluded were those less than 40 and more than or equal to 90 years old, and those with previous spinal surgery. The prevalence of DISH by sex and age was determined according to radiographic criteria by Resnick. Results from Sweden were compared with the Japan data, which we previously reported.Results: Age of the eligible subjects (265 men and 153 women) ranged from 40 to 89 years, with a mean age of 63.4 years. Among men, 86 (32.5%) were diagnosed with DISH, and the results by age (40s, 50s, 60s, 70s, and 80s) were: 6 (10.7%), 13 (22%), 35 (46.1%), 17 (34%), and 15 (62.5%) patients, respectively. Among women, 16 (10.5%) had DISH, and the results by age were as follows: 1 (2.6%), 1 (3.3%), 2 (6.7%), 6 (22.2%), and 6 (22.2%) patients, respectively. These results did not differ from those previously published for Japan (Fisher exact test, men: P = 1, 0.27, 0.12, 0.06, and 1, respectively; women: P = 0.49, 0.62, 0.5, 0.8, and 0.3, respectively).Conclusion: The presented cohort study revealed that ethnicity and region may not be notable factors of DISH prevalence, since patients from both Japan and Sweden had similar DISH prevalence.Level of Evidence: 3
24.	Holy, Marek, 1981-, et al. (författare) A Novel Treatment of Pediatric Atlanto-Occipital Dislocation with Nonfusion Using Muscle-Preserving Temporary Internal Fixation of C0-C2 : Case Series and Technical Note 2023 Ingår i: Journal of Neurological Surgery Reports. - : Georg Thieme Verlag KG. - 2193-6358 .- 2193-6366. ; 84:01, s. E11-E16 Tidskriftsartikel (refereegranskat)abstract Study Design: Case series with surgical technical note.Objectives: This article reports experiences and results of muscle-preserving temporary C0-C2 fixation for the treatment of atlanto-occipital dislocation (AOD).Methods: AOD is a rare injury caused by high-energy trauma, occurring in less than 1% of pediatric trauma patients. Recommended treatment is C0-C2 fusion which, however, will result in significant loss of mobility in the craniocervical junction (CCJ), especially C1-C2 rotation. An alternative approach, with the ability of preserving mobility in the C1-C2 segment, is a temporary fixation that allows the ligaments to heal, after which the implants can be removed to regain function in the CCJ joints. By using a muscle-preserving approach and navigation for the C2 screws, a relatively atraumatic fixation of the CCJ can be achieved with motion recovery after implant removal.Results: We present two cases of AOD treated with temporary fixation. A 12-year-old boy involved in a frontal car collision, as a strapped back seat passenger, was treated with temporary C0-C2 fixation for 10 months. Follow-up at 11 months after implant removal included clinical evaluation, computed tomography, magnetic resonance imaging (MRI), and flexion-extension X-rays. He was free of symptoms at follow-up. The CCJ was radiographically stable and he had 45 degrees of C1-C2 rotation.A 7-year-old girl was hit by a car as she got off a bus. She was treated with temporary fixation for 4 months after which the implant was removed. Follow-up at 8 years included clinical evaluation and MRI in rotation. She was free of symptoms. The ligaments of the CCJ appeared normal and her C1-C2 rotation was 30 degrees.Conclusion: C0-C2 fixation without fusion allows the CCJ ligaments to heal in pediatric AOD. By removing the implants after ligament healing, rotation in the C1-C2 segment can be regained without subsequent instability. Both our patients tolerated the treatment well and were free of symptoms at follow-up.By using minimally invasive muscle-preserving technique and navigation, temporary fixation of the CCJ can be achieved with minimal damage to the soft tissues allowing recovery of almost normal function after implant removal.
25.	Holy, Marek, et al. (författare) Operative treatment of cervical radiculopathy : anterior cervical decompression and fusion compared with posterior foraminotomy: study protocol for a randomized controlled trial 2021 Ingår i: Trials. - : BioMed Central (BMC). - 1745-6215. ; 22:1 Tidskriftsartikel (refereegranskat)abstract Background; Cervical radiculopathy is the most common disease in the cervical spine, affecting patients around 50-55 year of age. An operative treatment is common clinical praxis when non-operative treatment fails. The controversy is in the choice of operative treatment, conducting either anterior cervical decompression and fusion or posterior foraminotomy. The study objective is to evaluate short- and long-term outcome of anterior cervical decompression and fusion (ACDF) and posterior foraminotomy (PF) Methods: A multicenter prospective randomized controlled trial with 1:1 randomization, ACDF vs. PF including 110 patients. The primary aim is to evaluate if PF is non-inferior to ACDF using a non-inferiority design with ACDF as "active control." The neck disability index (NDI) is the primary outcome measure, and duration of follow-up is 2 years. Discussion: Due to absence of high level of evidence, the authors believe that a RCT will improve the evidence for using the different surgical treatments for cervical radiculopathy and strengthen current surgical treatment recommendation.
26.	Jonsson, Bogi, et al. (författare) Outcome After Limited Posterior Surgery for Thoracic and Lumbar Spine metastases 1996 Ingår i: Eur Spine J. ; 5, s. 36- Tidskriftsartikel (refereegranskat)
27.	Kontakis, Michael G., et al. (författare) Artificial disc replacement and adjacent-segment pathology : 10-year outcomes of a randomized trial 2022 Ingår i: Journal of Neurosurgery. - : AMER ASSOC NEUROLOGICAL SURGEONS. - 1547-5654 .- 1547-5646. ; 36:6, s. 945-953 Tidskriftsartikel (refereegranskat)abstract OBJECTIVE: Artificial disc replacement (ADR) is designed to preserve motion and thus protect against adjacent-segment pathology (ASP) and act as an alternative treatment to fusion surgery. The question remains, how well do ADR devices perform after 10 years of follow-up compared with fusion surgery in terms of patient satisfaction, sustainability, and protection against ASP?METHODS: This was the 10-year follow-up study of 153 participants who underwent ADR or fusion surgery after anterior decompression due to cervical degenerative radiculopathy (ISRCTN registration no. 44347115). Scores on the Neck Disability Index (NDI), EQ-5D, and visual analog scale for neck and arm pain were obtained from the Swedish Spine Registry and analyzed using ANCOVA. Information about secondary surgical procedures was collected from medical records and presented as Kaplan-Meier curves. MRI and flexion-extension radiography were performed, and ASP was graded according to the Miyazaki classification system.RESULTS: Ten participants were lost to follow-up, which left 143 participants (80 underwent ADR and 65 underwent anterior cervical discectomy and fusion). There were no differences between groups in terms of patient-reported outcome measures (10-year difference in NDI scores 1.7 points, 95% CI -5.1 to 8.5, p = 0.61). Nineteen (24%) participants in the ADR group compared with 9 (14%) in the fusion group underwent secondary surgical procedures. The higher reoperation rate of the ADR group was mainly due to 11 female participants with device loosening. The rates of reoperation due to ASP were similar between groups, which was confirmed with MRI assessment of ASP that also showed no differences between the groups (p = 0.21).CONCLUSIONS: This was the first 10-year follow-up study to compare ADR with fusion surgery and to provide MRI information for the assessment of ASP. The authors found no benefit of ADR over fusion surgery after anterior decompression for cervical degenerative radiculopathy.
28.	MacDowall, Anna, et al. (författare) Anxiety and depression affect pain drawings in cervical degenerative disc disease 2017 Ingår i: Upsala Journal of Medical Sciences. - : TAYLOR & FRANCIS LTD. - 0300-9734 .- 2000-1967. ; 122:2, s. 99-107 Tidskriftsartikel (refereegranskat)abstract Introduction: Pain drawings have been frequently used in the preoperative evaluation of spine patients. Until now most investigations have focused on low back pain patients, even though pain drawings are used in neck pain patients as well. The aims of this study were to investigate the pain drawing and its association to preoperative demographics, psychological impairment, and pain intensity. Methods: We carried out a post hoc analysis of a randomized controlled trial, comparing cervical disc replacement to fusion for radiculopathy related to degenerative disc disease. Preoperatively the patients completed a pain drawing, the Hospital Anxiety and Depression Scale (HADS), and a visual analogue scale (VAS). The pain drawing was evaluated according to four established methods, now modified for cervical conditions. Comparisons were made between the pain drawing and age, sex, smoking, and employment status as well as HADS and VAS. Results: Included were 151 patients, mean age of 47 years, female/male: 78/73. Pain drawing results were not affected by age, sex, smoking, and employment status. Patients with non-neurogenic pain drawings according to the modified method by Ransford had higher points on HADS-anxiety, HADS-depression, and HADS-total. Patients with markings in the head region had higher score on HADS-depression. Markings in the neck and lower arm region were associated with high values of VAS-neck and VAS-arm. Conclusions: Pain drawings were affected by both pain intensity and anxiety/depression in cervical spine patients. Therefore, the pain drawing can be a useful tool when interpreting the patients' pain in correlation to psychological impairment and pain location.
29.	MacDowall, Anna, et al. (författare) Artificial disc replacement versus fusion in patients with cervical degenerative disc disease and radiculopathy : a randomized controlled trial with 5-year outcomes 2019 Ingår i: Journal of Neurosurgery. - 1547-5654 .- 1547-5646. ; 30:3, s. 323-331 Tidskriftsartikel (refereegranskat)abstract OBJECTIVEThe method of artificial disc replacement (ADR) has been developed as an alternative treatment to fusion surgery after decompression for cervical degenerative disc disease (DDD) with radiculopathy. Preserving the motion of ADR devices aims to prevent immobilization side effects such as adjacent-segment pathology (ASP). However, long-term follow-up evaluations using MRI are needed to investigate if this intent is achieved.METHODSThe authors performed a randomized controlled trial with 153 patients (mean age 47 years) undergoing surgery for cervical radiculopathy. Eighty-three patients received an ADR and 70 patients underwent fusion surgery. Outcomes after 5 years were assessed using patient-reported outcome measures using the Neck Disability Index (NDI) score as the primary outcome; motion preservation and heterotopic ossification by radiography; ASP by MRI; and secondary surgical procedures.RESULTSScores on the NDI were approximately halved in both groups: the mean score after 5 years was 36 (95% confidence interval [CI] 31–41) in the ADR group and 32 (95% CI 27–38) in the fusion group (p = 0.48). There were no other significant differences between the groups in six other patient-related outcome measures. Fifty-four percent of the patients in the ADR group preserved motion at the operated cervical level and 25% of the ADRs were spontaneously fused. Seventeen ADR patients (21%) and 7 fusion patients (10%) underwent secondary surgery (p = 0.11), with 5 patients in each group due to clinical ASP.CONCLUSIONSIn patients with cervical DDD and radiculopathy decompression as well as ADR, surgery did not result in better clinical or radiological outcomes after 5 years compared with decompression and fusion surgery.
30.	MacDowall, Anna, et al. (författare) Artificial Disc Replacement versus Fusion in Patients with Cervical Degenerative Disc Disease with radiculopathy : 5-year Outcomes from the National Swedish Spine Register 2019 Ingår i: Journal of Neurosurgery. - 1547-5654 .- 1547-5646. ; 30:2, s. 159-167 Tidskriftsartikel (refereegranskat)abstract OBJECTIVE: The long-term efficacy of artificial disc replacement (ADR) surgery compared with fusion after decompression for the treatment of cervical degenerative disc disease and radiculopathy has not previously been investigated in a population-based setting.METHODS: All patients with cervical degenerative disc disease and radiculopathy who were in the national Swedish Spine Registry (Swespine) beginning in January 1, 2006, were eligible for the study. Follow-up information was obtained up to November 15, 2017. The authors compared, using propensity score matching, patients treated with anterior decompression and insertion of an ADR with patients who underwent anterior decompression combined with fusion surgery. The primary outcome was the Neck Disability Index (NDI), a patient-reported function score ranging from 0% to 100%, with higher scores indicating greater disability and a minimum clinically important difference of > 15%.RESULTS: A total of 3998 patients (2018: 1980 women/men) met the inclusion criteria, of whom 204 had undergone arthroplasty and 3794 had undergone fusion. After propensity score matching, 185 patients with a mean age of 49.7 years remained in each group. Scores on the NDI were approximately halved in both groups after 5 years, but without a significant mean difference in NDI (3.0%; 95% CI -8.4 to 2.4; p = 0.28) between the groups. There were no differences between the groups in EuroQol-5 Dimensions or in pain scores for the neck and arm.CONCLUSIONS: In patients with cervical degenerative disc disease and radiculopathy, decompression plus ADR surgery did not result in a clinically important difference in outcomes after 5 years, compared with decompression and fusion surgery.
31.	MacDowall, Anna, 1976- (författare) Cervical Radiculopathy : Studies on Pain Analysis and Treatment 2018 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Background: Knowledge about how to interpret pain-analyzing tools such as the pain drawing test and the visual analog scale (VAS) in cervical spine patients are sparse; hence, they have never been validated for this subgroup of patients. The method of artificial disc replacement (ADR) has been developed as an alternative treatment to fusion surgery after decompression for cervical degenerative disc disease (DDD) with radiculopathy. Preserved motion of ADR devices aims to prevent immobilization side effects such as stiffness, dysphagia and adjacent segment pathology. Long-term follow-ups of these devices compared with the gold standard treatment are needed to create future guidelines.Objectives: This thesis aims at (1) validating the pain drawing as an investigational tool for the cervical spine, (2) validating the VAS for the cervical spine regarding the measurement noise and the minimum clinically important difference (MCID), (3) comparing ADR with fusion surgery at 5-years of follow-up regarding outcome and complications in a randomized controlled trial (RCT) as well as in the Swedish spine (Swespine) registry, and (4) investigating possible predictors to outcome after surgical treatment of cervical radiculopathy.Methods: An RCT with 153 patients undergoing surgery for cervical radiculopathy was performed. Baseline data, the Neck disability index (NDI), two sets of VAS-neck and VAS-arm scores, the EQ-5D, Hospital anxiety and depression scale (HADS), Dysphagia short questionnaire and a pain drawing test were gathered preoperatively and after 5 years. Radiographs in flexion/extension and MRIs were done preoperatively and at follow-up. All patients registered in Swespine since January 1st, 2006 with cervical DDD and radiculopathy treated with ADR or fusion surgery, were included. Baseline data, the NDI, EQ-5D, and VAS-neck and VAS-arm scores were analyzed at 1, 2, 5 and 10-years of follow-up as well as the information regarding secondary surgeries.Results: Pain drawings interpreted with the simple body region method showed good inter-rater reliability in cervical spine patients. Markings in the upper arm region on the pain drawing predicted surgical treatment outcome and markings in the head region predicted depression. The measurement noise was ~10 mm and the MCID was ~20 mm on a 100 mm pain VAS. In both the RCT and Swespine register the outcome after ADR surgery were comparable with fusion at 5 years of follow-up, except for an elevated risk regarding secondary surgery on the index level in the ADR group. Fifty percent of the patients in the RCT, allocated to ADR surgery had preserved motion of less than 5°, at the 5-year follow-up, and 25%, mostly men were spontaneously fused. Preserved motion did not prevent adjacent segment pathology. High values of preoperative HADS scores were negative predictors of outcome.Conclusions: In patients with cervical DDD and radiculopathy both the pain drawing test and the VAS are validated tools to interpret the patients’ pain. Preoperative mental distress affects long-term outcome much more than the allocated treatment, ADR or fusion surgery in patients with cervical radiculopathy.Clinical Trial Registration: ISRCTN, registration number: 44347115.
32.	MacDowall, Anna, et al. (författare) Effects of preoperative mental distress versus surgical modality, arthroplasty, or fusion on long-term outcome in patients with cervical radiculopathy 2018 Ingår i: Journal of Neurosurgery. - : AMER ASSOC NEUROLOGICAL SURGEONS. - 1547-5654 .- 1547-5646. ; 29:4, s. 371-379 Tidskriftsartikel (refereegranskat)abstract OBJECTIVE Several efforts have been made to investigate the long-term efficacy of artificial disc replacement surgery compared with that of fusion after decompression for the treatment of cervical degenerative disc disease and radiculopathy. However, research on the impact of mental distress on surgical treatment outcome has been sparse. The aim of the authors was to investigate the potential predictive value of preoperative risk factors in determining long-term outcome. METHODS A total of 153 patients (mean age 47 years) with single-or double-level cervical degenerative disc disease and radiculopathy were randomly assigned to undergo either anterior cervical discectomy and fusion (n = 70) or artificial disc replacement (n = 83). The primary outcome was the Neck Disability Index (NDI) score, a patient-reported function score that ranges from 0% to 100%; higher scores indicate greater disability. Preoperative variables such as sex, age, smoking status, employment status, having a strenuous job, neck pain duration, arm pain duration, amount of regular exercise, Hospital Anxiety and Depression Scale (HADS) score, NDI score, whether surgery was performed on 1 or 2 levels, and allocated treatment were analyzed in multiple linear regression models with the 5-year NDI score as the outcome. RESULTS A total of 47 (31%) patients had either a HADS anxiety or HADS depression score of 10 points or higher. High values on the preoperative HADS were a negative predictor of outcome (p = 0.009). Treatment allocation had no effect on 5-year NDI scores (p = 0.32). CONCLUSIONS Preoperative mental distress measured with the HADS affects long-term outcome in surgically treated patients with cervical radiculopathy.
33.	MacDowall, Anna, et al. (författare) Pain drawings predict outcome of surgical treatment for degenerative disc disease in the cervical spine 2017 Ingår i: Upsala Journal of Medical Sciences. - : Uppsala Medical Society. - 0300-9734 .- 2000-1967. ; 122:3, s. 194-200 Tidskriftsartikel (refereegranskat)abstract INTRODUCTION: Pain drawings have been frequently used in the preoperative evaluation of spine patients. For lumbar conditions comprehensive research has established both the reliability and predictive value, but for the cervical spine most of this knowledge is lacking. The aims of this study were to validate pain drawings for the cervical spine, and to investigate the predictive value for treatment outcome of four different evaluation methods.METHODS: We carried out a post hoc analysis of a randomized controlled trial, comparing cervical disc replacement to fusion for radiculopathy related to degenerative disc disease. A pain drawing together with Neck Disability Index (NDI) was completed preoperatively, after 2 and 5 years. The inter- and intraobserver reliability of four evaluation methods was tested using κ statistics, and its predictive value investigated by correlation to change in NDI.RESULTS: Included were 151 patients, mean age of 47 years, female/male: 78/73. The interobserver reliability was fair for the modified Ransford and Udén methods, good for the Gatchel method, and very good for the modified Ohnmeiss method. Markings in the shoulder and upper arm region on the pain drawing were positive predictors of outcome after 2 years of follow-up, and markings in the upper arm region remained a positive predictor of outcome even after 5 years of follow-up.CONCLUSIONS: Pain drawings were a reliable tool to interpret patients' pain prior to cervical spine surgery and were also to some extent predictive for treatment outcome.
34.	MacDowall, Anna, et al. (författare) Posterior foraminotomy versus anterior decompression and fusion in patients with cervical degenerative disc disease with radiculopathy : up to 5 years of outcome from the national Swedish Spine Register 2020 Ingår i: Journal of Neurosurgery. - : American Association of Neurological Surgeons. - 1547-5654 .- 1547-5646. ; 32:3, s. 344-352 Tidskriftsartikel (refereegranskat)abstract OBJECTIVE: The long-term efficacy of posterior foraminotomy compared with anterior cervical decompression and fusion (ACDF) for the treatment of degenerative disc disease with radiculopathy has not been previously investigated in a population-based cohort.METHODS: All patients in the national Swedish Spine Register (Swespine) from January 1, 2006, until November 15, 2017, with cervical degenerative disc disease and radiculopathy were assessed. Using propensity score matching, patients treated with posterior foraminotomy were compared with those undergoing ACDF. The primary outcome measure was the Neck Disability Index (NDI), a patient-reported outcome score ranging from 0% to 100%, with higher scores indicating greater disability. A minimal clinically important difference was defined as > 15%. Secondary outcomes were assessed with additional patient-reported outcome measures (PROMs).RESULTS: A total of 4368 patients (2136/2232 women/men) met the inclusion criteria. Posterior foraminotomy was performed in 647 patients, and 3721 patients underwent ACDF. After meticulous propensity score matching, 570 patients with a mean age of 54 years remained in each group. Both groups had substantial decreases in their NDI scores; however, after 5 years, the difference was not significant (2.3%, 95% CI -4.1% to 8.4%; p = 0.48) between the groups. There were no significant differences between the groups in EQ-5D or visual analog scale (VAS) for neck and arm scores. The secondary surgeries on the index level due to restenosis were more frequent in the foraminotomy group (6/100 patients vs 1/100), but on the adjacent segments there was no difference between groups (2/100).CONCLUSIONS: In patients with cervical degenerative disc disease and radiculopathy, both groups demonstrated clinical improvements at the 5-year follow-up that were comparable and did not achieve a clinically important difference from one another, even though the reoperation rate favored the ACDF group. This study design obtains population-based results, which are generalizable.
35.	MacDowall, Anna, et al. (författare) Validation of the Visual Analogue Scale in the Cervical Spine 2018 Ingår i: Journal of Eurosurgery. - Charlottesville, Virginia. - 1547-5654 .- 1547-5646. ; 28:3, s. 227-235 Tidskriftsartikel (refereegranskat)abstract Objective: The Visual analogue scale (VAS) is frequently used to measure treatment outcome in patients with cervical spine disorders. The minimum clinically important difference (MCID) is the smallest change in a score that has clinical importance to the patient. Although it has been established for other medical fields, knowledge of the VAS MCID for the cervical spine is sparse, and it has rarely been considered in relation to measurement noise. The goals in this study were as follows: 1) to validate the VAS-neck and VAS-arm instruments for the cervical spine (e.g. repeatability); 2) to investigate the possible influence of predictive factors and the Hospital Anxiety and Depression Scale (HADS) score on repeatability; and 3) to compute the MCID with five different methods.Methods: A post hoc analysis of a prospective randomized controlled trial with 151 patients undergoing surgery for cervical radiculopathy due to degenerative disc disease (DDD) was performed. Information on age, sex, smoking habits, exercise and employment status, HADS score, and VAS-neck and VAS-arm scores was gathered before surgery and after 1 year. The VAS was applied twice on every occasion with 15 minutes in-between. Repeatability and the association with predictors and HADS score were analyzed using the one-sample t-test, linear regression models and Spearman correlation. The MCID was calculated with the following methods: average change, change difference, receiver operating characteristic curve, effect size, and minimum detectable change (MDC).Results: The repeatability in VAS-neck was 8.1 mm and in VAS-arm 10.4 mm. Less consistent values on the VAS correlated to female sex and higher values on HADS. For VAS-neck the MCID ranged from 4.6 to 21.4 and for VAS-arm it ranged from 1.1 to 29.1. The highest MCID came from the MDC method, which was the only method that gave values above the measurement noise in both VAS-neck and VAS-arm.Conclusions: Measurement noise in VAS-neck and VAS-arm for the cervical spine was influenced by female sex and HADS score. The only method to compute MCID that consistently gave results above the measurement noise in VAS-neck and VAS-arm was the MDC.
36.	Manabe, Nodoka, et al. (författare) The Relationship between the Occipitocervical Junction and Thoracic Kyphosis in Ankylosing Spondylitis : A Retrospective Cohort Study of 86 Cervical Fractures in Surgically Treated Patients 2019 Ingår i: Asian Spine Journal. - : Asian Spine Journal (ASJ). - 1976-1902 .- 1976-7846. ; 13:1, s. 103-110 Tidskriftsartikel (refereegranskat)abstract Study Design: Retrospective analysis of prospectively collected data.Purpose: To describe the radiological characteristics of the occipitocervical area in patients with ankylosing spondylitis (AS) using the novel measure X-angle and to describe the correlation between the ankylosed occipitoatlantoaxial (OAA) joint and thoracic kyphosis (TK).Overview of Literature: AS affects the axial skeleton, leading to progressive ankylosis of all vertebral segments. The effect of ankylosis on the upper cervical area of these patients is not well documented.Methods: All patients with complete ankylosis of the spinal column between C3 and T1, treated for cervical spinal fracture between 2007 and 2014, were eligible for inclusion in this study. The level of cervical fracture was identified. The T1-12 and T5-12 angles were measured using preoperative lateral radiography. The progressive degeneration of the C0-C1-C2 joints was evaluated via the new indicator X-angle, through the measurement of the angle of the C0-C1-C2 articulations in the coronal plane using computed tomography.Results: We included 86 consecutive patients with AS (67 males) aged 69±12 years. The patients were divided into two groups according to the degenerative change in the C0-C1 joint (62 patients with a mobile joint and 24 patients with an ankylosed joint). There was no significant difference between the two groups in terms of age (p =0.094) and level of fracture (p =0.949). The most commonly affected level was C6. There was no requirement for revision due to non-union in any of the patients. There was a statistically significant difference observed in the T1-12, T5-12, and X-angles (p =0.004, 0.001, and <0.001, respectively). TK was greater in the ankylosed joint group than in the mobile joint group. The X-angle was also greater in the ankylosed joint group because of the vertical destruction of the OAA joint.Conclusions: Thoracic hyperkyphosis resulted in degenerative changes in the C0-C1-C2 joint in patients with AS. The X-angle is a reliable method for measuring the integrity of the C0-C1-C2 joint in such patients.
37.	Marques, Catarina, 1969-, et al. (författare) Accuracy and Reliability of X-ray Measurements in the Cervical Spine 2020 Ingår i: Asian Spine Journal. - : KOREAN SOC SPINE SURGERY. - 1976-1902 .- 1976-7846. ; 14:2, s. 169-176 Tidskriftsartikel (refereegranskat)abstract Study Design: This study is a post hoc analysis of a multicenter prospective randomized controlled trial which compared artificial disc replacement and anterior cervical discectomy and fusion. Purpose: Useful radiographic parameters for assessing cervical alignment include the Cobb angles, T1 slope (TS), occipitocervical inclination (OCI). K-line tilt (KLT), and cervical sagittal vertical axis (cSVA). This study aimed to determine measurement accuracy and reliability for these parameters. Overview of Literature: Various authors have assessed repeatability by comparing different methods of measurement, but knowledge of measurement error and minimal detectable change is scarce. Methods: We evaluated 75B lateral cervical radiographs. One medical student and one spine surgeon (i.e., measured x2 within 4 weeks) independently measured the parameters obtaining 5,850 values. Standard error of measurement (SEm) and minimum detectable change (MDC) were calculated for each parameter. The accuracy and reliability of the Cobb angle measurements were calculated for the different types of angles: cervical lordosis, prosthesis angle, segmental angle with two hone surfaces (SABB), and segmental angle with one bone and one metal surface. Reliability was determined with intraclass correlation coefficient (ICC). Results: SEm was 1.8 degrees and MDC was 5.0 degrees for the Cobb angle, with an intraobserver/interobserver ICC of 0.958/0.8B6. All the different subtypes of Cobb angles had an ICC higher than 0.950, except SABB (intraobserver/interobserver ICC of 0.922/0.716). The most accurate and reliable measurement was for KLT. Conclusions: This study provides normative data on SEm and MDC for Cobb angles, T1S, KLT, OCI, and cSVA in cervicalcervicai lateral radiographs. Reliability was excellent for all parameters except SABB (e.g., good).
38.	Marques, Catarina, 1969- (författare) Studies on Cervical Artificial Disc Replacement 2022 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Artificial disc replacement (ADR) was developed as an alternative to anterior fusion after decompression for cervical degenerative radiculopathy. By preserving motion, it was expected to prevent acceleration of adjacent segment pathology (ASP) associated with fusion, and lead to better clinical outcomes. The aims of this thesis were to evaluate whether ADR surgery leads to better outcomes than fusion surgery, to investigate if it prevents the acceleration of ASP, and to analyze its potential complications. In a multicenter randomized controlled trial (RCT) 153 patients were randomized to ADR (DiscoverTM implant) or fusion surgery (autograft, plate and screws). The outcomes at 5 and 10 years postoperatively were analyzed with Neck Disability Index (NDI) as primary measure. Heterotopic ossification (HO), ASP, and secondary surgery where analyzed. The measurements of radiographic parameters used in the assessment of cervical alignment where validated.To further analyze secondary surgery after ADR, a descriptive register cohort study was done with 42 patients whose data were retrieved from Swespine and completed with medical charts, images, and a telephone interview. There was no difference in NDI scores between groups in the RCT, 5 or 10 years postoperatively. Radiological and clinically significant ASP were similar in both groups. There was more secondary surgery in the ADR group compared with the fusion group, mainly due to device loosening in women. Severe HO was seen in 71% of the ADR implants 5 years postoperatively, and 27% were fused, male sex being a clear risk factor.Normative data for measurement error were provided on the cervical alignment measurements, and the most reliable were the K-line tilt and the cervical sagittal vertical axis (cSVA). In the 42 patients in the register cohort study the most common diagnosis leading to reoperation was loosening of the ADR implant and/or ASP, predominantly treated with fusion surgery. Reoperation resulted in good outcomes in the vast majority of patients. At the long-term, there is no clinical benefit of ADR over fusion surgery after decompression for cervical degenerative radiculopathy. ADR, compared with fusion surgery, does not prevent acceleration of ASP, and results in more reoperations. Revision surgery for failed cervical ADRs is effective and justified.
39.	Marques, Catarina, 1969-, et al. (författare) The fate of failed cervical arthroplasties: outcome of revision surgery Annan publikation (övrigt vetenskapligt/konstnärligt)abstract Purpose: To analyze the diagnoses leading to secondary surgery, the surgical methods used in reoperations, and the final clinical outcomes, in patients reoperated after a primary reconstruction with a cervical artificial disc replacement (ADR). Methods: Descriptive cohort study of 42 ADR patients who underwent secondary surgery at the index or adjacent level. Data collected from the National Swedish Register for Spine Surgery 2006 through 2018, completed with information from patients’ charts, images, and a telephone interview with the patients. Analysis of time to reoperation, diagnosis leading to reoperation, surgical method, and outcome at 2 years, measured as change in neck pain, arm pain and function, as well as overall patient satisfaction. Results: The most common diagnosis leading to reoperation was loosening (n=16), clinical adjacent segment pathology (ASP) (n=8), or a combination thereof (n=6). Thirty-four of the surgeries were performed at the index level. Mean time to reoperation was 44 months.Reoperation consisted of extraction of the ADR and fusion surgery in 32 cases. Function improved after the reoperation in 32 patients. Twenty-four of 30 patients who had neck pain, and 28 of 32 who had arm pain improved after the reoperation. No patients reported post-operative aggravation of symptoms.Conclusion: Failure of ADR is mainly due to loosening of the implant and/or ASP, and is predominantly treated with fusion surgery. Reoperation results in good outcomes (complete or nearly complete recovery) in the vast majority of patients. We conclude that revision surgery for failed cervical arthroplasty is effective and justified.
40.	Marques, Catarina, 1969-, et al. (författare) Unintended fusion in cervical artificial disk replacement : a prospective study on heterotopic ossification, progression, and clinical outcome, with 5-year follow-up 2021 Ingår i: European spine journal. - : Springer. - 0940-6719 .- 1432-0932. ; 30:6, s. 1662-1669 Tidskriftsartikel (refereegranskat)abstract Purpose Heterotopic ossification (HO) may cause unintended fusion in artificial disk replacement (ADR), failing to preserve motion. The reported incidence of HO varies hugely. This study aimed to determine prevalence of HO, progression, predisposing factors to occurrence and to progression, and potential effect on clinical outcomes. Methods Eighty-three patients treated with ADRs for cervical radiculopathy at one or two segments were extracted from a previously published RCT. Of the 83 patients, 59 had remaining ADR (79 implants) and sufficiently high-quality X-rays at 5 years of follow-up to allow analysis. HO was graded on plain films according to Mehren/Suchomel. Prevalence, progression, predisposing factors and effect on clinical outcome (Neck Disability Index-NDI) were analyzed. Results At 2 years, HO was seen in 46/55 ADR implants (84%), severe enough to affect mobility in 27/55 (49%). At 5 years, HO was seen in 92% of 79 implants, severe in 71%. Male sex was a predisposing factor to HO. No predisposing factors to progression were identified. NDI was not affected by the severity of HO. Conclusion Almost all ADR implants in our study have HO at 5 years of follow-up. Male sex is a risk factor. Severe HO did not affect clinical outcome.
41.	Olerud, Claes, et al. (författare) Cervical spine fractures in the elderly. Factors influencing survival in 65 cases 1999 Ingår i: Acta Orthop. Scand.. ; 70, s. 509- Tidskriftsartikel (refereegranskat)
42.	Olerud, Claes (författare) Studies on functional anatomy and traumatology of the ankle joints 1985 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)
43.	Papavero, Luca, et al. (författare) Degenerative Cervical Myelopathy : A 7-Letter Coding System That Supports Decision-Making for the Surgical Approach 2020 Ingår i: Neurospine. - : The Korean Spinal Neurosurgery Society. - 2586-6583 .- 2586-6591. ; 17:1, s. 164-171 Tidskriftsartikel (refereegranskat)abstract OBJECTIVE: To validate with a prospective study a decision-supporting coding system for the surgical approach for multilevel degenerative cervical myelopathy.METHODS: Ten cases were presented on an internet platform, including clinical and imaging data. A single-approach (G1), a choice between 2 (G2), or 3 approaches (G3) were options. Senior and junior spine surgeons analyzed 7 parameters: location and extension of the compression of the spinal cord, C-spine alignment and instability, general morbidity and bone diseases, and K-line and multilevel corpectomy. For each parameter, an anterior, posterior, or combined approach was suggested. The most frequent letter or the last letter (if C) of the resulting 7-letter code (7LC) suggested the surgical approach. Each surgeon performed 2 reads per case within 8 weeks.RESULTS: G1: Interrater reliability between junior surgeons improved from the first read (κ = 0.40) to the second (κ = 0.76, p < 0.001) but did not change between senior surgeons (κ = 0.85). The intrarater reliability was similar for junior (κ = 0.78) and senior (κ = 0.71) surgeons. G2: Junior/senior surgeons agreed completely (58%/62%), partially (24%/23%), or did not agree (18%/15%) with the 7LC choice. G3: junior/senior surgeons agreed completely (50%/50%) or partially (50%/50%) with the 7LC choice.CONCLUSION: The 7LC showed good overall reliability. Junior surgeons went through a learning curve and converged to senior surgeons in the second read. The 7LC helps less experienced surgeons to analyze, in a structured manner, the relevant clinical and imaging parameters influencing the choice of the surgical approach, rather than simply pointing out the only correct one.
44.	Robinson, Anna-Lena, 1971- (författare) Axis Fractures in Elderly : Epidemiology and Treatment related outcome 2018 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Background: Axis fractures are a common injury in the elderly population. Treatment is often complicated due to osteoporosis and patient comorbidity. Knowledge of the incidence of these fractures, as well as their treatment, outcome and mortality rate, will improve knowledge and decision-making processes for this fragile group of patients.Objectives: This thesis aims (1) to review the literature on the non-surgical and surgical treatment of odontoid fractures type 2 in the elderly population, (2) to provide an updated overview of axis fracture subtypes, their incidence and their treatment in a cohort in two university cities, (3) to map the incidence of fractures and the treatment of these patients in Sweden, (4) to investigate the effect on mortality of both the surgical and non-surgical treatment of axis fractures and (5) to present the protocol for a randomized controlled trial (RCT) on the treatment of odontoid fractures type 2 in the elderly population.Methods: A systematic review was performed using the MeSH keywords “odontoid AND fracture AND elderly”. The data for the cohort study were extracted from the regional hospital information system. The radiographs were reviewed retrospectively. Data were extracted from the Swedish National Patient Registry (NPR) and the mortality registry for the national registry studies. Finally, the RCT protocol was carried out according to the SPIRIT and CONSORT statements for clinical trial reporting.Results and conclusions: So far, there has been a scarcity of existing evidence on treatment of odontoid fractures type 2 in the elderly population. In this thesis, we found in two university cities an increased incidence, and a trend towards more surgical treatment of type 2 and 3 odontoid fractures 2002-2014. Between 1997 and 2014 in Sweden, there was an increasing incidence of C2 fractures, but the treatment trend went towards more non-surgical treatment. Surgically treated patients had a greater survival rate than non-surgically treated patients. Among those over 88 years of age, surgical treatment lost its effect on survival. In the RCT we will study the function of patients with odontoid fractures type 2 and by comparing non-surgical treatment with posterior C1-C2 fusion, the cost-effectiveness of the treatment options.
45.	Robinson, Anna-Lena, 1971-, et al. (författare) C2 Fracture Subtypes, Incidence, and Treatment Allocation Change with Age : A Retrospective Cohort Study of 233 Consecutive Cases 2017 Ingår i: BioMed Research International. - : HINDAWI LTD. - 2314-6133 .- 2314-6141. Tidskriftsartikel (refereegranskat)abstract The currently available data on the distribution of C2 fracture subtypes is sparse. This study was designed to identify the proportions of the second cervical vertebra (C2) fracture subtypes and to present age and gender specific incidences of subgroups. A dataset of all patients treated between 2002 and 2014 for C2 fractures was extracted from the regional hospital information system. C2 fractures were classified into odontoid fractures types 1, 2, and 3, Hangman's fractures types 1, 2, and 3, and atypical C2 fractures. 233 patients (female 51%, age 72 +/- 19 years) were treated for a C2 fracture. Odontoid fractures were found in 183 patients, of which 2 were type 1, 127 type 2, and 54 type 3, while 26 of C2 fractures were Hangman's fractures and 24 were atypical C2 fractures. In the geriatric subgroup 89% of all C2 fractures were odontoid, of which 71% were type 2 and 29% type 3. There was an increasing incidence of odontoid fractures types 2 and 3 from 2002 to 2014. 40% of C2 fractures were treated surgically. This study presents reliable subset proportions of C2 fractures in a prospectively collected regional cohort. Knowledge of these proportions facilitates future epidemiological studies of C2 fractures.
46.	Robinson, Anna-Lena, 1971-, et al. (författare) Epidemiology of C2 Fractures in the 21st Century : A National Registry Cohort Study of 6,370 Patients from 1997 to 2014 2017 Ingår i: Advances in Orthopedics. - : Hindawi Publishing Corporation. - 2090-3464 .- 2090-3472. Tidskriftsartikel (refereegranskat)abstract Objective. C2 fractures are a common injury in the elderly population. Treatment is often complicated due to osteoporosis and patient comorbidity. This study aims to investigate the incidence and treatment trend of C2 fractures in Sweden. Methods. Patients with the principal and secondary diagnosis of fracture of the second vertebrae (ICD-10: S12.1) between 1997 and 2014 were identified in the Swedish National Patient Registry (NPR). Results. Between 1997 and 2014, 6,370 patients with a C2 fracture (51% male; age: ) were identified in the NPR. The incidence of C2 fractures increased from 3 to 6 per 100,000 (; ), mainly due to an increase of incidence in the geriatric subgroup (≥70 years). The percentage of surgically treated patients decreased from 1997 to 2014 (; ). Younger age, male gender, spinal cord injury, and earlier year of admission were associated with surgical treatment assignment.Discussion. This study documents a rising incidence of C2 fractures in the elderly during the last two decades in Sweden. Greater awareness of fractures, improved diagnostics, coding, and a higher activity level of the patients are plausible causes. The declining trend of surgical treatment warrants further study.
47.	Robinson, Anna-Lena, 1971-, et al. (författare) Protocol for a multicentre randomised controlled trial on surgical versus non-surgical management of displaced odontoid fractures type 2 in patients aged ≥75 years : Uppsala Study on Odontoid Fracture Treatment (USOFT) Annan publikation (övrigt vetenskapligt/konstnärligt)
48.	Robinson, Anna-Lena, 1971-, et al. (författare) Surgical treatment improves survival of elderly with axis fracture : a national population-based multi-registry cohort study 2018 Ingår i: The spine journal. - : Elsevier BV. - 1529-9430 .- 1878-1632. ; 18, s. 1853-1860 Tidskriftsartikel (refereegranskat)abstract Background ContextFractures of the axis (C2) are the most common cervical spinal injuries in the elderly population. Several authors have reported improved survival among elderly patients with C2 fractures when treated surgically.PurposeWe aimed to analyze whether surgery improves survival of elderly with C2 fractures.Study Design/SettingAn observational population-based longitudinal multi-registry study was carried out.Patient SampleSwedish Patient Registry 1997 to 2014 and Swedish Cause of Death Registry 1997 to 2014 served as source of patient sample.Outcome measuresSurvival after C2 fracture according to non-surgical and surgical treatment was the outcome measure.MethodsWe included all patients treated for the primary diagnosis of C2 fracture (10th revision of the International Statistical Classification of Diseases and Related Health Problems or ICD-10: S12.1) at an age ≥70 years and receiving treatment at a health-care facility. Non-surgical treatment comprises cervical collar or halo-vest treatment. Surgical treatment was identified in the Swedish patient registry extract using the Swedish classification of procedural codes. Survival was determined using the Kaplan-Meier method. Comorbidity was determined using the Charlson Comorbidity Index.ResultsOf the included 3,375 elderly patients with C2 fractures (43% men, aged 83±7 years), 22% were treated surgically. Surgical treatment was assigned based on age, gender, and year of treatment. The 1-year survival of 2,618 non-surgically treated patients was 72% (n=1,856), and 81% (n=614) for the 757 surgically treated (p<.001, relative risk reduction=11%). Adjusted for age, gender, comorbidity, and year of injury, surgically treated patients had greater survival than non-surgically treated patients (hazard ratio=0.88, 95% confidence interval: 0.79–0.97). Among those above 88 years of age (95% confidence interval: 85–92), surgical treatment lost its effect on survival.ConclusionsDespite the frailty of elderly patients, the morbidity of cervical external immobilization with a rigid collar seemingly weighs greater than surgical morbidity, even in octogenarians. For those above 88 years of age, non-surgical treatment should be primarily attempted.
49.	Robinson, Anna-Lena, 1971-, et al. (författare) Surgical vs. non-surgical management of displaced type-2 odontoid fractures in patients aged 75 years and older : study protocol for a randomised controlled trial 2018 Ingår i: Trials. - : BMC. - 1745-6215. ; 19 Tidskriftsartikel (refereegranskat)abstract Background: Displaced odontoid fractures in the elderly are treated non-surgically with a cervical collar or surgically with C1-C2 fusion. Due to the paucity of evidence, the treatment decision is often left to the discretion of the expert surgeon.Methods: The Uppsala Study on Odontoid Fracture Treatment (USOFT) is a multicentre, open-label, randomised controlled superiority trial evaluating the clinical superiority of the surgical treatment of type-2 odontoid fractures, with a 1-year Neck Disability Index (NDI) as the primary endpoint. Fifty consecutive patients aged >= 75 years, with displaced type-2 odontoid fracture, are randomised to non-surgical or surgical treatment. Excluded are patients with an American Society of Anaesthesiologists (ASA) score >= 4, dementia nursing care or anatomical cervical anomalies. The minimal clinically important difference of the NDI is 3.5 points. A minimum of 16 patients are needed in each group to test the superiority with 80% power. By considering a 1-year mortality forecast of 29%, up to 25 participants are recruited in each group. The non-surgical group is fitted with a rigid cervical collar for 12 weeks. The surgical group is treated with a posterior C1-C2 fusion. All participants are monitored with regard to the NDI, EuroQol score (EQ-5D), socio-demographics and computed tomography (CT) at the time of injury, at 6 weeks, 3 months and 12 months. At 12 months, a dynamic radiographical investigation of upper cervical stability is performed. The secondary endpoints are: EQ-5D score, activities of daily living (ADL), bony union, upper cervical stability and mortality.Discussion: USOFT is the first randomised controlled trial comparing non-surgical and surgical management of type-2 odontoid fractures in the elderly. Using the NDI and EQ-5D as endpoints, future value-based decisions may consider quality-adjusted life years gained. Major limitations are (1) the allocation bias of the open-label study design, (2) that only higher training levels of all core specialties of spine surgery are included in the surgical treatment arm and (3) that only one type of surgical stabilisation is investigated (posterior C1-C2 fusion), while other methods are not included in this study.
50.	Robinson, Yohan, 1977-, et al. (författare) Biological disease-modifying anti-rheumatic treatment delayed spinal fractures related to ankylosing spondylitis : National multi-registry cohort study from the Swedish Patient Registry and the Swedish Prescribed Drugs Registry Annan publikation (övrigt vetenskapligt/konstnärligt)abstract ObjectiveAnkylosing spondylitis (AS) is associated with increased spinal fracture risk due to loss of elasticity in spinal motion segments. With the introduction of biological disease modifying anti-rheumatic drugs (bDMARD) treatment for AS patients the individual course of the disease has been decelerated. This study aims to clarify whether the improved medical therapy reduced the spinal fracture incidence.MethodsIncluded were all patients with the diagnosis of AS 1987 to 2014 from the Swedish Patient Registry. From the Swedish Prescribed Drug Registry the Anatomical Therapeutic Chemical codes for bDMARD, non-steroidal anti-inflammatory drugs (NSAID), methotrexate (MTX) and sulfasalazine were extracted and numbers of prescriptions and years of treatment counted since 2005.Results 12297 patients with ankylosing spondylitis were included between 1987 and 2014 (age 67±19, 67% male). Of these 291 had spinal fractures between 2011 and 2014. The number of prescriptions of bDMARD increased during the last decade, but not of MTX, sulfasalazine and NSAID. 64% of all AS patients used NSAID, 13% used bDMARD, 13% used MTX, and 10% used sulfasalazine. A multivariate analysis of patients with spinal fractures 2011-2014 found bDMARD delaying spinal fracture debut by 1.24 years per year of bDMARD treatment (p=0.028). The use of bDMARD had no significant effect on spinal fracture risk (OR=0.93, 95%-C.I.=0.85-1.01, p=0.09).ConclusionThis study failed to demonstrate a beneficial effect on spinal fracture risk for AS patients treated with bDMARD during the last decade. Still bDMARD treatment delayed spinal fracture occurrence, which is promising with regard to results from future studies.Trial registrationClinicalTrials.gov, Identifier NCT02840695.

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