Ankylosing Spondylitis in Orthopedic Surgery 

  • Author: S Craig Humphreys, MD; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: Apr 7, 2011
 

Background

Ankylosing spondylitis (AS) is a chronic, multisystem inflammatory disorder of the sacroiliac (SI) joints and the axial skeleton.[1, 2, 3, 4] AS is characterized as a seronegative spondyloarthropathy. The disorder is often found in association with other seronegative spondyloarthropathies, including reactive arthritis, psoriasis, juvenile chronic arthritis, ulcerative colitis, and Crohn disease.

The etiology of this condition is not understood completely; however, a strong genetic predisposition exists.[5, 6] A direct relationship between AS and the major histocompatibility human leukocyte antigen (HLA)-B27 has been determined.[7] The precise role of HLA-B27 in precipitating AS remains unknown; however, it is believed that HLA-B27 may resemble or act as a receptor for an inciting antigen such as bacteria.

A genetic predisposition exists among persons with the HLA-B27 major histocompatibility antigen. The prevalence increases from 0.1-0.2% in the general population to 1-2% in persons with the HLA-B27 antigen. Additionally, 10-20% of those who have a first-degree relative with AS and who inherit the HLA-B27 antigen eventually develop AS.

Patients often have a family history of either AS or another seronegative spondyloarthropathy.

An image depicting ankylosing spondylitis can be seen below.

Patient with ankylosing spondylitis affecting the Patient with ankylosing spondylitis affecting the cervical and upper thoracic spine. The patient's spine has been fused in a flexed position.
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Pathophysiology

AS most commonly affects the SI joints and the axial skeleton. Involvement of the SI joints is required to establish the diagnosis. Hip and shoulder joints are affected less frequently. Peripheral joint involvement is least common.

The initial presentation generally occurs in the SI joints and is followed by involvement of the discovertebral, apophyseal, costovertebral, and costotransverse joints and the paravertebral ligaments.

Early lesions include subchondral granulation tissue that erodes the joint and is replaced gradually by fibrocartilage and then ossification. This occurs in ligamentous and capsular attachment sites to bone and is called enthesitis.[8]

In the spine, this initial process occurs at the junction of the vertebrae and the anulus fibrosus of the intervertebral discs. The outer fibers of the discs eventually undergo ossification to form a syndesmophyte. The condition progresses to the characteristic bamboo spine appearance.

The inflammatory response includes CD4+ and CD8+ T lymphocytes and macrophages as well as cytokines, including tumor necrosis factor-alpha (TNF-α) and transforming growth factor-beta (TGF-β).[9, 10]

Extra-articular involvement can include acute iritis, aortitis, aortic fibrosis, pulmonary fibrosis, and neurologic deficits.

Acute iritis occurs in 25-30% of patients and generally is unilateral. Symptoms include pain, lacrimation, photophobia, and blurred vision.

Cardiac involvement is generally a late finding. Severe cases can lead to complete heart block.[11]

Pulmonary involvement is secondary to inflammation of the costovertebral and costotransverse joints, which limits chest-wall range of motion (ROM). Pulmonary fibrosis is generally an asymptomatic incidental radiographic finding.

Neurologic deficits are secondary to spinal fracture or cauda equina syndrome resulting from spinal stenosis. Spinal fracture is most common in the cervical spine.

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Epidemiology

Frequency

United States

AS affects 0.1-0.2% of the US population.

International

AS affects 0.1-1.0% of the world population.

Mortality/Morbidity

Chronic pain and stiffness are the most common complaints of patients with AS. More than 70% of patients report daily pain and stiffness.[12]

Fatigue is another common complaint of patients with AS, occurring in approximately 65% of patients. Most patients report their fatigue to be moderately severe. Increased levels of fatigue are associated with increased pain and stiffness and decreased functional capacity.[13, 14]

Severe physical disability is not common among patients with AS. Problems with mobility occur in approximately 47% of patients. Disability is related to the duration of the disease, peripheral arthritis, cervical spine involvement, younger age at onset of symptoms, and coexisting illnesses. Disability has been demonstrated to improve with prolonged periods of exercise or surgical correction of peripheral joint and cervical spine involvement.

Most patients are able to continue to work after onset of symptoms.[15, 16, 17, 18, 19] Vocational counseling has been demonstrated to decrease the risk of employment disability by greater than 60%. Although most patients are able to continue to work, up to 37% change occupations to less physically demanding jobs as symptoms progress.

Emotional problems related to the disease are reported in 20% of patients. Depression is more common among women, and contributing factors include the level of pain and functional disability involved.

Increased rates of mortality related to AS are rare. Death is generally the result of long-standing disease with either extra-articular manifestations, such as heart block, or from coexisting diseases, such as inflammatory bowel disease.

Race

  • The disease is most prevalent in persons of northern European heritage and least prevalent in sub-Saharan Africa.
  • The less common juvenile-onset version of AS is more common among Native Americans, Mexicans, and persons in developing countries.

Sex

  • The male-to-female incidence for AS is 3:1.

Age

  • Symptoms generally develop in late adolescence or early adulthood. Onset of symptoms in an individual older than 45 years is uncommon.
  • If symptoms develop when an individual is younger than 16 years, the disease is termed juvenile-onset spondylitis.
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Contributor Information and Disclosures
Author

S Craig Humphreys, MD  Orthopedic Spine Surgeon, Department of Orthopedic Surgery, Center for Sports Medicine and Orthopedics

S Craig Humphreys, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Spinal Injury Association, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jason C Eck, DO, MS  Assistant Professor, Department of Orthopedics and Physical Rehabilitation, UMass Memorial Medical Center

Jason C Eck, DO, MS is a member of the following medical societies: American Osteopathic Academy of Orthopedics, American Osteopathic Association, International Society for the Study of the Lumbar Spine, and North American Spine Society

Disclosure: Medtronic Honoraria Speaking and teaching

Scott D Hodges, DO  Consulting Surgeon, Department of Orthopedic Surgery, Center for Sports Medicine and Orthopedics

Scott D Hodges, DO is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Medical Association, American Osteopathic Association, American Spinal Injury Association, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association, and Tennessee Medical Association

Disclosure: Medtronic Royalty Consulting; Biomet Spine Royalty Consulting

Specialty Editor Board

James F Kellam, MD  Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center

James F Kellam, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

William O Shaffer, MD  Professor, Vice-Chairman and Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, and Southern Orthopaedic Association

Disclosure: DePuySpine 1997-2007 (not presently) Royalty Consulting; DePuySpine 2002-2007 (closed) Grant/research funds SacroPelvic Instrumentation Biomechanical Study; DePuyBiologics 2005-2008 (closed) Grant/research funds Healos study just closed; DePuySpine 2009 Consulting fee Design of Offset Modification of Expedium

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

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Patient with ankylosing spondylitis affecting the cervical and upper thoracic spine. The patient's spine has been fused in a flexed position.
Posterior view of a patient with ankylosing spondylitis affecting the cervical and upper thoracic spine. The patient's spine has been fused in a flexed position.
Anteroposterior radiograph of the sacroiliac joint of a patient with ankylosing spondylitis. Bilateral sacroiliitis with sclerosis can be observed.
Anteroposterior radiograph of the spine of a patient with ankylosing spondylitis. Ossification of the anulus fibrosus can be observed at multiple levels, which has led to fusion of the spine with abnormal curvature.
Anteroposterior radiograph of the spine of a patient with ankylosing spondylitis. Ossification of the anulus fibrosus at multiple levels and squaring of the vertebral bodies can be observed.
Anteroposterior radiograph of the spine of a patient with ankylosing spondylitis.
Anteroposterior (left) and lateral (right) radiographs of a patient with ankylosing spondylitis.
Radiographs of a hand (top) and an arm (bottom) of a patient with peripheral involvement of ankylosing spondylitis. Fusion of the joint spaces and deformity can be observed.
Sagittal magnetic resonance image of the thoracolumbar spine of a patient with ankylosing spondylitis. Degenerative disc disease and bridging osteophytes can be observed at multiple levels.
Radiograph showing a vertebral fracture in a patient with ankylosing spondylitis.
 
 
 
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