Ankylosing Spondylitis in Orthopedic Surgery Treatment & Management

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

Medical Care

  • No preventive measure or definitive treatment exists for individuals with AS. Early diagnosis and proper patient education are important.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to reduce pain and decrease inflammation. Aspirin has been reported to have limited benefit. Oral steroids are not used for long-term management of AS because of the high risk of adverse effects.
  • Sulfasalazine has been reported to be effective in some patients with peripheral involvement. Sulfasalazine is also useful in patients with coexisting inflammatory bowel disease.
  • Laboratory values, including those of ESR and CRP, are used commonly to monitor the progression of the disease and the effectiveness of treatment.
  • After identifying persons with extra-articular manifestations, provide proper treatment or refer them to the appropriate specialist. These extra-articular manifestations include acute iritis, aortitis, heart block, pulmonary fibrosis, amyloidosis, and neurologic deficits, including cauda equina.
  • Genetic counseling and patient support groups are useful in further educating patients about the disease process and in identifying individuals at increased risk.
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Surgical Care

  • Surgical treatment is geared toward resolution of the complications related to AS. No curative surgical treatment exists.
  • Patients with fusion of the cervical or upper thoracic spine may have significant impairment in line of sight, eating, and psychosocial well-being. These patients may benefit from extension osteotomy of the cervical spine.[25] This procedure is difficult and hazardous; however, if successful, it allows the patient to return to a more functional life.
  • Patients with fusion of the spine secondary to AS who report a change in position of the spine should be cautiously treated and should be considered to have sustained a spinal fracture. Surgical intervention may be necessary to stabilize the fracture and prevent neurologic deficit.[26, 27]
  • Patients with AS are vulnerable to cervical spine fractures. Long-standing pain may mask the symptoms of fracture. Radiological imaging may fail to identify the fracture due to the distorted anatomy, ossified ligaments, and artifacts. A retrospective case series of 32 patients with AS and cervical spine fractures revealed that in 19 patients (59.4%), a fracture was not identified on plain radiographs. Only 5 patients (15.6%) presented immediately after the injury. Of the 15 patients (46.9%) who were initially neurologically intact, 3 patients had neurological deterioration before admission. Early diagnosis with appropriate radiological investigations may prevent the possible long-term neurological cord damage.[28]
  • Note: Patients who develop bowel or bladder dysfunction should be evaluated immediately with MRI to assess for possible cauda equina syndrome secondary to spinal stenosis. The presence of cauda equina syndrome is a surgical emergency requiring decompression within 48 hours to prevent permanent loss of function.
  • Patients with significant involvement of the hips may benefit from total hip arthroplasty.[29] Following surgery, heterotropic bone formation can be reduced with use of indomethacin or radiation therapy.
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Consultations

  • Rheumatologist: Consult a rheumatologist for evaluation and management of ongoing medical treatment of patients with AS. Additional coexisting seronegative spondyloarthropathies can be assessed.
  • Gastroenterologist: Refer patients with symptoms suggesting coexisting inflammatory bowel disease to a gastroenterologist for evaluation.
  • Cardiologist: Refer patients with cardiac involvement, including aortitis or heart block, to a cardiologist for evaluation.
  • Physical therapist or physical medicine and rehabilitation specialist: Refer all patients to a physical therapist or rehabilitation specialist. Symptoms of AS are worse with inactivity and are relieved with exercise. As a result, a proper exercise program is a crucial element of treatment.
  • Geneticist: Patients may be referred for genetic counseling to assess questions regarding the probabilities of relatives developing the disease.
  • Support groups: Many patients benefit from various support groups, which can provide further education on the disease process and available treatment options.
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Diet

  • Generally, no dietary restrictions are implemented for patients with AS; however, patients with coexisting diseases, such as inflammatory bowel disease, have dietary restrictions.
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Activity

  • A proper exercise program is a crucial component in the treatment of AS. Patients obtain a significant reduction in symptoms following exercising. Referral to physical therapy or to a rehabilitation specialist is useful in assisting patients to develop an appropriate exercise program.[30, 31]
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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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