MANAGEMENT OF SPINAL DEFORMITIES IN ANKYLOSING SPONDYLITIS DR. RAJESH KURAPATI 3 RD YR PG DEPARTMENT OF ORTHOPAEDICS
• INTRODUCTION • ETIOLOGY • PATHOLOGY • CLINICAL FEATURES • INVESTIGATIONS • DIFFERENTIAL DIAGNOSIS • TREATMENT
INTRODUCTION • Marie Strumpell disease/ Bechetrew disease • Seronegative spodyloarthropathy • Mainly affects spine and sacroiliac joints • (M:F-2:1-10:1) • Age: 15 -40 years • Familial tendency (HLA-B27)
ETIOLOGY • Triggering factor - • Associated with antibody response to Genitourinary bacterial antigen Bowel Infection closely resembling HLA Reiters Disease B27. Ulcerative Colitis • Putative organism maybe carried to the spine by local lymphatic drainage
PATHOLOGY • Synovitis of sacroiliac • 3 stages and vertebral facet 1. inflammatory joints . reaction, granulation • Inflammation affects tissue formation and erosion of bone intervertebral discs 2. replacement with sacroiliac ligaments fibrous tissue symphysis pubis 3. ossification and manubrium sterni ankylosis of joint bony insertions of large tendons(enthesopathy).
CLINICAL FEATURES • back ache and stiffness recurring at intervals • Starts insidiously • worse in early morning and after inactivity • General fatigue, pain and swelling of joints, tenderness at the insertion of achillies tendon, foot strain or intercostal pain and tenderness. • Peripheral joints
CLINICAL FEATURES • Limitation of extension in lumbar spine initially • Diffuse tenderness over the spine and sacroiliac joints(FABER test) • Typical posture, fixed deformities • Diminised spinal movements in all directions –loss of extension is more severe(wall test)
CLINICAL FEATURES • Advanced stage-complete ankylosis from occiput to sacrum • Marked loss of cervical extension may restrict the line of vision to a few paces • MEASUREMENTS • Chest expansion is markedly diminished • Occiput to wall distance • Schober’s test • Finger floor distance
ORTHOPAEDIC MANIFESTATIONS • Bilateral sacroilitis • Progressive spinal kyphotic deformity • Spine fractures • Large joint arthritis(hip and shoulder)
EXTRASKELETAL MANIFESTATIONS • Chronic prostatitis • Pulmonary: b/l upperlobe fibrosis • CVS : aortic incompetence cardiomegaly conduction defects • Amyloidosis leading to renal failure • Neurological : Cauda equia(late stages) • Eye : conjuctivitis , iritis and uveitis
INVESTIGATIONS ( RADIOGRAPHS) • SI joints Erosion and fuzziness Periarticular sclerosis Finally bony ankylosis • Peripheral joints Erosive arthritis or progressive bony ankylosis
INVESTIGATIONS ( RADIOGRAPHS) • Spine Squaring Of Vertebral Bodies Ossification Of Ligaments Forming Bridging Syndesmophytes Bamboo Spine Osteoporosis Hyperkyphosis Of Thoracic Spine Due To Wedging Of The Vertebral Bodies(cobbs angle) Andersson lesion
INVESTIGATIONS • MRI • Evaluation of si joints may note erosions or edema • Blood • ESR and CRP are usually elevated during active phase • HLA-B27 positive • RA factor negative
THE NEWYORK CRITERIA • CLINICAL CRITERIA • Limitation of lumbosacral movement in three planes • History of pain at lumbosacral junction with or without lumbar spine pain • Limited chest expansion of 2.5cm or less at 4 th intercostal pain
THE NEWYORK CRITERIA RADIOLOGICAL CRITERIA BASED ON SACROILIAC JOINT RADIOGRAPHS • GR 0 : Normal • GR 1 : Possibly normal (minimal sclerosis) • GR 2 : Definite marginal sclerosis • GR 3 : Definite erosion and sclerosis • GR 4 : Complete obliteration and ankylosis
DIFFERENTIAL DIAGNOSIS DISH INFECTIONS • OTHER SERONEGATIVE SPONDYLOARTHROPATHIES REITERS DISEASE PSORIATIC ARTHRITIS INFLAMMTORY BOWEL DISEASE BEHCETS SYNDROME
TREATMENT • General measures maintain satisfactory posture preserve movement • Anti-inflammatory drugs for pain and stiffness • TNF inhibitors for severe disease • Surgeries to correct deformity.
GENERAL MEASURES • Patients are encouraged to remain active as far as possible Taught how to maintain satisfactory posture and urged to perform spinal extension exercises everyday Swimming, dancing, yoga and gymnastics are ideal forms of recreation Rest and immobilistaion are contraindicated
NSAIDS • Control pain and counteract soft-tissue stiffness, thus making it possible to benefit from exercise and activity Indomethacin, Aspirin, Naproxen etc DMARDS Sulfasalazine, Methotrexate
TNF inhibitors • Possible to treat underlying inflammatory process active in disease • Results in significant improvement in disease activity including remission • Reserved for individuals who have failed to be controlled with NSAIDS Etanercept
SURGICAL MANAGEMENT Kyphotic deformity of spine may be severe enough to warrant a lumbar, thoracic or cervical osteotomy Osteotomies of vertebrae are difficult and potentially hazardous procedures Hip replacements, If spinal deformity is combined with hip stiffness (permitting full extension) often suffice.
INDICATIONS FOR SURGERY • Severe kyphotic deformity measured by • Increased thoracic kyphosis and loss of lumbar lordosis Chin Brow angle Occiput to wall distance Finger to floor measurement • Patients field of vision limited to small area near feet. • Extremely difficult walking. • GI symptoms : dysphagia and choking Chin Brow angle
AIM OF SURGERY • Correction of deformity • Horizontal gaze (Chin brow to vertical angle of 10-20 degrees) • Saggital balance
SURGICAL PROCEDURES • SMITH PETERSEN OSTEOTOMY • PEDICLE SUBSTRACTION OSTEOTOMY • EGGSHELL OSTEOTOMY
SMITH PETERSON OSTEOTOMY • Excellent option for correction of smaller deformities. Resection of pars • 10 degrees of correction and facet joint for each 10mm of No vertebral resection. resection • Symmetrical resection essential to avoid coronal plane deformity. • Excessive resection may result in foraminal stenosis. Osteotomy is closed with compression or with in situ rod contouring + bone graft
PEDICLE SUBTRACTION OSTEOTOMY (THOMASEN) • Indications Significant sagittal Resection of pedicle, imbalance of more than facet joint and vertebra 4 cm. Immobile or fused disc For more than 30 degrees of correction
PEDICLE SUBTRACTION OSTEOTOMY (THOMASEN) • Position of the patient Prone position with appropriate padding and with reverse table bending.
PEDICLE SUBTRACTION OSTEOTOMY (THOMASEN) • Procedure • Midline vertical incision. • Exposure and dissection subperiosteally. • Pedicle screw fixation done leaving the level of osteotomy. • Facetectomies and rigorous posterior release are done to increase flexibility of spine. • Osteotomy is begun after meticulous haemostasis.
PEDICLE SUBTRACTION OSTEOTOMY (THOMASEN) posterior elements • resected from 1cm below the pedicle screw of the vertebra above the osteotomy site to 1 cm above the pedicle screw of the vertebra below . Spinous processes of the • 2 adjacent vertebra are completely resected. Exiting roots are • exposed. Interbody fusion is done • above and below the osteotomy site to prevent pseudoarthrosis.
PEDICLE SUBTRACTION OSTEOTOMY (THOMASEN) • Osteotomy is done at the base of the transverse process. • Dissection of the lateral wall of the vertebral body. • Pedicle is resected to its base. • Vertebral osteotomy is done by decancellation technique. • Posterior based triangular wedge is prepared.
PEDICLE SUBTRACTION OSTEOTOMY (THOMASEN) • Maneuver to close the osteotomy Reverse breaking of table • Posterior interlaminar contact to be achieved at the end of closure of ostetomy. • C arm lateral view to measure the final lordosis.
EGGSHELL OSTEOTOMY • Uses both anterior & posterior approaches. • Indicated in severe sagittal and coronal imbalance more than 10 cm. • Anterior decancellation, removal of posterior elements, instrumentation, deformity correction and fusion.
CERVICAL OSTEOTOMY • Indications chin to chest deformity difficulty in opening mouth improve ability to see ahead to prevent subluxations dysphagia and dyspnoea neurological disturbances • Operation performed with patient sitting on stool, leaning forward with arms on operation table.
CERVICAL OSTEOTOMY • Level of osteotomy depends on deformity and degree of ossification of ALL • done at C3 to C7 levels
THR • If the patient has associated hip deformity, bilateral total hip replacement is done first.
COMPLICATIONS OF THE PROCEDURE • Rupture of aorta, IVC • Injury to spinal nerves • Cauda eqiuna syndrome • Pseudoarthrosis • Coronal plane deformities • Anaesthetic complications
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