MANAGEMENT OF SPINAL DEFORMITIES IN ANKYLOSING SPONDYLITIS DR. - - PowerPoint PPT Presentation

MANAGEMENT OF SPINAL DEFORMITIES IN ANKYLOSING SPONDYLITIS

• DR. RAJESH KURAPATI

3RD 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-

antibody response to bacterial antigen closely resembling HLA B27.

• Putative organism

maybe carried to the spine by local lymphatic drainage

• Associated with
• Genitourinary
• Bowel Infection
• Reiters Disease
• Ulcerative Colitis

PATHOLOGY

• Synovitis of sacroiliac

and vertebral facet joints .

• Inflammation affects
• intervertebral discs
• sacroiliac ligaments
• symphysis pubis
• manubrium sterni
• bony insertions of large

tendons(enthesopathy).

• 3 stages

 1. inflammatory reaction, granulation tissue formation and erosion of bone  2. replacement with fibrous tissue  3. ossification and ankylosis of joint

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 4th

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.

• 10 degrees of correction

for each 10mm of 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

Resection of pars and facet joint No vertebral resection

PEDICLE SUBTRACTION OSTEOTOMY (THOMASEN)

• Indications

 Significant sagittal imbalance of more than 4 cm.  Immobile or fused disc  For more than 30 degrees of correction

Resection of pedicle, facet joint and vertebra

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

• steotomy.
• 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

• steotomy site to 1 cm

above the pedicle screw

• f 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

• steotomy 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
• steotomy

 Reverse breaking of table

• Posterior interlaminar

contact to be achieved at the end of closure of

• stetomy.
• 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

• n operation table.

CERVICAL OSTEOTOMY

• Level of osteotomy

depends on deformity and degree of ossification

• f 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

CONCLUSION

• Pedicle substraction osteotomy is performed usually

at lumbar level as spinal canal here is large and the

• steotomy is distal to the cord.
• Motion of spine is not increased but lumbar lordosis is

created to compensate for thoracic kyphosis .

• Up to 30 degrees or more correction can be achieved

with a single osteotomy, can be combined with other methods for higher degrees of correction if required.

• Patient attains a good gaze and sagittal balance after

the procedure with less complications.

REFERENCES

• CAMPBELL’S OPERATIVE ORTHOPAEDICS,

TWELFTH EDITION, PAGES 2029-2034

• APLEY’S SYSTEM OF ORTHOPAEDICS AND

FRACTURES, NINTH EDITION, PAGES 66-70.

• BENZEL SPINE SURGERY, FOURTH EDITION,

PAGES 345-389.

THANK YOU