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

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