Surgery for Ankylosing Spondylitis

4 potential indications that spine surgery is necessary to treat ankylosing spondylitis

Peer Reviewed

Ankylosing spondylitis (AS) is a type of inflammatory arthritis that can affect the spine, such as the sacroiliac (SI) joints and facet joints. In severe cases of AS, new bone formation can cause the spine to abnormally fuse (join or grow together). Fortunately, most patients with ankylosing spondylitis do not require surgery. However, there are four basic indications when surgery may be considered or recommended.

#1. The spinal deformity is in a fixed flexed position. The magnitude (angle) of the deformity is the most important consideration. An example is forward flexion so great the chin rests near or on the chest (commonly called chin-on-chest deformity). The functional limitations of this particular deformity are great. In the example, the patient would be unable to look forward, make visual contact, drive, and may even have difficulty eating.

chin-on-chest deformity, front view, x-rayThe severity of the spinal deformity (eg, chin-on-chest), rigidity of the spine and your age can all dictate the type of surgery that is recommended.#2. The stability of the spine is compromised. An unstable spine means that it moves too much and the joints aren't controlling the spine mobility as they should. Spinal instability puts the patients more at risk for nerve damage.

#3. Neurologic deficit exists. "Neurologic deficit" means a nerve problem that causes sensory (eg, pain, tingling sensations) and/or motor changes (eg, weakness).

#4. A combination of any of the above.

Type of Spine Surgery
The type of spine surgery your surgeon recommends is based on many factors including your symptoms, the severity of the spinal deformity (eg, chin-on-chest),  rigidity of the spine, your age, lifestyle (eg, use tobacco), and overall health. Sometimes the surgery involves one or more procedures. Three of the procedures to treat ankylosing spondylitis are explained below.

  • Osteotomy: During an osteotomy, bone is cut to correct angular deformities. The bone ends are realigned and allowed to heal. Spinal instrumentation and fusion may be combined with an osteotomy to stabilize the spine during healing.
  • Decompression: Other procedures, such as laminectomies, decompress the spinal canal and associated nerves, restoring or preventing neurologic dysfunction. "Decompress" means to take pressure off the spinal cord or nerves.
  • Spinal Instrumentation and Fusion: These are surgical procedures used to correct spinal deformity and to provide permanent stability to the spinal column. These procedures join and solidify the level where a spinal element has been damaged or removed. Instrumentation uses medically designed hardware such as rods, bars, wires, and screws. These devices hold the spine straight during fusion. Fusion is the adhesive process joining bony spinal elements.

Recovery from Surgery for Ankylosing Spondylitis
Immediately following surgery, you are moved from the operating room into the recovery area. There nurses and other medical professionals monitor your vital signs, including postoperative pain. Some types of spinal surgical procedures require you to wear a brace, which is explained to you before surgery.

Depending on the type of surgery, you may spend one or more nights in the hospital. During hospitalization, nurses keep a close watch on you and you will be up sitting in a chair and walking soon. Again, depending on the type of surgery, some patients are up and walking with assistance the same day of surgery.

Commentary by Baron S. Lonner, MD

Dr. Shaffrey has presented an overview of problems manifested in the patient with ankylosing spondylitis. He has pointed out that the majority of patients do not require surgery for related spinal disorders.

A number of points warrant further emphasis. First of all, these patients are prone to fracture of the rigid spinal column even with relatively trivial trauma, such as a fall or a low-speed motor vehicle accident. This can result in severe instability, spinal deformity, and most importantly, deteriorating neurological function or paralysis. If an individual with AS has pain following a trauma, further investigation with x-rays and possibly CT scan and/or MRI is warranted.

The problem of spinal malalignment, such as chin-on-chest deformity, has been discussed by Dr. Shaffrey. Once a deformity has been established, it is quite rigid or stiff and typically is not correctible. Before this occurs, exercise and stretching and even bracing may be considered to minimize these deformities, which can be debilitating. The patient tends to be pitched forward and often has difficulty looking straight ahead as the head is often fixed in a downward position. If this occurs, osteotomies or cutting through the spinal column may be required to restore a more horizontal gaze and comfortable alignment.

Consultation with a spinal specialist early in the disease process may be warranted.

Updated on: 04/30/18
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Surgery Recovery: From Hospital to Home
Baron S. Lonner, MD
Professor of Orthopaedic Surgery
Mount Sinai Hospital
New York, NY
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