CHAPTER 35 Ankylosing Spondylitis
The association between the major histocompatibility complex antigen HLA-B27 and AS has been well established.1–6 Approximately 90% of AS patients are positive for the HLA-B27 antigen, although less than 10% of patients who are HLA-B27 positive manifest the signs and symptoms of AS. First-degree relatives of AS patients who are HLA-B27 positive who are also positive for the antigen have a 30% risk of having AS, in contrast to the prevalence in the general population, which is 1% to 2%. The exact mechanism of the AS and HLA-B27 connection is unknown, although a bacterial association has been proposed.
Physical Examination and Diagnosis
Sacroiliitis is usually identified on an anteroposterior pelvis film (with or without a Ferguson view). It is widely accepted that the presence of sacroiliitis is crucial for the diagnosis of AS. Sacroiliac joint destruction is the earliest manifestation of AS. The earliest stages of sacroiliitis show some blurring of the cortical margins; this progresses to subcortical erosions (more commonly on the iliac side because it is less robust than the sacral side). In advanced stages, the sacroiliac joints become completely fused, and the cortical erosions disappear. Sacroiliac joint involvement usually is symmetrical and bilateral. Studies have suggested that the use of bony pelvis computed tomography (CT) or magnetic resonance imaging (MRI) in conjunction with plain radiographs may lead to earlier diagnosis of AS.7 It has yet to be determined whether this early diagnosis favorably affects clinical outcomes.
Management of Acute Injury
A patient with AS may present with a progressive neurologic deficit without obvious bony injury or with progression of the deformity and increased pain. Many patients with missed spinal column injuries present at a later time to the clinic or the emergency department with progressive neurologic deficit or worsening of deformity or both. The evaluating clinician must also be aware of possible hyperextension through a fracture at a kyphotic segment, which may result in relatively normal sagittal alignment; attempts to determine the patient’s preexisting deformity from history and prior radiographs should always be made. There have been reports of neurologic injury in patients strapped to spine boards in a position of hyperextension when compared with their preinjury alignment.8–10 Because of the stiff and osteoporotic spine, minor trauma may result in acute angulation or moderately rapid deformity progression. One should refrain from attempting acute correction through such a fracture. The patient should be initially immobilized in a halo vest in the preinjury alignment.
It is generally accepted that AS patients sustain more spinal fractures and dislocations than individuals without AS.11–15 Cooper and colleagues16 retrospectively looked at 158 patients in Rochester, Minnesota, with AS and found a sevenfold increase in the incidence of spinal fractures over that of a cohort of patients without AS. They found no such increase in extremity fractures. The patients with spinal fractures tended to be older and had a greater preinjury involvement of the spine than patients without fractures. Cooper and colleagues16 also noted that this higher incidence was mainly during the first 5 years after diagnosis and suggested that this was due to a greater percentage of bone density loss during this period, resulting in a decreased fracture threshold. In addition, the dampening structures present in a normal spine have lost their load-absorbing qualities in the ankylosed spine. The intervertebral discs are stiff, as are the ligamentous structures, and the facet joints are ankylosed.
Whang and colleagues17compared a cohort of 12 patients with AS who sustained spinal injuries with 18 patients with diffuse idiopathic skeletal hyperostosis (DISH) who sustained spinal injuries. The DISH group represents a group of patients of similar age whose spinal condition results in stiff segments above and below any spinal fracture. Falls from a standing position were the most common mechanism of injury. There was a greater likelihood that the DISH patients did not incur any neurologic deficit (44.4%) compared with AS patients (25% of whom did not have a neurologic deficit). Complication rates were higher in the AS group (42% vs. 33% in the DISH group). There were two deaths in each group related to the injury or its treatment, all of which were considered to be related to the use of the halo vest (aspiration [two deaths], respiratory failure, and multisystem organ failure). Several patients died of unrelated causes during the follow-up period; however, all surviving patients were contacted and were classified as having excellent or good outcomes.
Finkelstein and colleagues18 looked retrospectively at 21 AS patients with a diagnosis of spinal trauma. One third of these patients had a delay in diagnosis; three had complete spinal cord injuries on presentation, and three experienced neurologic deterioration to complete spinal cord injuries after admission. Finkelstein and colleagues18 recommended quick screening cervical and thoracic MRI (one film) and screening lumbosacral spine MRI (one film) for diagnosis, in addition to minimal transfers and immediate stabilization. They did not comment on their definitive protocol for treatment of these patients (operative vs. nonoperative).
Hitchon and colleagues19 retrospectively reviewed 11 patients with AS and thoracic and lumbar fractures. They found 10 of these patients had sustained three-column injuries; 9 patients had extension-type injuries. More than half of these patients had a neurologic deficit (the specifics of which the study authors did not mention); half of these neurologically injured patients had some improvement in function. Hitchon and colleagues19 recommended surgical intervention for stabilization of thoracic and lumbar three-column injuries because of their inherent instability.
Graham and van Peteghem20 looked retrospectively at 15 patients over 6 years (1978-1984) comparing types of injuries and treatments. Of patients, 12 had cervical spine injuries; 9 of these had spinal cord injuries. The two patients with thoracic injuries had anterior cord syndromes. There were no compression-type injuries; most injuries resulted from a flexion-extension type of mechanism. The only patient treated with operative intervention was the patient with the lumbar injury, who had hardware failure and had to undergo revision. Two patients died, and three patients had pulmonary complications.
Apple and Anson21 looked at AS patients with spinal fracture and spinal cord injury, comparing operative versus nonoperative treatments. This study was a retrospective, multicenter study of 59 patients. In the operative group, 37 patients were treated with a variety of procedures. Patients in the nonoperative group were placed in halo traction and then halo vests and placed on bed rest. There were no significant differences between the two groups with regard to motor recovery, fusion complications, or mortality rate (22% in both groups). The nonoperative group did have significantly shorter hospital stays. No analysis of the patients according to type of injury or treatment was done, and no discussion of the deaths was presented.
Hunter and Dubo12 reviewed the cases of 19 AS patients who had sustained cervical spine fractures. Five of these patients had a complete spinal cord injury, and all of these patients died after their injury. All of these patients were treated nonoperatively. No patient developed neurologic deterioration, and all of the patients with incomplete cord injury regained some function. Hunter and Dubo12 concluded that nonoperative treatment worked well in these patients, although they suggested that surgery be considered in patients with grossly unstable injuries.
Bohlman retrospectively reviewed 300 patients with cervical spine injuries.21a He found only eight patients who carried a preinjury diagnosis of AS. Five of these patients died of pulmonary or gastrointestinal causes. Clinically significant epidural hematomas were found only in the AS patients. Bohlman recommended decompression for patients with progressive neurologic deficit. There was a delay in diagnosis in four patients, all of whom developed spinal cord injuries.
Complications can arise at the time of injury and from treatment of the injury. Deformity and neurologic injury can occur as a result of the injury; treatment with decompression and internal fixation carries risks of nonunion, hardware failure, failure of the bone-screw interface resulting in loss of fixation, and infection. Even halo management has complications. Skull fractures, pin tract infections, intracerebral hemorrhage, and intracranial air all have been reported with halo immobilization in these patients.9,22 Taggard and Traynelis24 described a posterior cervical fusion (lateral mass plating) they used in seven AS patients who had sustained fractures. The fusions were supplemented with autologous rib grafts. Postoperatively, the patients were immobilized in collars only, with the exception of one, who was placed in a sternal-occipital-mandibular immobilizer. Fusion occurred in all patients; there were two deaths in quadriplegic patients. Taggard and Traynelis24 recommended operative intervention as a means of avoiding postoperative halo immobilization.
Deformity
From a radiographic standpoint, a full spine lateral radiograph with the neck in a neutral position and the hips in a fully extended position is crucial for surgical planning. This radiograph allows measurement of the chin-brow angle, which is formed by a line from the chin-brow to the floor vertical angle. This measurement is helpful when planning any osteotomy. Ideally, the chin-brow angle should be zero. Suk and colleagues23