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Spine Surgery in Patients with Ankylosing Spondylitis

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Spine Surgery in Patients with Ankylosing Spondylitis ORIGINAL ARTICLE Spine surgery in patients with ankylosing spondylitis Natália Maria Fernandes Britto, M.D.1 Beatriz Souza Renor, M.D.1 Enrico Ghizoni, M.D., Ph.D.2 Helder Tedeschi, M.D., Ph.D.2 Andrei Fernandes Joaquim, M.D., Ph.D.3 1. Neurosurgery resident - Universidade Estadual de Campinas, Unicamp, Campinas-SP, Brasil. 2. Neurosurgery Professor - Universidade Estadual de Campinas, Unicamp, Campinas-SP, Brasil. 3. Neurosurgeon – Universidade Estadual de Campinas, Unicamp, Campinas-SP, Brasil. http://dx.doi.org/10.1590/1806-9282.64.04.379 SUMMARY INTRODUCTION: Ankylosing spondylitis (AS) is an idiopathic seronegative spondyloartropathy that involves mainly the axial skeleton and the sacroiliac joints. AS promotes biomechanical changes in the spine that predispose to fractures, spinal deformity and spondylo- discitis. The aim of this article is to report the clinical and laboratorial characteristics of patients with AS who underwent spinal surgery at our Institution. METHODS: Retrospective review of medical charts of patients who had AS and underwent spinal interventions. RESULTS: Nine patients were found and eight were included in the present study. There were three men and six women and the patients’ mean age was 57 years old. All patients had pain at the involved spinal level and one patient had tetraparesis due to cervical myelop- athy. Acute-phase proteins were positive in six patients (75%), and HLA-B27 was found in two patients (25%). Four patients had the radiological diagnosis of spondylodiscitis (50%) and underwent a spinal disc biopsy. They were all characterized as having aseptic spondylodiscitis. Three patients were free of pain with analgesics in their last follow-up and one patient had only partial solution of his pain. Three additional patients had spinal fractures surgically treated (37.5%) and one patient was operated because of a cervical kyphotic deformity (12.5%). There were no deaths or surgical complications in this series. CONCLUSIONS: the majority of our clinical and laboratories findings were discrepant with the medical literature. These differences may be secondary to regional characteristics or by the fact that our population included only those patients who underwent spinal surgery. KEYWORDS: Spondylitis, ankylosing. Fractures, bone. Discitis. ABBREVIATIONS: MRI = magnetic resonance imaging; CT = computed tomography, AS= Ankylosing spondylitis, HLA=Human leuko- cyte antigen, ASAS= Assessment of Spondyloarthritis international society, SpA= Spondyloarthitis, NSAIDSs= Nonsteroidal anti-in- flammatory drugs. INTRODUCTION There is a rough correlation between the preva- Ankylosing spondylitis (AS) is an idiopathic se- lence of HLA B27 and the incidence and prevalence ronegative spondyloartropathy that involves mainly of AS.2 Although 6-10% of the world population is pos- the axial skeleton and the sacroiliac joints. The dis- itive for HLA B27, only 5% of them will develop AS. ease has an estimated prevalence of 0.1 to 1.4% of the However, almost 90% of the AS patients are positive adult population, typically affecting men and with to HLA B27.1,3,4 There are no laboratorial findings that clinical symptoms starting at 20-30 years of age.1 define AS, and in contrast to other systemic inflam- DATE OF SUBMISSION: 28-Jun-2017 DATE OF ACCEPTANCE: 15-Jul-2017 CORRESPONDING AUTHOR: Andrei F. Joaquim Departamento de Neurologia - Hospital das Clínicas da Faculdade de Medicina de Campinas [email protected] Cidade Universitária Zeferino Vaz [email protected] Rua Padre Anchieta, 2770 – CEP 13083-888 – Campinas-SP [email protected] E-mail: [email protected] [email protected] 379 REV ASSOC MED BRAS 2018; 64(4):379-383 SPINE SURGERY IN PATIENTS WITH ANKYLOSING SPONDYLITIS matory diseases, acute-phase proteins are frequently METHODS in the normal range. A retrospective study at the University Hospital The diagnosis was first defined using the modi- of the State University of Campinas, São Paulo, Bra- fied New York criteria.4, 5 These criteria presented sil, was performed. The medical charts of all patients high sensibility and specificity; however they were with the diagnosis of AS that had spine surgery, were not useful for early diagnosis or prevention. Because reviewed. Institutional Review Board approval was of that the most recent ASAS classification criteria obtained under the number 17337313.7.0000.5404. for axial spondyloarthritis were developed for early The inclusion criteria were: patients with diagno- and established cases and include the MRI technique sis of AS established by the internal medical depart- (to depict active inflammation) as an important tool ment of our institution that underwent a spinal pro- for early diagnosis (Table 1).6 cedure by any reasons in our hospital. All procedures AS has a caudo-rostral progression, altering the were performed by the same spine surgeon (AFJ). biomechanical properties of the spine and diminish- The exclusion criteria were: lack of medical or ra- ing its resistance through a process of remodeling, diological data or lack of postoperative follow-up. which involves ligamentary ossification, vertebral The following variables evaluated were: joint fusion, osteoporosis and finally, spinal defor- Clinical information: gender, age, time of disease mity. The ankylosed spine is prone to fractures even progression, clinical manifestation, neurological sta- after minor traumas; additionally, fractures are often tus at diagnosis, description of the surgical proce- unstable and require proper treatment to avoid pri- dure and clinical evolution, conventional criteria to mary and secondary neurological injury, disability, evaluation of AS (peripheral arthritis, enthesopathy, and progressive deformity.7,8,8,10 uveitis), comorbidities, and history of trauma. Other possible complication is the occurrence of Laboratorial information: acute-phase proteins re- spondylodiscitis, especially for those patients who sults, presence of antigen HLA B27, results of hemo- receive medicaments such as biologic agents or tu- cultures and biopsy results mor necrosis factor antagonists, who may increase Radiological findings: reported on spine MRI and the chances of infections. It is radiologically suspect- CT scans. ed by the combination of narrowing of the disc space and erosions at the terminal plates summed to pe- RESULTS ripheral sclerosis, most of the times with gadolini- um enhancement at the MR. Of note, it may also be Nine patients were found (three males and six fe- aseptic, secondary to AS disease itself.9, 10,11,12,13 males), but one patient was excluded due to the lack The aim of the present manuscript is to ana- of data in the medical charts. Eight patients were in- lyze the patients with AS who underwent spinal sur- cluded in the present study and were fully evaluated. geries at our tertiary University Hospital. The male/ female ratio was 1:3; the mean age was 57 years, ranging from 30 to 73 years; the mean time of disease progression was 9.5 years, ranging from TABLE 1 - ASAS CLASSIFICATION CRITERIA FOR AXIAL five to 20 years. The most common clinical presen- SPONDYLOARTHRITIS (SPA) tation of spinal disease was pain in the affected seg- In patients with ≥ months back pain and age onset < 45 years ment, present in all cases. OR Considering the neurological status, only one pa- Sacroiliitis on imaging and ≥1 HLA B27 positive and ≥2 other tient had incomplete neurological deficits (Frankel C) SpA feature SpA features (12.5%). This patient was diagnosed with spondylo- Spa features: Sacroiliitis on imaging discitis at C45 and C67 disc and had a concomitant Inflammatory back pain Active (acute) inflammation on Arthritis MRI highly suggestive of sacroilii- myelophaty and tetraparesis. He underwent an open Enthesitis (heel) tis associated with SpA anterior cervical disc biopsy, and the tetraparesis Uveitis Definite radiographic sacroiliitis Dactylitis according to Modified New York improved spontaneously after a few months. No bac- Psoriasis criteria Crohn´s / colitis teriological origin was confirmed. All the remaining Good response to NSAIDs patients were neurologically intact. Family history of SpA HLA B27 Peripheral arthritis was documented in 50% of Elevated C reactive protein the cases, entesopathy in 25% of them and uveitis REV ASSOC MED BRAS 2018; 64(4):379-383 380 JOAQUIM A. F. ET AL pain medication and physical therapy. The outcome was complete pain resolution in three patients, and one patient had partial resolution of the pain in the following months. Three patients had spinal fractures (37.5%), as- sociated with minor trauma and one woman had a cervical kyphotic deformity that precluded her from looking horizontally when walking (12.5%). The cer- vical kyphotic deformity was treated by posterior instrumented cervical fusion (C2T3) with a pedicle subtraction osteotomy of c7. The three patients with thoracic fractures were treated by a posterior instrumented fusion and had an AO type B3 injury with anterior distraction (T1011; T910 and T89 fractures). All of them had a posterior instrumented fusion two segments above and two segments below the involved level with a reasonable clinical improvement of their pain. FIGURE 1 – Sagittal T2 sequence thoracic spine MRI show- ing vertebral body edema at T1112 and T12L1 in the interver- DISCUSSION tebral discs. This 57 years-old man underwent a spinal needle biopsy at the T1112 disc due to persistent back pain. Final Our spine surgery division performs around 150 result was compatible with a chronic inflammatory process
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