Orthopedics - Oleksa A.P. 2006

Spinal disorders causing pain
Ankylosing spondylitis

Ankylosing spondylitis (Fig. 301) is a chronic inflammatory disease affecting the sacroiliac symphysis, small JOINTS OF THE spine, and paraspinal Tissues.

In medical literature, this condition is described as Marie-Strümpell disease, Bechterew's disease (ankylosing spondylitis, spondylose rhizomélique, pelvospondylitis). It is diagnosed more frequently in men than in women (6:1), typically between the ages of 20 and 25. The Etiology of the disease remains fully unknown to this day. O. Vojtíšek (1965) and Z. Jancelewicz (1966) associate the onset of ankylosing spondylitis with hypothermia, poor living conditions, and other adverse environmental factors. A. Grimble and M. Lessof (1965), H. Julkunen et al. (1966), and R. Romanus and S. Ydén (1955) suggest that genitourinary infections may be a potential underlying cause. Wright et al. (V. Wright, J. Moll, 1973) observed typical clinical manifestations of ankylosing spondylitis in 15 out of 234 patients with Ulcerative Colitis, along with radiological Changes in the sacroiliac joints in 42 patients.

Literature reports (W. Brühl et al., 1964; E. Bywaters, A. Dixon, 1965; F. Coste, J. Solnica, 1966; M. Kahn, W. Hall, 1965) indicate that ankylosing spondylitis has been observed in patients with psoriatic polyarthritis, with F. Coste and J. Solnica (1966) identifying it in 33% of 186 such patients. Currently, some authors consider Bechterew's disease to be a variant of the chronic rheumatoid process.

A hereditary factor in The Development of ankylosing spondylitis is also noted (F. Kuthan, J. Navrátil, 1966; J. De Blécourt et al., 1961).

The disease has a typical clinical course. It generally begins with an inflammatory process in the sacroiliac joints, subsequently spreading to the small joints of the spine and paraspinal tissues. Inflammation of the synovial membrane of the spinal joints leads to lymphocytic and plasma Cell infiltration, which extends to involve the fibrous structures and perivertebral tissues, promoting The formation of intervertebral bridges, or syndesmophytes (Fig. 301). Initially, this inflammatory-ossifying process appears on the anterior surfaces of the vertebral margins and intervertebral discs, in the region of the anterior longitudinal ligament, and is known as anterior spondylitis (spondylitis anterior; S. Desseze et al., 1965). In the spinal joints, ossification begins at the sites of Joint Capsule attachment.

In descriptions of the course of ankylosing spondylitis, the term spondylodiscitis has emerged. It involves the proliferation of dense fibrous tissue within the intervertebral discs, which subsequently ossifies not only the discs but also fuses them with the vertebrae, producing a radiographic appearance reminiscent of a "bamboo spine" (Fig. 302).

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Fig. 301. Ankylosing spondylitis in a 55-year-old patient.

Fig. 302. Radiograph of a "bamboo spine" in Bechterew's disease in a 46-year-old patient.

Clinical symptoms. In the majority of patients, the disease begins with a dull ache in the sacroiliac joints, which may radiate to the thighs or inguinal regions, accompanied by general malaise, poor appetite, weight loss, and sometimes low-grade fever. These symptoms are non-specific, and the inflammatory process progresses very slowly; consequently, the Diagnosis is typically established over time, sometimes years after onset. The inflammatory process gradually ascends from the sacroiliac joints up the spine, initially involving the lumbar region, then the thoracic, and later the cervical region.

The course of the disease includes remissions, which can be prolonged. The clinical picture depends on the degree and levels of spinal involvement, but the diagnosis is confirmed by radiographs of the sacroiliac joints, which reveal fusion of these bones (ankylosis). While stiffness in the lumbar spine, aside from pain, may not cause significant impairment, involvement of the small joints of the thoracic spine, along with the costovertebral joints, leads to Kyphosis, restricted chest mobility, and a gradual shift to abdominal-type breathing. Although this process occurs quite slowly, inspiratory respiratory capacity gradually decreases, while expiration remains largely unaffected. Such respiratory impairment reduces tissue oxygenation to some extent, though patients often fail to notice this due to gradual adaptation, experiencing shortness of breath only during brisk walking or running.

In Bechterew's disease, numerous Organs and body systems are drawn into the pathological process.

The onset of pain during neck movements indicates involvement of the cervical vertebrae joints, eventually resulting in restricted mobility and ankylosis.

According to the World Health Organization criteria established in Rome (1963), the main diagnostic criteria for Bechterew's disease are:

1. Pain and stiffness in the lumbosacral region lasting more than three months.

2. Spinal pain and limitation of chest expansion.

3. Restricted movement in the lumbar spine.

4. Restricted chest mobility.

5. Radiological evidence of bilateral sacroiliitis.

Disease progression is monitored dynamically through systematic measurements of:

1. The distance from the chin to the suprasternal notch during forward HEAD flexion.

2. The distance from the occiput to the spinous processes of the vertebrae with the neck extended.

3. Chest expansion during maximal inspiration.

4. Mobility of the thoracic spine.

5. Mobility of the lumbar spine.

6. Finger-to-floor distance during trunk flexion.

Diagnostic radiological criteria for Bechterew's disease in the sacroiliac joint:

1. Stage 0 — no radiographic changes are visible.

2. Stage I — blurring of the joint spaces, slight periarticular Osteoporosis.

3. Stage II — widened joint spaces and sclerosis of the bone adjacent to the Cartilage.

4. Stage III — uneven width of joint spaces, prominent adjacent sclerotic changes in the bone, defects on the articular surfaces, partial bony fusion.

5. Stage IV — complete bony fusion. In the spine:

1. Stage I — no radiological signs.

2. Stage II — reduction of lumbar lordosis, slight thoracic kyphosis.

3. Stage III — blurring of the intervertebral spaces and marginal changes around at least one vertebra.

4. Stage IV — Bone Formation processes along the anterior margins of the vertebrae, bridging of one or more vertebrae by bone bridges.

5. Stage V — extensive proliferation of intervertebral bone bridges connecting the vertebrae to each other.

In the late stage of ankylosing spondylitis, there are no diagnostic difficulties. The patient's posture alone indicates spinal pathology. Clinical examination refines, and radiological examination confirms the diagnosis and determines the stage of the disease.

Sometimes ankylosing spondylitis must be differentiated from degenerative changes in the spine with spondylarthrosis.

Spondylarthrosis develops in individuals over 40 years of age, pain is significantly less or may be absent altogether, and there is neither such restriction of spinal movement nor extensive bony fusion between the vertebrae.

Sometimes ankylosing spondylitis is mistaken for Scheuermann's disease (juvenile kyphosis), which occurs As a result of impaired endochondral Ossification of the vertebrae. Lateral radiographs reveal node-like protrusions of the intervertebral discs, sometimes wedge-shaped flattening of the vertebral bodies along their anterior margin, causing kyphosis. The General condition of the patients is satisfactory, and there are no laboratory Blood abnormalities. This process ceases after skeletal growth is complete.

In Rheumatoid Polyarthritis, the spine, particularly its cervical region, is sometimes involved in the process. The clinical course of the disease itself, a positive Waaler-Rose test, the absence of chest stiffness, and the absence of ossification of paravertebral tissues argue against ankylosing spondylitis.

In Reiter's Syndrome, the sacroiliac joints may be involved in the inflammatory process, but this syndrome manifests with classic signs: Arthritis, Conjunctivitis, and urethritis or cystitis.

It is almost never necessary to differentiate ankylosing spondylitis from Tuberculosis of the spine.

Treatment. Ankylosing spondylitis has a very slow chronic inflammatory course that patients may not notice for years and therefore do not seek medical attention in the Cytology/cytology/16.html">Early stages of the disease. Only the sensation of stiffness and limited spinal mobility are frequent reasons for seeking help.

After examining the patient and establishing a diagnosis, conservative treatment is prescribed, which includes pharmacotherapy, physical and balneotherapy, and a set of measures used in the treatment of rheumatoid polyarthritis. Sanatorium-resort treatment is beneficial (Lubin Velyky, Nemyriv, Khmilnyk, Kuyalnik). Permanent comprehensive conservative treatment (in courses) significantly helps patients, slows down the progression of the process, and preserves working capacity for a long time.

Today, in cases of severe trunk deformity, spinal surgeons use Surgical treatment, considering corrective vertebrotomy to be the only effective method that improves spinal statics and its vital Functions (Kazmin A.I., Vetrile S.T., 1986; Tsyvian Ya.L., Maerova N.D., 1986).

Given that the deformity in Bechterew's disease is localized in the thoracic and thoracolumbar spine, when deciding on the level of vertebrotomy, it would be logical to operate at the apex of the maximal curvature. However, surgery at this level carries the risk of a dangerous complication — disruption of the Spinal Cord Blood supply; therefore, vertebrotomy is more frequently performed at the lumbar spine level.

The surgery should be performed during the stage of subsidence and stabilization of the spinal process. Herbert's vertebrotomy is most commonly used.

Surgical technique. The operation is performed with the patient in the prone or lateral position under endotracheal anesthesia with full anesthetic support. However, since oral intubation is not always feasible in patients with cervical spine lesions, intubation is performed either nasally or following tracheotomy.

Turning the patient to the prone position may occasionally lead to circulatory complications, specifically a drop in blood pressure. In this position, the head is positioned lower than the trunk, which can also impair cerebral Circulation. To prevent this, Tsivyan administered Trental and prednisolone. The surgical team must be prepared for significant blood loss, which averages about 1.5 liters and sometimes considerably more. Therefore, autologous blood and an adequate supply of donor blood should be prepared in advance.

A linear incision is made along the spinous processes over the apex of the deformity, and the spinous process at the peak of the curvature is resected along with partial resection of the adjacent neighboring processes. This creates a wedge-shaped defect with its apex directed toward the spinal canal. Subsequently, the ankylosed articular processes and laminae are resected at the level of spinal correction. The spine is then carefully and smoothly hyperextended by applying pressure on both sides of the resected spinous processes until the edges of the wedge approximate. During spinal realignment, the intervertebral disc ruptures, which is accompanied by a characteristic cracking sensation.

If this cannot be achieved, resection of the transverse process along with the Head and Neck of the rib becomes necessary to expose the vertebra anteriorly and laterally. Access to the twelfth thoracic and lumbar vertebral bodies is less traumatic and safer. Following partial resection of the vertebral body, successful spinal correction is achieved.

The operation is concluded with posterior fusion utilizing the preserved spinous processes with a tension wire or Wilson plates, combined with bone grafting (using auto- or allografts). The wound is drained and closed in layers. A plaster jacket is applied, incorporating both thighs down to the lower third.

Postoperatively, patients are monitored in the intensive care unit, where donor blood transfusions, Oxygen therapy, and correction of Metabolic Disorders are continued, alongside the maintenance of blood rheology. Intensive infusion therapy and adequate pain management reduce the likelihood of gastrointestinal paresis.

Severe postoperative complications include Mallory-Weiss syndrome. Tears or fissures of the gastric mucosa may occur mechanically as a result of extensive spinal deformity correction or due to microcirculatory disorders, which significantly complicate the postoperative period.

Additionally, cast syndrome (superior mesenteric artery syndrome) may occur, characterized by acute gastric dilation and vomiting. Treatment for this condition involves gastric lavage, parenteral Nutrition, and the infusion of fluids and electrolytes (Tsivyan Ya.L., Maerova N.D., 1986).

Patients remain on strict bed rest in a brace for three months. Afterwards, the plaster jacket is replaced, and patients are permitted to walk. For the following six months, patients must continuously wear a polyethylene brace for a total duration of one year. By this time, bony fusion of the operated vertebrae is established, rendering the brace unnecessary thereafter. In cases of non-union accompanied by pain, the patient must continue wearing the brace.

Vertebrotomy corrects spinal curvature (Fig. 303 a, b) and improves the patient's well-being; however, it must be borne in mind that this Procedure does not alter the underlying pathological process, and therefore comprehensive conservative treatment should be continued.

It should be noted that vertebrotomy Procedures are performed both abroad and in Ukraine (by M.I. Khvysiuk, O.O. Korzh, M.O. Korzh, H.H. Hruntovsky, V.Ya. Fyshchenko, and others).

Fig. 303. Posture of a patient with Bechterew's disease: a — before surgery, b — after surgery, c — spinal radiograph following wedge resection of L1.