Ankylosing Spondylitis of spine orthopedics.pptx

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1. Ankylosing Spondylitis

2. Ankylosing Spondylitis A Chronic Systemic Inflammatory Disease That Primarily Affects The Axial Skeleton And Adjacent Structures Seronegative Spondyloarthropathies

3. Ankylosing Spondylitis – Greek Origin Angylos – Bent Or Crooked Spondylos – Spine Vertebra Itis – Inflammation First Reported Case Egyptian Mummies – Paleopathological Studies In Fifth Century Hippocrates Described A Condition Suggestive Of Ankylosing Spondylitis. History

4. First Clinical Description Bernard Connor, An Irish Physician, In 1691 In His Medical Dissertation. “ the vertebral bodies of the individual were so straightly and intimately joined, their ligaments perfectly bony, and their articulations so effaced, that they really made but one uniform continuous bone”

5. Strumpell - Marie - Bechterew A. Strumpell of Leipzig, Germany, Vladimir Bechterew of St. Petersburg, Russia, Pierre Marie Of Paris, France. Identified Three Of The Most Detailed Description Of Ankylosing Spondylitis.

6. Who Gets Ankylosing Spondylitis Prevalence Of 0.3% - 1.5% In US Men : Women = 3 : 1 Age group 16 – 35 years Positive family History - 15 to 20% Race, Ethnicity, Genetic & Environmental Factors

7. AS – An Autoimmune Disorder HLA-B27 , ARTS-1, IL-23R Molecular Mimicry – K.Pneumoniae in HLA-B27 Positive Individuals

8. Immune Mechanism Activation In AS

9. System Involved Axial Skeleton Vertebral Column Rib Cage Appendicular Skeleton Hip Shoulder Knee Elbow Feet Extra Skeletal Involvement Lungs – Pulmonary Fibrosis Eyes – Uveitis/ Iritis Bowel - IBD Heart - Aortitis

10. Pathophysiology - Overview Inflammation Enthesopathy Erosion Fusion

11. Sequence Of Events Enthesitis Arthritis Osteoporosis Ankylosis Fractures Pseudoarthrosis

12. Enthesitis Inflammation at the site of insertion of ligaments, tendons, or joint capsule to bone Pain, stiffness, limited range of movements Swelling of the inflamed area Difficulty in sitting on hard surface

13. Enthesitis

14. Arthritis – One third Of AS patient Hip Shoulder Ankle Finger & Toes Peripheral Joint Synovitis Involves Both Capsule & Synovial Lining

15. Osteoporosis 1/3 of AS Patients Thinning Of Bone Tissue & loss of bone density Correlates With Disease Activity Risk Of Vertebral Fractures

16. Fractures Lever Arm Is Longer Osteoporosis Subaxial Cervical Fractures C1-C2 Instability (25-90%)

17. Clinical Presentation Early Stage – Fatigue, Anorexia, Generalized Physical Discomfort Chronic Inflammatory Low Back Pain Spine Kyphosis Hunch back

18. Inflammatory Back Pain Younger Age at Onset Of pain Pain & early morning stiffness of the spine or buttocks Gradual, insidious onset Improvement with exercise or other physical activity Symptoms duration longer than 3 months Restriction of spinal mobility and deep breathing

19. Sleep Disturbances due to pain Radiographic evidence of Sacroiliitis or ankylosis

20. Diagnosis of AS History Clinical Examination Blood Investigation Radiological X-ray, MRI Diagnosing criteria Management

21. History Age Of Onset Gradual Onset – Worsens Overtime Early Morning Stiffness For One Hour Improves With Exercise Sleep Interruption Relieved With Over The Counter Medication Family History

22. Clinical Examination Pain And Tenderness Spine Pelvic Bones Sacroiliac Joint Chest Heel Limited Chest Movement Limited Hip & Spine Mobility

23. AS – Screening Test

24. Chest Expansion

25. Spinal Movements

26. Modified Schober’s Test

27. Chin Brow Angle

28. Gaze Angle

29. Occiput To Wall Test

30. Test For Sacroiliac Joint Patrick Test or Fabers test Gaenslen’s test Gillie’s Test Pump Handle Test Pelvic Compression Test Or Erichson’s Sign Pelvic Distraction Test Or Gapping Test

31. Patrick Test

32. Gaenslen’s Test

33. Gillie’s test

34. Pump Handle test

35. Investigation Lab Work Up HLA – B27 ESR CRP WBC count Radiology Advanced Disease Stage – Irreversible Damage MRI Detects Disease At Early Stage Plays A Role In Prognosis And Response To Treatment HLA – B27 Positive in 95% Of AS Patient Only 5% HLA – B27 Population Develops AS

36. Radiological Findings Squaring Of Vertebra Bamboo Spine Romanus Lesion Anderson lesion

37. Radiological Findings Diffuse Osteoporosis Dagger Sign Sacroiliitis Ankylosis

38. Ferguson View - Sacroiliitis

39. Grading Of Sacroiliitis

40. Sacroiliitis Imaging

41. The Modified New York Classification For AS - 1984 Clinical Criteria Low Back Pain > 3 Months That Improves With Exercise But Not With Rest Limitation Of Lumbar Spine Mobility In Both Sagittal & Coronal Planes Limitation Of Chest Expansion As Compares With Normal Age & Gender Radiological Criteria Unilateral Sacroiliitis Of Grade 3 Or 4 Or Bilateral Sacroiliitis Of Grade >2

42. Diagnosis Definite AS If Radiological Criterion Is Associated With At least One Clinical Component Probable AS Only The Three Clinical Component Are Present Or Only Radiological Component Is Present

43. Assessment Of SpondyloArthritis International Society (ASAS) – Rome Criteria Presence Of Sacroiliitis In X-ray Or MRI With At least One Feature Of Spondyloarthritis (Or) Presence Of HLA-B27 At least Two Feature Of Spondyloarthritis

44. Other Manifestation Of AS Eye – Anterior Uveitis Affects Iris & Ciliary Body 25% To 40% Of AS First Manifestation Of AS Starts Early Before Onset Of Back Pain Affects Only One Eye At A Time Sudden Onset Pain Redness Extreme Sensitivity To Light Tearing Blurring Of Vision

45. HLA – B27 - Seronegative Arthropathies

46. Cardiac Events Occurs late with onset of AS Majority are HLA - B27 Positive Typical presentation Heart valve dysfunction – Aortic regurgitation Conduction disturbances LV dysfunction Heart failure

47. Prognosis Earlier The Onset – Poorer Is The Outcome Long Standing Disease Have Greater Mortality - Cardiovascular Complications

48. Differential Diagnosis Mechanical Low Back Pain Rheumatoid Arthritis Diffuse Idiopathic Skeletal Hyperostosis (DISH) Lumbar Canal Stenosis

49. Treatment Medical Physical Exercise Surgical

50. Medical NSAIDS Newer COXIBs Sulfasalazine – (2-3g/day) Methotrexate – 25mg/week

51. Anti TNF – Alpha Agents Infliximab – iv infusion 5mg/kg body wt 0,2,8 weeks followed by 8 weeks interval Etanercept – 25mg subcutaneously twice weekly Adalimumab , Golimumab , Certolizumab Pamidronate

52. Newer Agents Monoclonal Antibodies Secukinumab Ixekizumab Tofacitinib Upadacitinib Bimekizumab Brodalumab

53. Exercise & Physical Therapy Back Stretches Deep Breathing Exercise Controlled Stretches

54. Surgical Fracture Spine Stabilisation Spinal Osteotomy THA

55. Cervical Spine More Prone For Fractures & Instability Longer Lever Arm Rigid Spine & Osteoporosis Lower Subaxial Cervical Fractures

56. Pre Op X Ray

57. Pre Op CT Sagittal Images

58. Pre Op CT Coronal Images

59. Post Op X ray

60. Thoracolumbar Osteotomies Smith Peterson Osteotomy – 10 Degree correction with 10mm Resection Pedicle Subtraction Osteotomy – More than 30 degree correction With Single Posterior Osteotomy

61. Spinal Osteotomy

62. Anesthesia Consideration Limited chest movement Cardiac Conduction Disturbances Patient Positioning – Hyperextension injuries Cervical Kyphosis – Difficult Intubation

63. Ideal Postioning

64. THA - Indications Hip Pain Postural & Functional Disability Pain In Adjacent Joints Anterior Dislocation of Hip Hip Arthroplasty Vs Spinal Osteotomy

65. Pre Op planning Posterior Tilt >20 Degree Reduced Acetabular Cup Anteverison Increasing The Horizontal Offset Reduces Hip Dislocation & Improves ROM

66. THA

67. Thank You