Asymptomatic spondylodiscitis. An unusual feature of ankylosing spondylitis

Symptomatic pseudarthrosis in ochronotic spine: case report

In this study the authors report the first example of spinal pseudarthrosis in a patient with ochronosis, and they describe the application of posterior-only 360° surgery as an alternative approach to combined anterior-posterior surgery in the management of pseudarthrosis of an ankylosed spine, regardless of its etiology. Spinal involvement in ochronosis produces loss of flexibility and ankylosis of thoracic and lumbar segments. Pseudarthrosis is a serious complication of the diseases that present with ankylosis of the spine. However, its occurrence in ochronotic spine has not been reported previously. Evaluation of progressive paraparesis in a 68-year-old man with ochronosis revealed pseudarthrosis at the T11-12 level. Circumferential dural sac decompression, debridement of the disc space, interbody fusion, and screw-rod fixation were all done via a posterior-only approach. Postoperatively the patient exhibited a marked recovery in terms of pain and neurological status. At the 3-month follow-up, he was able to walk independently. Ochronosis should be included in the etiology of pseudarthrosis. With aggravation of back pain and the appearance of neurological deficits in an already stable patient with any ankylosing disease, pseudarthrosis should be suspected. Furthermore, single-stage, 360°, posterior-only surgery may obviate the need for single-stage or staged anterior-posterior surgical intervention in patients with pseudarthrosis of the thoracic and lumbar spine.

Discovertebral lesion in ankylosing spondylitis: differential diagnosis with discitis by magnetic resonance imaging

Abstract  Ankylosing spondylitis (AS) is occasionally accompanied by erosive changes in the vertebral endplate at one or more restricted levels (Andersson lesions). The radiographic findings of this lesion are similar to those of bacterial discitis, and a differential diagnosis between them is often difficult. These diseases must be diagnosed correctly because they require different treatments. In order to evaluate the prevalence of Andersson lesions in the Japanese population, we examined 31 cases of AS which were treated in our department, and Andersson lesions were found in three (9.7%) of them. All these three cases developed Andersson lesions in the earlier phase of the AS, and differentiating the lesions from bacterial discitis was difficult. The details of these three cases are reviewed, and the importance of differentiating between Andersson lesions and bacterial discitis is discussed. Plain radiographs showed no clear difference between these conditions, but magnetic resonance imaging (MRI) was found to be more efficient.

The Andersson lesion in ankylosing spondylitis: distinguishing between the inflammatory and traumatic subtypes

A number of causes have been advanced to explain the destructive discovertebral (Andersson) lesions that occur in ankylosing spondylitis, and various treatments have been proposed, depending on the presumed cause. The purpose of this study was to identify the causes of these lesions by defining their clinical and radiological characteristics. We retrospectively reviewed 622 patients with ankylosing spondylitis. In all, 33 patients (5.3%) had these lesions, affecting 100 spinal segments. Inflammatory lesions were found in 91 segments of 24 patients (3.9%) and traumatic lesions in nine segments of nine patients (1.4%). The inflammatory lesions were associated with recent-onset disease; a low modified Stoke ankylosing spondylitis spine score (mSASSS) due to incomplete bony ankylosis between vertebral bodies; multiple lesions; inflammatory changes on MRI; reversal of the inflammatory changes and central bony ankylosis at follow-up; and a good response to anti-inflammatory drugs. Traumatic lesions were associated with prolonged disease duration; a high mSASSS due to complete bony ankylosis between vertebral bodies; a previous history of trauma; single lesions; nonunion of fractures of the posterior column; acute kyphoscoliotic deformity with the lesion at the apex; instability, and the need for operative treatment due to that instability. It is essential to distinguish between inflammatory and traumatic Andersson lesions, as the former respond to medical treatment whereas the latter require surgery.

Fracture dislocation of the spine after total hip arthroplasty in a patient with ankylosing spondylitis with early pseudoarthrosis

BACKGROUND CONTEXT

There are no studies suggesting the management of asymptomatic, early pseudoarthrosis with advanced hip and spine deformities in patients with ankylosing spondylitis. Literature advocates the correction of the hip deformity first and that of spine later.

PURPOSE

To highlight the importance of asymptomatic, early pseudoarthrosis lesion in a patient of ankylosing spondylitis with advanced hip and spine deformities.

STUDY SETTING

A 25-year-old female patient suffering from ankylosing spondylitis with 70 degrees of flexion deformity at right hip and rounded kyphosis of thoracolumbar spine was admitted for right total hip arthroplasty.

METHODS

Cementless total hip arthroplasty and flexor tendon release were performed on right hip under general anesthesia and patient was nursed in supine position postoperatively.

RESULTS

The patient developed cauda equina syndrome and loss of sensation below twelfth thoracic segment on the second postoperative day. Radiological evaluation showed a fracture dislocation of the second and third lumbar vertebrae. Retrospective re-examination of preoperative radiographs showed small erosion of the anteroinferior margin of the second lumbar vertebra. Patient's neurological status did not improve after decompression and posterior stabilization of fractured spine.

CONCLUSION

Careful evaluation of the spine in patients with spondyloarthropathy with advanced hip and spine deformities should be done. Any lesion that can potentially destabilize the spine should be treated first before correcting hip deformity.

Spinal pseudarthrosis in advanced ankylosing spondylitis with sagittal plane deformity: clinical characteristics and outcome analysis

STUDY DESIGN

A retrospective study of consecutive ankylosing spondylitis (AS) patients with spinal pseudarthrosis.

OBJECTIVES

To review the clinical characteristics and assess the outcomes of surgical treatment of spinal pseudarthrosis in advanced AS patients with sagittal plane deformity.

SUMMARY OF BACKGROUND DATA

There have been several reports describing the clinical findings of spinal pseudarthrosis in AS. However, few have studied the outcomes of surgical treatment of spinal pseudarthrosis with sagittal plane deformity in advanced AS patients.

METHODS

A total of 19 destructive vertebral lesions in 12 patients were reviewed. We performed Smith-Petersen osteotomy (SPO) at the same level for correction of sagittal plane deformity and anterior interbody fusion (AIF) for repair of pseudarthrosis. Pedicle subtraction osteotomy (PSO) was performed additionally at the lumbar spine in six severe kyphotic patients. Outcome variables included radiographic measurement from preoperative, immediate postoperative and follow-up films (mean, 51 months; range, 35-108 months), and clinical assessment using visual analog scale for back pain and the modified SRS outcome instruments satisfaction domain and the review of postoperative complications.

RESULTS

Clinical characteristics including trauma and inflammatory reaction were variable. The mean time for radiographic union of pseudarthrosis was 4.2 months (range, 2.5-6 months). Average correction of segmental kyphosis with SPO at the level of pseudarthrosis was 20.9 degrees (range, 5 degrees -34 degrees ) and 26.3 degrees (range, 20 degrees -32 degrees ) with lumbar PSO. Mean sagittal imbalance had improved 15.2 cm (range, 6.7-34.7 cm) at the last follow-up. All 12 patients had improvement of pain and neurologic deficit. The mean visual analog scale for pain had improved 4.8 (range, 4-7). The mean SRS score for patient satisfaction at the last follow-up was 4.6 of a possible 5. There were 7 cases of complications, including 3 cases of intraoperative dural tear, 2 cases of postoperative radiculopathy, and 1 case of wound infection. There was no permanent complication.

CONCLUSIONS

SPO at the level of pseudarthrosis was a safe and effective technique to correct sagittal imbalance without vascular complication. Surgical repair of pseudarthrosis with AIF provided successful fusion and good clinical results. For patients with lumbar hypolordosis, additional PSO was effective in restoration of sagittal balance.

Atypical clinical presentation of ankylosing spondylitis

OBJECTIVES

To describe a subgroup of patients with ankylosing spondylitis (AS), whose disease evolved without the characteristic inflammatory back pain or significant disability.

METHODS

Three patients who were diagnosed in their late 5th decade of life as having AS are described. Information about asymptomatic cases of AS or patients who were unaware of their disease was gathered from case reports and from studies involving HLA-B27-positive individuals. Another source of information derived from studies that investigated conditions known to be a complication of AS, such as heart block or aortic regurgitation.

RESULTS

The data collected from the literature suggest that 1.5% to 10% of the patients with AS are asymptomatic or have very mild disease. These patients are diagnosed late in the course of the disease.

CONCLUSIONS

Because of the mild nature of the symptoms, the real prevalence of atypical AS is unknown. The information gathered from the literature allows to delineate 4 subgroups of patients with AS: (1) Classic AS with characteristic clinical and radiographic manifestations; (2) Asymptomatic AS with characteristic radiographic findings; (3) Asymptomatic AS with extra-articular features as the presenting manifestations; (4) Symptomatic AS without radiographic supporting evidence. Patients with asymptomatic or mild symptoms deserve more attention, because a better understanding of the factors that affect the expression of pain in different individuals may generate better pain control therapies.

Spondylodiscitis in ankylosing spondylitis, inflammation or trauma? A description of six cases

An uncommon, but well recognised complication of Ankylosing Spondylitis (AS) is spondylodiscitis, a destructive discovertebral lesion also called the Andersson lesion. We describe six cases, with variable clinical presentation and radiological appearance. Two had multiple lesions, in one patient spondylodiscitis was the presenting symptom of AS. None had a history of even a minor trauma. Prognosis was good with conservative treatment including NSAID's, rest, and physiotherapy. In two cases histopathology was studied and suggested sterile inflammation as the main etiologic factor. The literature is reviewed regarding the mechanisms that may contribute to these lesions: mainly inflammatory like increasing enthesopathy or mainly mechanical like pseudoarthrosis about a fracture site. It may be that both mechanisms can result in similar destructive intervertebral disc lesions.

Spondylodiscitis and pseudarthrosis in a patient with enteropathic spondyloarthropathy

Images

A destructive discovertebral lesion: septic discitis, ankylosing spondylitis, or rheumatoid arthritis?

A 41-year-old male with a 20-year history of classical ankylosing spondylitis, psoriasis and seropositive, nodular erosive rheumatoid arthritis presented with a 12-month history of thoracolumbar junction pain following minor trauma. A pseudoarthrosis was noted at the T11/12 level on plain radiographs and tomograms. A gallium scan showed no increased isotope uptake, and a computed tomogram (CT) revealed no evidence of a paraspinal collection. Conservative management including cast immobilisation and local radiotherapy was ineffective, and spinal fusion was required. A typical Andersson lesion was found at operation. The diagnostic and therapeutic problems of such discovertebral lesions are discussed.

Unexplained acute backache in longstanding ankylosing spondylitis

Patients with longstanding ankylosing spondylitis who develop untypical severe backache may have spinal lesions.

Ankylosing spondylitis presenting as spondylodiscitis

Spondylopathy is a relatively common finding in advanced ankylosing spondylitis (AS). However non-infectious spondylodiscitis as an early manifestation of AS seems to be exceptional. In this article, we present such a case in an adolescent.

Spondylitis erosiva: report on 9 patients

Nine patients (5 male and 4 female) are described with mild pain in the lumbar and thoracolumbar spine, early morning pain, morning stiffness, and moderately reduced mobility of the spine. Initial x-ray examination of the spine revealed sclerosis of one or several vertebral bodies and erosions in various parts of the vertebral bodies. In the further course of the disease squaring, sacroiliitis, and arthritis of the apophyseal joints was found. Seven of the 9 patients had the histocompatability antigen HLA B27. On the basis of these observations it is considered that 7 of these 9 patients had ankylosing spondylitis, the erosive lesions of the vertebral bodies being the first visible signs of the disease.

The detection of spinal pseudarthrosis in ankylosing spondylitis

Spinal pseudarthrosis in ankylosing spondylitis can be difficult to detect radiologically. This paper assesses the value of bone radioscintigraphy in relation to radiological examination. The patterns of tracer uptake in the spine were recorded in 16 patients in whom established ankylosing spondylitis was complicated by pseudarthrosis. Twenty such lesions were identified in 16 patients, mostly occurring at one level in a junctional region of the spine. Four patients had two lesions. Standard radiography failed to demonstrate this abnormality in seven patients and in these, tomography was required to confirm the scintigraphic findings. On the other hand, bone scanning was much less accurate in detecting the minor forms of marginal vertebral end plate destruction (spondylo-discitis) than conventional radiology. This study suggests that 99TcmMDP scanning is a useful primary investigation for the detection of spinal pseudarthrosis in patients with chronic ankylosing spondylitis who suffer late onset back pain.

Aspects of atypical degenerative lesions of vertebrae

Over the last 20 years, several authors have reported aspects of degenerative disease of the vertebral column with irregularity and sclerosis of the margins of the vertebral bodies [2, 4, 7-9, 13, 15, 17]. Twenty cases of such atypical degenerative vertebral lesions have been studied over a two year period and their radiological characteristics have been compared with vertebral lesions of infective origin and in the rheumatoid disorders.

Erosive spondylopathy

Seven patients with chronic dorsolumbar pain, stiffness and some restriction of spinal movements are described. Multiple lesions of the vertebral bodies were present. The lesions occurred at various levels and all had similar radiological characteristics, often returning to normal after several years. Vertebral changes of this type may be seen in patients with ankylosing spondylitis but for a variety of cogent reasons presented in this report our patients did not readily fall into this diagnostic group. The aetiology of these vertebral lesions is unknown but available evidence indicates that they should not be attributed to an infectious or neoplastic process.

Spondylodiscitis and ankylosing spondylitis: HLA typing and nosological implications

Nine cases from among 64 patients with ankylosing spondylitis (AS) are described. In addition to bilateral sacroiliitis these cases had a peculiar type of spondylodiscitis characterised by quite diffuse and marked sclerosis of multiple vertebral bodies, with only minimal erosions of the adjacent vertebral plates while classical syndesmophytosis was absent. The antigen HLA-B27 was found only in 1 of these 9 cases. This type of spondylodiscitis could discriminate among all the patients with AS a subgroup with a peculiar clinical pattern and a probably distinctive pathological mechanism.