summary Ankylosing Spondylitis is a chronic seronegative autoimmune spondyloarthropathy characterized by bridging spinal osteophyte formation, enthesitis, sacroiliitis, and uveitis. Diagnosis is made with the presence of HLA-B27 antigens, the presence of bilateral sacroiliitis, and ocular examination to assess for uveitis. Treatment is observation, NSAIDs, and physical therapy for mild symptoms. Surgical management is indicated for unstable spinal fractures, progressive deformity, and the presence of neurological deficits. Epidemiology Incidence affects ~0.2% of Caucasian population Demographics 4:1 male:female usually presents in 3rd decade of life juvenile form <16-years-old includes enthesitis fewer than 10% of HLA-B27 positive patients have symptoms of AS Etiology Pathoanatomy exact mechanism is unknown, but most likely due to an autoimmune reaction to an environmental pathogen in a genetically susceptible individual. theories of relation to HLA-B27 include HLA-B27 aggregates with peptides in the joint and leads to a degenerative cascade cytotoxic T-cell autoimmune reaction against HLA-B27 enthesitis entheses inflammation leads to bony erosion, surrounding soft-tissue ossification, and eventually joint ankylosis preferentially targets sacroiliac joints, spinal apophyseal joints, symphysis pubis this differentiates from RA, which is a synovial process disc space involvement inflammation of the annulus lead to bridging osteophyte formation (syndesmophytes) Genetics there is a genetic predisposition, but mode of inheritance is unknown HLA-B27 is located on sixth chromosome, B locus Diagnostic criteria bilateral sacroiliitis +/- uveitis HLA-B27 positive (90% positive) Systemic manifestations acute anterior uveitis & iritis heart disease (cardiac conduction abnormalities) pulmonary fibrosis renal amyloidosis ascending aortic conditions (aortitis, stenosis, regurgitation) Klebsilella pneumoniae synovitis HLA-B27 individuals are more susceptible to Klebsilella pneumoniae synovitis Orthopaedic manifestations bilateral sacroiliitis progressive spinal kyphotic deformity cervical spine fractures large-joint arthritis (hip and shoulder) Anatomy Enthesis defined as the insertion of tendon, ligaments, or muscle into bone Presentation Symptoms lumbosacral pain and stiffness present in most patients worse in morning insidious onset in 3rd decade of life neck and upper thoracic pain occurs later in life acute neck pain should raise suspicion for fracture sciatic likely originates from sciatic nerve involvement in the pelvic (piriformis spasm) loss of horizontal gaze shortness of breath caused by costovertebral joint involvement, leading to reduced chest expansion Physical exam limitation of chest wall expansion < 2cm of expansion is more specific than HLA-B27 for making diagnosis decreased spine motion Schober test used to evaluate lumbar stiffness kyphotic spine deformity chin-on-chest (flexion) deformity of the spine caused by multiple microfractures that occur over time chin-brow-to-vertical angle (CBVA) measured from standing exam of standing lateral radiograph useful for preoperative planning correction of this angle correlates with improved surgical outcomes hip flexion contracture examining patient in supine and sitting position helps differentiate sagittal plane imbalance due to hip flexion contractures or kyphotic spinal deformity sacroiliac provocative tests Faber test flexion abduction external rotation of the ipsilateral hip causes pain Imaging Radiographs spine recommended views standing full-length AP and lateral of axial spine findings negative in 50% of cases with spine fractures squaring of vertebrae with vertical or marginal syndesmophytes late vertebral scalloping (bamboo spine) measurements chin-brow to vertical angle used to measure chin-on-chest deformity useful for preoperative planning for osteotomy pelvis & lower extremity recommended views Ferguson pelvic tilt view allows for improved visualization of anterior SI joint xray beam directed 10 to 15 degrees cephalad findings bilateral symmetric sacroiliac erosion earliest radiographic sign is erosion of iliac side of sacroiliac joint joint space narrowing ankylosis CT will show bony changes but not active inflammation CT is most sensitive test to diagnose cervical fractures in patients with AS entire spinal axis should be imaged in patients presenting with trivial trauma MRI will detect inflammation, making it the best modality for early detection of AS in young patients obtain with cervical fractures to look for epidural hemorrhage Bone scan will show inflammation in the sacroiliac joints, but lacks specificity Studies Labs little diagnostic value often see nonspecific elevations in ESR and CRP RF negative (seronegative) Diagnostic Injections SI joint injection local anesthetic injected into SI joint under fluoroscopic guidance often most sensitive diagnostic test Differentials DISH vs. Ankylosing Spondylitis DISH Ankylosing spondylitis Syndesmophytes Nonmarginal Marginal Radiographs "Flowing candle wax" "Bamboo spine", squaring of vertebral bodies, "shiny corners" at the attachment of annulus fibrosus (Romanus lesions) Disc space Preservation of disc space AS in cervical spine will show ossification of disc space Osteopenia No osteopenia (rather, there may be increased radiodensity) Osteopenia present HLA No evidence of association with HLA-B27 Associated with HLA-B8 (common in patients with DISH and diabetes) Strong association with HLA-B27 Age group Older patients (middle-aged) Younger patients SI joint involvement No involvement (SI joint abnormality generally excludes the diagnosis of DISH) Bilateral sacroiliitis Diabetes Yes No Treatment General Nonoperative NSAIDS, COX-2 inhibitors, and therapy indications first line of treatment for pain and stiffness oral steroids not recommended techniques physical therapy should focus on maintaining flexibility TNF-alpha-blocking agents indications second line of medical management techniques includes infliximab, etanercept, adalimumab outcomes clinical studies show significant improvement in severity of symptoms Operative see below Spine Trauma Introduction epidemiology most occur in midcervical and cervicothoracic junction (some occur at thoracolumbar junction) pathanatomy often extension-type fracture that involved all three columns prognosis high mortality rate secondary to epidural hemorrhage 75% neurologic involvement Presentation symptoms usually present with pain after low energy fall physical exam neurologic deficits often present late and therefore patients should be admitted and observed Imaging radiographs may be occult CT if suspicious consider CT scan (best modality to make diagnosis) MRI high mortality rate secondary to epidural hemorrhage Treatment nonoperative immobilize in existing kyphotic position, admit for observation and advanced imaging indications stable spine fractures with no neurologic deficits technique low-weight traction may facilitate reduction operative spinal decompression with instrumented fusion indications progressive neurologic deficit epidural hematoma with neurologic compromise unstable fracture patterns technique decompression decision to go anterior or posterior depends on fracture level, presence and location of hematoma, and osteoporosis instrumentation need to obtain long fusion construct multiple points of fixation above and below the fracture are necessary because of osteoporosis long lever arms of the ankylosed spine do not make an effort to correct deformity outcomes & complications high rate of complications including progressive deformity nonunion hardware failure infection Spinal Deformity Introduction usually a kyphotic deformity of upper spine be sure to eliminate hip contractures as reason for deformity Treatment lumbar osteotomy indications thoracolumbar kyphotic deformity goals goal is to restore sagittal balance and horizontal gaze techniques closing wedge (pedicle subtracting) osteotomy transpedicular decancelization procedure with removal of posterior elements location of osteotomy determined by type of spine flexion deformity hinge located on anterior vertebral body considered procedure of choice due to greater deformity correction (30 t0 40 degrees per level) better fusion and stability due to direct bony apposition vertebral body resection entire vertebral body is removed and replaced with a cage single-level opening wedge osteotomy hinges on posterior edge of vertebral body requires rupture of ALL multi-segment opening osteotomy advantage of less bone loss and preservation of ALL by distributing correction over multiple levels outcomes & complications lumbar approach avoids complications of thoracic cage, spinal cord injury, and has potential for greater correction due to long lever arm C7-T1 cervicalthoracic osteotomy indications cervicothoracic kyphotic (chin-on-chest) deformity goals slight under-correction with final brow-to-chin angle of 10 degrees technique osteotomy advantage of C7-T1 osteotomy include vertebral artery is external to transverse foremen larger canal diameter requires wide decompression with removal of C7 lateral mass and portions of C7-T1 pedicles to prevent iatrogenic SCI instrumentation usually a combination of lateral mass screws, pedicle screws, and sublaminar hooks postoperative postoperative halo immobilization often required in patients with poor bone quality outcomes & complications increased risk of venous air embolus (VAE) in the sitting operative position Large-Joint Arthritis Introduction asymmetric involvement of large joints shoulder and hip most commonly involved Treatment total hip replacement indications in patients with severe arthritis of this hips secondary to AS technique patients have more vertical and anteverted acetabulum (may lead to anterior dislocations after total hip arthroplasty) bilateral total hip arthroplasty indications kyphotic deformity due to hip flexion contracture deformity outcomes & complications at risk for dislocation
QUESTIONS 1 of 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ19.233) A 78-year-old male who presents to the ED following a MVC in which he rear-ended another vehicle traveling 20 MPH. He reports a long history of chronic low back pain and neck pain for which he reports he is taking Etanercept, but denies any history of gait instability or dexterity problems with his hands prior to the accident. He denies a history of diabetes or taking blood thinner or other medications. Upon presentation he has no motor or sensory deficits, but is complaining of posterior neck pain. A radiograph taken on admission is shown in Figure A. A CT scan is subsequently obtained and negative for fracture. On tertiary exam 3 hours later, the patient is found to have severe weakness in both his upper and lower extremities. An MRI of the cervical spine is most like to show which of the following? QID: 214135 FIGURES: A Type & Select Correct Answer 1 Severe degenerative stenosis 13% (145/1107) 2 Epidural hemorrhage 53% (591/1107) 3 Vertebral artery injury 8% (86/1107) 4 Myelomalacia 17% (189/1107) 5 Spinal cord infarct 8% (90/1107) L 4 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ19.137) A 56-year-old male presents with neck pain after a fall from ground level height when he tripped over a box in his house. On physical exam, he is neurologically intact but has pain reproducible with cervical spine range of motion. Current imaging is shown in figures A-D. Which statement is true regarding this patient's condition? QID: 214039 FIGURES: A B C D Type & Select Correct Answer 1 Occult injuries are rare following trivial trauma 2% (12/702) 2 Spinal fractures most commonly involve the lumbar spine 4% (26/702) 3 Delay in diagnosis of spinal fractures is uncommon 1% (7/702) 4 Computed tomography of the entire spinal axis should be performed 93% (650/702) 5 There is a low rate of adverse events and mortality following spinal fractures 1% (4/702) N/A Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18SP.69) A 36-year-old presents to the emergency department with upper back and neck pain after being rear-ended by another vehicle. The patient’s past medical history is significant for ankylosing spondylitis, for which he takes etanercept. On physical exam, he has tenderness to the cervical spine posteriorly, walks with a normal gait and is neurovascularly intact to the bilateral upper and lower extremities. AP and lateral radiographs of the cervical and thoracic spines show squaring of the vertebral bodies but are otherwise unremarkable. What is the best next step? QID: 211861 Type & Select Correct Answer 1 Flexion extension radiographs of the cervical spine 11% (226/2053) 2 CT cervical, thoracic and lumbar spines 84% (1725/2053) 3 Soft cervical collar 1% (25/2053) 4 Outpatient follow up with repeat radiographs in 7-10 days 1% (24/2053) 5 NSAIDs and physical therapy evaluation 2% (35/2053) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ15.27) A 65 year-old man known to have ankylosing spondylitis slipped on ice and sustained a fall from standing height. Upon arrival to the hospital, the patient complains of neck pain. On physical examination, no neurological deficits are identified. Several hours later the patient develops progressive lower extremity weakness. Figure A is an MRI of the patient’s cervical spine. Management of this patient’s condition should consist of the following: QID: 5712 FIGURES: A Type & Select Correct Answer 1 Immobilization with hard-collar and observation 3% (74/2420) 2 Dexamethasone followed by repeat MRI 3% (77/2420) 3 Halo-vest immobilization 1% (28/2420) 4 Anterior instrumented fusion 7% (161/2420) 5 Posterior decompression and instrumented fusion 85% (2053/2420) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.236) A 39-year-old male falls off his bicycle and complains of neck pain and tingling in his fingers. Trauma series radiographs are seen in Figures A and B. Which of the following is likely to be true? QID: 4871 FIGURES: A B C Type & Select Correct Answer 1 Examination would likely reveal a short neck, low posterior hairline and limited neck motion. 2% (124/5468) 2 Serum human leukocyte antigen B27 is likely to be positive. 75% (4108/5468) 3 He is likely to be of Japanese descent. 1% (81/5468) 4 The disease is defined by flowing ossification of the anterior longitudinal ligament at 4 consecutive levels. 18% (1004/5468) 5 Rheumatoid factor is likely to be positive. 2% (106/5468) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ13.162) A 48-year-old man is brought in by emergency services after falling down a flight of stairs. He complains of weakness in both hands. Examination reveals weak grip bilaterally. Injury CT scans are shown in Figure A. What is the most appropriate treatment option? QID: 4797 FIGURES: A Type & Select Correct Answer 1 Hard cervical orthosis 12% (641/5180) 2 Immobilization in cervico-thoraco-lumbo-sacral orthosis 3% (174/5180) 3 Anterior decompression and fusion of C4-C7 18% (954/5180) 4 Posterior decompression and fusion of C5-C6 7% (386/5180) 5 Posterior decompression and fusion of C3-T2 58% (2992/5180) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12SP.61) A 73-year-old male presents to the emergency department after a fall from a ladder complaining of severe acute on chronic neck pain. Physical exam shows he has diffuse tenderness in the posterior cervical spine, normal strength in all motor groups, and 2+ bilateral patellar reflexes. A clinical photograph of him prior to the fall is shown in Figure A. The patient had bilateral hip replacements 2 years ago in the same hospital and his preoperative radiographs are shown in Figure B. He has a long history of chronic low back pain, and radiographs of the lumbar spine from 1 year ago are shown in Figure C. What is the most likely diagnosis, and what should be the next step in management? QID: 3759 FIGURES: A B C Type & Select Correct Answer 1 Ankylosing spondylitis, immobilize in hard collar in existing kyphotic position, admit for addition imaging and observation 86% (2005/2325) 2 Ankylosing spondylitis, immobilize in hard collar in existing kyphotic position, discharge with followup with surgeon within 5 days 4% (98/2325) 3 Ankylosing spondylitis, immobilize in hard collar in neutral kyphosis, discharge with followup with surgeon within 5 days 1% (30/2325) 4 DISH, immobilize in hard collar in existing kyphotic position, admit for addition imaging and observation 7% (167/2325) 5 DISH, immobilize in hard collar in neutral kyphosis, discharge with followup with surgeon within 5 days 0% (5/2325) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (SBQ12SP.90) A 55-year-old otherwise healthy man presents to the emergency department with severe back pain after fall down two stairs outside his home. Genetic testing has shown he is positive for HLA-B27. He has no numbness or tingling, full sensation and motor function, and intact bladder/bowel function. His injury is shown in Figures A and B. What is the best course of management? QID: 3788 FIGURES: A B Type & Select Correct Answer 1 Bedrest for 3 days then gradual mobilization with thoracolumbrosacral orthosis (TLSO) 3% (105/3517) 2 Immediate mobilization with TLSO 5% (183/3517) 3 TLSO placement, standing upright xrays, then mobilization based on alignment on xrays 13% (445/3517) 4 Posterior fusion with short segment pedicle screw fixation 4% (127/3517) 5 Posterior fusion with long segment pedicle screw fixation 75% (2637/3517) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.257) Which of the following is the greatest risk factor for a paradoxical embolus from a venous air embolus (VAE) when performing complex cervical spine deformity operations in the beach-chair position? QID: 3070 Type & Select Correct Answer 1 Nitrous oxide anesthesia 9% (263/2841) 2 Persistent foramen ovale (PFO) 72% (2056/2841) 3 Severe hypotension 11% (305/2841) 4 Obesity 3% (77/2841) 5 Emphysema 4% (126/2841) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.12) All of the following are characteristics of juvenile ankylosing spondylitis EXCEPT? QID: 2825 Type & Select Correct Answer 1 Spinal stiffness 1% (45/3108) 2 Sacroiliitis 1% (40/3108) 3 Urethritis 58% (1799/3108) 4 Enthesitis 7% (224/3108) 5 Kyphosis 32% (984/3108) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ08.77) A patient with ankylosing spondylitis and a hip flexion contracture undergoes uneventful right total hip replacement using a Kocher (posterior) approach. This patient is at increased risk for which of the following complications post-operatively? QID: 463 Type & Select Correct Answer 1 Posterior hip dislocation 66% (1568/2372) 2 Anterior hip dislocation 27% (641/2372) 3 Deep infection 2% (48/2372) 4 Osteolysis 1% (24/2372) 5 Periprosthetic fracture 3% (80/2372) L 5 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ07.14) A 75-year-old man presents to your office complaining of inability to lift his head and look ahead. He states that initially he was unable to turn his head sideways, and that this progressed to his current state. A clinical photo is provided in Fig A. Radiographs of his cervical spine and lumbar spine are provided in Figure B and C. What is the most appropriate management? QID: 675 FIGURES: A B C Type & Select Correct Answer 1 Anterior osteotomy, anterior decompression and fusion 5% (199/3962) 2 Halo traction for 6 weeks only 1% (23/3962) 3 Posterior fusion in situ 1% (54/3962) 4 Anterior osteotomy, posterior instrumentation 14% (546/3962) 5 Posterior extension osteotomy, then posterior fusion and instrumentation 79% (3116/3962) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (SBQ06SN.5) A 61-year-old man with ankylosing spondylitis falls and hits his forehead while getting out of the shower. On arrival to the emergency room he complained of neck pain, but his neurologic exam is normal. A CT scan shows a nondisplaced extension-type fracture of the lower cervical spine and no evidence of epidural hematoma. He is treated with a cervical orthosis and admitted for pain management. Seven hours later he reports increasing paresthesias in his upper and lower extremities. Examination now shows weakness in his upper and lower extremities, including 3+/5 ankle dorsal and ankle plantar flexion. An MRI scan is performed emergently and is shown in Figure A . What is the most appropriate next step in management. QID: 1690 FIGURES: A Type & Select Correct Answer 1 Methylprednisolone at 30 mg/kg over 1st hour followed by 5.4 mg/kg/hr drip for 23 hours 8% (276/3659) 2 Repeat MRI in twelve hours with serial neurologic exam 1% (46/3659) 3 Anterior cervical fusion 13% (484/3659) 4 Posterior cervical laminectomy 3% (101/3659) 5 Posterior cervical laminectomy and fusion with instrumentation 75% (2731/3659) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ06.154) A 32-year-old man presents with low back and hip pain that has been gradually worsening over the past year. He reports the symptoms are worse in the morning. Radiographs are shown in Figure A. Laboratory studies show a positive HLA-B27. What additional finding will help confirm the diagnosis? QID: 340 FIGURES: A Type & Select Correct Answer 1 Erythema marginatum 1% (42/3492) 2 Positive HLA-DR3 5% (192/3492) 3 Uveitis 80% (2789/3492) 4 Positive Rheumatoid Factor 7% (229/3492) 5 Elevated urine phosphoethanolamine 6% (225/3492) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ04.29) A 69-year-old man falls on the ice. On arrival to the emergency room he is found to have a 2 cm laceration on the back of his head. He complains of neck pain, but is oriented to place and time and his neurologic exam is normal. Cervical and lumbar radiographs are shown in Figures A-C. What is the next most appropriate step in treatment? QID: 90 FIGURES: A B C Type & Select Correct Answer 1 Obtain flexion-extension radiographs 6% (186/3351) 2 Obtain a CT scan of the lumbar spine 1% (45/3351) 3 Obtain a CT scan of the cervical spine 89% (2980/3351) 4 Obtain a technetium bone scan 2% (58/3351) 5 Treat with soft collar and discharge patient to home 2% (64/3351) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ04.50) A 45-year-old man with ankylosing spondylitis presents with fixed sagittal imbalance and difficulty with horizontal gaze. His kyphotic deformity is localized to the thoracolumbar spine. Which of the following procedures allows the most correction in the sagittal plane at a single level without having to resect the intevertebral disc? QID: 111 Type & Select Correct Answer 1 Smith-Petersen osteotomies 8% (198/2503) 2 Pedicle subtraction osteotomy (PSO) 71% (1785/2503) 3 Vertebral column resection (VCR) 7% (185/2503) 4 Single-level opening wedge osteotomy 6% (161/2503) 5 Multi-level opening wedge osteotomies 6% (158/2503) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (0) Podcasts (2) Spine⎪Ankylosing Spondylitis Spine - Ankylosing Spondylitis Listen Now 24:37 min 10/16/2019 1025 plays 4.9 (8) Question Session⎪Ankylosing Spondylitis, Hip Osteonecrosis & Osteogenesis Imperfecta Orthobullets Team Spine - Ankylosing Spondylitis Listen Now 31:23 min 11/8/2019 110 plays 3.0 (1)