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[Surgical treatment of spondylodiscitis in ankylosing spondylitis. Two cases report]
M Escosa Bagé1, E García Navarrete, J M Pascual Garvi
1Servicio de Neurocirugía. Planta 7; Hospital Universitario de la Princesa, Madrid, 28006, España. escosamar@terra.es
Introduction:
Spondylodiscitis in ankylosing spondylitis has a prevalence of 5%. Mechanical and inflammatory factors are involved in its pathogenesis. Neurosurgical operation is required when neurological complications or vertebral instability occur. Surgery is complicated by the increased fragility of the vertebral column, advanced stage of the disease in many patients, and serious pulmonary complications.
Clinical Cases:
We report two patients who had had ankylosing spondylitis for over 20 years. Both presented complaining of symptoms for several months with lumbar pain and signs of spinal cord lesions. There were signs of discitis and destruction of the adjacent vertebral bodies at T11 T12 and T12 L1 on imaging investigations of the first and second patient respectively. In both cases an anterior approach was used for discectomay and resection of the adjacent vertebral plates. Then an autologous rib graft was done, and anterolateral fixation with plate and screws to the adjacent vertebral bodies. The patients condition improved. Their pain and previous clinical neurological disorder had disappeared by 5 and 1 year later.
Discussion And Conclusions:
The prevalence of patients operated on for spondylodiscitis in the context of ankylosing spondylitis is not known. Dorsolumbar pain with inflammatory characteristics of recent onset in patients with chronic ankylosing spondylitis should lead to suspicion of spondylodiscitis. Although it may be related to previous trauma, discitis is the fundamental mechanism. MR is the most sensitive imaging technique. There may be marked osteoporosis and stenosis of the vertebral canal together with marked ossification of all the paraspinal ligaments. This hinders the approach to the vertebral bodies and their subsequent fixation. Decompression of the vertebral canal using an anterior approach (thoracotomy or thoraco phreno laparotomy) and anterior spinal fixation is the treatment of choice in cases with neurological involvement or involvement of the anterior and medial columns of Denis.