Radiographic features

Squaring of the anterior border of the lower thoracic and lumbar vertebrae is one of the earliest radiographic features of ankylosing spondylitis, best demonstrated on the lateral radiograph of the spine (Fig. 4.28). As the condition progresses, delicate desmophytes are formed bridging the vertebral bodies, these have a vertical rather than horizontal orientation distinguishing them from osteophytes of degenerative disease. Paravertebral ossifications are also common. Apophyseal joint and vertebral body fusion usually later on in the course of the disease is a pathognomonic radiographic finding known as the 'bamboo spine' (Fig. 4.29). Sacro-iliac joint involvement is usually present with sacro-iliitis being the hallmark of AS. Most patients will have abnormal 191

sacro-iliac joints radiographically on initial presentation. This is usually a bilateral and symmetric process initially affecting the iliac side of the joint, and progressing along the inferior synovial portion of the joint. The initial signs are osteoporosis, loss of cortical definition, superficial erosions and focal sclerosis with eventual obliteration of the sacro-iliac joint space with resultant bony ankylosis [5] (Fig. 4.30).

Complications of ankylosing spondylitis in the cervical spine include atlanto-axial subluxation (Fig. 4.31), which may become fixed with multilevel spinal fusion. Ankylosing spondylitis patients are more prone to fractures following relatively minor trauma. The fixed spinal segments can result in increased mechanical forces with the formation of a pseudoarthrosis with resultant deformity and bone loss. Ankylosing spondylitis patients are also more predisposed to infection of the spine with tuberculosis.

The implications for anesthesia include difficulties in endotracheal intubation as well as the problems in ventilation associated with a poorly compliant thoracic cage and possibly pulmonary fibrosis affecting the upper lobes. Given the effects on the spine described, this might also affect the application of an epidural anaesthetic.

Long-term use of non-steroidal anti-inflammatory drugs may be complicated by upper gastrointestinal bleeding.

m What is the

m How is it distinguished from ankylosing spondylitis?

Fig. 4.32 Quiz case.

m What is the diagnosis

m How is it distinguished from ankylosing spondylitis?

Fig. 4.32 Quiz case.

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