Correlation between clinical outcome and spinopelvic parameters in ankylosing spondylitis

Purpose

Little data are available on the relationship between sagittal spinopelvic parameters and health related quality of life (HRQOL) in ankylosing spondylitis (AS) patients. The aim of this study was to identify the relationships between spinopelvic parameters and HRQOL in AS.

Methods

The study and control groups comprised 107 AS patients and 40 controls. All underwent anteroposterior and lateral radiographs of the whole spine including hip joints and completed clinical questionnaires. The radiographic parameters examined were sacral slope, pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis, and sagittal vertical axis. A Visual Analogue Scale (VAS: 0–10) score for back pain, the Oswestry disability index (ODI) questionnaire, Scoliosis Research Society (SRS-22) questionnaire and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were administered to evaluate QOL. Statistical analysis was performed to identify significant differences between the study and control groups. In addition, correlations between radiological parameters and clinical questionnaires were sought.

Results

The AS patients and controls were found to be significantly different in terms of sagittal vertical axis, sacral slope, pelvic tilt, pelvic incidence, and lumbar lordosis. However, no significant intergroup difference was observed for thoracic kyphosis (P > 0.05). Of the 107 AS patients, there were 18 women and 89 men. Correlation analysis revealed significant relationships between radiographic parameters and clinical outcomes. Multiple regression analysis was performed to identify predictors of clinical outcome, and the results obtained revealed that sagittal vertical axis and sacral slope significantly predicted VAS, ODI and BASDAI scores and that sagittal vertical axis and lumbar lordosis predicted SRS-22 scores.

Conclusions

AS patients and normal controls were found to be significantly different in terms of sagittal spinopelvic parameters. Correlation analysis revealed significant relationships between radiographic parameters and clinical outcomes. In particular, sagittal vertical axis, sacral slope and lumbar lordosis were found to be significant parameters in prediction of clinical outcomes in AS patient.     

Ankylosing spondylitis: recent breakthroughs in diagnosis and treatment

Ankylosing spondylitis (AS) is generally easy to diagnose when the characteristic findings of the "bamboo" spine and fused sacroiliac joints are present on radiographs. Unfortunately, these changes are usually seen late in the disease after tremendous suffering has been incurred by the patient. Diagnostic delay averages seven to ten years. Historically, once the diagnosis was made, the treatment options were often inadequate or poorly tolerated in many individuals. This condition most often starts in early adulthood when people are typically in the earlier stages of their careers, resulting in diminished workforce participation and decreased quality of life. If an individual has a family physician, this might be the first encounter with a healthcare provider. Quite often, the initial practitioner is sought at a public walk-in clinic or chiropractic office. In recent years, there have been two major developments in the management of AS that make earlier diagnosis possible and offer the hope of alleviating pain and preventing structural changes that result in loss of function. These developments include the use of magnetic resonance imaging (MRI) to visualize the inflammatory changes in the sacroiliac joint and the axial spine, and the demonstration that tumor necrosis factor (TNF) blocking agents are highly efficacious in reducing spinal inflammation and possibly in slowing radiographic progression. This review outlines diagnostic strategies that can help identify AS in its earlier stages. Special attention is focused on treatment advances, including the use of anti-TNF agents, and how these medications have been incorporated into clinical recommendations for daily use.     

Ankylosing spondylitis: experience in surgical management of 21 patients

Between 1976 and 1984, twenty-one patients with ankylosing spondylitis were treated surgically. Eight patients with rigid thoracic kyphosis underwent a two-stage combined procedure. The average correction was 36 degrees. Eight patients underwent a single-stage lumbar osteotomy with Harrington compression instrumentation. The average correction was 31 degrees. Five patients presented with stress fractures and back pain. All underwent combined anterior and posterior surgery. The average correction was 9 degrees. Two patients underwent anterior decompression for progressive paraplegia. Both showed improvement in neurologic function. At follow-up, all but one patient had improvement in pain and spinal alignment. There have been no deaths or persistent neurologic problems from these procedures.     

Improvement of clinical outcome by early nephrology referral in type II diabetics on hemodialysis

OBJECTIVES: To evaluate the influence of early nephrology referral on clinical outcome in type II diabetes mellitus patients on maintenance hemodialysis dialysis. PATIENTS AND METHODS: This study retrospectively analyzed the type II diabetic patients entering our PD program from February 1988 to June 2001. Patients who were presented to a nephrologist more than 6 months before starting dialysis were defined as early referral (ER). Patients were considered late referral (LR) if they were transferred to the nephrology department within 6 months before initial dialysis. RESULTS: Hundred and fifteen type II diabetic patients receiving HD for at least 3 months were enrolled in this study. Sixteen of the 53 patients (46.1%) were in the ER group and 62 of the 115 (53.9%) were in the LR group. In univariate analysis by Cox proportional hazards mode, the early referral (Exp (Coef) = 0.423, p < 0.01), good glycemic control (Exp (Coef) = 0.16, p < 0.05), and age at dialysis (Exp (Coef) = 1.026, p < 0.05 (had significantly influenced the patient survival. The residual renal function in the ER group, estimated by creatinine clearance (Ccr), significantly exceeded that of the LR group (ER vs. LR: 4.46 +/- 1.56 vs. 2.51 +/- 1.70 mL/min, p < 0.001). The patients with early referral had significantly better survival (p < 0.05). Five-year survival improved significantly in the early referral group compared to the late referral group (ER: 72.4%; LR: 35.2%, p < 0.05). CONCLUSIONS: We demonstrate that the time of referral before starting dialysis is a predictor of survival for type II diabetics on HD. Patients with early referral are associated with longer survival. The beneficial effect might be associated with the timely initiation of the chronic HD program. These results suggest that early referral before dialysis is important in determining the long-term prognosis in type II diabetics on HD.     

Ankylosing spondylitis, HLA-B27 positivity and the need for biologic therapies

ObjectivesHLA-B27 positivity strongly influences Ankylosing spondylitis (AS) disease susceptibility and phenotype. The aim of this study was to analyse an AS cohort with respect to quality of life (ASQoL), extra-articular disease, markers of disease activity (BASDAI), functional capacity (BASFI), biologic requirement, and the influence of HLA-B27 on these parameters.MethodsData recorded in 82 patients included demographics (age, sex), extra-articular disease (GI, ocular, dermatological, GU), cardiac and pulmonary diagnoses. BASDAI, BASFI, ASQoL, joint counts, disease duration and past/present treatment (NSAID, DMARD, steroid and biologic use) were also recorded.Results90.2% of the cohort was B27 positive with significantly longer disease duration (17.6 v 6.9 years, p < 0.05). BASFI (42.2 v 5.9), BASDAI (3.22 v 1.3), ASQoL (10 v 4), physician assessment of biologic need (24 v 5), steroid (15.7% v 12.5%) and NSAID use (98.6% v 75%) were higher in the B27 positive group, as were ocular (38.9% v 12.5%), pulmonary (4.2% v 0%) and cardiac (4.3% v 0%) features. Negative patients displayed more GI (37.5% v 19.4%), dermatological (25% v 19.7%) and GU (25% v 4.2%) features. Patients satisfying ASAS (AS assessment study group) criteria and receiving biologic therapy were 18.9% (B27 positive group) and 0% (B27 negative group).ConclusionsAS patients have significantly longer disease duration if B27 positive, higher markers of disease activity, poorer functional status, poorer quality of life, and more extra-articular manifestations. These findings were reflected in the percentage of patients needing biologic therapies.     

Ankylosing spondylitis. Therapy and complications of 34 spine fractures]

BACKGROUND: Spine fractures in ankylosing spondylitis (AS) are extremely unstable and associated with a high complication rate. The aim of this retrospective study was to evaluate the therapy and complications of these fractures in AS for a better understanding and management. PATIENTS AND METHODS: A total of 32 patients with 34 traumatic spine fractures were treated from 1981 to 2002. Cause of trauma, fracture site, and neurological examination were assessed. Analyses of the management of the treatment and complications were performed. RESULTS: Banal traumas resulted mostly in spinal fractures at the C 5/6 and C 6/7 level. Two patients were treated conservatively, while the others were stabilized operatively. Before therapy was undertaken, six patients suffered from a cervical radiculopathy, ten patients had an incomplete and two a complete paraplegia. After therapy, neurological status improved in eight patients, but one had a deterioration of neurological symptoms. CONCLUSIONS: Dorsal or combined dorsoventral stabilization of these fractures is necessary for better mobilization of these patients and to avoid further complications.     

Ankylosing spondylitis: a difficult diagnosis in patients on long-term renal replacement therapy

We report the case of a 48-year-old male, whose musculoskeletal manifestations, previously related to long-term renal replacement therapy (RRT), were diagnosed as ankylosing spondylitis when symptoms changed their pattern on daily hemodialysis (DHD). The patient started RRT in 1981; in 1985 he received a cadaver graft, which failed in 1987. Secondary hyperparathyroidism, amyloid geoids, bilateral carpal tunnel syndrome and high aluminium levels were present. Musculoskeletal pain, reported since 1986, involved feet, heels, hips, shoulders, hands, spine. Symptoms impairing daily life did not improve after parathyroidectomy. He developed chronic hypotension and recurrent atrial fibrillation. In 1994 and 1998, because of thoracic pain, coronarography was performed (normal on both occasions). In June 2000, DHD was started. Equivalent renal clearance increased from 9-12 to 15-17 mL/min. Well-being remarkably improved. In September 2000, musculoskeletal pain worsened and bilateral Achilles tendinitis occurred. The worsening of musculoskeletal symptoms despite the improvements in well-being and other dialysis related symptoms prompted a re-evaluation of the case. The diagnosis of ankylosing spondylitis was based on: history of plantar fasciitis, bilateral Achilles tendinitis, inflammatory spinal pain with limitation of lumbar spine mobility (positive Schober test), radiological evidence of grade 2 bilateral sacroiliitis, presence of HLA-B27. This diagnosis cast light on the episodes of chest pain, explained by enthesopathy at the costosternal and manubriosternal joints and atrial fibrillation, due to HLA-B27 associated impairment in heart conduction. This case exemplifies the difficulty of differential diagnosis of multisystem illness in patients with long RRT follow-up.     

Ankylosing spondylitis presenting to a chiropractic office: a report of two cases

Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that predilects young men. It is difficult to diagnose in its early stages and challenging to manage, once detected. Two cases of patients with previously undiagnosed AS are presented. The role of the clinical history and examination, imaging, and paraclinical studies are discussed. Suggestions for management and outcome measures for patients with ankylosing spondylitis are presented.     

时差成像系统对IVF-ET结局的改善及其优选模型初探

目的比较时差成像(time-lapse imaging,TLI)系统与常规胚胎培养的胚胎结局和临床妊娠结局,探讨基于TLI技术的胚胎优选模型的临床应用价值。方法回顾性分析2019年6~11月在我院行体外受精/卵泡浆内单精子注射-胚胎移植(IVF/ICSI-ET)助孕的610个周期患者资料。按胚胎培养方式的不同分为常规培养组(n=543)和TLI组(n=67),常规培养组通过胚胎形态学评分优选胚胎,TLI组结合胚胎形态学和动力学方法优选胚胎。比较两组患者女方年龄、不孕年限、BMI、激素水平、胚胎结局、种植率和临床妊娠率等临床资料;再将两组根据女方年龄、获卵数和可用胚胎数进行分组,比较各亚组间种植率和临床妊娠率的差异。结果两组患者间的一般资料和获卵数、正常受精数、可用胚胎数、囊胚形成率均无显著性差异(P>0.05);TLI组的卵母细胞利用率显著高于常规培养组(37.15%vs.35.30%)(P<0.05)。进行新鲜周期移植的两组患者在移植日的子宫内膜厚度和移植个数上均无显著性差异(P>0.05),TLI组的种植率和临床妊娠率较常规培养组略有增高,但无显著性差异(P>0.05)。亚组分析显示,不同年龄段,TLI组的种植率和临床妊娠率较常规培养组均略有提升,但无显著性差异(P>0.05);获卵数≥10个或D3可用胚胎数/移植个数>3时,TLI组的临床妊娠率和种植率较常规培养组均有增高趋势,但无显著性差异(P>0.05)。结论TLI系统可显著提高卵母细胞利用率,TLI优选模型是一种简单的胚胎优选方案;获卵数>10个或D3可用胚胎数/移植胚胎数>3时,TLI胚胎优选方案的种植率和临床妊娠率较常规优选方案可能有所改善。     

关节镜手术治疗强直性脊柱炎髋关节早期病变的中期临床效果分析

目的 :探讨对强直性脊柱炎髋关节早期病变进行麻醉下推拿活动联合关节镜清理手术治疗的效果。方法:2011年6月至2013年6月采用全身麻醉下推拿活动及关节镜下探查清理、滑膜切除、软骨修整手术治疗22例强直性脊柱炎髋关节早期病变患者,其中男6例,女16例;年龄17~35岁,平均24.7岁;病程10~41个月,平均22.1个月。经6个月正规保守治疗髋部受限疼痛等症状无缓解。通过患侧髋关节活动度、VAS疼痛评分、m HHS评分、NAHS评分对比进行术前和术后随访评估。结果:全部患者获随访,时间26~44个月,平均30.2个月。患髋屈伸、内收外展、伸直位及屈曲90°位的内外旋角度范围分别由术前的(78.2±10.2)°、(36.3±6.4)°、(31.1±9.2)°及(37.3±10.5)°升至术后的(113.5±8.4)°、(55.7±8.4)°、(58.7±2.1)°及(60.1±9.8)°;VAS评分由术前的8.5±9.4降至术后的5.5±7.1;改良的Harris和NAHS评分分别由术前的60.8±6.9及56.9±6.25升至术后的88.1±10.4及84.6±5.4。结论:全身麻醉下髋关节推拿活动及关节镜手术能够有效恢复强直性脊柱炎髋关节病变患者的关节活动度,减轻疼痛症状,延缓关节畸形及强直,具有出血少、恢复快等优势,能显著改善患者生活质量。     

Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis

BACKGROUNDAnkylosing spondylitis at total hip arthroplasty (THA) has significant hip stiffness with flexion deformity, restricted mobility, and function. Range of movement (ROM) improvement with good functional outcome is seen following THA in these hips. The modified Hardinge approach without abductor compromise is helpful in these stiff hips with associated flexion deformity.AIMTo assess improvement in ROM and functional outcomes with a modified lateral approach THA in ankylosing spondylitis with stiff hips.METHODSA total of 69 hips that underwent THA with a modified Hardinge approach in 40 patients were evaluated at a mean follow-up of 38.33 mo. All individuals ambulated with weight-bearing as tolerated and ROM exercises from the 1^st postoperative day. Modified Harris hip score and ROM were assessed during follow-up. Quality of life assessments using the 36-item and 12-item short form health surveys were done along with clinical and functional outcomes at follow-up. SPSS 22.0 was used for statistical analysis. The correlation of ROM and functional score change was performed using Pearson’s correlation coefficient.RESULTSSixty-nine hips with a significant decrease in ROM preoperatively with 32 clinically fused hips showed significant improvement in flexion range. The mean flexion in 69 hips improved from 29.35 ± 31.38 degrees to 102.17 ± 10.48 degrees. The mean difference of 72.82 with a P value < 0.0001 was significant. In total, 45 out of 69 hips had flexion deformity, with 13 hips having a deformity above 30 degrees. The flexion during the follow-up was below 90 degrees in 3 hips. Eleven hips had flexion of 90 degrees at follow-up, while the remaining 55 hips had flexion above 100 degrees. Modified Harris hip score improved from 17.03 ± 6.02 to 90.66 ± 7.23 (P value < 0.0001). The 36-item short form health survey at the follow-up indicated health status in 40 patients as excellent in 11, very good in 20, good in 5, fair in 3, and poor in 1. The mean mental health score was 84.10 ± 11.58. Pain relief was good in all 69 hips. Altogether, 28/40 patients (70%) had no pain, 9 patients (22%) had occasional pain, and 3 patients (8%) had mild to moderate pain with unusual activity. Heterotopic ossification was seen in 21 hips with Brooker class 1 in 14 hips.CONCLUSIONModified Hardinge approach THA in ankylosing spondylitis with stiff hips with flexion deformity significantly improved ROM, Harris hip score, and quality of life indicated by the 36-item and 12-item short form health surveys.     

Ankylosing spondylitis and its variants. A review of recent developments for orthopedic surgeons

Recent developments in genetic tissue typing have altered concepts of ankylosing spondylitis (AS) or variants of this spondylitic arthritis. It is now apparent that AS is separate and distinct from rheumatoid arthritis; and the term "rheumatoid" should be avoided except as it applies to the latter, usually characterized by rheumatoid factor or nodules and symmetrical arthritis of peripheral joints. Classical definitions of AS require X-ray evidence of sacroiliitis and/or restriction of chest expansion. Recent studies suggest that many patients, especially women, may have symptoms of AS without typical roentgenographic or clinical findings. Use of the HL-A B27 genetic test is useful for identifying AS patients. Radioisotope bone or joint scanning techniques further augment present diagnostic capabilities. Atypical AS may be a very common form of morbidity among patients with back pain in the United States. Since patients have a tendency to form osseous reankylosis after total hip replacement, it is especially important for orthopedic surgeons to identify incipient AS and related disorders. Inappropriate treatment or procedures may be avoided by use of these newer clinical tools in the evaluation of patients with chronic back or skeletal pain.     

The clinical spectrum of ankylosing spondylitis

Ankylosing spondylitis is more common in young men than in young women and is insidious in onset. Typically, patients complain of pain and stiffness around the sacroiliac region. At the disease progresses, pain is often felt in the mid-lumbar, thoracic and cervical regions resulting in a significant reduction in the range of motion of the entire spine. About one fourth of the patients display involvement of proximal synovial joints. Acute anterior uveitis may precede AS or can occur when the disease is otherwise in apparent remission. Each patient with established disease should be carefully evaluated for cardiovascular, pulmonary, and neurologic complications. Early detection of AS is important, since proper management may well prevent the severe fixed deformities of the spine and root joints that is liable to occur in these patients.     

Functional outcome after lumbar closing wedge osteotomy in ankylosing spondylitis

This study entails a prospective evaluation of lumbar closing wedge osteotomy for correction of thoracolumbar kyphotic deformity in ankylosing spondylitis. Twenty patients with a median age of 52 years (range, 26–70) underwent follow-up at one year. The lumbar closing wedge osteomtomy was stabilised by metallic rods fixed by transpedicular screws. Outcome measures were quality of life (EuroQol), occiput-to-wall distance, pain, fatigue, complications, technical and radiological evaluation. The technical result was good in 16 and fair in four patients; two had neuropraxia. The deformity was reduced an average of 17° (95% confidence interval 15–25°) at one-year follow-up. Pain during activity, pain at night, and fatigue were significantly reduced. EuroQol improved from 0.42 to 0.69 (p = 0.002) and occiput-to-wall distance from 26 to 18 cm (p = 0.005). Functional outcome was improved after lumbar closing wedge osteotomy in ankylosing spondylitis.

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Résumé  Evaluation prospective d’une ostéotomie lombaire à foyer fermé pour correction de cyphose lombaire chez les patients présentant une spondylarthrite ankylosante. Matériel et méthode: 20 patients dont l’age moyen était de 52 ans (entre 26 et 70 ans) ont été suivis pendant un an et demi. Les vertèbres lombaires ont été stabilisées par deux tiges métalliques fixées par des vis transpédiculaires. Le devenir des patients a été analysé selon les critères de vie EUROQOL, selon la déformation résiduelle, les douleurs, la fatigue, les complications et la radiologie. Résultats: les résultats ont été bons chez 16 patients et passables chez 4 patients qui présentaient des troubles neurologiques résiduels (neuropraxie). A un an de recul, a déformation a été réduite en moyenne de 17°. La douleur, l’activité et la fatigue ont été significativement diminuées. L’index d’EUROQOL amélioré de 0,42 à 0,69 (p = 0,002), la flèche de cyphose mesurée en C1 de 26 à 18 cm (p = 0,005). Conclusion: dans les spondylarthrite ankylosante, l’ostéotomie lombaire à foyer fermé peut améliorer le devenir fonctionnel des patients.