1. Department of Anesthetic and Perioperative Care of HTO
Perioperative challenges of Anesthetic in surgical management of Ankylosing spondylitis
NGUYEN Trung Nhan, MD.
Department of Anesthetic and Perioperative Care of HTO

2. Content Overview of Ankylosing spondylitis Diagnosis Treatment
Perioperative management of Ankylosing spondylitis in Orthopedic surgery

3. Overview
Ankylosing spondylitis is a form of chronic inflammatory arthritis:
Sacroiliitis, peripheral arthropathy, enthesopathy
Propensity for sacroiliac and spinal fusion.
The role of genes ( HLA-B27)
Family of disease
Ankylosing spondylitis is a form of chronic inflammatory arthritis punctuated by exacerbation and quiescent periods. It is characterised by sacroiliitis, peripheral arthropathy and enthesopathy ( pathological changes at the site of insertion of libaments and tendons).
It is marked propensity for sacroiliac and spinal fusion
The initiating cause of AS is not known but enviromental factors ( bacterial, virus), susceptibility genes ( HLA-B27), gender, age play a role
And overall, it is a familial disease

4. Overview spinal and pelvic Epidemiology:
A peak age onset: years ( juvenile onset: years)
Different proportion ( HLA-B27): 0.1-2%
Men: 1%
spinal and pelvic
In Vietnam: 20% osteoarthropathy
After 10 years: 27% disabled patient
> 20 years: 43 % disabled patient
Women: 0.5%
- peripheral joints (hips, knee, ankles, wrists)
AS is more prevalent in males with a peak age onset of years, juvenile onset of years,
the proportion of AS has a wide difference between some countries.
The men tend to have more severe spinal and pelvic disease, whereas women have peripheral joints involvement ( like hips, knee, ankles, wrists)
In Vietnam, there was some report from Bach mai hospital, AS had a 20% of the patients with osteoarthropathy
27% of AS patient become disabled after 10 years
43% after 20 years.
Jimener-Bladeras FJ et al. Ankylosing spondylitis: clinical course in women and men. Journal of Rheumatology 1993;20:

5. Overview Pathogenesis: Clearly unknown.
Enviromental factors ( bacterial, virus ), gender, age.
Familial disease
Susceptibility genes HLA-B27 
5% HLA-B27 (+)  AS (+).
90-95% of patient with AS possess HLA-B27 alleles
ARTS1 and IL23R (2007) : 3 genes (+)  70% AS (+)
The initiating cause of AS is nor known but enviromental factors ( as unidentified bacterial or viral agents), gender, age and HLA-B27 play a role.
This is a familial disease.
Althrough only 5% of HLA-B27 positive individuals develop AS, 90-95% of patient with AS possess HLA-B27 alleles
In 2007, they discorved 2 more genes ARTS1 and IL23R. together with HLA-B27, these 2 genes account for 70% of the overall incidence of AS .
(ankylosing spondylitis (AS), autoimmune thyroid disease (AITD), multiple sclerosis (MS) and breast cancer (BC). 
Brophy S, Calin A. “Ankylosing spondylitis: interaction between genes, joints, age at onset and disease expression”. Jounal of Rheumatology 2001: 28:
Burton PR et al. “ Association scan of nonosynonymousSNPs in four diseasesidentifies aautoimmunity variants”. Nature Genetic 2007; 39:

6. Clinical features Pain: Arthritis: Early symptom
Inflammatory pain and morning stiffness.
Site: lower spine and the sacroiliac joint.
Arthritis:
Absence of specific pathognomonic clinical feature and laboratory test  delay the diagnosis by 7-10 years
Pain and the moring stiffness, patient fells worse at rest but improves with exercise in the lower spine and the sacroiliac joint
The most common joint affected are the hips and shoulders.
The absence of any specific pathognomonic clinical feature and laboratory test tends to delay the diagnosic by 7-10 years from onset the symptoms

7. Clinical feature
Spinal disease: fracture, spinal collapse, nerve root compression.
Temporomandibular joint  limited mouth opening.
Cardiovascular complications :
Aortic insufficiency
conduction defect
mitral valve disease
Respiratory complications :
upper lobe fibrosis
restrictive lung defect
Sometime, we can see some patients who come to hospital with complications of severe spinal disease include fracture with little or no history of trauma, spinal collapse of vertebral end- plate or nerve root compression.
Some patients present a temporomandibular joint caused limited mouth opening.
Or cardiovascular complications:
Aortic insufficiency, conduction defect or mitral valve disease
Or respiratory complications include upper lobe fibrosis and reduce the chest expansion, restrice lung defect
Peters MJ, Van Der Horst-Bruinsma IE, Dijkmans BA, Nurmohamed MR. Cardiovascular risk profile of patients with spondyloarthropathies, particularly ankylosing spondylitis and psoriatic arthritis. Seminars in Arthritis and Rheumatism2004; 34: 585–9.

8. Diagnosis Clinical criteria:
- Low back pain > 3 months duration, improves with exercise and is not relieved by rest.
- Limitation of motion of lumbar spine in sagital and coronal planes
- Limitation of chest expansion relative to nomal values corrected for age and sex ( < 2.5cm)
Clinical criteria
Low back pain > 3 months duration, improves with exercise and is not relieved by rest.
Limitation of motion of lumbar spine in sagital and coronal planes
Limitation of chest expansion relative to nomal values corrected for age and sex
Radiological criteria
Bilateral sacroilitis- grade 2 ( sclerosis with some erosions) or higher
Unilateral sacroilitis – grade 3 ( severe erosions, pseudodilatation of joint space and partial ankylosis) or grade 4 ( complete ankylosis)
Van Der Linden S, Valkenburg HA, Cats A. “ Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria”. Arthritis and Rheumatism 1984; 27: 361–8

9. Diagnosis Radiological criteria:
- Bilateral sacroiliitis- grade 2 ( sclerosis with some erosions) or higher
- Unilateral sacroiliitis – grade 3 ( severe erosions, pseudo dilatation of joint space and partial ankylosis) or grade 4 (complete ankylosis)
Laboratory test :
Blood test is shown a inflammation.
HLA-B27 possitive (80-90%)

10. MRI
You know, the pateint come to see you with just pain at lower spine without any specific pathognomonic, the conventinal radiography is ordered and you can find nothing…..
I found many studys they talk about the ealier diagnosis of sacroilitis and the MRI is most sensitive and superior to quantitative SI scintigraphy or conventional radiography. MRI picks up an additional 75% of early cases not diagnosed by radiography.
So we need to have an algorithm for evaluation of patient with suspected active sacroilitis

11. Detection and diagnosis of sacroiliitis
MRI
Detection and diagnosis of sacroiliitis
Sensitivity
Specificity
MRI
95%
100%
Scintigraphy
48%
97%
Conventional radiography
19%
47%
You know, the pateint come to see you with just pain at lower spine without any specific pathognomonic, the conventinal radiography is ordered and you can find nothing…..
I found many studys they talk about the ealier diagnosis of sacroilitis and the MRI is most sensitive and superior to quantitative SI scintigraphy or conventional radiography. MRI picks up an additional 75% of early cases not diagnosed by radiography.
So we need to have an algorithm for evaluation of patient with suspected active sacroilitis

12. Treatment General: Internal medical Physical therapy Surgical
The main aim of treatment:
Anti-inflammation,
Pain management;
Early diagnosis and treatment of spinal deformity
Joint replacement and spinal surgery are considered
The main aims of the management of AS patients are to relive pain, reduce inflammation and maintain good posture and function. Early diagnosis and treatment may prevent spinal deformity.
Education, exercise and physical therapy are the cornerstones of management for AS.
Joint replacement and spinal surgery is considered in patient with severe advanced disease associated with refratory pain and disability.

13. Total hip replacement

14. Total hip replacement Manage pain Restore the function ( walking)
Improve quality of life

15. Preoperative management
Cushing symptom
Malnutrition
Respiratory assessment:
Criteria of difficulty intubation
Cardiovascular assessment
Cushing synptom: because of AS patient use NSAID and cyclooxygenase-2 specific inhibitor for controlling spinal pain, we have to give calcium for preventing the peroperative hypotension.
Malnutrition pain, limited mouth opening
Respiratory assessment: we need to find some pulmonary complication, chest X ray may show a fibrosis, pumonary function test may reveal a restrictive lung defect…
Criteria of difficulty intubation: stiffness of the cervical spine, mouth opening…
Cardiovascular assessment

20. Difficulty intubation and spinal anesthesia
Airway damage due to difficulty intubation
Complication due to patient positioning during and post-op
unstable fracture.
Muscle- neurological complications
Neurolophysiological monitoring
Comfortable positioning, specially bed for AS
Intraoperative blood loss
the presence of large anterior cervical osteophytes may prohibit successful visualization of the larynx and may prevent endotracheal intubation due to significant mass obstruction.
Proper positioning of a patient with AS in the operating room or the ICU is imperative in all AS patients because of their an increased risk of iatrogenic injury.
neurological complications due to the potential for iatrogenic cervical subluxation and spinal cord compromise

21. Perioperative challenges

22. Difficulty airway respiratory control
The devices for intubation difficult
Triệu chứng bắt đầu là đau vùng thắt lưng, theo thời gian, đau và viêm đính tiến triển ảnh hưởng đến cột sống vùng ngực cổ

23. Spinal anesthesia

24. Post-operative management

25. Post-operative management
1006 patients with AS undergoing THA
Risk ratio
90 days
2 yrs
Hip dislocation
1.44 (Cl, )
1.67 ( Cl, )
Periprosthetic fracture
2.5 (Cl, )
1.99 ( Cl, )
Revision THA
1.46 ( Cl, )
1.69 (Cl, )
Wound complication NA
Infection

26. Post-operative management
Anesthetic:
Complications of spinal anesthesia: hypotension, leg movement…
Complications of difficult intubation: upper airway injury …
Surgical site: bleeding, infection ….
Comfortable positioning: avoiding iatrogenic injuries…
Multimodal analgesia : opioid + paracetamol + NSAID….
Surgery:
Respiratory physiotherapy
Rehabilitation therapy

28. Summary Ankylosing spondylitis: HLA-B27.
Injury to the sacroiliac, spine and lower limb joints.
Later diagnosis, tendency to joint fusion
Surgery .
Many perioperative complications (respiratory, cardiovascular...)
Great challenge with Anesthesia (respiratory management, anesthesia technic).
Physical therapy before and after surgery.
Ankylosing spondylitis:
HLA-B27 tissue-adipose antigen.
Injury to the sacroiliac, spine and lower limb joints.
Late diagnosis, tendency to joint.
Joint Surgery.
Many complications, perioperative complications (respiratory, cardiovascular ...)
Great challenge with GMHS (breath management, anesthesia).
The role of physical therapy before and after surgery.

29. Thank you!