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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_31_библиотеки_им_акад_М_И_Перельмана
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Y. P. Charles
54.2 Natural History
Axial spondylarthropathies such as are associated with back pain and inammation
of sacroiliac joints. Additional clinical features of inammatory rheumatic diseases
such as skin psoriasis, heel enthesitis, dactylitis, uveitis, or colitis can be present.
Over time, vertebrae may fuse and result in spinal deformity. Cervicothoracic
kyphosis can lead to loss of horizontal gaze. Global thoracolumbar kyphosis is the
most common deformity, which can induce anterior trunk malalignment. In severe
cases, kyphosis increases pressure on the abdominal cavity and reduces lung
capacity.
The exact pathogenesis of DISH remains unclear to date. An occasional familial
incidence of DISH raised suspicion of genetic predisposition. Diabetes mellitus and
obesity represent frequent comorbidities of DISH (23% to 40%). It is also associated with diminished glucose tolerance, gout, hypertriglyceridemia, and
hyperretinolemia.
54.3 Physical Examination
Inammatory pain and alternate buttock pain are typical in AS.Pain is usually present for more than 3 months. Morning stiffness, which improves with exercise, is
common, whereas rest does not improve pain. Some patients report pain during
nighttime. Decreased lumbar range of motion can be measured using the Schober
method by drawing to points: one at the upper sacral level and another one 10cm
above. Normal range of motion of the lumbar spine is observed if the distance
between both points increases to 15cm in maximal anterior trunk exion (Schober
10/15cm). Any shorter distance indicates limited range of motion of the lumbar
spine. The patient should further be examined for cervical and thoracolumbar sagittal plane deformities (Fig.54.1). Pelvic retroversion and knee exion indicate the
compensation mechanism of anterior malalignment of the trunk.
Many patients with DISH have only mild clinical symptoms. They include stiffness in the cervical spine and eventually the lumbar spine. Ossications might
restrict range of motion in these mobile vertebral segments. Pain is reported by
some patients, but its intensity is variable, and it is not constantly present. In severe
cervical anterior ossication, dysphagia might be present.
Blood Tests. There are no specic lab tests to identify ankylosing spondylitis.
Inammatory markers such as C-reactive protein (CRP) can check inammation,
but CRP is nonspecic for sacroiliitis progression, and it is not always elevated. The
HLA-B27 gene is associated with AS.However, it is also positive in 8% of the normal population.
54 Ankylosing Disorders oftheSpine: ASandDISH
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Fig. 54.1 The clinical
aspect of a xed
thoracolumbar kyphosis
in AS
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54.3.1 Imaging
The standard radiographic examination consists of anterior-posterior (AP) and lateral radiographs of the spine (Video 54.6), the pelvis, and sacroiliac joints. During
the initial phase of AS and DISH, anterior shiny corners of vertebral bodies can be
observed. Syndesmophytes then turn out the fusion between vertebral bodies.
Radiologic ndings of DISH are typically found in the thoracic and cranial lumbar
spine rst (Fig.54.2).
Computed tomography (CT) scan provides good-quality images of bony fusion.
In AS, posterior facet joint fusion develops over time and results in a typical “bamboo spine.” Bone mineral density can decrease within vertebral bodies in AS, resulting in a trabecular aspect of cancellous bone.
Magnetic resonance imaging (MRI) is indicated in AS to evaluate sacroiliac
joints on T2-STIR sequences. A hypersignal indicates an active inammatory process (Fig.54.3).
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Fig. 54.2 The
radiographic aspect of
ossication of the anterior
longitudinal ligament in
the caudal thoracic and
cranial lumbar spine
in DISH
Y. P. Charles
T1 T2-STIR
Fig. 54.3 MRI images showing an inammatory sacroiliac joint on the T2-STIR sequence
54 Ankylosing Disorders oftheSpine: ASandDISH
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54.4 Differential Diagnosis
Differential diagnoses of AS are nonspecic low back pain (Chap. 41), degenerative
changes of the intervertebral disc, facet joints and sacroiliac joints, or inammatory
diseases such as rheumatoid arthritis.
A possible link between DISH and ossication of the posterior longitudinal ligament of the spine (OPLL) has been genetically investigated. However, it seems that
both entities are different. DISH occurs more often in Caucasian patients, whereas
OPLL is more frequent in Asian patients. Ossication of the posterior longitudinal
ligament in OPLL typically leads to clinical signs of myelopathy or radiculopathy,
which is rare in DISH (Chaps. 42 and 43).
54.5 Treatment Options
The management of AS relies on education, physical therapy, rehabilitation, and the
treatment of pain using analgesics and nonsteroidal anti-inammatory drugs. Tumor
necrosis factor (TNF) blockers or an interleukin-17 (IL-17) inhibitor should be prescribed to reduce pain and stiffness. The following TNF blockers can be used: adalimumab, certolizumab pegol, etanercept, golimumab, or iniximab. Surgical
treatment is indicated in severe kyphotic deformities. The indication for surgical
correction of the xed sagittal deformity is to improve global alignment and to
restore a horizontal visual axis if necessary. It has been shown that deformity correction by single- or two-level pedicle subtraction osteotomy (PSO) might improve
disability, pain derived from muscle fatigue, respiratory function, and quality of life
(Fig.54.4).
The treatment of DISH remains symptomatic using analgesics. Cervical osteophyte resection might be indicated in rare cases of dysphagia, and neurologic
decompression might be considered in neurologic symptoms.
54.6 Expected Outcomes
Conservative treatment of AS using TNF blockers in combination with regular exercise improves the inammatory process and the course of the disease. Surgical treatment should be carefully planned in severe deformity only, but it can improve the
quality of life in severe rigid/xed deformities.
54.7 Potential Complications
Ankylosed spines in AS and DISH are fragile, and low-energy trauma can cause
unstable vertebral fractures. The cervical spine between C5 and C7 accounts for
75% of traumatic spinal injuries and carries a high risk of neurologic complications
such as tetraparesis or tetraplegia (Fig. 54.5). Non-displaced thoracolumbar
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Fig. 54.4 Pre- and postoperative radiographs of xed sagittal thoracolumbar kyphosis correction
in AS by two-level pedicle subtraction osteotomy at L2 and L4
Y. P. Charles
Fig. 54.5 CT and MRI of a displaced C6-C7 fracture in DISH showing spinal cord compromise
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Fig. 54.6 Preoperative CT and postoperative radiographs of a patient with unstable thoracic fracture treated by minimal invasive percutaneous instrumentation
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fractures caused by low-energy trauma may be challenging to diagnose. There is a
high risk of secondary displacement and neurologic complications. Therefore, surgical treatment using percutaneous instrumentation should be preferred (Fig.54.6)
over conservative brace treatment.
54.8 What Should Patient andFamily Know?
AS is an inammatory disease that belongs to the group of axial spondyloarthropathies, which occurs in younger patients and requires lifelong treatment. DISH is a
noninammatory ankylosing disorder of the axial skeleton of the elderly patient,
who often remains asymptomatic. Both entities lead to stiff ossied spines that are
at high risk of secondary displacement and neurologic complications in the event
of trauma.
Further Readings
Bredin S, Fabre-Aubrespy M, Blondel B, Falguières J, Schuller S, Walter A, Fuentes S, Tropiano
P, Steib JP, Charles YP.Percutaneous surgery for thoraco-lumbar fractures in ankylosing spon-
dylitis: study of 31 patients. Orthop Traumatol Surg Res. 2017;103:1235–9.
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Charles YP, Ntilikina Y, Collinet A, Steib JP.Combined percutaneous and open instrumentation for
thoracolumbar kyphosis correction by two-level pedicle subtraction osteotomy in ankylosing
spondylitis. Eur J Orthop Surg Traumatol. 2020;30:939–47.
Mader R, Verlaan JJ, Buskila D. Diffuse idiopathic skeletal hyperostosis: clinical features and
pathogenic mechanisms. Nat Rev. Rheumatol. 2013;9:741–50.
Taurog JD, Chhabra A, Colbert RA.Ankylosing spondylitis and axial spondyloarthritis. N Engl J
Med. 2016;374:2563–74.
Y. P. Charles
Vertebral Hemangioma
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BurakKaraaslan andAlpÖzgünBörcek
55.1 Definition
Pathologically, hemangiomas are benign, unencapsulated proliferation of vascular
channels. Pathologically, there are three types, capillary, cavernous, and mixed.
They can occur anywhere, but the most common locations are the skin of the face,
scalp, chest, or back. Vertebral hemangiomas have an incidence of 11% on autopsy
series, and most of them are asymptomatic and discovered incidentally. İncidence
increases with age, and about 30% of patients have multiple lesions. There is a
female predominance (3:1).
55.2 Natural History
Vertebral hemangiomas (VH) may be either progressive or silent. Most of the
asymptomatic patients remain so for several years. In case of a painful lesion, the
amount of involvement of the vertebra and the location should be considered.
Lesions conned to the vertebral body of a lumbar or cervical region are not
expected to progress; in those patients, other pain sources should be evaluated
(Chap. 41). On the contrary, a thoracic lesion extending outside the vertebra body
with soft tissue expansion should be considered as a potentially progressive lesion.
Especially in younger patients, even if the lesion is discovered incidentally, the
patient should be followed carefully.
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_55].
B. Karaaslan · A. Ö. Börcek (*)
Division of Pediatric Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
e-mail: burakkaraaslan@gazi.edu; alpborcek@gazi.edu.tr
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_55
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B. Karaaslan and A. Ö. Börcek
55.3 Physical Examination
There is no physical examination nding for pure VH.Only 1% to 1.2% of all hemangiomas are symptomatic, pain being the most common symptom. Young adults present with cord compression or radiculopathy symptoms more commonly. Neurological
ndings change related to the level of the lesion and presence of expansile character or
soft tissue involvement (Video 55.4). Decits can occur due to either direct compression of the spinal cord or a change in blood ow dynamics. Additionally, fractures,
spinal epidural hematoma, or direct vascular compression may cause spinal decits.
The clinical picture is usually progressive; however, there are sudden changes that can
also be observed. Of note, pregnancy—probably due to both increased venous tonus
and hormonal activity—may aggravate symptoms. Additionally, there are reports of
the uctuating clinical pictures in premenopausal women.
55.4 Imaging
HVs are usually found incidentally. In rare cases, they may show ndings of pathological fractures or deformative changes. On plain radiographs, the presence of
coarse vertical striations—“honeycomb” appearance within the vertebra body—is
the main nding. On T1- and T2-weighted magnetic resonance imaging (MRI) pictures, they have increased signal intensity. Soft tissue parts have usually lower signals. HV enhances intensely with contrast medium. More than 70% of the lesions
are found in the thoracic spine, and they can involve every part of the vertebra
including the posterior arcs, and they can also have soft tissue components with
expansile behavior. In up to 65% of cases, all parts of the vertebra are involved. The
presence of adipose tissue in hemangiomas may be a sign of a benign course. For
cases that are not diagnosed easily with MRI, angiography may show dense
opacication of the vertebral body (Fig.55.1).
According to their clinical and radiological features, they can be divided into
three groups:
• Type A: lesion presenting with cord compression due to the extraosseous exten-
sion of the tumor.
• Type B: lesion presenting with local pain without extraosseous extension.
• Type C: most common type, asymptomatic. However, in young patients, those
lesions should be followed up.
55.5 Differential Diagnosis
Symptomatic VH is a potential cause of back pain (Chaps. 11 and 41). In cases with
incompatible radiographic ndings, other causes of back pain should be ruled out.
Paget disease (Chap. 63), metastasis mainly from osteosarcoma (Chap. 38), prostate
ab
cd
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Fig. 55.1 MRI and computed tomography pictures of a 9-year-old patient with symptomatic thoracic vertebral hemangioma managed with radiotherapy. (a) T1-weighted image of the vertebral
hemangioma. (b) T2-weighted image of the lesion with signicant anterior and posterior cord
compression. (c) Axial CT image of the lesion. (d) Post-radiotherapy image 3 months after the
treatment showing complete resolution of the extraosseous lesions and the cord compression
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