Ankylosing Spondylitis Surgery

In rare cases of advanced ankylosing spondylitis or acute injury, spine or hip surgery is recommended to restore function and mobility to improve quality of life. 

Surgery is beneficial when ankylosing spondylitis causes difficulties with daily activities, such as driving or working, or more serious complications from spinal deformities, such as difficulty breathing or swallowing. ¹ Spondyloarthritis in over 16s: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2017 Jun. (NICE Guideline, No. 65.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK553609/

Indications for Ankylosing Spondylitis Surgery

Surgery is typically recommended when optimal non-surgical therapies do not adequately treat severe and progressing ankylosing spondylitis and when deformities significantly impact the quality of life. ¹ Spondyloarthritis in over 16s: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2017 Jun. (NICE Guideline, No. 65.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK553609/

Specific indications for surgery include ² Lacy J, Bajaj J, Gillis CC. Atlantoaxial Instability. [Updated 2023 Jun 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519563/ ^{, 3} Lam JC, Mukhdomi T. Kyphosis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558945/ :

• Atlantoaxial instability, characterized by excessive movement and instability between the first two cervical vertebrae, with neurologic impairment
• Cervical flexion deformities (hyperkyphosis) with impaired ability to look in a forward direction
• Severe hip involvement, with persistent pain or limitation in mobility
• Severe functional disability, with difficulty completing everyday tasks, such as eating and drinking

Surgical intervention is also recommended for some acute spinal fractures, which commonly occur in the cervical spine. ¹ Spondyloarthritis in over 16s: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2017 Jun. (NICE Guideline, No. 65.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK553609/ ^{, 4} Lazennec JY, d'Astorg H, Rousseau MA. Cervical spine surgery in ankylosing spondylitis: Review and current concept. Orthop Traumatol Surg Res. 2015;101(4):507-513. doi:10.1016/j.otsr.2015.02.005 ^{, 5} Lukasiewicz AM, Bohl DD, Varthi AG, et al. Spinal Fracture in Patients With Ankylosing Spondylitis: Cohort Definition, Distribution of Injuries, and Hospital Outcomes. Spine (Phila Pa 1976). 2016;41(3):191-196. doi:10.1097/BRS.0000000000001190

Types of Surgeries for Ankylosing Spondylitis

There are several approaches aimed at addressing severe joint damage and spinal deformities in ankylosing spondylitis. Standard surgical procedures are discussed below.

• Spinal osteotomy involves reshaping or realigning the vertebrae to correct deformities, but this procedure does not fully restore the mobility and flexibility of the spine. ⁶ Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? European Spine Journal. 2017;27(S1):70-100. doi:10.1007/s00586-017-5421-z
• Spinal fusion is performed to stabilize the spinal segment by fusing two or more vertebrae and immobilizing the spinal motion segment(s). ⁷ Akhondi H, Varacallo M. Rheumatoid Arthritis and Ankylosing Spondylitis. [Updated 2022 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532288/

  Read more about Spinal Fusion Surgery on Spine-health.com

• Spinal decompression surgery involves removing a piece of bone that places pressure on the spinal cord or spinal nerve roots. The most common type of decompression surgery is a laminectomy. ⁸ Joaquim AF, de Oliveira SA, Appenzeller S, Patel AA. Spine Surgery and Ankylosing Spondylitis: Optimizing Perioperative Management. Clin Spine Surg. 2023;36(1):8-14. doi:10.1097/BSD.0000000000001306

  Read more about Laminectomy Surgery on Spine-health.com

• Total hip arthroplasty involves the replacement of a severely damaged hip joint with an implant in advanced ankylosing spondylitis with hip involvement. ⁷ Akhondi H, Varacallo M. Rheumatoid Arthritis and Ankylosing Spondylitis. [Updated 2022 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532288/ ^{, 8} Joaquim AF, de Oliveira SA, Appenzeller S, Patel AA. Spine Surgery and Ankylosing Spondylitis: Optimizing Perioperative Management. Clin Spine Surg. 2023;36(1):8-14. doi:10.1097/BSD.0000000000001306

  Read more about Total Hip Arthroplasty

Most spinal surgeries involve correcting deformities and hunched posture (kyphosis). ⁶ Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? European Spine Journal. 2017;27(S1):70-100. doi:10.1007/s00586-017-5421-z

When Ankylosing Spondylitis Surgery May Not be Performed

Surgical procedures are not indicated when symptoms of ankylosing spondylitis are mild to moderate and well-controlled with medications and physical therapy. 

Additionally, surgery is not always the preferred course of action for acute fractures or dislocations, and some experts believe that these injuries should be managed by immobilization only, such as with a brace. ⁴ Lazennec JY, d'Astorg H, Rousseau MA. Cervical spine surgery in ankylosing spondylitis: Review and current concept. Orthop Traumatol Surg Res. 2015;101(4):507-513. doi:10.1016/j.otsr.2015.02.005

Individuals with certain underlying medical conditions (eg, severe malnutrition or severe hyperkyphosis, which interferes with intubation) are at a significantly increased risk for surgical complications, and the potential benefits of surgery do not always outweigh the risks in these cases. ⁹ Tsantes AG, Papadopoulos DV, Lytras T, et al. Association of malnutrition with surgical site infection following spinal surgery: systematic review and meta-analysis. J Hosp Infect. 2020;104(1):111-119. doi:10.1016/j.jhin.2019.09.015

Ankylosing Spondylitis Surgery: Potential Risks and Side Effects

The complications of ankylosing spondylitis surgery vary depending on the type of procedure. Potential risks and side effects include ⁶ Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? European Spine Journal. 2017;27(S1):70-100. doi:10.1007/s00586-017-5421-z , ¹⁰ Liu H, Yang C, Zheng Z, et al. Comparison of Smith-Petersen osteotomy and pedicle subtraction osteotomy for the correction of thoracolumbar kyphotic deformity in ankylosing spondylitis: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2015;40(8):570-579. doi:10.1097/BRS.0000000000000815 , ¹¹ Bortz C, Pierce KE, Brown A, et al. Frequency and Implications of Concurrent Complications Following Adult Spinal Deformity Corrective Surgery. Spine (Phila Pa 1976). 2021;46(21):E1155-E1160. doi:10.1097/BRS.0000000000004064 :

• Bleeding
• Post-surgical infection
• Thromboembolism (blood clot)
• Nerve damage
• Aortic rupture
• Dysphagia (difficulty swallowing)

Permanent or life-threatening complications of corrective spinal surgeries are rare. ¹¹ Bortz C, Pierce KE, Brown A, et al. Frequency and Implications of Concurrent Complications Following Adult Spinal Deformity Corrective Surgery. Spine (Phila Pa 1976). 2021;46(21):E1155-E1160. doi:10.1097/BRS.0000000000004064

Factors such as age and underlying conditions (eg, obesity, osteoporosis, or cardiac disease) impact the overall risks of surgical procedures and recovery. ⁶ Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? European Spine Journal. 2017;27(S1):70-100. doi:10.1007/s00586-017-5421-z ^{, 11} Bortz C, Pierce KE, Brown A, et al. Frequency and Implications of Concurrent Complications Following Adult Spinal Deformity Corrective Surgery. Spine (Phila Pa 1976). 2021;46(21):E1155-E1160. doi:10.1097/BRS.0000000000004064

Ankylosing Spondylitis Surgery: Success Rate and Long-Term Outcomes

The factors affecting the success rate and long-term outcomes of ankylosing spondylitis spinal surgery are related to the area of the spine where the surgery is performed and the experience and skill of the surgeon. ⁶ Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? European Spine Journal. 2017;27(S1):70-100. doi:10.1007/s00586-017-5421-z

Surgical corrections of the thoracolumbar spine appear to be associated with a greater risk of post-surgical complications. ⁶ Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? European Spine Journal. 2017;27(S1):70-100. doi:10.1007/s00586-017-5421-z

Hip surgery outcomes in ankylosing spondylitis

Most individuals who elect to have a total hip replacement experience long-term pain relief and improved mobility for at least 10-15 years post-surgery. ¹² Putnis SE, Wartemberg GK, Khan WS, Agarwal S. A Literature Review of Total Hip Arthroplasty in Patients with Ankylosing Spondylitis: Perioperative Considerations and Outcome. Open Orthop J. 2015;9:483-488. Published 2015 Sep 30. doi:10.2174/1874325001509010483

It is essential to discuss the risks, benefits, and surgical alternatives with the surgeon before considering surgery for ankylosing spondylitis.