An Overview of Ankylosing Spondylitis Surgery

Most people with ankylosing spondylitis (AS), a type of chronic inflammatory arthritis, don’t require surgery. A procedure is typically only recommended if spine or joint damage becomes severe enough that it causes intense daily pain or restricts mobility and the ability to perform daily tasks.

This may happen when non-surgical treatments like physical therapy and medications that ease inflammation and help reduce joint degeneration and deformity are not given, fail, or are started late.

The type of surgery recommended—be it a joint replacement or spine surgery—depends on the case.

This article will explore joint replacement surgeries and spine surgeries for ankylosing spondylitis, common preparation instructions, risks, and the recovery process.

Purpose of AS Surgery

Ankylosing spondylitis can affect the body in a few ways, each of which may prompt the need for surgery.

Repair or Replace an Affected Joint

AS causes joint inflammation that typically begins with the sacroiliac (SI) joints, which are located on either side of the lower back between the base of the spine and pelvis.

SI joints support the entire upper body and are connected by strong ligaments. Joints like the hips, knees, or shoulders can become deformed and damaged due to the inflammation.

Surgery to repair or either partially or completely replace the affected joint may be done to:

• Address severe pain
• Improve mobility

Correct Spine Issues

As ankylosing spondylitis progresses, it often affects the facet joints, which are located in the back of the spinal column. People have two facet joints between each pair of vertebrae, which are the small bones forming the backbone.

Degeneration and fusion (joining) of the facet joints and vertebrae impairs mobility because facet joints provide much of the bending and twisting ability of the spine.

If facet joints are severely affected, a C-shape rounding of the back known as kyphosis may occur. This may affect portions of the lower (lumbar), middle or upper (thoracic), or top of spine at the neck (cervical).

A person with kyphosis may no longer be able to stand up straight and may be forced to look downward.

Facet joint damage can also put pressure on the spinal cord and nerves, causing pain, numbness, weakness, loss of coordination, and tingling in the arms and legs.

Surgery can:

• Relieve pressure off the spinal cord and nerve roots to help ease pain
• Realign and stabilize the spine
  

Types of Surgery for AS

There are several types of procedures that can be performed to repair spine deformity and joint damage in people with ankylosing spondylitis.

The type of surgery recommended will depend on each person’s individual situation and symptoms.

Hip Replacement

People with AS frequently develop damage in the tissues and joints of the hips. In fact, it’s estimated that about 40% of people with AS have some hip involvement and up to 30% have joint damage.

Hip replacement surgery can be helpful for severe damage that restricts mobility and compromises quality of life. This procedure involves removing part of the joint and replacing it with a metal, plastic, or ceramic device called a prosthesis to help improve mobility and reduce pain.

Research on outcomes for people with ankylosing spondylitis who have hip replacements is still somewhat limited, however.

A 2019 review of four small studies that included a total of 114 cases of bilateral (both sides) total hip replacements in patients with AS suggests that this surgery is an effective treatment for advanced hip damage and improves hip function.

That said, the authors noted that debate still exists on which surgical methods and type of prosthesis may be best to use in patients with AS. The authors caution that each patient’s individual factors should be considered when planning for surgery to help reduce risk of complications.

Other Joint Replacements

People who have other types of joint damage from AS may consider other types of joint replacement, including repairs to shoulder and knee joints. 

Much like hip surgery, replacement surgery for a knee or shoulder joint usually involves replacing cartilage and bone surfaces with man-made materials, including plastic and metal. 

Hip, shoulder, and knee replacements are a common choice for people who live with severe pain and limited mobility from ankylosing spondylitis.

Osteotomy of the Spine

Osteotomy is surgery to cut and reshape bone. There are a variety of osteotomy surgeries that may be done to help realign and straighten the spine in people with ankylosing spondylitis.

Studies have found that osteotomy surgeries are typically successful for kyphosis in patients with AS. They are able to look straight ahead when walking and lie on their backs again after the procedure.

However, spine surgeries do come with risks.

A study of more than 400 people with AS who had osteotomy surgery found that complications occurred in about 7% of one-level osteotomies, which are performed in one location of the spine, and in 24% of two-level osteotomies, which are performed in two places on the spine for more severe kyphosis cases.

The most common complications were lower back pain and leaking of cerebrospinal fluid (CSF), which surrounds and cushions the spinal cord. There were no deaths or cases complete paralysis reported.

Because of this, it is a good idea to find an orthopedic surgeon who specializes in correcting this type of deformity.

Spinal Fusion Instrumentation

A spinal fusion instrumentation is when a surgeon fuses two or more vertebrae together using special hardware, including screws and rods.

This may be done to stabilize the spine. It may be done after an osteotomy if bones become damaged or if there was significant bone removal.

After this surgery, the joints that are fused will not have movement or be as flexible as before, which unfortunately is a trade-off to spine stability.

Laminectomy

Surgeries that take pressure off the spinal cord and nerves are called decompression surgeries. Laminectomy is one such procedure commonly performed on people with AS.

This procedure involves removing part of the vertebral bone called the lamina—the flattened part of the arch that forms the roof of the spinal canal (the channel that covers the spinal cord and nerves). Muscles in the area are pushed aside as well.

By doing this, pressure is taken off the spine and compression of the nerve roots is eliminated.

When done as part of a stabilization and fusion procedure, the spine is more easily accessible so that grafts, screws, and/or rods can be placed.

The procedure is minimally invasive, takes a couple of hours, and requires a small incision in the back.

Before Surgery

Having surgery for AS can help to relieve pain and allow you to live a fuller, more active life. 

Planning ahead for surgery and recovery will help ensure a successful outcome.

Educate Yourself

Take the time to educate yourself about what to expect before, during, and after surgery. Talk to a healthcare provider and ask questions about concerns.

Here are some questions patients may want to ask:

• How long is the hospital stay?
• What type of anesthesia is used?
• What type of implant or prosthesis options are there? Why do you recommend one over the other?
• How long will the recovery take and what does it entail?
• How will pain be managed after surgery?

Make sure to speak up about anything confusing or any worries regarding surgery, hospital stay, recovery, or pain management.

Gather Medical and Personal Information

During the weeks before surgery, patients will be asked about insurance coverage, medical history, and legal arrangements. 

It might be a good idea to put together a list of personal and medical information to speed up the process to avoid pulling the same information together over and over.

The list of information should include the following:

• The name of the loved one who will come to appointments, stay at the hospital, and help remember healthcare instructions
• Contact information for all of the healthcare providers actively treating the patient undergoing surgery and why each provider is treating them
• A list of any medication problems and all the medications actively being taken: Be sure to include dosage and frequency of medications and any over-the-counter medications, vitamins, and supplements regularly taken
• Any previous surgeries, even those not related to the current procedure
• Any patient allergies or adverse reactions in the past to drugs or anesthesia, including drug names, types of reaction, and when they occurred
• Any food allergies or diet restrictions
• All patient health insurance information: Be sure to bring your insurance card(s) to the hospital.
• Any advance directives, such as a living will or healthcare power of attorney: Bring copies of any legal documents to the hospital.

Physical Preparations

Getting the body in good physical shape before surgery helps to lessen the potential for complications and may shorten recovery.

For example:

• If a patient smokes, quit, or at least cut down. Smoking affects blood circulation, slows down healing, and increases the risk for complications. Talk to a healthcare provider about resources for quitting smoking.
• Eat a healthy diet. Consume lots of fruits and vegetables, which are filled with vitamins and minerals, and limit or avoid red and processed meats that can contribute to inflammation and take a long time to break down.
• If a patient consumes alcohol, don’t drink for at least 48 hours prior to surgery.
• Talk to a healthcare provider about alternatives to help manage pain in the days before surgery.
• Ask a healthcare provider about exercises to do prior to surgery, especially those that can make the upper body and legs stronger.

Planning for the Return Home

Joint replacement and spine surgeries are major surgeries and a patient will need several weeks to recover. 

To make recovery easier, take time to make home more comfortable and safer. 

Consider these preparations for returning home:

• Arrange for someone to provide a ride home from the hospital and for a caregiver to stay over for the first few days after surgery.
• If responsible for preparing meals at home, prepare and freeze enough food for a week or two so ready-made meals are available. Some grocery stores also offer pre-made meals.
• Place items typically needed at arm level. For example, stack cereal bowls in the counter instead of leaving them in the cupboard. Keep things used often, like a phone, tissues, and remote controls, close to sitting areas.
• Purchase or borrow a walker or crutches and practice moving through the home. Rearranging furniture or temporarily changing rooms used in the home may be needed.
• Remove any throw and area rugs to avoid falls and make sure electrical cords are hidden so they aren’t tripping hazards.
• Consider adding a shower chair, gripping bar, and/or raised toilet seat in the bathroom.
• Shop for assistive devices, like a grabbing tool or a long-handled shoehorn, to make life easier after surgery.
• Consider getting a handicap parking permit before surgery. Contact the local Bureau of Motor Vehicles or ask a healthcare provider’s office for more information.

Surgery Preparations

Make sure to follow through on any instructions given prior to surgery. These may include:

• An examination to assess health and risk for anesthesia complications
• Preoperative testing, including blood work, an echocardiogram (imaging of the heart), and X-rays
• Making a surgeon aware of all active health conditions and current medications to determine what needs to be stopped prior to surgery
• Notify the healthcare provider if facing an illness, fever, or cold in the week before surgery
• Getting dental work done in advance of surgery and not scheduling any dental procedures, including cleanings, for several weeks after surgery
• Meeting with the surgeon for an orthopedic evaluation, a review of the procedure, and any last-minute questions

Last-Minute Preparations

The day before surgery will be a busy time filled with last-minute preparations. The surgery team may recommend:

• Showering the night before using antibacterial soap or medical wash to reduce infection risk
• Not shaving the surgical area (it will be done at the hospital, if necessary)
• Removing makeup, lipstick, or nail polish before going to the hospital
• Not eating or drinking after midnight the night before surgery
• Packing a small bag that includes slippers, a robe, underwear, copies of insurance cards, medical directives and medication history, personal care items, and a loose-fitting outfit and comfortable shoes to wear home

Ask a friend or family member to help out with anything else needed before the procedure. Recovery will be a lot quicker if one has what they need and asks for help.

At the Hospital

Upon arrival at the hospital, patients will be checked in, and given a gown, cap, and socks to change into. Patients will also be assigned a secure place to keep belongings. 

Once changed, patients will meet with the preoperative nurse who will prepare them for the procedure. Patients will then read and sign surgical and anesthesia consent forms. 

The procedure will be explained, blood work (if needed) will be taken, and an IV (access to a vein) started. Patients can ask any remaining questions they have at this time.

The anesthesiologist and surgeon may also speak with the patient, explain their roles, and answer any additional questions.

Patients will then be taken to the operating room, placed in the right position for the procedure, and given blankets and/or pillows to make them more comfortable. 

They will be hooked up to machines to measure heart rate, breathing, blood pressure, and blood oxygen. 

The anesthesiologist will likely talk about the anesthesia, how it will be administered, side effects, and what to expect. The anesthesiologist will likely will be given general anesthesia to put the patient to sleep.

The surgeon will then arrive and perform the procedure.

During Surgery

Minimally invasive joint replacement and spinal surgeries are good options for many people with ankylosing spondylitis. With minimally invasive procedures, incisions are smaller, which may lead to less blood loss and pain.

This also reduces the risk of complications and may shorten the hospital stay, reduce scarring, and speed healing.

Hip Replacement

The healthcare provider cuts alongside the side of the hip and moves the muscles on top of the thighbone to expose the hip joint.

The ball of the joint is removed with a saw, and an artificial joint is attached to the thighbone either with cement or other material. The healthcare provider will then remove any damaged cartilage and attach the replacement socket to the hipbone.

The new part of the thighbone is inserted in the socket of the hip, the muscles are reattached, and the incision is closed.

Spine Surgery

The surgeon makes an incision over the spine and exposes the bones of the spinal column. 

Screws are often inserted in the vertebrae above and below the bone. 

Depending on the nature of the spine surgery, the surgeon may cut and remove or realign parts of the lamina and facet joints.

Next, the spine may be realigned. The surgeon will manipulate the spine to a new position, using implants to help determine the needed correction.

For spinal fusion surgery, the surgeon may apply bone grafts (transplanted bone) to permanently connect bones, which is crucial for long-term spine stability. 

Once the vertebrae are realigned, rods are placed into the screws added at the start of the surgery. This is done to help hold the vertebrae in place so they can heal in the new position. 

Finally, the incision is closed in layers and the wound dressed with a gauze bandage.

After Surgery

Patient stays in the recovery room depend on the extent of the procedure they underwent, how it went, personal health, and how patients feel in the aftermath.

Monitors will be checking heart rate, breathing, blood pressure, and blood oxygen levels. 

Nurses will check the surgical area. Patients may be placed on oxygen until they recover fully from the anesthesia. They may also be given pain medicine ordered by the surgeon. 

Once alert, patients might be offered a snack or drink, and when oral fluids are tolerable, the IV may be removed.

Once able to go home, patients will be given instructions about activity, medication, hygiene, comfort measures in pain management, and medical equipment the surgeon has ordered.

Once home, patients will need to make an appointment for a follow-up postoperative visit with the surgeon.

Recovery

Both spinal surgery and joint replacement surgery may respond better with physical therapy (PT) afterward. PT can be an important part of helping patients to heal and also plays a role in the successes and gains of AS surgery. 

A program may involve strengthening, conditioning, and stretching to offer patients the most positive outcomes.

Patients can also take prescribed pain medications to make the process easier and less painful.

Also consider joining a digital or in-person support group, such as those offered through the Spondylitis Association of America, to connect with other individuals or families of loved ones with the condition. It may help patients feel more supported and offer a chance to share experiences and resources.

Complications and Risks

Surgeons do everything to avoid and manage potential problems that may arise during or after surgery. Most joint replacement surgeries and spine surgeries don’t have major complications.

However, the reality is that all surgeries—whether major or minor—generally do come with risks, including:

• Post-operative infections, which healthcare providers may try to avoid with the administration of antibiotics
• Blood clots that may appear after surgery, which can mostly be avoided with appropriate medication and movement after the surgery
• Blood vessel damage if blood vessels close to the implant are damaged during the surgery
• Nerve damage if nerves close to the implant become severely affected
• Blood effusion to a joint (when a joint becomes filled with blood)
• Bone fracture during prosthesis insertion, especially if bones are fragile
• Bleeding
• Scar formation
• Implant failure due to improper placement of the prosthesis, dislocation from muscle weakness, and limited range of motion
• Joint stiffness
• Allergic reaction: Some people have allergic reactions to the cement used for implants or metal components. Some people may be allergic to anesthesia.
• Leg length differences, occurring occasionally after knee replacement

Spine surgeries carry the same risks as other orthopedic surgeries, but they also carry additional risks. 

One 2015 study that looked at 95 patients who underwent spine surgery found that just over a quarter of them experienced complications. The most common complication was infection at the surgical site.

Risks associated with spinal surgery may include:

• Pain and discomfort in hardware
• Infection to the treated vertebrae
• Damage to the spinal nerves, resulting in pain, weakness, and bowel or bladder problems
• Additional stress to the bones near the fused vertebrae
• Persistent pain on the bone graft site
• Blood clots

When to Call a Doctor

Call a healthcare provider or go to the local emergency room if experiencing any of the following symptoms:

• Sudden swelling in a calf, ankle, or foot
• Redness or tenderness above or below the knee
• Calf pain
• Groin pain
• Shortness of breath
• Signs of infection, including swelling or redness in the wound area
• Drainage from the wound
• Fever
• Chills or shaking
  

Summary

If the spine or joints are severely affected by AS, surgery can be an option to reduce pain and/or improve mobility.

The type of surgery that’s recommended will vary based on an individual’s AS symptoms and how it affects their spine or joints. Risks also vary based on the type of surgery and individual health conditions.

Hip and other joint replacement surgeries can improve mobility and reduce pain.

Spine surgery may involve a laminectomy to take pressure off nerve roots for pain relief or an osteotomy to help realign a curved spine.