An Overview of Ankylosing Spondylitis Surgery

Many people with ankylosing spondylitis (AS), a type of chronic inflammatory arthritis that primarily affects the spine and pelvis, do not require surgery.

Treatments typically involve a combination of physical therapy and medications such as non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, biologics, and disease-modifying anti-rheumatic drugs (DMARDs). These non-surgical treatments can help ease pain and reduce or prevent joint degeneration and deformity in most cases. 

However, if spine or hip damage becomes severe enough that it causes intense daily pain or restricts mobility and the ability to perform daily tasks, surgery may be recommended.  

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

What Is AS?

AS is a type of inflammatory arthritis that commonly affects the spine, sacroiliac (SI) joints, and facet joints.

Your SI joints, which support the entire upper body, are located on either side of your lower back between the base of your spine and pelvis and are connected by strong ligaments.

Your facet joints are located in the back of the spinal column. You have two of them between each pair of vertebrae, which are the small bones forming the backbone. There is a facet joint on each side of the spine.

In severe cases of AS, new bone formation causes the spine to abnormally fuse, or join together.

AS also causes inflammation, so other joints, like the hips, knees, and shoulders, may also become deformed and damaged.

Recap

AS is an inflammatory arthritis that primarily affects the spine and pelvis. Most people with AS never have surgery, but it's an option when AS leads to severe pain, spinal deformities, or joint problems. 

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 AS.

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

Joint replacement, especially hip replacement, is more common in people with AS than spine surgeries.

Hip Replacement

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

Hip replacement surgeries involve 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.

Hip replacement can be helpful for severe damage that restricts mobility and compromises quality of life, but research on outcomes for people with AS who have hip replacements is still somewhat limited.

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 it is an effective treatment for advanced hip damage and improves hip function.

However, 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.

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 AS.

Osteotomy of the Spine

There are a variety of osteotomy surgeries that may cut and reshape bones to help realign and straighten the spine.

AS can make the spine less flexible and cause bone to develop between two or more vertebrae, causing them to fuse, or connect. This can lead to a C-shape rounding of the back, known as kyphosis.

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

AS-associated kyphosis can affect vertebrae in any region of the spine. It may include portions of the lower (lumbar), middle or upper (thoracic), or top of spine at the neck (cervical).

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

However, spine surgeries do come with risks, so it is a good idea to find an orthopedic surgeon who specializes in correcting this type of deformity.

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.

There were no deaths or cases complete paralysis from the surgeries in the study.

The most common complications were lower back pain and leaking of the cerebrospinal fluid (CSF) that surrounds and cushions the spinal cord.

Spinal Fusion Instrumentation

A spinal fusion instrumentation 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.

A surgeon will fuse two or more bones together using special hardware, including screws and rods.

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

AS can put pressure on the spinal cord and nerves, causing numbness, weakness, loss of coordination, and tingling in the arms and legs.

Surgeries that take pressure off the spinal cord and nerves are called decompression surgeries. A common decompression surgery performed on people with AS is a laminectomy.

It can help relieve pain in those with AS. The goal of laminectomy surgery is to eliminate compression of nerve roots and to stabilize and fuse the spine with grafts, screws, and rods.

This procedure involves removing part of the vertebral bone called the lamina, which is the flattened part of the vertebral arch that forms the roof of the spinal canal—a bony channel that covers the spinal cord and nerves. 

The lamina is removed to access the disk. Removing the lamina takes pressure off the spine. Muscles are pushed aside—rather than cut—so they no longer put pressure on the spine. The procedure is minimally invasive, takes a couple of hours, and requires a small incision in the back.

Recap

Joint replacements, which are the most common surgeries in those with AS, involve removing parts of a joint and replacing them with a prosthesis.

Spine surgeries for AS typically involve removing parts of bone to either relieve pressure on nerves or to help realign the spine. In some cases, screws and rods are used to hold vertebrae together after a procedure.

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

You should take the time to educate yourself about what to expect before, during, and after surgery. Talk to your healthcare provider and ask about things that concern you. Your questions may include:

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

Make sure you speak up about anything you don’t understand or worries you regarding surgery, hospital stay, recovery, or pain management.

Ankylosing Spondylitis Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Doctor Discussion Guide Man

Gather Medical and Personal Information

During the weeks before surgery, you 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 and so you don’t have to keep pulling together the same information together over and over.

Your list should include the following:

  • The name of the loved one who will come with you to appointments, stay with you at the hospital, and help you to remember healthcare instructions
  • Information, including names and phone numbers, for all the healthcare providers who are treating you and what they are treating you for
  • Any medication problems you have and all the medications you are taking. Be sure to include dosage and frequency of medications and any over-the-counter medications, vitamins, and supplements you regularly take.
  • Any previous surgeries you have had, even those not related to the current procedure
  • Any allergies or adverse reactions you have had in the past to drugs or anesthesia, including drug names, types of reaction, and when they occurred
  • Any food allergies or diet restrictions
  • Your 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 with you.

Physical Preparations

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

  • If you smoke, quit, or at least cut down. Smoking affects blood circulation, slows down healing, and increases the risk for complications. Talk to your healthcare provider about resources for quitting smoking.
  • Eat a healthy diet. Consume lots of fruits and vegetables that 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 you consume alcohol, don’t drink for at least 72 hours prior to surgery.
  • Discuss all supplements and medications with your healthcare provider since they can impact surgery. Talk to your healthcare provider about alternatives to help you manage pain in the days before surgery.
  • Ask your healthcare provider about exercises to do prior to surgery, especially those that can make your upper body and legs stronger.

Planning for Your Return Home

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

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

However, if you live alone, will have little or no help, or have special needs, it may make sense to consider a specialized rehabilitation center to stay at after the hospital discharge and through recovery.

Consider these preparations for your return home:

  • Arrange for someone to drive you home from the hospital and to stay with you the first few days after surgery.
  • If you are responsible for preparing meals at home, prepare enough food for a week or two, and put in the freezer, so you have ready-made meals when you get home. Alternatively, stock up on grocery store ready-made foods you like.
  • Place items you use regularly at home at arm-level, so you are not reaching up or bending down.
  • Purchase or borrow a walker or crutches and practice moving through your home. You may need to rearrange furniture or temporarily change rooms.
  • 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 to make life easier after surgery, like a grabbing tool or a long-handled shoehorn.
  • Place items you regularly use—your phone, remote control, facial tissues, reading materials, and medications—within reach so you do not have to keep getting up.
  • If you don’t have a handicap parking permit, consider getting one before surgery. Contact your local Bureau of Motor Vehicles or ask your healthcare provider's office for more information.

Surgery Preparations

Make sure you follow through on any instructions you are 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 your surgeon aware of all health conditions and medications you are taking to determine what needs to be stopped prior to surgery
  • Notifying your healthcare provider if you come down with 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. Your surgery team may recommend:

  • Showering the night before using antibacterial soap or medical wash to reduce infection risk
  • Not shaving the surgical area. If it is necessary, it will be done at the hospital.
  • 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 comfortable slippers, a robe, a cotton shirt, and underwear to wear under the hospital gown, copies of insurance cards, medical directives and medical history, all medications you take daily, personal care items (hair brush, toothbrush, eyeglasses, etc.) and a loose-fitting outfit and comfortable shoes to wear after discharge from the hospital. 

Ask a friend or family member to help out with anything you have not yet done. Have someone check on you daily. Your recovery will be a lot quicker if you ask for help and don’t do everything yourself.

At the Hospital

Once you arrive at the hospital, you will be checked in, and given a gown, cap, and socks to change into. You will be given a secure place to keep belongings. 

Once you are changed, you will meet with the preoperative nurse who will prepare you for the procedure. The operative nurse will have you read and sign surgical and anesthesia consent forms. 

The procedure will be explained, blood work (if needed) will be taken, an IV (access to a vein) started, and you can ask any remaining questions you or family members have. 

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

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

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

The anesthesiologist will tell you about the anesthesia, how it will be administered, side effects, what to expect and then administer the anesthesia. 

The surgeon will then arrive and perform the procedure.

Recap

Before surgery, you will need time to prepare yourself, both physically and psychologically. Ask questions whenever you have them so that you understand the steps of the surgery and can evaluate your options.

Arrange for someone to drive you home from the hospital and to stay with you the first few days after surgery.

During Surgery

Joint replacement and spine surgeries are now mostly minimally invasive, meaning the incisions are smaller. A smaller cut may lead to less blood loss and pain.

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

Hip Replacement

At the start of the hip replacement procedure, you likely will be given general anesthesia to put you to sleep. 

The healthcare provider will then cut alongside the side of the hip and move 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 to attach the bone to the new joint. 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

With spine surgery, you are placed under general anesthesia and put to sleep. 

The process includes the surgeon making an incision over the spine and exposing the bones of the spinal column. 

Screws are often inserted in the vertebrae above and below the bone. At the end of the surgery, rods will be inserted to immobilize the spine that fit into those screws, so the vertebrae can heal in the new position. 

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

Lastly, the spine may be realigned. The surgeon will manipulate the spine to a new position, using implants to help determine the needed correction. Once the vertebrae are realigned, rods are placed into the screws added initially. 

These will hold the bones in the position achieved from the surgery. The surgeon may apply bone grafts (transplanted bone) to fuse bones (grow them permanently together), which is crucial for long-term spine stability. 

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

Recap

Joint replacement and spine surgeries are often minimally invasive to reduce the risk of complications and speed healing. General anesthesia is typically used to put you in a sleep-like state for surgery.

After Surgery

Your stay in the recovery room depends on the extent of your procedure, how it went, your personal health, and how you are feeling. 

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

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

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

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

You will need to have someone drive you home. Once you are home, you will need to make an appointment for a follow-up postoperative visit with the surgeon.

Physical Therapy

Both spinal surgery and joint replacement surgery may respond better with physical therapy (PT) afterward. PT can be an important part of helping you 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 you the most positive outcomes. You can also take prescribed pain medications to make the process easier and less painful.

Recap

How long you stay in the hospital after surgery will depend on the nature of your surgery and how you are feeling afterward. During your recovery, physical therapy can be a key part of healing and regaining mobility.

Complications and Risks

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

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, but risks can be avoided by determining this with preoperative testing
  • 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

Call your healthcare provider or go to your local emergency room if you experience 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

Recap

Most joint replacement and spine surgeries don't have major complications, but all surgeries come with risks of complications, such as infection or blood clots. Seek medical attention if you have any sudden swelling, pain, difficulty breathing, or signs of infection after surgery.

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.

A Word From Verywell

If you are considering joint or spine surgery for AS, discuss all options and concerns with your healthcare providers to better understand and evaluate your situation. Surgery is often successful and can improve quality of life, but it's not without risks.

After a spine or joint surgery, make sure you keep up with any recommended physical therapy afterward to increase your chances of a successful outcome.

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8 Sources
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