An Overview of Ankylosing Spondylitis Surgery

Treatment for ankylosing spondylitis (AS) usually includes non-steroidal anti-inflammatory drugs (NSAIDs), steroids, biologics, disease-modifying anti-rheumatic drugs (DMARDs), and physical therapy. These treatments should be enough to prevent severe joint degeneration and deformity. For some people, however, spine and hip damage become severe enough that they affect mobility and ability to perform daily tasks, and quality of life becomes comprised. In these cases, surgeons suggest surgical options for correcting AS spine problems and replacing deformed joints. Joint replacement, especially hip replacement, is more common in people with AS than spine surgery.

What Is AS?

Ankylosing spondylitis (AS) is a type of inflammatory arthritis that affects the spine, sacroiliac (SI) joints, SI joints, and facet joints. Ankylosing spondylitis (AS) is a type of inflammatory arthritis that affects the spine, sacroiliac (SI) joints, and facet joints. Your SI joint, which supports the entire upper body, is located between the sacrum and ilium bones of the pelvis, 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 (small bones forming the backbone), one on each side of the spine.

In severe cases of AS, new bone formation causes the spine to abnormally fuse. Because AS also causes inflammation, other joints, like the hips, knees, and shoulders, may also become deformed and damaged.

Types of Surgery for AS

The type of surgery recommended will depend on a person’s situation and what symptoms they have. But there a number of procedures that are often performed to repair spine deformity and joint damage in people with AS.

Most people with AS never have surgery. However, surgery is an option when a person has significant spinal deformities and severe joint problems. 

Hip Replacement

People with AS frequently develop damage in the tissues and joints of the hips. Hip replacement can be helpful, but there are few studies on potential outcomes for people with AS who have a hip replacement. However, one 2014 study compared the results of people with AS and osteoarthritis (OA) who had hip replacements. While many of the AS patients had more severe function difficulty pre-surgery in comparison to the OA patients, two years after surgery, there was no level of function or pain differences between the AS patients and the OA patients.

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

AS can cause the cervical vertebrae (the top part of the spinal column, at the neck) to fuse, resulting in a frozen bent-over position. When bones become fused, bone has developed between two or more joints, causing them to connect. When the upper part of the spine becomes fused, it makes it hard to stand up straight or face forward. Instead, it forces the person to look downward.

An osteotomy surgery that cuts and reshapes bone can help. But spine procedures do come with risk. It is a good idea to find an orthopedic surgeon who specializes in correcting this type of deformity. The success rate for this type of procedure could be up to 80% when done correctly by a qualified surgeon. To straighten the curvature, the bone must be removed from the neck’s base and remaining bone fused together.

Spinal Infusion Instrumentation

A spinal infusion 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.


AS puts 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. The most common decompression surgery performed on people with AS is a laminectomy.

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 the spinal cord (the posterior part of the spinal ring that covers the spinal cord and nerves). The lamina is removed to access the disk. Removing the lamina will take 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.

Before Surgery

Having surgery for AS complications can help to relieve pain and allow you to live a fuller, more active life. Before surgery, you will need time to prepare yourself, both physically and psychologically. 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 doctor and ask about things that concern you. Your questions may include:

  • How long will you be in the hospital?
  • What type of anesthesia is used?
  • What type of implant or prosthesis will be used?
  • 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.

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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 doctors 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.

Get Your Body in Shape

Getting your body in good physical shape before surgery helps to lessen the potential for complications and shortens 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 doctor about resources for quitting smoking.
  • Eat a healthy diet. If you are overweight, ask your doctor about a weight loss program designed for people getting ready for surgery.
  • If you consume alcohol, don’t drink for at least 72 hours prior to surgery.
  • Don’t use controlled substances, as these medications can impact surgery. Talk to your doctor about alternatives to help you manage pain in the days before surgery.
  • Ask your doctor about exercises to do prior to surgery, especially those that can make your upper body and legs stronger. You may need to use crutches or a walker after surgery and the stronger your body is, the easier it will be to get around. Plus, it is a good idea to familiarize yourself with exercises now, so you can perform them after surgery.

Planning for Your Return Home

Both joint replacement surgery and spine surgery 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 disabled parking permit, consider getting one before surgery. Contact your local Bureau of Motor Vehicles or ask your doctor’s office for more information.

Surgery Preparation

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, 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 doctor 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 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.

During Surgery

Joint replacement and spine surgeries are now minimally invasive, meaning the incisions are smaller. The smaller the cut is, the less blood loss and pain there is. This also shortens hospital stay, reduces scarring, and speeds healing.

Hip Replacement

At the start of the hip replacement procedure, you likely will be given anesthesia to relax muscles and put you to sleep. The doctor 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 doctor 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. Once you are unconscious, you are placed face down on the operating table.

Depending on the nature of the spine surgery, the process includes the surgeon making an incision over the spine and exposing the bones of the spinal column. Screws are 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. The surgeon will cut and remove any bony spurts extending from the back part of the vertebra. Parts of the lamina and facet joints may be removed or realigned as well.

Lastly, the spine is 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.

After Surgery

Your stay in the recovery room depends on the extent of your procedure, how it went, 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 will 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 a responsible adult drive you home. Once you are home, you will need to make an appointment for a follow-up postoperative visit with the surgeon.

Complications and Risks

Joint replacement surgeries and spine surgeries don’t generally involve major complications. This is because surgeons do everything to avoid and manage potential problems that may arise during surgery. But the reality is, all surgeries— whether major or minor—generally do come with risks, including:

  • Post-operative infections, which doctors try to avoid with the administration of antibiotics before, during and after surgery
  • Blood clots that may appear after surgery, but these can 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 shows at least a quarter of patients who have spine surgery may experience complications.

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

Blood clots and infections are the most common complications associated with orthopedic surgery and may occur in the first few days and weeks following the surgery. 

Call your doctor 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 of over 100 degrees
  • Chills or shaking

A Word From Verywell

Both spinal surgery and joint replacement surgery respond better with physical therapy (PT) afterward. PT is an important part of helping you to heal and also plays a role in the successes and gains of AS surgery. A program that involves strengthening, conditioning, and stretching will offer you the most positive outcomes. Therefore, it is important to participate in all sessions, take prescribed pain medications to make the process easier and less painful, and put in a good faith effort.

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Article Sources
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