Ankilozan Spondilitte PSO Sonrası Ağrı Azalması ve Fonksiyonel İyileşme Üzerine Osteotomi Seviyesinin Etkisi: Retrospektif Kohort Çalışması

Abstract

Amaç: L3 ile L4 Pedikül subtraksiyon osteotomisi (PSO) seviyesinin karşılaştırması, rijit torakolomber kifoz nedeniyle düzeltici cerrahi geçiren ankilozan spondilit (AS) hastalarında ağrı ve fonksiyonel sonuçlar üzerindeki etkisini, Oswestry Disabilite İndeksi (ODI) ve Vizüel Analog Skala (VAS) gibi geçerliliği kanıtlanmış klinik ölçütler kullanarak değerlendirmek. Yöntem: Bu retrospektif karşılaştırmalı çalışmaya, Ocak 2017 ile Aralık 2024 tarihleri arasında tek seviyeli PSO uygulanan 34 ankilozan spondilit hastası dahil edildi. PSO işlemi L3 seviyesinde (n = 17) veya L4 seviyesinde (n = 17) gerçekleştirilmiştir. Tüm cerrahiler yalnızca posterior yaklaşımla, anterior destek olmadan uygulanmıştır. Preoperatif ve postoperatif ağrı ve fonksiyonel yetersizlik, ODI puanı, ODI yüzdesi ve VAS ile değerlendirilmiştir. Osteotomi seviyeleri arasındaki klinik iyileşme derecesi istatistiksel olarak karşılaştırılmıştır. Bulgular: Her iki grupta da postoperatif dönemde ODI ve VAS skorlarında anlamlı iyileşme gözlenmiştir. Ortalama ODI yüzdesi preoperatif %53,6’dan postoperatif %42,2’ye gerilemiş, VAS skorları ise ortalama 5,6’dan 3,3’e düşmüştür. L4 grubunda, L3 grubuna kıyasla ODI ve VAS skorlarında daha yüksek ortalama azalma saptanmış olsa da, bu fark istatistiksel olarak anlamlı bulunmamıştır. Majör nörolojik komplikasyon bildirilmemiştir. Sonuç: Hem L3 hem de L4 seviyesinde yapılan tek seviyeli PSO, ankilozan spondilitli ve rijit kifotik deformiteli hastalarda ağrıyı ve fonksiyonel kısıtlılığı azaltmada etkilidir. Her iki seviyede de klinik olarak anlamlı sonuçlar elde edilirken, L4 osteotomisi, pelvik hizalanma üzerindeki etkisi nedeniyle ek fonksiyonel ve semptomatik fayda sağlayabilir. Bu hasta grubunda optimal osteotomi seviyesinin belirlenmesi için ileriye dönük çalışmalara ihtiyaç vardır.

Keywords

• Ankilozan spondilit
• pedikül subtraksiyon osteotomisi
• sagital dengesizlik
• Oswestry Disabilite İndeksi
• vizüel analog skala

Effect of osteotomy level on pain relief and functional recovery after PSO in ankylosing spondylitis: A retrospective cohort study

Abstract

To evaluate the effect of pedicle subtraction osteotomy (PSO) level-L3 versus L4-on pain and functional outcomes in patients with ankylosing spondylitis (AS) undergoing corrective surgery for rigid thoracolumbar kyphosis, using validated clinical measures including the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS). This retrospective comparative study included 34 patients with ankylosing spondylitis who underwent single-level PSO at either L3 (n = 17) or L4 (n = 17) between January 2017 and December 2024. Osteotomy level was selected according to the apex of the kyphotic deformity, segmental sagittal morphology, and the intended correction point. Clinical outcomes were assessed using the Oswestry Disability Index and Visual Analog Scale. Radiological assessment included preoperative and postoperative sagittal vertical axis, pelvic tilt, sacral slope, and pelvic incidence–lumbar lordosis mismatch. Operative time, estimated blood loss, complications, and follow-up duration were also recorded. Both groups demonstrated significant postoperative improvement in Oswestry Disability Index and Visual Analog Scale scores. The mean ODI percentage improved from 53.6% preoperatively to 42.2% postoperatively, and VAS scores decreased from 5.6 to 3.3 overall. The L4 group showed greater mean improvement in ODI percentage than the L3 group, although the difference approached but did not reach statistical significance. Intergroup comparisons showed p-values of 0.162 for ODI score improvement, 0.067 for ODI percentage improvement, and 0.235 for Visual Analog Scale improvement. Radiological assessment showed improvement in sagittal vertical axis, pelvic tilt, sacral slope, and pelvic incidence–lumbar lordosis mismatch in both groups, with greater pelvic tilt correction in the L4 group. Mean follow-up duration was 18.7 ± 5.4 months in the L3 group and 19.3 ± 6.1 months in the L4 group. No major neurological complications were observed. Single-level PSO at either L3 or L4 is effective in improving pain and disability in patients with ankylosing spondylitis and fixed kyphotic deformity. While both levels yielded clinically meaningful outcomes, L4 osteotomy may offer additional functional and symptomatic benefit due to its influence on pelvic alignment. Further prospective studies are needed to confirm the optimal level of osteotomy in this patient population.

Keywords

• Ankylosing spondylitis
• pedicle subtraction osteotomy
• sagittal imbalance
• Oswestry Disability Index
• visual analog scale

References

1. Braun J, Sieper J. Ankylosing spondylitis. Lancet 2007;369(9570):1379-1390 DOI: 10.1016/S0140-6736(07)60635-7. Singh M, Muhamad Ariffin MH, Tan JA, Sabri S, Baharuddin A. From looking at the floor to looking forward: a case of hyperkyphotic spine in an ankylosing spondylitis patient. Cureus. 2024;16(9):e70091. DOI: 10.7759/cureus.70091.
2. Ward MM, Deodhar A, Gensler LS, et al. 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. DOI:10.1002/art.41042.
3. Luo J, Wu T, Yang Z, et al. An effective strategy for treatment of severe kyphosis secondary to ankylosing spondylitis: one-level modified osteotomy combined with shoulders lifting correction method. J Orthop Surg Res. 2024;19:536. DOI: 10.1186/s13018-024-05005-2.
4. Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Baldus C, Blanke K. Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am. 2004;86(1 Suppl):44-50. DOI: 10.2106/00004623-200403001-00007
5. Luan H, Liu K, Kahaer A, et al. Pedicle subtraction osteotomy for the corrective surgery of ankylosing spondylitis with thoracolumbar kyphosis: experience with 38 patients. BMC Musculoskelet Disord. 2022;23:731. DOI: 10.1186/s12891-022-05693-z.
6. Yıldız F, Akgül T, Ekinci M, Dikici F, Şar C, Domaniç Ü. Results of closing wedge osteotomy in the treatment of sagittal imbalance due to ankylosing spondylitis. Acta Orthop Traumatol Turc. 2016;50(1):63-8. doi: 10.3944/AOTT.2016.14.0059.
7. Debarge R, Demey G, Roussouly P. Sagittal balance analysis after pedicle subtraction osteotomy in ankylosing spondylitis. Eur Spine J. 2011;20(Suppl 5):619-625. DOI: 10.1007/s00586-011-1929-9.
8. Tang ZL, Qian BP, Qiu Y, Liu ZJ, Zhao SZ, Huang JC. Does the Level of Pedicle Subtraction Osteotomy Affect the Surgical Outcomes in Ankylosing Spondylitis-Related Thoracolumbar Kyphosis With the Same Curve Pattern? Global Spine J. 2022 Sep;12(7):1392-1399. doi: 10.1177/2192568220980716.

9. Xu H, Zhang Y, Zhao Y, Zhang X, Xiao S, Wang Y. Radiologic and clinical outcomes comparison between single- and two-level pedicle subtraction osteotomies in correcting ankylosing spondylitis kyphosis. Spine J. 2015;15(2):290-297. DOI: 10.1016/j.spinee.2014.09.014.
10. Zhang PC, Deng Q, Sheng WB, Guo HL, Mamat M, Luo YX, Gao ST. The Sagittal Parameters and Efficacy of Pedicle Subtraction Osteotomy in Patients with Ankylosing Spondylitis and Kyphosis Under Different Lumbar Sagittal Morphologies. Int J Gen Med. 2021 Feb 5;14:361-370. doi: 10.2147/IJGM.S292894.
11. Barrey C, Perrin G, Michel F, Vital JM, Obeid I. Pedicle subtraction osteotomy in the lumbar spine: indications, technical aspects, results and complications. Eur J Orthop Surg Traumatol. 2014;24(Suppl 1):S21–S30. DOI: 10.1007/s00590-014-1470-8.