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P-351
Ankilozan Spondilitte Dorsal Spondilodiskitin Ortopedik Cerrahi Giriflim
Sonras› Uzun Dönem Takibi: Olgu Sunumu
Hidayet Sar› 1, Kerem Gün 1, Tu¤çe Özekli M›s›rl›o¤lu 1, Önder Ayd›ngöz 2
1 ‹stanbul Üniversitesi Cerrahpafla T›p Fakültesi Fiziksel T›p ve
Rehabilitasyon Anabilim Dal›, ‹stanbul
2 ‹stanbul Üniversitesi Cerrahpafla T›p Fakültesi Ortopedi ve
Travmatoloji Anabilim Dal›, ‹stanbul
Ankilozan spondilitte (AS) spondilodiskit (SD) geliflimi fliddetli s›rt ve bel a¤r›s›n›n önemli
sebeplerinden biridir ve omurga k›r›klar› ile enflamatuvar diskitlerle kar›flabilmektedir.
Konservatif tedavi s›kl›kla yeterli olmakla birlikte, baz› olgularda cerrahi müdahaleye ihtiyaç
duyulabilir. Biz bu olgu sunumunuzda ani fliddetli s›rt a¤r›s› ile baflvuran, dorsal SD tan›s›
koydu¤umuz ve konservatif tedaviye cevap vermeyen bir AS olgumuzu sunmak istiyoruz.
Oniki y›ld›r AS tan›s› ile takip edilen 35 yafl›nda erkek hasta 2 sene önce bafllayan, son 3 ayd›r
fliddetlenen s›rt a¤r›s› flikayetiyle baflvurdu. Bilinen bir travmas› olmayan hastan›n a¤r›s› özellikle
hareketle art›yor, a¤r› kesicilere yan›t vermiyordu. Fizik muayenesinde dorsal kifoz
artm›flt›. D5-D10 dorsal vertebralar› presyonla a¤r›l›, vertebral kolon hareketleri her yöne ileri
derecede k›s›tl› ve a¤r›l›yd›. Hastan›n laboratuvar tetkiklerinde ESH 2mm/sa, CRP 3,1 idi.
Hastan›n dorsal MRG’sinde D7-8, D8-D9, D9-10 disklerde ve komflu end platelerde T1’de hipo,
T2’de hiperintens izlenen, kontrast tutulumu gösteren SD ile uyumlu görünüm mevcuttu.
Hastada enfeksiyöz SD ay›r›c› tan›s› yap›ld›ktan sonra hastaya AS’ye ba¤l› SD tan›s› konularak
torako-lumbo-sakral ortez (TLSO) verildi. Öncesinde indometasin 150 mg/gün, sülfasalazin
2000 mg/gün kullanan hastaya infliksimab tedavisi baflland›. Yaklafl›k 2 ay bu tedavi ile takip
edilen hastada klinik ve radyolojik olarak anlaml› bir de¤ifliklik izlenmeyince hasta operasyon
amac›yla ortopedi klini¤ine yönlendirildi. Hastaya D2-L2 aras› posterior enstrümentasyon ile
tespit operasyonu uyguland›. Operasyon sonras› erken dönemde de¤erlendirilen hastan›n
fliddetli s›rt a¤r›s› dramatik bir flekilde azald›. Yedi y›l boyunca takip edilen hastan›n flikayetlerindeki
iyilik hali süreklilik arz ederken ileri dönemlerde SD seviyelerinde füzyon geliflti¤i
saptand›. Sonuç olarak AS’ye ba¤l› SD’li konservatif tedaviye cevap vermeyen olgularda cerrahi
giriflimin a¤r› ve enflamasyonu kontrol alt›na alarak k›sa dönemde faydal› oldu¤u, uzun
dönemde de dorsal kifoz geliflimini engelleyerek postürü korudu¤u ve fonksiyonlar›n
kayb›nda önleyici oldu¤u sonucuna var›lm›flt›r.
Anahtar Kelimeler: Ankilozan spondilit, posterior enstrümentasyon, spondilodiskit
P-352
Ankilozan Spondilit mi, Diffüz ‹diopatik ‹skeletal Hiperostoz mu? Karar›n›z Nedir?
Tu¤çe Özekli M›s›rl›o¤lu, Hidayet Sar›, Nurettin ‹rem Örnek, Ülkü Akar›rmak
‹stanbul Üniversitesi Cerrahpafla T›p Fakültesi Fiziksel T›p ve
Rehabilitasyon Anabilim Dal›, ‹stanbul
Ankilozan spondilit (AS) özellikle gençlerde ortaya ç›kan ve omurgay› tutan, sistemik, kronik,
iltihabi bir romatizmal hastal›k olmas›na ra¤men diffüz idiopatik iskeletal hiperostoz (D‹SH)
ileri yafllarda ortaya ç›kan yayg›n, dejeneratif bir eklem hastal›¤›d›r. Bu iki hastal›¤›n flikayet ve
klinik bulgular› tamamen ayr› olmas›na ra¤men radyolojik bulgular›nda benzerlikler nedeniyle
kar›flabilir, yanl›fl teflhis ve tedavilere yol açabilir. Özellikle sessiz seyreden AS’li hastalar
teflhiste gecikmeler nedeniyle ileri yafllarda dejeneratif omurga hastal›klar›yla kar›flabilir.
Ayr›ca, D‹SH hastal›¤›ndaki radyolojik bulgular nedeniyle ileri yaflta karfl›m›za gelen olgularda
AS mi yoksa D‹SH mi karar› vermek zorlaflabilir. Biz bu olgu sunumuzda 40 senedir boyun,
s›rt, bel ve her iki kalçada a¤r› flikayetleri olan 73 yafl›nda erkek hastay› ele al›yoruz. Hastan›n
radyolojik incelemesinde dorsal ve lomber omurgada bambu kam›fl› manzaras›, dorsal ve
lomber ön ligaman kalsifikasyonu geliflimi ile tipik bir AS görünümü mevcuttu. Sakroiliak
eklemin incelemesinde iliolumbar ligaman kalsifikasyonu, BT incelemesinde ise dejeneratif
sakroiliak eklem görünümü tespit edildi. Hastan›n HLA-B27 antijeni negatifti. Akut fazlar› normal
bulundu. AS ve D‹SH ileri yafllarda klinik ve radyolojik olarak birbirleri ile kar›flabilir.
Bu nedenle erken yafllarda sessiz seyreden AS olgular›n›n ileri yafllarda D‹SH bulgular› ile
karfl›m›za ç›kmas› mümkündür. Bu olgumuzun AS mi, D‹SH mi oldu¤una siz karar verin
diyoruz.
Anahtar Kelimeler: Ankilozan spondilit, diffüz idiopatik iskeletal hiperostoz, sakroiliit
327
23. Ulusal Fiziksel T›p ve Rehabilitasyon Kongresi / 23 rd National Physical Medicine & Rehabilitation Congress
Türk Fiz Rehab Derg 2011:57Özel Say›; 1-334 /Turk J Phys Med Rehab 2011:57Suppl; 1-334
P-351
Long Term Follow-Up of Dorsal Spondylodiscitis in Ankylosing Spondylitis
After Orthopedic Surgery: Case Report
Hidayet Sar› 1, Kerem Gün 1, Tu¤çe Özekli M›s›rl›o¤lu 1, Önder Ayd›ngöz 2
1 Istanbul University Cerrahpasa School of Medicine Department of Physical
Medicine and Rehabilitation, Istanbul
2 Istanbul University Cerrahpasa School of Medicine Department of
Orthopedics Surgery, Istanbul
Spondylodiscitis (SD) in ankylosing spondylitis (AS) is an important cause of severe back and
low back pain and can be confused with fractures of spine and inflammatory discitis.
Although conservative treatment is often sufficient, surgery is needed in some cases. In this
case report, we present you a patient with AS who was diagnosed as SD after admitting to
our clinics with sudden severe back pain but did not relieve after the conservative treatment.
A 35 years old man, known to have AS, admitted to our clinics with severe back pain which
had started two years ago but had been increasing gradually for the last three months. The
pain, without a history of preceding trauma, was increasing during movement and was not
relieving with nonsteroidal anti-inflammatory drugs. In his physical examination dorsal
kyphosis was increased. The pression of D5-10 vertebrae were painful and movements of
vertebral column were limited and painful. In his laboratory examination, ESR was 2mm/hr
and CRP was 3.1. His dorsal MRI was compatible with SD at D7-8, D8-9, D9-10 end-plate and
disc levels which showed hypointensity in T1-, hyperintensity on T2-weighted images and
increased contrast enhancement. After infectious SD was eliminated and the patient was
diagnosed as SD caused by AS, thoraco-lumbo-sacral orthesis (TLSO) was given. Using
indomethasin of 150 mg/day and sulphasalasin of 2000 mg/day beforehand, we started
infliximab treatment. Since there was not a significant improvement both clinically and
radiologically after 2 months of follow-up, the patient was referred to orthopedics for
surgery. A stabilization operation with posterior instrumentation was performed between the
levels of D2-L2. There was a dramatic relief of his severe dorsal pain in early periods
postoperatively. While wellness of the patient continued for the last seven years of follow-up,
fusions at the levels of severe SD were observed. In conclusion, we came into the result that
when conservative treatment fails, surgical operation is helpful in patients with SD caused by
AS by taking pain and inflammation under control in the early period and preventing from
development of dorsal kyphosis and loss of function in the late period.
Keywords: Ankylosing spondylitis, posterior instrumentation, spondylodiscitis
P-352
Do You Think it is Ankylosing Spondylitis or Diffuse Skeletal Hyperostosis?
What is Your Decision?
Tu¤çe Özekli M›s›rl›o¤lu, Hidayet Sar›, Nurettin ‹rem Örnek, Ülkü Akar›rmak
Istanbul University Cerrahpasa School of Medicine Department of Physical
Medicine and Rehabilitation, Istanbul
Ankylosing spondylitis (AS) is a chronic systemic rheumatologic disease of spine mostly
affecting young people. On the other hand, diffuse skeletal hyperostosis (DISH) is a
degenerative joint disease mostly affecting people of old age. Although both of the diseases
have different symptoms and clinical signs, their radiological findings are common, so they
can be easily confused with each other and this can cause mistakes in diagnosis and
treatment. Because of the delay in diagnoses, especially in silent forms of AS can be confused
with degenerative spine diseases at the old ages. Besides when a patient with DISH admits
to us at old ages, because of the radiological findings, it can be difficult to decide whether the
patient has AS or DISH. In this case report, we represent you a 73 years old man
complaining of neck, back and hip pain for 40 years. He seemed to have a typical AS with
bamboo spine and anterior ligament calcification of dorsal and lumbar spine. In the
radiological examination of sacroiliac joints, there was iliolumbar ligament calcification in
x-ray and degeneration in CT. His HLA-B27 antigen was negative and acute phase reactants
were normal. In conclusion, AS and DISH can be easily confused both clinically and
radiologically at the old ages. Therefore, it is possible for AS cases that are silent in young
ages to be present with the signs of DISH in when they are old. For this case, we are leaving
the decision to you: Is our case AS or DISH?
Keywords: Ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, sacroileitis