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| Year : 1987 | Volume
: 33
| Issue : 3 | Page : 146-8 |
Vertebro-basilar insufficiency associated with longstanding ankylosing spondylitis.
Sharma RR, Sharma AA, Shah ND, Patkar SV, Goel AA, Sharma NN
How to cite this article:
Sharma R R, Sharma A A, Shah N D, Patkar S V, Goel A A, Sharma N N. Vertebro-basilar insufficiency associated with longstanding ankylosing spondylitis. J Postgrad Med 1987;33:146 |
How to cite this URL:
Sharma R R, Sharma A A, Shah N D, Patkar S V, Goel A A, Sharma N N. Vertebro-basilar insufficiency associated with longstanding ankylosing spondylitis. J Postgrad Med [serial online] 1987 [cited 2023 May 31];33:146. Available from: https://www.jpgmonline.com/text.asp?1987/33/3/146/5271 |
Neurological complications in the patients with long-standing ankylosing spondylitis (A.S.) have very rarely been described,[6] that too, only recently.[8] We came across a patient of long-standing AS who presented with a clinical picture of vertebro-basilar insufficiency. The same is being reported here.
A 40 year old female, who was a known case of long standing AS with involvement of both hips was admitted with us. She used to get pain in both lower limbs, off and on. Since last 10 years, prior to admission, she was getting progressive pains and restriction of movements along the entire spinal column but more in cervical region. However, she had attributed these symptoms to spinal anaesthesia given to her for tubal ligation a decade prior to admission. Progressively she started stooping while walking and used to rest for a while after a short walk.
Since 4 months prior to admission, suddenly she began to experience acute, episodic attacks of paraesthesia and stiffness of one half of the body (either right or left half at a time) with much distress and palpitations. Severe giddiness, unsteadiness, light headedness and heaviness in right eye were always associated during these attacks. Attacks were more common in periods of active household work, especially during evening hours before retiring to bed. She used to feel much relieved in lying down position. Each attack was lasting for 1-2 hours. But during intervals in between these attacks she remained free from any one of these distressing symptoms. There was no history of fall, trauma, infection, diabetes, hypertension, cardiorespiratory and vascular disorders, fluorine intoxication, hypervitaminosis 'A', hyperparathyroidism or any other major illness in the past.
General physical examination was unremarkable except that she was obese. Her resting pulse rate was 80 per minute, regular in rate and rhythm and good in volume. Blood pressure was stable around 130/90 millimeters of mercury in both supine and standing positions. Respiratory rate was 18 per minute. No signs suggestive of systemic disorder were recorded. Central nervous system examination, too, was normal except for depressed deep tendon reflexes in the lower limbs. The spinal column movements were markedly restricted. In the cervical region only 15° to 20° of side to side rotation and flexion-extension movements were possible without experiencing discomfort.
Laboratory investigations were unremarkable. Plain X-rays of pelvis and spine revealed typical features of ankylosing spondylitis. Frontal view of cervical spine [Fig. 1] showed diffuse osteopenia. The vertebral end plates were irregular in outline, the disc spaces being reduced. Prominent lateral osteophytic spurring was seen in relation to the Luschka's joints. Arthritis with articular irregularity and joint space reduction was also seen along the facet joints (most evident at C6-7). Incidentally, arthr of the costo-transverse joint at D1 level was noted. Lateral views of cervical spine in flexion [Fig. 2], and in extension [Fig. 3] ruled out instability at the atlanto-ocipital and atlanto-axial joints. Facetal arthritis with new bone formation was confirmed all along the cervical region. Absence of posterior spurring and canal stenosis was noted. However, this patient was treated symptomatically. Analgesics and cervical immobilization with a cervical collar reduced the episodes considerably giving the patient substantial relief.
Ankylosing spondylitis and its different spinal, extra-spinal, musculoskeletal and extra-musculoskeletal involvement has been described in literature.[3],[4]
Vertebral arteries due to their peculiar course in the cervical region through foramina transversorium and over first cervical vertebrae remain in a precarious state in patients with severe long standing AS even in absence of cranio-spinal instability. Blood flow in these vessels may be severely compromised due to encroachment upon them by overgrown new bone and ossified soft tissues including ligaments, and may result in vertebro-basilar insufficiency. This is more likely during active movements of ankylosed cervical spine. Minor degrees of movements, which are of no consequences in normal individuals, may result in sudden unwarranted alterations in delicate state of these vessels in patients with severe long standing AS. Thus, these patients feel much comfortable after immobilization of cervical spine with a cervical collar and in a supine position, which was what happened in our patient. It was suggested that commonly such patients tend to be in middle or old age and arterial degenerative changes may be in part responsible.[7] However, our patient had no indication of such changes. To the best of our knowledge, therefore, only two cases of vertebro-basilar insufficiency in AS perse are reported in the literature by Thomas et al[5] in some details. Their first patient, aged 56, had had AS for 28 years and for 2 years had suffered attacks of vertigo provoked by neck movements. During these attacks nystagmus was also evident. Their second patient aged 58 had attacks of vertigo associated with visual disturbances. At all times he showed nystagmus, intention tremor, and an ataxic gait. His symptoms were controlled to some extent by a cervical collar, as in our patient. They commented that 'vertebral angiography was not attempted but it is reasonable to assume that both vertebral arteries were kinked forwards by the new bone formation'. In the opinion of present authors, vertebral angiography procedure may be hazardous in such patients, as manipulations of cervical spine while taking X-rays, and manipulation with vertebral arteries while negotiating a catheter may lead to disastrous neuro-vascular complications. However, intravenous digital substraction techniques will be of great help in such patients in evaluation of the state of the vertebral arteries. The purpose of this article is to recognise this poorly understood, rare and serious complication in AS and be familiar with its clinical profile and 'preventive' management.
We gratefully thank Professor S. K. Pandya, M.S., Head, Department of Neurosurgery, Seth G. S. Medical College and K.E.M. Hospital, Bombay, for his persistent encouragement and guidance. Thanks to our Dean for permitting us to utilize hospital data and to Mr. U. M. Godhwani, Mr. V. Ambetkar and Mr. K. B. Dave for their excellent secretarial help.
| 1. | Coste, F.: Aubigne, R. M. and Garcin, R.: Paroxysmal bulbar disorders caused by anterior atlanto-occipital subluxation in a case of ankylosing spondylarthritis. Favourable result of a posterior graft, Sem. Hop. Paris, 36: 1130-1133, 1960. Quoted by Whitfield.[8]  |
| 2. | Davidson, R. 1. and Tyler, H. R.: Bulbar symptoms and episodic aphonia associated with atlanto-occipital subluxation in ankylosing spondylitis. J. Neurol. Neurosurg. Psychiat., 37: 691-695, 1974. |
| 3. | Guttmann, L.: Tetraplegia in ankylosing spondylitis. In, "Handbook of Clinical Neurology." Vol. 26: Editors: P. J. Vinken and G. W. Bruyn. North-Holland Publishing Co. Amsterdam, New York and Oxford, 1976, Pp. 175-183. |
| 4. | Smukler, N.: Arthritic disorders of the spine. In, "The Spine," Vol. 2. Editors: R . H. Rothman and F. A. Simeone. W.B. Saunders Co. Philadelphia, London and Toronto, 1975, Pp. 721-790. |
| 5. | Thomas, O. J., Kendall, M. J. and Whitefield, A. G. W.: Nervous system involvement in ankylosing spondylitis. Brit. Med. J., 1: 148-150, 1974. |
| 6. | Weinstein, P. R., Karpman, R. R., Gal, E. P. and Pitt, M.: Spinal cord injury, spinal fracture and spinal stenosis in ankylosing spondylitis. J. Neurosurg., 57: 609-616. 1982. |
| 7. | Whitfield, A. G. W.: Ankylosing spondylitis. J. Roy. Coll. Phys., 11: 107-120, 1976. |
| 8. | Whitfield, A. G. W.: Neurological complications of ankylosing spondylitis. In "Handbook of Clinical Neurology." Vol. 38. Editors: P. J. Vinken and G. W. Bruyn, North-Holland Publishing Co Amsterdam. New York and Oxford, 1979. Pp. 505-510. |
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