Dialysis-associated spondylarthropathy

Report of 10 cases

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✓ Ten patients undergoing long-term renal dialysis for end-stage renal failure developed a destructive, noninfectious spondylarthropathy. All 10 patients had biopsy-proven dialysis-associated spondylarthropathy and subsequent spinal instability secondary to beta 2-microglobulin deposition in the vertebrae, intervertebral disc spaces, and support structures of the spine. Nine patients had cervical spinal instability and one had thoracolumbar spinal instability, with resultant neural compression. In at least one patient, the spinal instability was rapidly progressive. All had received renal dialysis for 34 months or longer (mean 109 months, range 34 to 154 months). Each patient required spinal stabilization (external in seven patients, internal in three). Nine of the 10 patients underwent neural decompression and spinal stabilization and fusion procedures.

One patient's neurological condition was worse following surgery due to a postoperative cervical epidural hematoma; in the other nine patients, the presenting symptoms and signs improved. Three of these chronically ill patients did not survive their hospitalization, for a perioperative mortality rate of 30%. Death was due to cardiopulmonary arrest in two patients on Day 5 and 9 postoperatively and to sepsis in the third on Day 14. Of the seven early survivors, two additional patients died: one on Day 59 due to congestive heart failure and the other on Day 273 due to a cerebrovascular accident. Four of five patients who were followed for 8 months or longer (mean 14 months, range 8 to 20 months) had successful neural decompression and spinal stabilization procedures with evidence of stable bone fusion, indicating that these chronically ill, difficult-to-manage patients can be successfully treated. Clinicians who treat patients with renal disease and neurosurgeons who treat spinal disorders should be aware of dialysis-associated spondylarthropathy as a potential cause of degenerative vertebral column instability.

Article Information

Address reprint requests to: Mark N. Hadley, M.D., Division of Neurological Surgery, University of Alabama at Birmingham, 1813 Sixth Avenue South/ME 520, Birmingham, Alabama 35294.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Left: X-ray film demonstrating “skip lesions” at C3–4 and C5–6. Note the destructive changes involving the adjoining vertebral endplates at C3–4 and C5–6, with sparing of the C4–5 interspace. Right: X-ray film obtained 9 months following multilevel cervical corpectomies with strut fusion showing spinal stability and fusion incorporation. The patient had worn a halo vest for 5 months following surgery.

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    Case 6. Left: X-ray film showing minimal destructive changes at C5–6 (arrows). The patient suffered neck pain only. Right: X-ray film obtained 12 months later demonstrating marked destructive changes at C5–6. The patient developed myeloradiculopathy and cervical spinal instability.

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    Case 7. Left: Magnetic resonance T1-weighted image showing the low signal intensity of a destructive lesion at C7-T1 without a paravertebral mass. Right: Magnetic resonance image after intravenous gadolinium infusion revealing enhancement at the C7-T1 level (arrows). This imaging study was the only one for a dialysis-associated spondylarthropathy patient that revealed contrast enhancement.

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    Case 10. Upper Left: Lateral radiograph revealing destructive changes at C3–4 and C4–5. Note the congenital block vertebrae at C5–7. Upper Right: Magnetic resonance T2-weighted image showing degenerative changes and stenosis at C3–4 and C4–5. Lower Left: Postoperative radiograph obtained at the 2-month follow-up examination showing the interpositional graft from the middle of C-3 through the superior portion of C-6 with internal screw-plate fixation. Lower Right: Postoperative radiography obtained at the 12-month follow-up evaluation. Note breakage of superior fixation screws. The patient is asymptomatic with stability and apparent fusion.

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