What are the advances for surgical therapy of inflammatory diseases of the spine?

Surgery for rheumatoid arthritis (RA) and spondyloarthropathies is a palliative surgery, and testifies to the failure of conservative treatment. In RA, surgery is generally used to deal with upper cervical instability and peridens pannus compression. These complications can have dramatic neurological consequences and can even be life threatening. Every effort must be made to avoid unnecessary surgery but, if needed, the indication must be precise and timely to be efficient. Instrumented fusion is indicated but the need for pannus excision is discussed. In ankylosing spondylitis (AS), major deformity will be the indication for corrective surgery if this deformity induces a marked decrease in the field of vision, thoracicy or abdominal problems or respiratory and mandibular troubles in the cervical spine. Different types of osteotomies with instrumented fixation are described. In AS. surgery is also indicated in fractures that are potentially unstable. At the cervical level these fractures are a surgical emergency. Neurological compressions and spondylodiscitis are other reasons for surgery in AS. Complications of other spondyloarthropathies, which include accompanying psoriasis, reactive arthritis, enteropathic arthritis or Behcet's syndrome are occasionally treated surgically along the same lines as RA or AS. Surgery for spinal inflammatory disorders involves major procedures with a high rate of severe complications. The indications for this type of surgery must be extremely precise and both the surgeon's and the patient's expectations must be clear and realistic. The surgery should only be performed by a surgeon who is experienced with this type of patient and procedure but, furthermore, it should also only be camed out in a centre with a team of neurologists, anaesthetists, nurses and physical therapists who have the expertise to work with these pathologies and these often severely debilitated patients. Only under these conditions will the outcome justify the burden and the risks.