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Ankylosing Spondylitis





  • Potential difficult airway

  • Risk of ↓ c-spine mobility/fusion/instability 

  • Atlanto-axial subluxation possible 

  • Multisystem disease with extra-articular features: 

    • Cardiac: aortic insufficiency, myocarditis, conduction defects, cardiomegaly, cardiomyopathy, pericardial effusion

    • Respiratory: restrictive lung disease from parenchymal fibrosis & chest wall musculoskeletal disease 

    • Neuro: spondylolisthesis (cord compression), uveitis

    • Heme: anemia of chronic disease 

  • Difficult/impossible regional & neuraxial anesthesia due to poor positioning, axial spine fusion, epidural space obliteration, & underlying radiculopathies/neuropathic pain

    • Higher risk epidural hematoma (ASRA)

    • Paramedian might be a better approach

  • Medications: NSAIDS, steroids, immunomodulators: marrow suppression, platelet dysfunction, renal impairment, need for steroid coverage, ↑ infection risk 





  • Minimize c-spine manipulation with airway management, consider AFOI, videolaryngoscopy, lighted stylet

  • Management of multisystem disease features, especially cardiopulmonary 

  • Patient positioning

  • Recognition of difficult neuraxial & unpredictable response to neuraxial local anesthetics



Pregnancy Considerations 


  • Complicated due to difficult airway & difficult neuraxial technique, have multiple plans in place

  • For neuraxial: consider paramedian approach & ultrasound guidance 

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