Ank Spond

Question 1

what is ankylosing spondylitis

Answer 1

hla-b27 assoc spondyloarthropathy

axial spondyloarthritis
chronic progressive INFLAMMATORY arthropathy

may lead to radiographical changes in the spine and SI joints (then known as ankylosing spondylitis)

Question 2

typical presentation of ank spond:

Answer 2

insidious onset of LBP
stiffness worse in morning, improved by activity
pain at night
relieved by NSAIDs

Question 3

epidemiology of ank spond

Answer 3

males 3:1
20-30y

Question 4

ix ank spond

Answer 4

MOST USEFUL: plain x-ray of pelvis (best supported by evidence of sacroilitis)

esr, crp raised - but normal levels don’t exclude
hla-b27 + (but not specific/sensitive enough so not used alone)

Question 5

changes on radiograph in ank spond

Answer 5

early: maybe normal

later:
- sacroilitis: subchondral erosion, sclerosis SIJ
- squaring lumbar vertebrae
- bone fusion
- bamboo spine (uncommon though?)
- syndesmophytes
- CXR shows apical fibrosis

Question 6

why do syndesmophytes occur in ank spond

Answer 6

ossification of outer fibres of annulus fibrosus

Question 7

presentation of ank spond?

Answer 7

severe pain and spinal stiffness (worse in morning and improve throughout day), which may lead to radiographical changes in the spine and SI joints.

progression may lead to spinal fusion (complete spinal fusion -> extreme disability).

mainly affects the axial skeleton, although peripheral joints, entheses, and extra-articular sites (e.g. eye and bowel) are frequently affected(

Question 8

if xray -ve for SI joint involvement but HIS of ank spond then…?

Answer 8

MRI

Question 9

why may spirometry be used in ank spond ix?

Answer 9

may show restrictive defect due to combination of pulmonary fibrosis, kyphosis, ankylosis of costovertebral joints

Question 10

mx of ank spond

Answer 10

regular exercise
nsaids - first line
physio

anti-tnf (etanercept, adalimumab) if persistently high disease activity

Question 11

typical presentation of ank spond:

Answer 11

insidious onset of LBP
worse in morning, improved by activity
relieved by NSAIDs

Question 12

ank spond grading: new york criteria?

Answer 12

0: normal
I: some blurring of joint margins
II: minimal sclerosis with some erosion
III: definite sclerosis both sides of joint OR severe erosions with widening of joint space with or without ankylosis
IV: complete ankylosis

Question 13

clinical exam findings of ank spond?

Answer 13

reduced lat flexion
reduced forward flexion (Schober’s test)
reduced chest expansion

Question 14

what is Schober’s test?

Answer 14

line drawn 10m above and below L5
distance between two lines should increase by >5cm as pt bends forward as far as possible

Question 15

As a/w ank spond

Answer 15

apical fibrosis
ant uveitis
aortic regurg
achilles tendonitis
av node block
amyloidosis

CES
peripheral arthritis

Question 16

why does ank spond reduce chest expansion?

Answer 16

rib involvement can cause breathing discomfort -> reduced chest expansion -> shallower breaths over time

Question 17

what does localised spine tenderness suggest?

Answer 17

malignancy or fracture

Question 18

lumbar flexion severity grading?

Answer 18

mild: >4cm
moderate: 2-4cm
severe: <2cm

Question 19

in what % of ank spond pt is hla-b27+?

Answer 19

90%

Question 20

why is ank spond a/w apical lung fibrosis?

Answer 20

thought to be due to reduced chest expansion and chronic interstitial inflammation over time

Question 21

why is ank spond a/w aortic regurgitation?

Answer 21

proliferation of smooth muscle cells or fibroblasts occluding proximal aorta vaso vasora

this causes aortitis and aortic regurgitation

Question 22

ocular manifestation commonly a/w ank spond?

Answer 22

ant uveitis

acute iritis is also seen in 1/3 of patients

Question 23

how does acute iritis present?

Answer 23

photosensitivity in both eyes

Question 24

role of DMARDs in ank spond?

Answer 24

not indicated

only useful if peripheral joint involvement

Question 25

what must be done before introducing an anti-tnf in ank spond mx?

Answer 25

trial at least two NSAIDs

Question 26

earliest signs of ank spond?

Answer 26

reduced lat flexion of lumbar spind

Question 27

how are spinal curves affected in ank spond?

Answer 27

loss of lumbar lordosis
accentuated thoracic kyphosis

(‘question mark’ spine)

Question 28

which valvular incompetence is a/w ank spond?

Answer 28

aortic valve (<3% cases)

Question 29

what bone disease is a/w ank spond?

Answer 29

osteoporosis

Question 30

enthesitis can occur in all seronegative spondyloarthropathies but is especially common in?

Answer 30

ank spond
esp affects achilles tendon

Question 31

what are syndesmophytes?

Answer 31

ossification of outer fibres of annulus fibrosus

look like bony outgrowths from inside a spinal ligament or of the annulus fibrosus

Question 32

what are lytic lesions in the spine due to?

Answer 32

bone destruction, usually 2o to malignancy (e.g. myeloma)

Question 33

how are osteophytes different to syndesmophytes?

Answer 33

they are bony projections that form at joint margins

Question 34

what is spondylolisthesis?

Answer 34

displacement of one vertebra over another

Question 35

when should anti-TNFa inhibitors be used in axial ankylosing spondylitis?

Answer 35

if ank spond failed on 2 different NSAIDs + meets active disease criteria on 2 occasions 12 weeks apart