Ank Spond Flashcards
what is ankylosing spondylitis
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)
typical presentation of ank spond:
insidious onset of LBP
stiffness worse in morning, improved by activity
pain at night
relieved by NSAIDs
epidemiology of ank spond
males 3:1
20-30y
ix ank spond
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)
changes on radiograph in ank spond
early: maybe normal
later:
- sacroilitis: subchondral erosion, sclerosis SIJ
- squaring lumbar vertebrae
- bone fusion
- bamboo spine (uncommon though?)
- syndesmophytes
- CXR shows apical fibrosis
why do syndesmophytes occur in ank spond
ossification of outer fibres of annulus fibrosus
presentation of ank spond?
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(
if xray -ve for SI joint involvement but HIS of ank spond then…?
MRI
why may spirometry be used in ank spond ix?
may show restrictive defect due to combination of pulmonary fibrosis, kyphosis, ankylosis of costovertebral joints
mx of ank spond
regular exercise
nsaids - first line
physio
anti-tnf (etanercept, adalimumab) if persistently high disease activity
typical presentation of ank spond:
insidious onset of LBP
worse in morning, improved by activity
relieved by NSAIDs
ank spond grading: new york criteria?
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
clinical exam findings of ank spond?
reduced lat flexion
reduced forward flexion (Schober’s test)
reduced chest expansion
what is Schober’s test?
line drawn 10m above and below L5
distance between two lines should increase by >5cm as pt bends forward as far as possible
As a/w ank spond
apical fibrosis
ant uveitis
aortic regurg
achilles tendonitis
av node block
amyloidosis
CES
peripheral arthritis
why does ank spond reduce chest expansion?
rib involvement can cause breathing discomfort -> reduced chest expansion -> shallower breaths over time
what does localised spine tenderness suggest?
malignancy or fracture
lumbar flexion severity grading?
mild: >4cm
moderate: 2-4cm
severe: <2cm
in what % of ank spond pt is hla-b27+?
90%
why is ank spond a/w apical lung fibrosis?
thought to be due to reduced chest expansion and chronic interstitial inflammation over time
why is ank spond a/w aortic regurgitation?
proliferation of smooth muscle cells or fibroblasts occluding proximal aorta vaso vasora
this causes aortitis and aortic regurgitation
ocular manifestation commonly a/w ank spond?
ant uveitis
acute iritis is also seen in 1/3 of patients
how does acute iritis present?
photosensitivity in both eyes
role of DMARDs in ank spond?
not indicated
only useful if peripheral joint involvement
what must be done before introducing an anti-tnf in ank spond mx?
trial at least two NSAIDs
earliest signs of ank spond?
reduced lat flexion of lumbar spind
how are spinal curves affected in ank spond?
loss of lumbar lordosis
accentuated thoracic kyphosis
(‘question mark’ spine)
which valvular incompetence is a/w ank spond?
aortic valve (<3% cases)
what bone disease is a/w ank spond?
osteoporosis
enthesitis can occur in all seronegative spondyloarthropathies but is especially common in?
ank spond
esp affects achilles tendon
what are syndesmophytes?
ossification of outer fibres of annulus fibrosus
look like bony outgrowths from inside a spinal ligament or of the annulus fibrosus
what are lytic lesions in the spine due to?
bone destruction, usually 2o to malignancy (e.g. myeloma)
how are osteophytes different to syndesmophytes?
they are bony projections that form at joint margins
what is spondylolisthesis?
displacement of one vertebra over another
when should anti-TNFa inhibitors be used in axial ankylosing spondylitis?
if ank spond failed on 2 different NSAIDs + meets active disease criteria on 2 occasions 12 weeks apart
