Ankylosing spondylitis

Question 1

What is Ankylosing spondylitis?

Answer 1

An inflammatory condition mainly affecting the spine causing progressive stiffness and pain

A seronegative spondyloarthropathy

Question 2

What gene is Ankylosing spondylitis associated with?

Answer 2

HLA B27

Question 3

What other conditions are associated with HLA B27?

Answer 3

Reactive arthritis
Psoriatic arthritis

*these are the other seronegative spondyloarthropathies

Question 4

What are the key joints affected in Ank Spond?

Answer 4

Sacroiliac joints

Joints of the vertebral column

Question 5

How does Ank Spond present?

Answer 5

Gradual onset over months

• Lower back pain and stiffness
• Sacroiliac pain (in the buttock region)
• Pain is worse with rest and at night/in the morning
• Pain is better with movement and progressively better throughout the day

Question 6

What is a key complication of Ank Spond?

Answer 6

Vertebral fractures

Question 7

What other symptoms can be present in Ank Spond?

Answer 7

Systemic symptoms e.g. weight loss, fatigue

The Extra-articular features (“A features”)
Apical pulmonary fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block (due to fibrosis of the heart’s conductive system)
Amyloidosis

Question 8

Examinations and investigations in suspected Ank Spond?

Answer 8

Examination of the spine including Schober’s test

Bloods - FBC, CRP, ESR, Rheumatoid factor, Rheumatoid screen

Spinal X-ray (and X-ray of sacrum)

Question 9

What X-ray changes may be seen in Ank Spond?

Answer 9

Bamboo spine - in later AS

Squaring of vertebral bodies

Bridging syndesmophytes

Subchondral sclerosis and erosions

Ossification of ligaments, discs and joints

Fusion of the facet, sacroiliac and costovertebral joints

CXR - may show apical fibrosis

Question 10

Management of Ank Spond?

Answer 10

NSAIDs for pain (first line)

Steroids can be used during flares

Anti-TNF medications e.g. etanercept or a monoclonal antibody against TNF e.g. infliximab, adalimumab - second line when there is persistent high disease activity

Secukinumab is recommended by NICE if response to NSAIDs and TNF inhibitors is poor

Also:

• Physiotherapy
• Exercise and mobilisation
• Surgery can be required for deformities to spine/ other joints