Ankylosing Spondylitis

Question 1

What is ankylosing spondylitis? (AS)

Answer 1

1. A chronic systemic inflammatory disease involving axial skeleton (spine) and SI joints of younger patients
2. Develops in males more then women
3. Progressive stiffness overtime (lack of ability to move the spine)

Question 2

If there is a patient with AS what are some of the key features?

Answer 2

1. Seronegative arthropathy (rf negative)
2. Pain and progressive stiffening of the spine
3. Late teens/early 20s onset
4. Ascending involvement of the spine (low back, hip first then to upper back)
5. May involve chest wall (decreased expansion)

Question 3

What is the suspected cause of AS?

Answer 3

1. A genetic predisposition, triggered by an environmental factor
2. HLA-B27 (has a high incidence)

Question 4

How does AS occur? (What are the steps to spinal fusion)

Answer 4

1. Activated T-cells and macrophages found at sites of inflammation with expression of IL-1B and TNF-a
2. The inflammatory cytokines cause erosion of cortical bone, new bone formation and loss of bone mass occur

Question 5

What are the clinical manifestations of AS?

Answer 5

1. Chronic LBP
   *morning stiffness with decreased ROM, back pain radiates to the thighs
2. Stiffness decreases with exercise
3. Patient is unable to put head down while supine
4. Peripheral arthritis may develop
5. Pulmonary fibrosis, aortitis, Achilles enthesitis, acture anterior uveitis (rare)

Question 6

How does sacroiliitis present in patients with AS?

Answer 6

1. Pain will radiate to the butt and upper posterior thighs
2. Might be U/L initially
3. Then becomes B/L and persistent

Question 7

What are some symptoms of AS?

Answer 7

1. Stiffness improves with exercises
2. Painful hips, shoulders, asymmetrical arthritis of lower limbs prior to spinal involvement
3. Cervical and thoracic pain and stiffness is frequent
4. Enthesitis (pain near the insertion of tendons and ligaments)
5. Chest pain aggravated by increasing intra-thoracic pressure

Question 8

What are the common symptom presentation in males?

Answer 8

1. Spine and pelvis more frequently involved
2. Some involvement of hips, shoulders, and chest wall
3. Overall more severe

Question 9

What are the common symptom presentations in women?

Answer 9

1. Pelvis
2. Hips
3. Knees
4. Wrists
5. Less severe involvement of the spine

Question 10

What is enthesitis?

Answer 10

1. Where the tendons and ligaments attach to a bone
2. It is the hallmark of spondyloarthropathies
3. *Inflammation of ligament and tendon

Question 11

What are the peripheral manifestations of AS?

Answer 11

1. Enthesitis
2. Peripheral arthritis
3. Dactylitis

Question 12

What other clinical features could be present in AS?

Answer 12

1. Asymptomatic GI inflammation present in 25-49% of AS
2. 50-60% of AS have microscopic inflammatory lesions
3. Anterior uveitis occurs in about 25%
4. Constitutional Sx similar to RA are absent in most
   *no fever, malaise, weight loss

Question 13

Upon examining for AS what might you find?

Answer 13

1. B/L SI joint tenderness
2. Peripheral joint synovitis
   *asymmetric, oligoarticular pattern (axial skeleton first)
3. Dactylitis of fingers and toes
4. Thickened Achilles’ tendon, planter fasciitis, chest wall tenderness

Question 14

What are the some advanced features of AS that you may see during a PE?

Answer 14

1. Changes in posture-flattening
   *flat in the lumbar area
   *thoracic kyphosis may be exaggerated
2. C-spine limitation in ROM with fusion

Question 15

What are the diagnostic test for AS?

Answer 15

1. Schober’s test
   *below 5cm is abnormal
2. Tragus to wall
3. Chest expansion

Question 16

What are some diagnostic tests that can help confirm the diagnosis of AS?

Answer 16

1. HLA-B27 testing
2. Increased ESR/ CRP
3. Symptoms of inflammatory back pain
4. Family history
5. B/L sacroiliitis on XR or MRI
6. Bamboo spine of X-ray
7. Loss of normal curvature
8. Rf, ANA, anti-CCP antibodies (negative)
9. Anemia

Question 17

What will imaging show for a patient with AS?

Answer 17

1. SI joints show first changes
   *bilateral and symmetric
2. Sclerosis of vertebral bodies followed by squaring
3. Bamboo spine

Question 18

What is bamboo spine?

Answer 18

1. A repeated process of healing and bone formation
2. The spine fuses together and expands laterally and downward

Question 19

Is it okay to use HLA b27 typing for the main investigation of AS?

Answer 19

No
*its an additional test to help validate the diagnosis

Question 20

What are some differential diagnoses of AS?

Answer 20

1. Mechanical LBP
2. RA
3. Sacroiliitis
4. ReA
5. PsA

Question 21

What is the management for AS?

Answer 21

1. NSAIDs (essential, first line)
   *Naproxen
   *celecoxib (not as harsh on stomach)
   *Ibuprofen
2. Anti TNF (infliximab, shows good symptom relief)

Question 22

What type of treatment is not recommended for AS?

Answer 22

1. DMARDs (worsens osteoporosis)
2. Steroids

Question 23

What types of surgeries are used for AS?

Answer 23

Surgery is rare
1. Hip arthroplasty
2. Corrective spinal osteotomy

Question 24

What is the prognosis for AS?

Answer 24

1. Depends on stage at diagnosis
2. Initiation of effective therapy
3. Worse in smokers (will lower blood supply and produce inflammation)

Question 25

What are the initial screening tests that a patient will complete, when they are suspected for AS?

Answer 25

1. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
2. Bath AS Functional Index (BASFI)