Ankylosing spondylitis

Question 1

What is Ankylosing Spondylitis (AS)?

Answer 1

Ankylosing Spondylitis (AS) is an inflammatory condition that primarily affects the axial skeleton, particularly the spine and sacroiliac joints, causing progressive stiffness and pain.

Question 2

Which parts of the body’s skeleton are mainly affected by AS?

Answer 2

The axial skeleton, mainly the spine and sacroiliac joints, is primarily affected by AS.

Question 3

What is another name for Ankylosing Spondylitis?

Answer 3

Ankylosing Spondylitis is also known as axial spondyloarthritis.

Question 4

What group of conditions does AS belong to, along with psoriatic arthritis and reactive arthritis?

Answer 4

AS is part of the seronegative spondyloarthropathy group of conditions, which includes psoriatic arthritis and reactive arthritis.

Question 5

Which joints are commonly affected by inflammation in AS?

Answer 5

The sacroiliac joints and the vertebral column joints are commonly affected by inflammation in AS.

Question 6

What complications can arise from AS, particularly when inflammation progresses?

Answer 6

AS can progress to spine and sacroiliac joint fusion.

Question 7

What is the significance of the HLA-B27 gene in relation to AS?

Answer 7

The HLA-B27 gene is strongly linked to AS.

Question 8

Approximately what percentage of AS patients have the HLA-B27 gene, and how likely is it for someone with this gene to develop AS?

Answer 8

Approximately 90% of AS patients have the HLA-B27 gene, and it is thought that less than 10% of people with the gene will develop AS.

Question 9

Is AS more common in men or women?

Answer 9

AS is more common in men, although women can also be affected.

Question 10

What is the typical age group for the presentation of AS?

Answer 10

The typical presentation of AS is in young adult males in their 20s.

Question 11

How long does it typically take for stiffness to improve in the morning in AS patients?

Answer 11

Stiffness in AS takes at least 30 minutes to improve in the morning.

Question 12

How do AS symptoms respond to activity and rest?

Answer 12

AS symptoms worsen with rest and improve with movement.

Question 13

What are the main presenting features of AS?

Answer 13

The main presenting features of AS are pain and stiffness in the lower back and sacroiliac pain in the buttock region.

Question 14

What are some additional symptoms and problems associated with AS?

Answer 14

Additional symptoms and problems associated with AS include chest pain related to costovertebral and sternocostal joints, enthesitis, dactylitis, vertebral fractures, and shortness of breath related to restricted chest wall movement.

Question 15

What are the key associations of Ankylosing Spondylitis (AS) that can be remembered with the “5 As” mnemonic?

Answer 15

The key associations of Ankylosing Spondylitis that can be remembered with the “5 As” mnemonic are Anterior uveitis, Aortic regurgitation, Atrioventricular block (heart block), Apical lung fibrosis (fibrosis of the upper lobes of the lungs), and Anemia of chronic disease.

Question 16

What does Schober’s test assess, and how is it performed to evaluate spinal mobility?

Answer 16

Schober’s test assesses spinal mobility. It is performed by locating the L5 vertebra with the patient standing straight, marking a point 10cm above and 5cm below this level (15cm apart), and then having the patient bend forward as far as possible. The distance between the marked points is measured.

Question 17

What does a length of less than 20cm between marked points indicate in Schober’s test, and how does it relate to AS diagnosis?

Answer 17

In Schober’s test, a length of less than 20cm between marked points indicates a restriction in lumbar movement, which can support a diagnosis of ankylosing spondylitis.

Question 18

What are the key investigations for diagnosing AS?

Answer 18

Key investigations for diagnosing AS include inflammatory markers (e.g., CRP and ESR), HLA B27 genetic testing, X-ray of the spine and sacrum, and MRI of the spine, which can show bone marrow edema early in the disease before there are any X-ray changes.

Question 19

What are the typical x-ray findings in the later stages of ankylosing spondylitis?

Answer 19

In the later stages of ankylosing spondylitis, a “bamboo spine” is the typical X-ray finding, where there is fusion of the sacroiliac and spinal joints.

Question 20

What are some x-ray changes that can be observed in AS?

Answer 20

X-rays in ankylosing spondylitis can show squaring of the vertebral bodies, subchondral sclerosis and erosions, syndesmophytes (areas of bone growth where the ligaments insert into the bone), ossification of the ligaments, discs, and joints (these structures start turning into bone), and fusion of the facet, sacroiliac, and costovertebral joints.

Question 21

Who typically manages patients with Ankylosing Spondylitis, and what are the treatment goals?

Answer 21

Patients with Ankylosing Spondylitis are typically managed by the rheumatology multidisciplinary team. The treatment aims to control symptoms and preserve function.

Question 22

What are the first-line medications for medical management of Ankylosing Spondylitis (AS)?

Answer 22

Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line medications for medical management of Ankylosing Spondylitis.

Question 23

What are the second-line medications for AS, and provide examples of anti-TNF medications?

Answer 23

The second-line medications for AS include anti-TNF medications, such as adalimumab, etanercept, or infliximab.

Question 24

What are the third-line medications for AS, and how do they work in the treatment of the condition?

Answer 24

Third-line medications for AS include Secukinumab and Ixekizumab, which are monoclonal antibodies against interleukin-17, and Upadacitinib, a JAK inhibitor.

Question 25

In what situations might intra-articular steroid injections be considered in AS?

Answer 25

Intra-articular steroid injections may be considered for specific joints in Ankylosing Spondylitis.

Question 26

Besides medication, what are some additional components of AS management?

Answer 26

Additional components of AS management include physiotherapy, exercise, and mobilization.

Question 27

What lifestyle choices are recommended for AS patients to improve their condition?

Answer 27

Patients with AS are recommended to avoid smoking to improve their condition.

Question 28

What is the role of bisphosphonates in the management of AS?

Answer 28

Bisphosphonates may be used for osteoporosis in the management of AS.

Question 29

When might surgery be required in the management of Ankylosing Spondylitis?

Answer 29

Surgery may be required for severe joint deformity in the management of Ankylosing Spondylitis.

Question 30

What is the primary characteristic of Ankylosing Spondylitis (AS) as described in the initial statement?

Answer 30

Ankylosing Spondylitis is a chronic inflammatory disease of the axial skeleton that leads to partial or even complete fusion and rigidity of the spine.

Question 31

What is the genetic predisposition associated with AS, and how common is this genetic factor among AS patients?

Answer 31

The genetic predisposition associated with AS is the presence of the HLA B27 gene, which is found in approximately 90% of AS patients. It often has a strong family history.

Question 32

What is the typical age range for the onset of AS?

Answer 32

The typical age of onset for AS is between 20-40 years.

Question 33

What are the key articular symptoms of AS, particularly in the spine and back?

Answer 33

Key articular symptoms of AS include inflammatory spinal and back pain, as well as peripheral arthritis (knee, shoulders, hips), although peripheral arthritis is rare.

Question 34

How does the pain in AS typically progress, and how is morning stiffness characterized in AS patients?

Answer 34

Pain in AS progresses gradually with a dull pain that develops slowly. Morning stiffness in AS patients lasts for more than 30 minutes and typically improves with activity.

Question 35

What is Schobers test, and how is it used to assess lumbar spine flexion in AS patients?

Answer 35

Schobers test is used to measure lumbar spine flexion in AS patients. It involves measuring 5cm below the posterior superior iliac crests and 10cm above while the patient is upright, then asking them to bend forward and remeasuring the distance. In normal situations, it should extend beyond 20cm.

Question 36

What signs are commonly observed in the lumbar, thoracic, and cervical spine in AS patients?

Answer 36

In the lumbar spine, AS patients often display restricted movements. In the thoracic spine, dorsal kyphosis can develop, and there may be reduced chest expansion. In the cervical spine, movements can be globally reduced, and the neck may be forced into a flexed position by dorsal kyphosis. Tenderness of the sacroiliac joints and inflammatory enthesitis in areas like the Achilles tendon and iliac crests can also be present. In late AS, there may be a loss of lumbar kyphosis with pronounced cervical lordosis, leading to a “question mark” posture.

Question 37

How is cervical spine mobility affected by AS, and what measurement is used to assess it?

Answer 37

Cervical spine mobility is globally reduced in AS, and the measurement used to assess it is the occiput-to-wall distance, with a normal measurement being 0.

Question 38

What are some extra-articular features or complications associated with AS?

Answer 38

Extra-articular features or complications of AS include anterior uveitis, aortitis leading to aortic regurgitation, upper lobe pulmonary fibrosis, IgA nephropathy, asymptomatic enteric mucosal inflammation, and rarely, A-A subluxation.

Question 39

What are the potential complications in the eyes, heart, lungs, and kidneys that can occur in AS patients?

Answer 39

Complications in AS patients can include anterior uveitis (20–30%), aortitis leading to aortic regurgitation, upper lobe pulmonary fibrosis, IgA nephropathy (5%), and asymptomatic enteric mucosal inflammation.

Question 40

What is the significance of “A-A subluxation” in the context of AS?

Answer 40

“A-A subluxation” refers to atlanto-axial subluxation, which is a rare complication or manifestation in AS. It involves instability or subluxation of the atlanto-axial joint in the upper spine.

Question 41

What are the blood tests used in the investigations of Ankylosing Spondylitis, and what is the role of HLA B27 in diagnosing AS?

Answer 41

Blood tests used in the investigations of Ankylosing Spondylitis include tests for raised inflammatory markers and HLA B27. HLA B27 is not diagnostic by itself, but it has a sensitivity and specificity of around 90%, making it a significant genetic factor in AS.

Question 42

What are the typical findings on X-rays for patients with AS, and what is the significance of “bamboo spine” in AS diagnosis?

Answer 42

X-rays for AS may show normal bone density in early disease but reduced bone density in later stages. X-rays can reveal sclerosis and fusion of the sacroiliac joints, bony spurs (syndesmophytes) bridging intervertebral discs resulting in the “bamboo spine” appearance. It is common for X-rays to be normal at the time of presentation.

Question 43

How does MRI contribute to the diagnosis of Ankylosing Spondylitis, and what specific features can it detect?

Answer 43

MRI can detect sacroiliitis (active inflammation) and earlier changes such as bone marrow edema and enthesitis of the spinal ligaments. In patients with inflammatory back pain and normal X-rays, a positive HLA B27, along with other features of ankylosing spondylitis, should prompt an MRI.

Question 44

What criteria are used for classifying axial spondylarthritis (SpA) according to ASAS (Assessment of SpondyloArthritis International Society)?

Answer 44

The ASAS classification criteria for axial spondylarthritis (SpA) are used for patients with more than three months of back pain and an age of onset less than 45 years. The criteria include sacroiliitis on imaging and one SpA feature or being HLA-B27 positive with at least two other SpA features.

Question 45

What non-medical approaches are part of the management of Ankylosing Spondylitis?

Answer 45

Non-medical approaches in the management of AS include physiotherapy, occupational therapy, orthotics, and chiropodist care.

Question 46

What is the first-line medical treatment for AS, and why is it often prescribed with a proton pump inhibitor (PPI)?

Answer 46

NSAIDs are the first-line medical treatment for AS. They are often prescribed with a proton pump inhibitor (PPI) to reduce the risk of gastrointestinal side effects.

Question 47

In what type of patients are DMARDs (Disease-Modifying Antirheumatic Drugs) like sulfasalazine and methotrexate useful in the treatment of AS?

Answer 47

DMARDs like sulfasalazine and methotrexate are useful in patients with peripheral joint disease in AS but do not improve spinal inflammation.

Question 48

What are the key categories of biological therapies used in AS management, and when are they typically prescribed?

Answer 48

Biological therapies used in AS management include anti-TNF agents as first-line options, anti-IL17 therapy as a second-line choice, and other biologics such as IL-12/23 inhibitors. The role of JAK inhibitors in AS is not yet clear.

Question 49

What is the role of surgery in the management of Ankylosing Spondylitis, and for which joints is it mainly reserved?

Answer 49

Surgery in the management of Ankylosing Spondylitis is mainly reserved for hip and knee arthritis. Kyphoplasty is controversial and carries considerable risk.