Ankylosing spondylitis

Question 1

What are spondylarthropathies

Answer 1

Group of clinically heterogeneous inflam rheumatologic condtiions
Axial, sacroiliac joints + spine
Peripheral - psoriatic arthritis, reactive, enteropathic

Question 2

What is ankylosing spondylitis

Answer 2

Axial spondyloarthritis - sacroilitis on X ray
Can be absent on X ray

Question 3

Features of ankylosing spondylitis

Answer 3

Chronic back pain - stiffness that improves with exercise
Sacroiliac joint and spinal fusion
Arthritis and enthesitis (lower limb, asymmetrical)
Dactylitis
Fatigue
Extra articular manifest

Question 4

What are syndesmophytes

Answer 4

Bony growths in IV joint ligaments in spine

Question 5

Extra articular manifestations of ank spond

Answer 5

Anterior uveitis
Psoriasis
IBD

Question 6

Cause of ank spond

Answer 6

HLA-B27
Genetic predisoposition triggered by environmental factors

Question 7

Who gets ank spond

Answer 7

2 x men than women
20-30 year onset
Majority under 45 years when diagnosed

Question 8

What are people with spinal rigidity more at risk of

Answer 8

Spinal fractures

Question 9

Complications of ank spondylitis

Answer 9

Ankylosis/spinal fusion
Aortic regurgitiation
Spinal fractures
Hip involvement
Anterior uveitis
Osteoporosis
Cardiac complications - aortic and non-aortic valvular heart disease and congestive heart failure. Arrhythmias
Lung involvement - restrictive pulm disease, apical fibrosis,
Neuro involvement - vertebral fracture, dislocation, cauda equina
Adverse effect from dugs
QOL decreased

Question 10

What see on MRI/x-ray

Answer 10

Persitent or fluctuating acial inflammation and new bone formation

Question 11

When sus ank spond

Answer 11

<45 yrs
Back pain > 3 months
Inflammatory, worse in morning, improves with movement
Current or prev buttock pain, thoracic or cervical spine pain, arhritis, enthesitis, ant uveitis, psoriasis or IBD
Symptoms awake in nght
Responsive to NSAIDs in 48 hours
FH of ank spond

Question 12

Diagnostic criteria for ank spond

Answer 12

Modified NY crtierira
Assessment of spondyloarthritis International society

Question 13

Clinica criteris NY criteria

Answer 13

Low back pain; > 3 months; improved by exercise but not relieved by rest. Limitation of lumbar spine motion in both the sagittal and frontal planes. Limitation of chest expansion relative to normal values for age and sex

Question 14

NY criteria for ank spond

Answer 14

Definite - radiological criteria + at least on clinical criteria
Porbably = 3 clinical criteria OR radiology alone

Question 15

ASAS classification of ank spond

Answer 15

,45 years + >3 months back pain
Sacroilitis on imagine + 1 or more spondyloarthritis featires
OR
HLA-B27 + and 2 or more spondyloarthritis features

Question 16

Spondyloarthritis features according to ASAS criteria

Answer 16

Inflammatory back pain
Arthritis
Enthesits
Uveitis
Dactylitis
Psoriasis
IBD
Responsive to NSAIDs
FH
HLA-B27
Elevated CRP

Question 17

Investiationg for AP

Answer 17

CRP, ESR
Basine bloods
X ray of spine
MRI - more senstivit, if no changes on C ray
HLA-B27
Spirometry

Question 18

Differentials ank spond

Answer 18

Degenerative or mechanical probelms eg disc, sponylosis, osteoarthritis
Fractures.
Infectious sacroiiitis.
Bone metastasis.
Primary bone tumours.
Spinal stenosis.
Hypermobility.

Question 19

When refer to rheumatology for ank spond

Answer 19

<45 + > 3 months of back pain +>4 of following:
Low back pain before 35
Wake during second hlf night w pain
Buttock pain
Improvement when moving, taking NSAIDs in 48 hours
first degree relative
Current or past arthritis, enthesits, psoriasis
HLA-B27 if 3 criteria

Question 20

What is anterior uveitis

Answer 20

Eye -> red, acutely painful, photphobia, blurred vision

Question 21

First line for ank spond

Answer 21

NSAID eg naproxen
If uncontrolled change or add another analgesia eg paracetmol, codeine

Question 22

How often should someone with ank spond have a DEXA scan

Answer 22

Every 2 years

Question 23

What need to be aware of in DEXA scans in ank spond

Answer 23

Bone mineral density may be increased on spine DEXA - syndesmophytes and ligament calcification
Do hip DEXA

Question 24

When refer ank spond

Answer 24

Vertebral fracture
Refractory hip pain or diasbility + structural damage onx ray for hip arthroplasty
Severe or progressive deformity of spine affecting QOL

Question 25

X ray changes in akylosing spondylitis

Answer 25

Sacroilitis - subchondral lesions, sclerosis
Squaring of lumbar vertebrae
Bamboo spine - late
Syndesmophytes - ossification of outer fibres of annulous fibrosus
CXR - apical fibrosis

Question 26

Why may spirometry be low in ank spond

Answer 26

Pulmonary fibrosis, kyphosis, ankylosis of costovertebral joints

Question 27

general mangement of ank spond

Answer 27

Regular exercise sp swimming
Physio
NSAIDs
DMARDs eg sulfasalzine only if peripheral joint involevemnt
Anit-TNF therapy if persistently high disease acitivty despite treatments eg etnercept, adalimumab