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Clinical lectures: Yr1 > Ankylosing spondylitis > Flashcards

Ankylosing spondylitis Flashcards

1
Q

Is the whole skeleton affected by ankylosing spondylitis?

A

No

Characterised by chronic inflammation of axial skeleton/spine

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2
Q

Which characteristic feature of ankylosing spondylitis occurs due to chronic inflammation of the axial skeleton?

A

Stiffening and fusion (ankylosing) of vertebral column and sacroiliac joints

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3
Q

How is ankylosing spondylitis related to axial spondyloarthropathies?

A

Ankylosing spondylitis is the radiographic subset of axial spondyloarthropathies

Radiographic-axSpa

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4
Q

Is ankylosing spondylitis equally common in men and women?

A

Higher prevalence in men

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5
Q

At what age are people typically diagnosed with ankylosing spondylitis?

A

Under 40 yrs old

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6
Q

At what age do most people with ankylosing spondylitis develop initial symptoms?

A

Under 30 yrs old

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7
Q

Does ankylosing spondylitis typically have a rapid or insidious onset?

A

Insidious onset

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8
Q

What is the initial stage of ankylosing spondylitis, and what cells are typically present?

A

Enthesitis of spinal ligaments with chronic inflammation characterised by presence of CD4, CD8 lymphocytes and macrophages

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9
Q

What are syndesmophytes, and why do they form after enthesitis, in AS?

A

Bony outgrowths from spinal ligaments

TNF-alpha and TGF-beta cytokines at sites of enthesitis promote fibrosis and ossification on top of old enthesis so that new enthesis forms: syndesmophyte

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10
Q

Give 2 examples of cytokines that characteristically promote syndesmophyte formation in ankylosing spondylitis?

A

TNF-alpha

TGF-beta

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11
Q

What causes vertebrae to appear square-shaped in ankylosing spondylitis, and what characteristic AS term is used to describe the spine now?

A

Supraspinous and interspinous ligaments have progressive calcification (dagger sign), so vertebrae appear square: bamboo spine

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12
Q

In ankylosing spondylitis, what is the most common initial symptom?

A

Low back pain and stiffness

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13
Q

In ankylosing spondylitis, what improves and exacerbates the low back pain and stiffness?

A

Improves with exercise

Exacerbated by staying still and not moving

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14
Q

In ankylosing spondylitis, is the severity of the low back pain and stiffness steady throughout the day?

A

No

Worst in morning upon waking (EMS), improves during day with movement, worst again at night when resting

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15
Q

What effect does ankylosing spondylitis have on normal posture?

A

Commonly causes hyperkyphosis: Excessive outwards curvature of spine

Most common in thoracic spine (thoracic hyperkyphosis)

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16
Q

What term is used to describe the shape of the back in ankylosing spondylitis, due to hyperkyphosis?

A

Hunchback: head in front of hips/pelvis when standing, hips flexed

17
Q

Why might a patient with ankylosing spondylitis find it painful to sit?

A

Tenderness over ischial tuberosities

18
Q

Why might a patient with ankylosing spondylitis find it painful to sleep on their side?

A

Tenderness over iliac crests

19
Q

Give 3 pelvic areas where people with ankylosing spondylitis are often tender?

A

Iliac crests

Ischial tuberosities

Pelvic brim (bony edge of pelvic ring)

20
Q

Why might a person with ankylosing spondylitis have a limp or cautiously place feet when walking?

A

Tenderness in heels

21
Q

Which neurological condition is a medical emergency, and a complication of ankylosing spondylitis?

A

Cauda equina syndrome

22
Q

How can ankylosing spondylitis affect the heart?

A

Complication of aortic regurgitation: reverse blood flow from the aorta into the left ventricle (LV) during diastole

23
Q

If ankylosing spondylitis causes enthesitis of costosternal and costovertebral muscles, what 3 lung complications can occur?

A

Pleuritic chest pain

Pulmonary fibrosis

Restricted chest movement (eg. pain during inspiration)

24
Q

What criteria is used to diagnose ankylosing spondylitis?

A

Modified New York criteria 1984

25
Q

According to the Modified New York criteria 1984, how many clinical and radiological findings must a person have to be diagnosed with AS?

A

At least 1 out of 3 clinical criteria

Must have the radiological criteria: Sacroiliitis grade ≥2 bilaterally, or grade 3 to 4 unilaterally.

26
Q

In the Modified New York criteria 1984, what are the 3 possible clinical findings to diagnose AS?

A

Low-back pain and stiffness for longer than 3 months, which improve with exercise but are not relieved by rest

Restriction of motion of the lumbar spine in both the sagittal and frontal planes

Restriction of chest expansion relative to normal values correlated for age and sex

27
Q

What are the 4 characteristic radiological signs of ankylosing spondylitis?

A

Dagger sign: calcification of the supraspinous and interspinous ligaments in vertebral column

Bamboo spine: Advanced ankylosing (fusion) of vertebrae makes spine look like straight column

Sacroiliitis

Shiny corner sign: Reactive sclerosis secondary to romanus lesions: Inflammatory erosion of corners of superior and inferior endplates of vertebral bodies

28
Q

When does bamboo spine develop in the progression of AS?

A

Advanced AS, when inflammation has been untreated for a long time

29
Q

Describe the shiny corner sign, and is this better seen on plain film or MRI, in AS?

A

Reactive sclerosis secondary to Romanus lesions: inflammatory erosions at the corners of superior and inferior endplates of the vertebral bodies

Better seen on MRI

30
Q

Which part of the spine most commonly has limited motion, in presentation of AS?

A

Limited lumbar spine motion

31
Q

What nonpharmacological management is used in AS to prevent spinal fusion in a flexed position?

A

Spinal extension exercises and physiotherapy

32
Q

In very severe AS, what surgery is recommended?

A

Spinal osteotomy: Techniques used to correct spinal deformity

33
Q

What is the first-line drug class to treat AS, and at what dosage?

A

NSAIDs at lowest effective dose, increase if needed and switch to other NSAID if not effective at max. Tolerated dose for 2-4 weeks

34
Q

What is the second-line drug class to treat AS, and give common examples, and why are they used instead of NSAIDs?

A

Conventional DMARDs eg. sulfasalazine, methotrexate

Or biological DMARDS eg. adalimumab, etanercept, infliximab

Given if NSAIDs ineffective/not tolerated

35
Q

What is the third-line drug class to treat AS, and give common examples, and why are they used instead of DMARDs?

A

Monoclonal antibodies/interleukin-17 inhibitors eg. secukinumab, ixekizumab

Given if anti-TNF biologics are ineffective/not tolerated

Clinical lectures: Yr1 (28 decks)

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