Ankylosing spondylitis

Question 1

What age range does ankylosing spondylitis (AS) onset?

Answer 1

30-40 years old

Question 2

What are some extra-articular manifestations of AS?

Answer 2

Red eye (uveitis)
Diarrhoea (GI involvement)
History of aortic regurgitation
Pulmonary apical fibrosis (worse if smoker)

Question 3

What kind of posture may you see in someone with AS?

Answer 3

Question mark posture

?

Loss of lumbar lordosis
Kyphoscoliosis of thoracic
Compensatory extension of C-spine

Question 4

What findings should you examine for specifically in AS?

Answer 4

Rotation of C-spine limited when patient asked to look either side, whole body will move with head

Reduced occiput-to-wall distance due to loss of upper thoracic and cervical mobility

<5cm seperation during Schober’s

<5cm chest expansion (measure with tape)

Question 5

What extra examinations should you notify the examiner about doing when presented with a patient with AS?

Answer 5

1. Eyes for iritis, anterior uveitis
2. Heart for aortic regurgitation
3. Lungs for apical fibrosis
4. Abdomen for protuberance (2dgr to lung restriction)
5. Foot for Achilles tendonitis and plantar fasciitis

Question 6

What are the 4 A’s of Ankylosing Spondilitis?

Answer 6

Apical fibrosis

Aortic regurgitation

Anterior uveitis

Achilles tendonitis (and plantar fasciitis)

Question 7

What other conditions can cause sacroiliitis?

Answer 7

Psoriasis
Reiters syndrome (Reactive arthritis)

Question 8

What are some diagnostic features of AS?

Answer 8

1. Lower back pain of > 3 months, improving with exercise but not relieved by rest
2. FHx of AS or HLA B-27 positive
3. Iritis (~40% of AS pt)
4. Male
5. Enthesis (esp heel, knee, tibial tuberosities)

Question 9

What radiological findings may you see at different stages of severity in AS?

Answer 9

Early
- Erosion and Sclerosis of lumbrosacral spine

Later
- Syndesmophytes (bony growth in ligament of spine, pathologically same as osteophytes)

Severe
- Bamboo spine

Question 10

How would you manage a patient with AS?

Answer 10

Physiotherapy and exercise to preserve back extension

NSAIDs

Methotrexate and Sulfasalazine

Biologics

Question 11

Which particular NSAID and Biologic is effective in AS?

Answer 11

NSAID: Indomethacin

Biologic: Etanercept

Question 12

What is the criteria for predicting lower-back pain as a precursor of AS?

Answer 12

Young to middle aged (<50 years)
Chronic back pain

1. Morning stiffness >30 min
2. Improved with exercise, not relieved by rest
3. Awakening due to pain during 2nd half of night only
4. Alternating buttock pain

Diagnosis confirmed if 2/4 are present.