Ankylosing Spondylitis

Question 1

What is the most useful investigation when investigations ankylosing spondylitis?

Answer 1

X-Ray of the lumbar spine and sacroiliac joints

Question 2

What are some of the features of an X-ray of the lumbar spine and sacroiliac joints in ankylosing spondylitis?

Answer 2

Sacroiliitis- sub-chondral erosions and sclerosis
Squaring of the lumbar vertebrae
Bamboo spine
Syndesmophytes- due to ossification of the outer annulus fibrosus

Question 3

What might be seen with spirometry in a patient with ankylosing spondylitis?

Answer 3

A restrictive pattern may be seen, this can be due to:
Pulmonary fibrosis
Restriction of movement of the thoracic cage

Question 4

What is the management for ankylosing spondylitis?

Answer 4

Encourage regular exercising (e.g. swimming) as this slows down the rate of fusion
Physiotherapy
NSAIDS are 1st Line (+PPI)
Analgesia- WHO Pain ladder
DMARDs (e.g. methotrexate, sulfasalazine)
Anti TNF Therapy- Adalimumab, enarcept
Surgery- Not very common

Question 5

What biologics may be used in the treatment of AS?

Answer 5

Anti- TNF

Adalimumab or etanercept

Note- NSAIDs are the first line management to try to control symptoms. Regular exercise and physiotherapy is advised.

Question 6

What is the first line medical management for AS?

Answer 6

NSAIDs

Question 7

What is it important to encourage all AS patients to do?

Answer 7

Regular exercise and physiotherapy

Swimming is a good sport for patients with AS.

Question 8

How should analgesia be provided for AS patients?

Answer 8

According to the WHO pain ladder, step up and down as approriate

Question 9

What are some of the symptoms of AS?

Answer 9

Morning neck/back stiffness that improves with movement or exercise
Progressive stiffness and reduced ROM of the neck and spine
Pain in hips and groin that radiates down the legs
Other common features of Seronegative Spondyloarthropathies: Anterior uveitis, plantar fasciitis, achilles tendonitis, costochondritis, oral ulcers, IBD, dactylitis, psoriasiform rashes

Question 10

What genetic association is seen in AS?

Answer 10

HLA- B27 Association- 85-95%

Question 11

What investigations might you do if suspecting AS?

Answer 11

X-Ray- Lumbar spine and sacroiliac joints
Spinal MRI

Bloods- ESR, CRP, HLA-B27

Question 12

What gender is AS more common in?

Answer 12

Men

Question 13

What is a syndesmophyte?

Answer 13

Calcification of the outer annulus fibrosus- grow out and lead to vertebral fusion resulting in bamboo spine.

Question 14

What extra-articular manifestations are seen in seronegative spondyloarthropathies?

Answer 14

Enthesitis- Plantar fasciitis, achilles tendonitis, costochondritis
Anterior uveitis
Oral ulcers
Dactylitis
IBD
Psoriasiform rashes
Aortic valve incompetence

Question 15

What % of patients with AS is HLA-B27 +ve?

Answer 15

85-95%

Question 16

What is the name for the test that checks forward flexion of the spine in AS?

Answer 16

Schober’s test

A line is drawn 10 cm above and 5 cm below the back dimples. Then asked to bend as far forward as they can an the distance should increase by more than 5cm.