Ankylosing spondylitis

Question 1

What are the spondyloarthritides?

Answer 1

• Ankylosing spondylitis
• Axial spondyloarthropathy
• Reactive arthritis
• Psoriatic arthritis
• Enteric arthropathy

Question 2

What are the shared clinical features of sponyloarthritides?

Answer 2

1. HLA-B27 association
2. Seronegativity (negative RF)
3. Axial arthritis: spine and SI joints
4. Asymmetrical large-join oligoarthritis
5. Enthesitis
6. Dactylitis
7. Extra-articular manifestations

Question 3

What is enthesitis?

Answer 3

• Inflammation of the site of insertion of tendon or ligament into bone
  
  • eg plantar fascitis, achilles tendonitis

Question 4

What is dactylitis?

Answer 4

• Inflammation of the entire digit (Sausage digit)
• Due to soft tissue oedema + joint inflammation

Question 5

Descrbe Ankylosing spondylitis?

Answer 5

• Presence of sacroilitis on x-ray
  
  • • other structural changes which may progress to spine fusion
• Mostly males
• HLA-B27 associated

Question 6

Read these case presentations of AS

Answer 6

Question 7

Risk factors for the development of AS?

Answer 7

• HLA-B27
• Positive family history
• Klebsiella pneumoniae

Question 8

Describe some of the signs and symptoms of AS?

Answer 8

• Progressive spinal inflammation
• Vertebral osteoporosis
• Question mark posture
• Extra-articular features

Question 9

What are some of the extra-articular manifestations of axial spondyloarthritis and ankyklosing spondylitis?

Answer 9

• Anaemia, fatigue
• Anterior uveitis
• Prostatitis, sterile urethritis
• Osteoporosis
• Inflammatory bowel disease

Question 10

What is used to diagnose AS?

Answer 10

• Modified new york criteria
  
  • X-ray evidence of sacroilitis
  • • 1 feature on history or examination

Question 11

Describe the modified new york criteria for AS?

Answer 11

Question 12

Describe the tests for AS?

Answer 12

• MRI
• X-ray
• FBC (normocytic anaemia), raised ESR, CRP
• HLA-B27 testing
• DXA scanning

Question 13

Describe the management of AS?

Answer 13

• Physiotherapy
• 1st: NSAIDs
  
  • Relieve symptoms within 48hr
• 2nd: TNF-_a blockers (etanercept, adalimumab)
• Bisphosphonates may reduced fracture risk

Question 14

What is pictured here?

Answer 14

Progression to question mark posture in AS

Question 15

Benefits of MRI in AS?

Answer 15

• More sensitive for detection of early sacroilitis
• Can detect inflammatory changes

Question 16

Signs of AS on X-ray?

Answer 16

• Sacroilitis
• Widening of SI joint space
• • Joint space narrowing and sclerosis occurs later
• Syndesmophytes and squaring of vertebral bodies
• Bamboo spine occurs in later stages

Question 17

What causes bamboo spine to occur in AS?

Answer 17

• Ossiciation of the anterior longitudinal ligament
• Facet joint fusion

Question 18

What are the aims for AS management?

Answer 18

• Relieve pain and sitffness
• Maintain range of skeletal movement
• Avoid development of deformities

Question 19

Describe the management of AS?

Answer 19

• Long-acting NSAID
  
  • Naproxen
• Mobilising exercises
• Intra-articular hydrocortisone injections
• Sulfaslazine
• Infliximab
• Spinal osteotomy can correct posture

Question 20

Describe the relation of AS to pulmonary function tests?

Answer 20

• Restrictive picture on spirometry
  
  • Kyphoscoliosis

Question 21

Describe a specific test from spine examin which would indicate AS?

Answer 21

• Schober’s test
  
  • Reduced forward flexion

Question 22

When should a patient be started on TNF-alpha blocker therapy?

Answer 22

When 2 different NSAIDs have failed and they meet the criteria for adult disease on 2 occassions, 12 weeks apart