Ankylosing spondylitis

Question 1

What are the symptoms (4)

Answer 1

Inflammatory back pain: worse AM, last >30 min, relieved by exercise (not rest), nocturnal pain that improves on walking

Buttock pain: poorly localised

Restricted spinal movement

Exaggeration of thoracic kyphosis + straightening of lumbar lordosis

Question 2

What are the extra-articular manifestations of ankylosing spondylitis and complications? (6)

Answer 2

From top-down:

Face: Anterior uveitis

Respiratory: Apical fibrosis, chest wall restriction

Cardiac: Early atherosclerosis, conduction disease, AR

Abdomen: IBD, amyloidosis / IgA nephropathy

Neuro: cervical myelopathy cauda equina

MSK: achilles tendonitis, _osteopenia, fracture_s

Extra-articular manifestations (complications): 4 A’s - AR, Apical fibrosis, Ant uveitis, achilles tendonitis

• CV risk
• Osteopenia + Fracture
• Secondary amyloidosis

Question 3

Ankylosing spondylitis: PRICMCP?

Answer 3

P: when dx, symptoms (inflammatory pain, back/SI pain, restricted spinal movement)

R: FH, other autoimmune diseases

I: Dx based on blood (HLA-B27) and/or imaging - XR, MRI

C: extra-articular manifestations + complications (osteopaenia, fracture, IgA nephropathy, neurological)

complications of medications (NSAIDs - CV/GI, TNF inhibitors - infection, cancers/skin (psoriasis), demyelination, HF)

M: any exercise programs/PT? (non-pharm 1st!), current meds, what was tried before (DID IT WORK), why was it ceased. Local steroids injections. Infection prophylaxis

C: has the bloods/radiology improved following therapy? how is AnkSpnd impacting you at your work, ability to cope at home, exercise

P: insights into the nature of chronic/debilitating disease, complications and side effects of immSx drugs.

Question 4

Ankylosing spondylitis examinations?

Answer 4

Look, feel, move, special, extra-articular.

Look: anterior uveitis, psoriasis, loss of cervical/lumbar lordosis, exaggeration of thoracic kyphosis

Feel: tenderness spine + SIJ + other joint involved

Move: ROM in CTLS spine

Special: Schober’s (<5cm), chest expansion (<5cm), occiput-wall distance, finger-floor distance

Extra-articular: CVS (AR, AF), Chest (apical fibrosis), Neuro (LL - cervical myelopathy), Legs (enthesitis/achilles tendonitis/plantar fasciitis)

Question 5

What investigations would you ask to confirm diagnosis of Ankylosing spondylitis - what would you look for in radiology (in stages)?

Answer 5

HLA-B27, raised inflammatory markers (CRP/ESR - poor correlation)

XR SIJ (erosion/sclerosis at margins → pseudo widening → joint space narrowing → fusion)

XR lumbar spine (loss of lordosis → squaring of vertebrae → syndesmophytes → bamboo spine → apophyseal joint fusion)

MRI: early changes include BM oedema, erosions detected earlier.

Exclude: malignancy & infection (CT / MRI tp r/o epidural abscess/discitis)

Question 6

What is your approach to managing this patient with ankylosing spondylitis?

Answer 6

C: confirm dx (HLA-B27, XR SIJ, spine, duration of symptoms, 2 x clinical features + HLAB27 +ve)

A: screen for depression. Rule out malignancy and infection (e.g. discitis/epidural abscess).

S: Specific goals = maintain mobility, posture, retard ankylosis.

T: Non-pharm

• Exercise + PT: ROM, balance + stretching, swimming, avoid cycling
• Lifestyle: smoking cessation, alcohol, balanced diet, good sleep hygiene
• Infection: hand/food hygiene, avoid contact, vaccination
• National Ank-Spond society

T: Pharm

• NSAIDs - shown to slow disease progression
• Steroid injection - can be helpful for SIJ disease or facet disease
• Limited role of DMARDs (no evidence) except for peripheral disease (Sulfasalazine)
• Anti-TNFs (spiel on pre-check) + reduce disease activity and improve function (80%)

Involve: GP and family to ensure continued support & motivation

Ensure follow-up + Screen for Complications:

• Clinical exam: murmur, apical fibrosis, joint tenderness, enthesitis
• Inflammatory markers, ECG (conduction), TTE (AR, RWMA-IHD), CXR/CT (Apical fibrosis), Urine for casts/protein (amyloid), DEXA (osteopaenia)

Question 7

What are the PBS criteria for starting anti-TNFs in Ankylosing spondylitis? (3)

Answer 7

Grade 2 bilateral sacroilitis

Grade 3 unilateral sacroilitis

Failure to respond to NSAIDs + exercise program for 3 months

Question 8

Clinical features of psoriatic arthropathy? (5)

Answer 8

Asymmetric or Symmetric mono/oligo/polyarthritis - very varied

Can have Spondyloarthroitis

Nail disease

Psoriasis

Dactylitis (sausage finger)

Enthesitis

Question 9

Psoriatic arthritis - Mx? (4)

Answer 9

Analgesia, NSAIDs, Physiotherapy

DMARDs (MTX, Sulfasalazine, Leflunomide) for peripheral disease

Biologics - anti-TNFs

Avoid steroids - as rapid wean can cause skin flare up