Ankylosing Spondylitis (from Secondary Care Lecture)

Question 1

What are the features of inflammatory back pain?

Answer 1

• good response to NSAIDs
• morning stiffness
• alternating buttock pain (pain down thigh)
• night pain

Question 2

What are the seronegative features?

Answer 2

• psoriasis
• eyes - redness, pain
• bowels - ulcerative colitis, crohns
• pain in small joints of hands/feet
• hip/shoulder pain
• cold hands/feet - raynauds
• dry eyes/mouth
• mouth ulcers

Question 3

What to include in a history for ank.spon ?

Answer 3

Features of inflammatory back pain
Seronegative features
Past medical history - osteoporosis? Arthritis?
Medications
Social history
Family history - espc of ulcerative colitis, crohns, ankylosing spondylitis, uveitis, reactive arthritis, enthesitis
Risk factors for osteoporosis

Question 4

What are the risk factors for osteoporosis?

Answer 4

Past low impact fractures
Height loss >1inch
FH of osteoporosis or hip fractures
Steroids
Early menopause
Low BMI
Smoking, alcohol

Question 5

What would you see on an MRI of ank.spon?

Answer 5

Subchondral bone marrow oedema

Question 6

What do you look for in a back examination?

Answer 6

From back:
- symmetry of chest wall
- swelling, scars
- muscle wasting - super/infraspinatus
- scoliosis (lateral curvature)
From side:
- cervical lordosis
- thoracic kyphosis
- lumbar lordosis

Question 7

What do you feel in a back examination?

Answer 7

From top of cervical spine downwards - every vertebrae
Paraspinal muscles (top to bottom)
Sacroiliac joint - posterior superior iliac spine (dimples)

Checking for tenderness

Question 8

What do you do in the move part of back examination?

Answer 8

Flexion of thoracic-lumbar spine (touch toes)
Extension of thoracic-lumbar spine (stabilise pelvis and lean backwards)
Lateral flexion of thoracic-lumbar spine (slide hand round outer aspect of thigh)
Rotation of thoracic-lumbar spine (seated, arms crossed, rotate)
Flexion of cervical spine (chin to chest)
Extension of cervical spine (chin to sky)
Rotation of cervical spine (look over shoulder)
Lateral flexion of cervical spine (ear to shoulder)

Question 9

What are the measurements for back examination?

Answer 9

Occipital wall distance. Back of head to wall. Normal = 0.
Tragic wall distance. Front of ear to wall. Normal <15.
Chest expansion. Level of 4th intercostal space (nipple). Normal = 4-6. x3 then take average/best.
Lateral flexion. Arms by side - distance from middle finger to floor, flex then remeasure - calculate difference. Normal >10. Compare both sides.
Schober test. Dot at posterior superior iliac spine (mid point), dot 10cm upwards. Bend forwards, measure distance between dots. Normal/negative schober >5cm.

Question 10

What are the extraskeletal manifestations of ank.spon?

Answer 10

AORTIC insufficiency, ascending aortitis, conduction abnormalities.
Nuero - atlantoaxial subluxation, cauda equina.
Kidney - secondary amyloidosis, c/c prostatitis.
Spine - cervical fractures, spinal stenosis, spinal osteoporosis.
PULMONARY - upper lobe fibrosis, restrictive changes.
OCULAR - anterior uveitis
Nephropathy
Discitis

(Pneumonic - ankspond)