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Year 3 > Ankylosing spondylitis (MSK) > Flashcards

Ankylosing spondylitis (MSK) Flashcards

1
Q

What is ankylosing spondylitis?

A

Seronegative spondyloarthropathy and a chronic inflammatory disease of the axial skeleton that leads to partial or complete fusion and rigidity of the spine

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2
Q

Describe the epidemiology of ankylosing spondylitis.

A

Young males:

  • M>F
  • 15-40y
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3
Q

What gene is ankylosing spondylitis associated with?

A

HLA-B27

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4
Q

What condition is ankylosing spondylitis associated with?

A

IBD - Crohn’s and UC

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5
Q

What conditions make up seronegative spondyloarthropathy? (4)

A
  • ankylosing spondylitis
  • psoriatic arthritis
  • reactive arthritis
  • enteropathic arthritis (IBD-associated)
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6
Q

What is the difference between axial spondyloarthritis and ankylosing spondylitis?

A
  • axial spondyloarthritis is a chronic progressive inflammatory arthropathy which can ultimately lead to radiographical changes in the spine and sacroiliac joints
  • this radiographical stage is known as ankylosing spondylitis (AS)
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7
Q

Describe the pathophysiology of ankylosing spondylitis.

A
  • chronic autoimmune (against type I+II collagen) inflammatory disease that affects vertebral joints
  • over time the inflammation destroys the intervertebral joints, facet and sacroiliac joints, and fibroblasts replace the destroyed joints with fibrin
  • layers of fibrin form a tough fibrous band around the outside of joints –> limited ROM + bamboo spine
  • eventually osteoblasts are activated and ossification starts when fibrous tissue turns to bone
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8
Q

What are syndesmophytes (ankylosing spondylitis)?

A

Small bony outgrowths form at the joint edges = syndesmophytes (vertical ossifications bridging the margins between adjacent vertebrae –> immobility) + cause bony joint fusion (ankylosis)

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9
Q

How do vertebral bodies look in ankylosing spondylitis?

A

Become more square

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10
Q

What is the hallmark clinical feature of ankylosing spondylitis?

A

Inflammatory back pain - insidious onset, early morning stiffness which improves with activity, worse when resting (at night)

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11
Q

What are the clinical features of ankylosing spondylitis?

A
  • inflammatory back pain - early morning stiffness/pain which improves with activity +/- night pain
  • anterior uveitis/iritis - eye pain, redness, photophobia
  • enthesitis - inflammation where tendon/ligament attaches to bone (Achilles most common site)
  • tenderness at sacroiliac joint
  • reduced spinal mobility + ROM
  • constitutional symptoms - fatigue, weakness, fever, WL
  • extra-articular features (6A’s)
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12
Q

What extra-articular features are seen in ankylosing spondylitis? (6A + 2)

A
  • Apical lung fibrosis
  • Amyloidosis
  • Anterior uveitis
  • Achilles tendinitis (heel pain)
  • Aortic regurgitation
  • AV node block
  • (Cauda equina syndrome)
  • (Peripheral Arthritis)
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13
Q

How does anterior uveitis present in ankylosing spondylitis? (3)

A
  • eye pain
  • redness
  • photophobia
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14
Q

What constitutional features are seen in ankylosing spondylitis? (4)

A
  • fatigue
  • weakness
  • fever
  • weight loss
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15
Q

What might be found on examination in ankylosing spondylitis? (5)

A
  • reduced range of spinal movement (especially hip flexion)
  • reduced lateral spinal flexion
  • reduced forward spinal flexion (Schober’s test)
  • tenderness over sacroiliac joints
  • reduced chest expansion
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16
Q

What is Schober’s test (ankylosing spondylitis)?

A

Line drawn 10cm above and 5cm below the back dimples - distance between the two lines should increase by >5cm when patient bends as far forward as possible (reduced movement suggests ankylosing spondylitis)

17
Q

What does Schober’s test show in ankylosing spondylitis?

A

Reduced forward flexion <5cm

18
Q

How does ankylosing spondylitis present in later stages? (3)

A
  • thoracic kyphosis
  • spinal fusion
  • question mark posture
19
Q

What are some risk factors for ankylosing spondylitis? (4)

A
  • male (3:1)
  • HLA-B27
  • IL23R and ERAP1
  • Fx
20
Q

What is the first-line investigation for ankylosing spondylitis?

A

Pelvic X-ray (requested in all patients presenting with inflammatory back pain)

21
Q

What does pelvic XR show in ankylosing spondylitis?

A

Sacroiliitis –> subchondral erosions and sclerosis

22
Q

What will lumbar XR show in ankylosing spondylitis? (2)

A
  • bamboo spine - syndesmophytes (ossification of outer fibres of annulus fibrosus) form between adjacent vertebrae
  • squaring of lumbar vertebrae
23
Q

What investigations are done in ankylosing spondylitis? (6)

A
  • pelvic XR (1st line)
  • lumbar XR
  • HLA-B27 (+ve but not diagnostic)
  • MRI
  • CXR + spirometry
  • Schober’s test (reduced forward flexion <5cm)
24
Q

When do we do MRI in ankylosing spondylitis?

A
  • if high suspicion for AS but XR negative
  • may show enthesitis
25
Q

What does CXR and spirometry show in ankylosing spondylitis?

A
  • CXR - apical lung fibrosis
  • spirometry - restrictive defect –> FEV1/FVC >0.7
26
Q

What might we see in later stages of ankylosing spondylitis? (3)

A
  • erosions
  • sclerosis
  • sacroiliac joint fusion
27
Q

What are some differential diagnoses for ankylosing spondylitis? (9)

A
  • OA - mechanical pain worse with activity, no morning Sx
  • diffuse idiopathic skeletal hyperostosis - mechanical Sx, older age
  • psoriatic arthritis
  • reactive arthritis - Hx infection
  • IBD-related arthritis - Hx Crohn’s/UC
  • infection (e.g. discitis)
  • vertebral fracture
  • bony metastases
  • ochronotic arthropathy
28
Q

What is the first-line management for ankylosing spondylitis?

A

NSAIDs + encourage regular exercise + physiotherapy

29
Q

How do we manage local intra-articular inflammation or enthesitis in ankylosing spondylitis?

A

Intra-articular corticosteroid injection (+ NSAIDs)

30
Q

How do we manage ankylosing spondylitis with peripheral joint involvement?

A

DMARDs (methotrexate or sulfasalazine)

+ NSAIDs

31
Q

How do we manage ankylosing spondylitis with high disease activity (refractory to 2 NSAIDs)?

A
  • 1st line: TNF-alpha inhibitor e.g. infliximab or etanercept
  • 2nd-line: IL-17 inhibitor
  • 3rd line: JAK inhibitor
  • (continue NSAIDs)
32
Q

What are some complications of ankylosing spondylitis? (6)

A
  • osteoporosis
  • cardiac involvement (e.g. AR)
  • pulmonary involvement (e.g. apical lung fibrosis, respiratory failure)
  • hip involvement
  • enthesitis (inflammation of site where tendon inserts into bone –> Achilles tendinitis, plantar fasciitis)
  • 6 A’s
33
Q

Describe the prognosis of ankylosing spondylitis.

A
  • patients who do well lead active lifestyles and maintain a disciplined exercise programme
  • disease progression may ultimately lead to fusion of sacroiliac joints and the vertebral column, resulting in bamboo spine

Year 3 (187 decks)

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