Ankylosing Spondylytis Flashcards
AS Signs and symptoms?
The signs and symptoms of ankylosing spondylitis often appear gradually, with peak onset being between 20 and 30 years of age.[9] Initial symptoms are usually a chronic dull pain in the lower back or gluteal region combined with stiffness of the lower back.[10] Individuals often experience pain and stiffness that awakens them in the early morning hours.[9]
As the disease progresses, loss of spinal mobility and chest expansion, with a limitation of anterior flexion, lateral flexion, and extension of the lumbar spine, are seen. Systemic features are common, with weight loss, fever, or fatigue often present.[9] Pain is often severe at rest but may improve with physical activity, but inflammation and pain to varying degrees may recur regardless of rest and movement.
AS can occur in any part of the spine or the entire spine, often with pain referred to one or the other buttock or the back of the thigh from the sacroiliac joint. Arthritis in the hips and shoulders may also occur. When the condition presents before the age of 18, it is more likely to cause pain and swelling of large lower limb joints, such as the knees.[11] In prepubescent cases, pain and swelling may also manifest in the ankles and feet where heel pain and enthesopathy commonly develop.[11] Less commonly ectasia of the sacral nerve root sheaths may occur
About 40% of people with AS will also experience inflammation of the anterior chamber of the eye, causing eye pain, redness, floaters and sensitivity to light. This is thought to be due to the association that both AS and uveitis have with the inheritance of the HLA-B27 antigen. Inflammation of the prostate occurs with increased frequency in men. Cardiovascular involvement may include inflammation of the aorta, aortic valve insufficiency or disturbances of the heart’s electrical conduction system. Lung involvement is characterized by progressive fibrosis of the upper portion of the lung.
AS Pathophysiology?
Ankylosing spondylitis (AS) is a systemic rheumatic disease, meaning it affects the entire body. Approximately 90% of people with AS express the HLA-B27 genotype, meaning there is a strong genetic association. 1–2% of individuals with the HLA-B27 genotype develop the disease
AS Diagnosis?
Ankylosing spondylitis is a member of the more broadly defined disease axial spondyloarthritis.[16] Axial spondyloarthritis can be divided into (1) radiographic axial spondyloarthritis (which is a synonym for ankylosing spondylitis) and (2) non-radiographic axial spondyloarthritis (which include less severe forms and early stages of ankylosing spondylitis) [16]
While ankylosing spondylitis can be diagnosed through the description of radiological changes in the sacroiliac joints and spine, there are currently no direct tests (blood or imaging) to unambiguously diagnose early forms of ankylosing spondylitis (non-radiographic axial spondyloarthritis). Diagnosis of non-radiologic axial spondyloarthritis is therefore more difficult and is based on the presence of several typical disease features.[16][17]
These diagnostic criteria include:
Inflammatory back pain:
Chronic, inflammatory back pain is defined when at least four out of five of the following parameters are present: (1) Age of onset below 40 years old, (2) insidious onset, (3) improvement with exercise, (4) no improvement with rest, and (5) pain at night (with improvement upon getting up)
Past history of inflammation in the joints, heels, or tendon-bone attachments
Family history for axial spondyloarthritis
Positive for the biomarker HLA-B27
Good response to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs)
Signs of elevated inflammation (C-reactive protein and erythrocyte sedimentation rate)
Manifestation of psoriasis, inflammatory bowel disease, or inflammation of the eye (uveitis)
If these criteria still do not give a compelling diagnosis magnetic resonance imaging (MRI) may be useful.[16][17] MRI can show inflammation of the sacroiliac joint
AS Treatment?
The mainstay of therapy in all seronegative spondyloarthropathies are anti-inflammatory drugs, which include NSAIDs such as ibuprofen, phenylbutazone, diclofenac, indomethacin, naproxen and COX-2 inhibitors, which reduce inflammation and pain. Indomethacin is a drug of choice. 2012 research showed that those with AS and elevated levels of acute phase reactants seem to benefit most from continuous treatment with NSAIDs.[21]
Opioid painkillers
Medications used to treat the progression of the disease include the following:
Disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine can be used in people with peripheral arthritis. For axial involvement, evidence does not support sulfasalazine.[22] Other DMARDS, such as methotrexate, did not have enough evidence to prove their effect. Generally, systemic corticosteroids were not used due to lack of evidence. Local injection with corticosteroid can be used for certain people with peripheral arthritis.[23]
Low intensity aerobic exercise
Transcutaneous electrical nerve stimulation (TENS)
Thermotherapy
Proprioceptive neuromuscular facilitation (PNF)
Exercise programs, either at home or supervised;
Group exercises;
Moderate-to-high impact exercises like jogging are generally not recommended or recommended with restrictions due to the jarring of affected vertebrae that can worsen pain and stiffness in some with AS
AS Prognosis?
Prognosis is related to disease severity.[9] AS can range from mild to progressively debilitating and from medically controlled to refractory. Some cases may have times of active inflammation followed by times of remission resulting in minimal disability while others never have times of remission and have acute inflammation and pain, leading to significant disability.[9] As the disease progresses, it can cause the vertebrae and the lumbosacral joint to ossify, resulting in the fusion of the spine.[33] This places the spine in a vulnerable state because it becomes one bone, which causes it to lose its range of motion as well as putting it at risk for spinal fractures. This not only limits mobility but reduces the affected person’s quality of life. Complete fusion of the spine can lead to a reduced range of motion and increased pain, as well as total joint destruction which could lead to a joint replacement.[34]
Osteoporosis is common in ankylosing spondylitis, both from chronic systemic inflammation and decreased mobility resulting from AS. Over a long-term period, osteopenia or osteoporosis of the AP spine may occur, causing eventual compression fractures and a back “hump”.[35] Hyperkyphosis from ankylosing spondylitis can also lead to impairment in mobility and balance, as well as impaired peripheral vision, which increases the risk of falls which can cause fracture of already-fragile vertebrae.[35] Typical signs of progressed AS are the visible formation of syndesmophytes on X-rays and abnormal bone outgrowths similar to osteophytes affecting the spine. In compression fractures of the vertebrae, paresthesia is a complication due to the inflammation of the tissue surrounding nerves.
Organs commonly affected by AS, other than the axial spine and other joints, are the heart, lungs, eyes, colon, and kidneys. Other complications are aortic regurgitation, Achilles tendinitis, AV node block, and amyloidosis.[36] Owing to lung fibrosis, chest X-rays may show apical fibrosis, while pulmonary function testing may reveal a restrictive lung defect. Very rare complications involve neurologic conditions such as the cauda equina syndrome.[36][37]
AS epidemiology?
Between 0.1% and 1.8% of people are affected.[3] The disease is most common in Northern European countries, and seen least in people of Afro-Caribbean descent.[9] Although the ratio of male to female disease is reportedly 3:1,[9] many rheumatologists believe the number of women with AS is underdiagnosed, as most women tend to experience milder cases of the disease. The majority of people with AS, including 95 percent of people of European descent with the disease, express the HLA-B27 antigen[43] and high levels of immunoglobulin A (IgA) in the blood.[citation needed]
