Clinical consultation

Question 1

Features of ankylosing spondylitis on examination

Answer 1

• Question-mark shaped kyphosis
• Restricted spinal movement in all directions
• Positive modified Schober’s sign
• Occiput to wall distance may be over 0cm

Question 2

What is the modified Schober’s sign?

Answer 2

You mark the level of the posterior iliac spines and sacral dimples, and a point 10 cm above this in the midline. When the patient flexes forward the distance between the two points normally increases to at least 15 cm, but does not in a positive test

Question 3

What are some symptoms associated with ankylosing spondylitis which you should ask about?

Answer 3

Seronegative spondyloarthropathies:
Skin problems (psoriasis)
Recent infections (reactive arthritis
Bowel problems (enteropathic arthritis)

Other associated symptoms:
Achilles tendonitis and plantar fasciitis
Anterior uveitis
Aortic regurgitation
Apical fibrosis
Amyloidosis
AV heart block

Question 4

How do you diagnose ankylosing spondylitis?

Answer 4

Clinical and radiological evidence

Inflammatory markers may be elevated
May be HLA B27 positive

The radiological features of established spondylitis and sacroiliitis are useful but in acute disease X-rays are normal

MRI sacroiliac joints is increasingly used to detect early disease

Question 5

How do you manage ankylosing spondylitis?

Answer 5

NSAIDS
Good posture, physiotherapy and home exercises including extension exercises
In severe AS with active spinal disease assessed on two separate occasions 12 weeks apart, and failure of at least two NSAIDs, can give anti-TNF (adalimumab, etanercept)