ANKYLOSING SPONDYLITIS

TANU TUESE Musculoskeletal System

OVERVIEW:• Epidermiology• Etiology and Risk factors• Clinical manifestations• Complications• Differential diagnosis• Diagnosis• Management

Epidemiology• Prevalence:– 4%-5% of patient-lowback pain.– 5% to 6% in HLA-B27 postive persons.– 0.1% to 1.4% depending on the population

studied.• Demographic:– Most common between the ages of 16 – 40– 3 times more frequent in men than in women– Common in white patients– HLA-B27 positive – 5% to 6% chance of developing

ankylosing spondylitis

Etiology• No specific cause• Risk factors:– HLA-B27 (genetic association).– Age ( adolescence or early childhood).– Sex – 2 to 3 times common in men than in women.

• Chronic inflammatory disease

Risk Factors

Pathophysiology

Pathophysiology

Clinical features• Insidious onset (over months or

years)• Episodes of low back pain and

muscle stiffness– Radiates to the buttocks or posterior

thighs.– Axial and symmetrical in distribution.– Most in the early morning and after

inactivity.– Relieved by movement.

• Physical signs:– lumbar lordosis– Pain on sacroiliac compression– restriction of chest expansion

Extraspinal featuresRare features

• Anterior uveitis (25%) and conjunctivitis(20%)

• Prostatitis(80% men)- usually asymptomatic

• Cardiovascular disease– Aortic incompetence– Mitral incompetence– Cardiac conduction

defects– Pericarditis

• Amyloidosis• Atypical upper lobe

pulmonary fibrosis

Differential diagnosis• Other spondyloarthropathies. – Enteropathic arthritis– Psoraitic arthritis– Reactive arthritis

• Degenerative disk disease• Diffuse idiopathic skeletal hyperostosis syndrome• Sarcoidosis• Infectious sacroiliitis

Complications• Neurological complication• Kidneys- Amyloidosis• Heart complication• Lung problems

Investigations• Physical Examination

– Schobers test– Chest expansion– Cervical mobility

• Laboratory findings:– ESR and CRP : usually raised.– Serum rheumatoid factor (RF) is negative.– Renal function test– FBC

• Imaging:– Spine X-rays- lateral thoracolumbar view– MRI and CT scan

Physical examination• Vital signs and check for fever and

signs of weight loss• Examine the skin and nails and

check for psoraisis• Examine the eyes for signs of

inflammation• Auscultate the chest • Examine the spine

– Schober test– Faber test– Range of movement

Imaging

Diagnosing • Clinical criteria:

– Low back pain with inflammatory characteristics– Limitation of lumbar spine motion in the sagittal and frontal planes– Decrease chest expansion

• Radiographic criteria:– Bilateral sacroiliitis of grade 2 or higher– Unilateral sacroiliitis of grade 3 or higher

• Radiologic criteria (grade 1 = suspicious change of the sacroiliac joints; grade 2 = minimal change consistent with sacroiliitis; grade 3 = unequivocal change in the sacroiliac joints; grade 4 = severe sacroiliitis with marked ankylosis).

• Need one clinical and one radiographic criterion

Management • Primary management

– NSAIDs (naproxen and indomethacin)– Muscle relaxants– DMARDs– Exercise therapy– Tobacco discontinuation

• Surgical therapy– Indication :

• sagittal plane deformity• Severe back pain• Upper cervical instability

Management(spine)• Opening wedge surgery

Management(spine)• Closing wedge surgery

Management(spine)A. PREOPERATIVEB. POSTOPERATIVE

CERVICOTHORACIC KYPHOSIS

Management(spine)

THORACOLUMBAR KYPHOSIS

Reference• Goldman’s Cecil Medicine, 24th edition• Rothman –Simeone The spine, 6th edition• Nelson textbook of Pediatrics,19th edition• Davison’s Priniciples and Practice of Medicine,21st edition

• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001457/• http://www.mayoclinic.com/health/ankylosing-spondylitis/DS00483• http://www.medicinenet.com/ankylosing_spondylitis/article.htm• http://www.spondylitis.org/about/complications.aspx#