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 features
Rare 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. PREOPERATIVE B. POSTOPERATIVE

CERVICOTHORACIC KYPHOSIS

Management(spine)

THORACOLUMBAR KYPHOSIS

Reference

Goldmans Cecil Medicine, 24th edition Rothman Simeone The spine, 6th edition Nelson textbook of Pediatrics,19th edition Davisons 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#