Ankylosing spondylitis

Question 1

What is ankylosing spondylitis?

Answer 1

Chronic inflammatory arthritis that most commonly affects the spine causing progressive stiffness and pain

Question 2

1) It is part of the seronegative spondyloarthropathy group of conditions relating to what gene?
2) What are the 2 other conditions in this group?

Answer 2

1) HLA-B27
2) Reactive arthritis, psoriatic arthritis

Question 3

What is psoriatic arthritis?

Answer 3

Inflammatory arthritis associated with psoriasis

Question 4

1) What is reactive arthritis?
2) What are the 3 classic features?
3) How is it managed?

Answer 4

1) Condition where synovitis occurs in the joints as a reaction to a recent infective trigger which results in an acute monoarthritis, affecting a single joint in the lower limb (most often the knee) presenting with a warm, swollen and painful joint.
2) Urethritis, arthritis, conjunctivitis
3) NSAIDs

Question 5

1) What are the key joints impacted in ankylosing spondylitis?
2) Ankylosing spondylitis can progress to cause fusion of these joints. Fusion of this joint can lead to which classical presentation on x-ray?

Answer 5

1) Sacroiliac and vertebral joints
2) Squaring of lumbar vertebrae and bamboo spine

Question 6

1) How does ankylosing spondylitis commonly present?
2) What effect does activity have?
3) At what time of the day is the pain worse?
4) Normally how long does it take for the pain in the morning to get better?

Answer 6

1) Lower back pain and stiffness and sacroiliac pain in the buttock region that develops gradually over 3 months, upper lobe pulmonary fibrosis
2) Worse with rest and improves with movement
3) Night and morning
4) At least 30 mins

Question 7

What is the key complication of ankylosing spondylitis?

Answer 7

Vertebral fracture

Question 8

Name 3 associated symptoms/conditions in other body systems that can be caused by ankylosing spondylitis

Answer 8

• Systemic symptoms (weight loss and fatigue)
• Chest pain related to costovertebral and costosternal joints
• Enthesitis inflammation of the entheses (where tendons or ligaments insert in to bone which can cause problems i.e. plantar fasciitis and achilles tendonitis.
• Dactylitis (inflammation in a finger or toe)
• Anaemia
• Anterior uveitis
• Aortitis
• Heart block (fibrosis of the heart’s conduction system)
• Restrictive lung disease (restricted chest wall movement)
• Pulmonary fibrosis (apical)
• IBD

Question 9

Schober’s Test is used as part of a general examination of the spine to assess mobility. How does this test work?

Answer 9

• Stand patient straight
• Find L5
• Mark a point 10cm above and 5cm below this point
• Ask px to bend forward as far as they can
• Distance between both points should be >20cm.
• If not, shows restricted lumbar movement

Question 10

1) What is the 1st line management (2)?
2) What drugs can be used for flare-ups?
3) Anti-TNF medication can be used, name one of these
4) TNF monoclonal antibodies can also be used, name one of these
5) If NSAIDs and anti-TNF medications aren’t effective, secukinumab can be used. What kind of drug is this?

Answer 10

1) NSAIDs and exercise regimen
2) Steroids
3) etanercept
4) Infliximab, adalimumab
5) IL17 monoclonal antibody