Ankylosing spondylitis Flashcards
What are the typical presentation of patient with ankylosing spondylitis?
- Young to middle age men (men > women 5:1)
- Back pain or back stiffness
- Abnormal back posture
- Shortness of breath
- Eye pain and redness
History taking in ankylosing spondylitis
- Back pain / back ache
- Site: cervical / thoracic / lumbar / buttock
- Onset: insidious > 3 months
- Character: dull pain
- Radiation: upper posterior thigh
- Aggravating: worse in morning / after rest
- Improves with activity > 30 minutes - Other sites of pain
- Shoulder and chest pain - pectoral joints
- Hip pain - hip joints
- Peripheral - plantar fasciitis, Archilles enthesitis
- Radicular pain - buttocks, thighs - Spinal stiffness and loss of mobility
- Dorsal kyphosis with loss of cervical and lumbar lordosis
- Deterioration of posture
- Paraspinal muscle wasting - Extraskeletal manifestations
(discussed in subsequent cards) - Complications of TNF-a treatment
- PTB or hep B infection
Extraskeletal manifestations of ankylosing spondylitis
- Anterior uveitis - unilateral eye pain, redness, photophobia, watery eyes, blurred vision
- Fatigue, sleep disturbances
- Dactylitis - diffuse swelling of fingers and toes
- Atlanto-axial subluxation - restricted neck movement
- Anterior chest pain - costochondritis
- Aortic regurgitation
- Pericarditis and AV conduction defects
- Apical fibrosis
- Cauda equina syndrome
- Archilles tendonitis
- Amyloidosis
Physical examination dance for ankylosing spondylitis
Identifying AS
1. Inspect- facial, skeletal, dermatological abnormalities
2. Ask patient to stand up - kyphosis, loss of lordosis
3. Neck movement (turn neck up/down/left/right) - reduced cervical moement
4. Sacroiliac joint tenderness
5. Flesche’s test - unable to touch occiput against the wall
(Measure distance between wall and occiput to determine flexion deformity)
6. Schober’s test - mark posterior iliac spine, additional 10cm above and 5cm below
(On maximal forward bending, distance between upper and lower increases by >5cm in normal)
Complications of AS
7. Anterior uveitis - eye redness, pain, watery eyes
8. Reduced chest expansion
9. Aortic regurgitation - EDM over aortic region
10. Apical fibrosis - upper zone fine crepitations
11. Pacemaker scars
12. Archilles tendonitis
Very relevant negatives
12. Psoriasis - look at nails, hairline
What is ankylosing spondylitis?
Chronic inflammatory rheumatic disease of sacroiliac joints and spine > 3 months, with HLA B27
A/w morning stiffness, worse with rest and improves with exercise
What are the peripheral joints involved in ankylosing spondylitis?
Occurs in 20-30% patients with juvenile onset disease
Commonly affects: knees, hips
Genetics of ankylosing spondylitis
HLA-B27 antigen present in 95% patients with AS
(General population HLA B27 is present in 8% adults, and 6% of them developing AS)
Diagnostic investigations of AS
Diagnostic Investigations
1. Clinically - back pain, morning stiffness, relieved with exercise, worse with rest
2. XR sacroiliac joints
- Sacroilitis, fusion, sclerosis, subchondral erosions
- Syndesmophytes
- Fusion of vertebral body (bamboo spine), edge sclerosis, dagger signs
3. MRI sacroiliac joints
4. HLA-B27 testing
Investigations for Complications
5. Spirometry - restrictive pattern
6. CXR - apical fibrosis
7. ECG - conductive defect
8. TTE - aortic regurgitation
Supplementary tests
9. ESR, CRP raised
10. RF, ANCA TRO other causes
Differential diagnosis of back pain and stiffness
- Mechanical back pain
- Psoriatic arthritis
- Reactive arthritis
- Whipple’s disease
- Osteoarthritis
What is seronegative arthritis?
Group of overlapping conditions (PEAR) : psoriatic arthropathy, enteropathic arthritis, ankylosing spondylitis, reactive arthritis
Asymmetrical oligoarthritis, particularly affecting spine
Associated with HLA-B27 and anterior uveitis
Negative rheumatoid factor (RF)
Management of ankylosing spondylitis
Involvement of multidisciplinary team
Non-pharmacological
1. Education and genetic counselling
2. Physiotherapy and occupational therapy - preserves spinal mobility
Pharmacological
3. Analgesics and NSAIDS
4. Pulsed IV methylprednisolone may be helpful
5. +/- DMARDs - methotrexate, sulphasalazine may have some effect on peripheral disease
6. Biologics (anti-TNFa) - adalimumab, etanercept
> Allows rapid reduction in symptoms, inflammation, reduces NSAIDs dependency, but expensive
What is the expected prognosis/clinical course of AS
80% good prognosis with exercise and pain control
50% passing HLA-B27 to offspring, with offspring 20% risk of developing AS
Bath AS Disease Activity Index (BASDAI)
(M: SAFEMM)
5 major symptoms: (no problem) 1 – 10 (worst problem)
- Spinal pain
- Arthralgia or swelling
- Fatigue
- Enthesitis, inflammation of tendons and ligament
- Morning stiffness duration*
- Morning stiffness severity*
* duration and severity score is averaged
BASDAI = total score divided by 5
Range: 1 to 10
Score ≥ 4 indicates suboptimal control of disease
What are the complications of TNF-A injection?
- Sepsis and infection
- Reactivation of latent PTB or Hep B
- Injection site pain
