Ankylosing Spondylitis

Question 1

Definition of ankylosing spondylitis

Answer 1

• Inflammatory condition mainly affecting the spine that causes progressive stiffness and pain

Question 2

Presentation of ankylosing spondylitis

Answer 2

• Key joints affected are sacroiliac joints and the joints of the vertebral column
• Typical presentation is a young adult male in their late teens or 20s
• Symptoms usually develop over more than 3 months
• Lower back pain and stiffness and sacroiliac pain in the buttock region - worse with rest and improves with movement
• Pain worse at night and in the morning - can wake from sleep
• Takes at least 30 minutes for the stiffness to improve in the morning and gets progressively better throughout the day
• Vertebral fractures are common

Question 3

Associations with ankylosing spondylitis

Answer 3

• Systemic symptoms such as weight loss and fatigue
• Chest pain related to costovertebral and costosternal joints
• Enthesitis is inflammation of the entheses.
• Dactylitis is inflammation in a finger or toe.
• Anaemia
• Anterior uveitis
• Aortitis
• Heart block can be caused by fibrosis of the heart’s conductive system
• Restrictive lung disease can be caused by restricted chest wall movement
• Pulmonary fibrosis at the upper lobes of the lungs occurs in around 1% of AS patients
• Inflammatory bowel disease is a condition associated with AS

Question 4

Schober’s test

Answer 4

• Patient stands straight
• Find L5 vertebrae
• Mark point 10cm above and 5cm below (15cm apart)
• Ask patient to bend forwards and measure distance
• If distance is less than 20cm this indicates restriction in lumbar movement and supports diagnosis

Question 5

X-ray changes in ankylosing spondylitis

Answer 5

• ‘Bamboo spine’
• Squaring of the vertebral arteries
• Subchondral sclerosis and erosions
• Syndesmophytes (areas of bone growth where the ligaments insert into bone)
• Ossification of the ligaments, discs and joints
• Fusion of the facet, sacroiliac and costovertebral joints

Question 6

Management of ankylosing spondylitis

Answer 6

• NSAIDs for pain
• Steroids to control symptoms during flares
• Anti-TNF for disease activity
• Secukinumab in a monoclonal antibody against interleukin-17
• Also incluide:
  
  • Physiotherapy
  • Exercise and mobilisation
  • Avoid smoking
  • Bisphosphonates to treat osteoporosis
  • Treatment of complications
  • Surgery for certain deformities