Ankylosing Spondylitis

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Ankylosing Spondylitis
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Symptoms

• Chronic systemic inflammatory disease involving
  axial skeleton of younger pts
• Develops in second/third decade
• Typically dull aching pain of insidious onset in
  lower lumber/ buttock region
• Early morning stiffness(ems) and nocturnal pain

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Symptoms

• Stiffness improves with exercises and recurs
  after periods of inactivity
• Some pts present with painful hips, shoulders,
  asymmetrical arthritis of lower limbs prior to
  spinal involvement
• Cervical and thoracic pain and stiffness is
  frequent

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Symptoms

• Enthesitis incl chest pain is common-aggravated
  by manoeuvres increasing intra-thoracic pressure
  (eg coughing)
• Peripheral joints shoulders, hips,
  costovertebral, costosternal, manubriosternal,
  sternoclavicular joints commonly symptomatic at
  presentation
• M gt F. 2-3.

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Symtoms and presentation

• Males spine and pelvis more frequently involved
  with some involvement of hips, shoulders and
  chest wall. Tend to have a more severe disease
  than females
• Females pelvis, hips, knees, and wrists with
  less severe inv of the spine
• Enthesitis-inflammation of ligament and tendon
  typical in seronegative arthritis. Eg achilles
  tendonitis, illiac crest pain, chest wall
  pain-from inv of costochondral, manubriosternal
  and sternoclavicular joints

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HLA-B27

• B27 ve in 90-95 of AS.
• Lower prevalence of B27 in african/african-america
  n population associated with a lower prevalence
  of AS in these populations
• B27 ve individuals have a 2-5 chance of
  developing AS
• Male sex, B27ve, FHx of AS frequent GI
  infections are all RFs for developing AS

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Pathogenesis

• ?development in genetically predisposed
  individuals, triggered by an environmental factor
  eg gastro-intestinal infection
• Reactive arthritis has a similar pathogenesis
  whereby chlamydia trachomatis, yersinia
  enterocolitica, shigella flexneri, campylobactor
  jejunii, salmonella typhymurium have been
  implicated.

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Pathogenesis

• B27 ve rats in a germ-free environment do not
  develop AS
• There is a high incidence of GI mucosal
  inflammation (both symptomatic and asymptomatic),
  this raises the possibility that the gut, with
  breakdown of the mucosal lining is a triggering
  event.

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Pathogenesis

• Activated T-cells and macrophages found at sites
  of inflammation with expression of IL-1ß, tnf-a
  and IF-?. These inflammatory cytokines cause
  erosion of cortical bone, new bone formation and
  loss of bone mass

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Associated features

• Extra-articular symptoms eg acute anterior
  uveitis.
• Inflammatory bowel disease and/or psoriases may
  be present
• AS associated with CD/UC occurs in 5-10 of
  individuals
• Asymptomatic GI inflammation present in 25-49 of
  AS

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Associated features

• 50-60 of AS have microscopic inflammatory
  lesions at any one time
• Uveitis occurs in 25-40
• Osteoporoses is a common feature-look out for
  this
• Less frequent-aortic incompetence, cardiac
  conduction anomalies, progressive, b/l apical
  cavitation/fibroses
• Other spondyloarthropathies-ReA, PsA Enteropathic
  arthritis commoner in relatives

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Examination

• B/L sacro-illiac joint tenderness (febere
  manoeuvre)
• Peripheral joint synovitis-asymmetric,
  oligoarticular pattern.
• Dactylitis of fingers and/or toes
• Enthesopathy-thickened achilles tendon, planter
  fascitis, chest wall tenderness etc

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Examination

• Advanced disease changes in posture-flattening
  of normal lumber lordoses, thoracic kyphoses may
  be exaggerated.
• C-spine-limitation in ROM with fusion in
  hyper-flexion

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Presentation

• Chronic low back pain-usually as a teenager
• Tend to remain active as way to ease pain and
  stiffness
• Back pain tends to become more progressive,
  symptomatic and severe-look for inflammatory back
  pain symptomatology
• Look for assoc chest wall tenderness, heel pain,
  buttock pain.

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Presentation

• Rarely may present with acute anterior uveitis
• Look for other features of extra-axial
  involvement which would aid diagnoses-
  asymmetrical oligoarthritis, enthesopathy.
• Sacro-illeitis present with pain radiating to
  buttock and radiating to upper posterior thighs.
  Usually U/L, intermittent or alternate from one
  to other side and eventually becomes B/L and
  persistent

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Examination

• Chest expansion, SIJ
• Typical spinal ankyloses occurs after 10yrs
• Osteoporoses more likely in severe advanced,
  long-standing AS esp in pts with immobile spine.
• Rigid osteoporotic spine susceptible to vertebral
  fractures-prophylactic treatment

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Diagnoses Investigations

• Based on clinical/blood test and radiological
  findings
• Symptoms of inflammatory back pain
• Family history
• Extra-articular lesions
• B/L sacro-illeitis on XR or MRI
• MRI-STIR sequences show up inflammation with bone
  marrow oedema and enthesopathy

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Diagnoses and investigations

• HLA B-27 in whom hx and examination is
  suggestive of a sero-negative spodyloarthropathy
  but have normal XRs
• Should not be used as a routine, diagnostic,
  confirmatory or screening test.
• Positive B-27 in the presence of non-inflammatory
  back pain with ve XRs does not confirm diagnoses
  and up to 8 fo normal pop are ve. Higher in
  normal relatives.
• ?esr/crp in 70 of AS, but no clear correlation
  with disease activity. Associated with peripheral
  arthritis rather than axial arthritis

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Management

• Combination of non-pharmocologic and
  pharmocological therapy depending on disease
  stage and symptoms
• Patient education essential-life long programme
  of exercise, use of individual, and group therapy
  as well as self-help groups
• Functional disability in AS progresses more
  rapidly in smokers and less so in those with
  better social support and reg exercises

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Management

• NSAIDs-essential
• DMARDs-not recommended for axial disease, however
  SASP found to be useful in periopheral arthritis
• Steroids-oral or parenteral not recommended
• Anti TNF-all three effective in AS in pts with
  persistently high BASDAI. No need to use MTX with
  anti-tnf prior to commencing anti-tnf

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Surgery

• Rare
• Hip arthroplasty-structuarl damage causing
  refractory pain
• Corrective spinal osteotomy. Fusion procedures in
  patients with segmental instability may be
  indicated.

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Prognoses

• Depends on stage at diagnoses
• Initiation of effective therarpy
• Worse in smokers, low socio-economic class
• Worse in pts poorly compliant with exercises
• Males worse than females

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Question?