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Ankylosing Spondylitis

Clinical features, Diagnosis, Management, Prognosis,

Ankylosing spondylitis ('inflammation of the vertebrae' from 'spondulos' - Greek for vertebra) is a chronic inflammatory arthritis that affects mainly the sacroiliac joints and spine and characterised by progressive stiffening and fusion of the axial skeleton. Males in the second and third decades are commonly affected (male to female ratio 4:1). More than 90% of affected individuals carry the histocompatibility (tissue) type HLA-B27 (the risk of ankylosing spondylitis in HLA-B27 positive individuals is about 20%), and positive family history, It is not known how this histocompatibility type actually predisposes for ankylosing spondylitis.

Pathologic findings are similar to those found in rheumatoid arthritis, but bony ankylosis occurs more frequently. The characteristic enthesopathy refers to inflammation of the ligamentous attachments to bone with adjacent bone erosion. Healing of similar lesions at the junction of the vertebral bodies and annulus fibrosus of the intervertebral discs leads to the new bone formation (syndesmophytes - bony spurs) which is the hallmark of the disease.

Clinical features:  < BACK TO TOP >

  • The onset is usually insidious with recurring episodes of low back pain in sacroiliac area and stiffness sometimes radiating to the buttocks or thighs.
  • Characteristically the symptoms are worse during the night and the early morning and improve during physical activity (similar to rheumatoid arthritis).
  • Chest pain aggravated by breathing and diminished chest expansion result from involvement of the costovertebral joints.
  • Plantar fasciitis and Achilles tendonitis are common and cause pain on walking (patients may complain of heel ache).
  • Tenderness over bony prominences such as the iliac crest, ischial tuberosity and greater trochanter are typical.
  • As the disease progresses the low back pain tends to ascend to the thoracic and cervical area and there is restriction of movement with the normal lumbar curve becoming flattened and the thoracic curve becoming more pronounced with forward tilt of the body (kyphosis).
  • Iritis occurs in up to one third of patients and presents with moderate pain, redness, photophobia, but it is usually self-limited.
  • The patient may complain of general symptoms such as low-grade fever, fatigue, anorexia and weigh loss.

Diagnosis:  < BACK TO TOP >

  • Testing for HLA-B27 is routinely carried out: HLA-B27 tissue type is present in the general population at about 5-8% but 90% in ankylosing spondylitis.
  • The sedimentation rate and C-reactive protein are elevated in about 85% of cases reflecting the inflammatory nature of the disease.
  • There may be a leukocytosis and anaemia present, but the rheumatoid factor and antinuclear antibodies are negative.
  • X-ray of the sacroiliac joints may show sclerosis (hardening) and erosions, eventually progressing to fusion (ankylosis).
  • In the lumbar spine there may be 'squaring' of the vertebral bodies caused by ossification of the anterior longitudinal ligament.
  • Progressive ossification and development of lateral syndesmophytes between the vertebrae results in the typical 'bamboo spine' appearance on X-ray, but this is seen only over an average period of 10 years.
  • CT of the sacroiliac joints may be needed early in the disease in order to detect early changes.
  • Radionuclide bone scanning may reveal evidence of sacroiliitis or spinal involvement when radiographs are negative but the increased uptake of the bone-seeking isotope is non-specific and reflects bone blood flow and turnover.

Management  < BACK TO TOP >

  • The principles are to relieve pain and stiffness, maintain a maximal range of skeletal mobility and avoid the development of deformities.
  • Early in the disease patients should be trained to do regular exercises at home and encouraged to take up acive low impact sports like swimming.
  • NSAID are used to relieve symptoms but do not themselves alter the course of the disease. Selective COX-2 inhibitors may be a better option due to less risk for side effects on the gastric mucosa and possibly also the kidney.
  • Radiotherapy is occasionally indicated if the response to drug therapy is unsatisfactory. It does not affect the course of the disease and earlier regimens of treatment, when excessive radiation was employed, were associated with a tenfold increase in the risk of developing leukaemia.
  • Local corticosteroid injections can be helpful for plantar fasciitis and the management of other manifestations of enthesopathy, topical corticosteroids can be helpful in iritis.
  • Systemic steroids are sometimes required for treatment of acute iritis but usually they are not very effective.

Prognosis  < BACK TO TOP >

  • The condition characteristically follows exacerbation/remission course. However 75% or more of patients with ankylosing spondylitis are able to remain in employment without significant loss of time from work.

(source : Dr Zoran Pletikosa)

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