Ankylosing Spondylitis

Ankylosing Spondylitis

• Marie-Strumpell disease

• Bechterew’s disease

• Rhizomelic spondylitis

• Pelvospondylitic ossificans

• Spondylitis ossificans ligamentosa

 Ankylosing Spondylitis
• Chronic inflammatory disorder of unknown cause that
principally affects the axial skeleton , although the
appendicular skeleton may also be significantly
involved

• Alterations occur in synovial and cartilaginous joints

and in sites of tendon and ligament attachment

• 5 -10 % patients with rheumatic symptoms and signs

History

• Bernard connor(1666–1698) – described a skeleton

with spondylitis
• Bones were straight and intimately joined
• Ligaments perfectly bony

• Von Bechterew , Strumpell and Marie – accurate

clinical description(1853–1940)

• Frankel and Simmonds – identified peculiar

abnormalities of the posterior joints of the vertebral
column
Cause

• Genetic - HLA – B27

• Human leukocyte antigen (HLA)-B27 is correlated
with 90% of Caucasian patients and 50% of black
patients with AS
• Immunopathological
• Triggering factor - Bacterial antigen resembling HLA
– B27
• PAIR– Psoriatic artritis, Anky.spond, IBD,Reactive
arthritis.
 Pathology

•Involves synovial and cartilaginous joints and in

sites of tendon and ligament attachment (entheses)

• Axial skeleton
• Sacroiliac joint
• Thoraco lumbar
• Lumbo sacral

• Peripheral joints
• Hip
• Shoulder
• Knees, hands, feet
Pathology

Pathological changes proceed in 3 stages:

1. Inflammatory reaction with round cells ,
granulation tissue formation , erosion of
adjacent bone
2. Replacement of granulation tissue with
fibrous tissue
3. Ossification of fibrous tissue leading to
ankylosis of joint
Pathology

Synovial articulations
• Synovitis
• Metastatic calcification
of cartilage and
capsule
• Intra articular bony
ankylosis
• Sub chondral
eburnation
Cartilagenous articulations
• Discovertebral junction , symphisis pubis and
manubrio sternal joints
• Inflammation
• Chondroid transformation
• Ossification – syndesmophytes

Enthesitis
Pathology

Spine :
• Disco vertebral junction
• Apophyseal joints
• Costo vertebral joints
• Posterior ligaments
• Atlanto axial joints
Pathology

• Late stages of spine

pathology fractures
occur due to
• Osteoporosis
• Ankylosis
• Cervical spine more
susceptible – typically
lower cervical spine
• Pseudo-arthrosis may
occur
Clinical features

• Age : 15 – 35 yrs
• increasing age of onset - good prognosis
• Younger patients – peripheral joint abnormalities
• Older pateints – axial skeleton

• Males > Females

• Familial – HLA-B27
Clinical features

• Symptom :
• Pain and stiffness in
low back
• Radiating pain in the
lower limbs
• Pain and swelling in
the peripheral joints
• Redness of eye
• Fatigue
 Clinical features
Signs :
• Local tenderness over sacroiliac joints
• Paravertebral muscle spasm
• Diminished chest expansion
• Loss of lumbar lordosis
• Exaggeration of normal thoracic kyphosis
• Limited cervical movements
• Head and neck protrude forwards
• Upright posture maintained by flexion at hip and
knee
Typical posture
Clinical features

Signs :
• Symmetrical involvement of peripheral joints
• Involvement of “root” joints
• Typical features:
• Regional pain
• Limitation of motion
• Muscle atrophy
• Flexion contracture
Clinical features

Signs:
Tenderness over bony prominences
•Calcaneum
•Symphysis pubis
•Iliac crest
•Trochanter of femur
•Ischial; tuberosity
•Costal cartilage
Clinical features
Systemic signs :

• Iritis

• Spondylitic heart disease

• Aortic insufficiency

• Pulmonary – fibrosis and cavitation

• Inflammatory bowel disease

• Amyloidosis
Special Tests
• Modified Schober index (MSI):.
• stands erect, with heels together
• marks are made directly over the spine 5 cm below
and 10 cm above the lumbosacral junction
(identified by a horizontal line between the
posterosuperior iliac spines.)
• The patient then bends forward maximally, and the
distance between the two marks is measured.
• The distance between the two marks increases by
greater than or equal to 5 cm in the case of normal
mobility and by <4cm in the case of decreased
mobility.
Special Tests
Cervical Rotation (CROT): distance between tip of
nose and the acromioclavicular joint in neutral and
maximal ipsilateral rotation.

Tragus-to-wall distance (TWD): measures the

horizontal distance between the right tragus and the
wall, standing with the heels and buttocks against
the wall, knees extended and chin tucked in. The
large the distance indicates worse spinal/upper
cervical posture. WALL TEST
Special Tests

Fingertip-to-Floor distance (FFD): distance between

the tip of the right middle finger and the floor
following maximal lumbar flexion, while maintaining
heel contact with the floor and without trunk
rotation.

Lumbar Lateral Flexion (LLF): distance between the

tip of the ipsilateral middle finger and the floor
following maximal LLF maintaining heel contact with
the floor and without trunk rotation.
• Chest expansion is measured as the difference between
maximal inspiration and maximal forced expiration in the
fourth intercostals space in males or just below the
breasts in females.

• Normal chest expansion is greater than or equal to 5 cm.

• Slight reduction in vital lung capacity, total lung capacity.

 Diagnosis
Modified New York Criteria (1984)
A. Diagnosis
1. Clinical criteria
• a. Low back pain and stiffness for more than 3
months which improves with exercise, but is
not relieved by rest.
• b. Limitation of motion of the lumbar spine in
both the sagital and frontal planes.
• c. Limitation of chest expansion relative to
normal values corrected for age and sex.
(<5cm=Abnormal in young adult)
2. Radiological criteria
• sacroiliitis grade greater than or equal to 2
bilaterally
• sacroiliitis grade 3-4 unilaterally.

Grades are as follows…

0 = normal
1 = suspicious changes
2 = minimum abnormality (small localized areas with
erosions or sclerosis)
3 = unequivocal abnormality (moderate or advanced
sacroiliitis with erosions, evidence of sclerosis,
widening, narrowing or partial ankylosis)
4 = severe abnormality (total ankylosis)
B. Grading
1. Definite ankylosing spondylitis diagnosis if the
radiologic criterion is associated with at least 1
clinical criterion.

2. Probable ankylosing spondylitis if:

• a. Three clinical criteria are present.

• b. The radiologic criterion is present without any

signs or symptoms satisfying the clinical criteria.
(Other causes of sacroiliitis should be
considered.)
Investigations

•Erythrocyte sedimentation rate (ESR)

elevated in 85% of the cases.

•C-reactive protein (CRP) often elevated.

• Human leukocyte antigen (HLA)-B27 is

correlated with 90% of Caucasian patients
and 50% of black patients with AS
Investigations

Radiological :
1. X – rays
2. CT– scan
3. MRI
• Sacroiliac joint:
• Symmentric pattern
• More in Ilium
• Bony erosion ,
eburnations
• Sclerois
• Narrowing of joint
space
• Ankylosis
• Spine :
• Romanus lesion – focal
destructive areas
• Osteitis
• Shiny corner sign
• Squaring
• Sydesmophyte
• Bamboo spine
• Discitis
• Disc ballooning
• Trolley – track sign
• Dagger sign
Thoraco dorsal region
Lumbosacral region
Cervial spine
• Hip : 1.Bilateral and symmentrical
2.Concentric joint space narrowing
3.Osteophytosis
4.Bony ankylosis
Diss Typ. Femoral Osteophytosis Others
ease Distri. head
mig.
AS B/L, Axial Lateral aspect of femur Cysts,bony
symme collar at head & neckjunction ankylosis,
ntrical protrusion
deformity

RA B/L, Axial Rare Osteoporosi

symme s,erosions,
ntrical protrusion
deformity

OA U/L or Superior Lateral and medial, femoral Sclerosis ,

B/L or medial and acetabular cysts,
buttressing
Treatment
Indications for Treatment:

1. impairments of pain

2. loss of function

3. weakness and loss of muscle performance

4. fatigue

5. loss of flexibility and range of motion (ROM)

Treatment
Consists of :
1. General measures to maintain satisfactory
posture and preserve movement
2. Anti – inflammatory drugs to counteract pain
and stiffness
3. Operation to correct deformity or restore
mobility
General measures:
• Encouraged to be active
• Taught how to maintain satisfactory position
• Spinal extension exercises every day
• Swimming , dancing
• Medications:

• Non-steroidal anti-inflammatory drugs (NSAIDs) -

Indomethacin being the most effective.

• Sulfasalazine is useful for peripheral arthritis but

not axial

• Anti-tumor necrosis factor (TNF) such as

Infliximab or Etanercept has been extremely
successful and show a 60% reduction in the Bath
Ankylosing Spondylitis Disease Activity Index
(BASDAI) 6.
• In 2005 the ASsessment in AS (ASAS) International
Working Group collaborated with the European League
Against Rheumatism (EULAR) and compiled a group of
evidence based medical recommendations for
treatment of AS

1. Optimal management of AS requires a

combination of non-pharmacological and
pharmacological treatments.
2. NSAIDs are recommended as first line drug
treatment for patients with AS with pain and
stiffness. In those with increased GI risk, non-
selective NSAIDs plus a gastroprotective agent, or
a selective COX-2 inhibitor could be used.
Contd ….
3. NSAIDS are insufficient, contraindicated, and/or
poorly tolerated, however, analgesics, such as
acetaminophen and opiods, might be considered
for pain control.
4. Corticosteroid injections directed to the local side
of musculoskeletal inflammation may be
considered. The use of systemic corticosteroids
is not supported by evidence.
Contraindications / Precautions for Treatment:

• Rest and immobilisation are contraindicated

• A fused osteopenic spine is at great risk for
fracture
• From the 1920’s until the last few decades AS was
treated effectively with spinal radiation. These
patients carry a higher risk of cancer such as
myeloid leukemias and hematologic
malignancies.