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BASIC INFORMATION
DEFINITION
Ankylosing spondylitis is a type of inflammatory arthritis involving the sacroiliac joints and
axial skeleton characterized by ankylosis and
enthesitis (inflammation at tendon insertions).
It is one of a family of overlapping syndromes
called seronegative spondyloarthropathies that
includes reactive arthritis (Reiter syndrome),
psoriatic spondylitis, and enteropathic arthritis.
ICD-9CM CODES
720.0 Ankylosing spondylitis
ICD-10CM CODES
M45.9 Ankylosing spondylitis of unspecified
sites in spine
EPIDEMIOLOGY &
DEMOGRAPHICS
PREVALENCE: Between 0.1% and 1% of the
population
PREDOMINANT AGE AT ONSET: 15 to 35 yr
PREDOMINANT SEX: Male/female ratio 2 to
3:1
LABORATORY TESTS
Elevated sedimentation rate, C-reactive protein
Mild hyperchromic anemia
Demonstration of inflammatory sacroiliitis by
radiography or MRI is essential for diagnosis
HLA/B27 antigen is not useful in the evaluation of noninflammatory back pain because it
is present in up to 8% to 10% of the normal
population.
ETIOLOGY
Genetic factors, particularly HLA-B27, play an
important role in susceptibility to the spondyloarthropathies. Infectious triggers have been
implicated in some cases. Tumor necrosis factor
is important in the inflammatory response.
IMAGING STUDIES
Classic features are those of bilateral sacroiliitis on radiographs of the pelvis
Vertebral bodies lose anterior concave shape
and become square
With progression, calcification of the annulus fibrosus and paravertebral ligaments
develop, giving rise to the so-called bamboo spine and a trolley track appearance
(Fig. A1-89).
MRI (Fig A1-90) may be useful in detecting
early inflammatory lesions and is especially
helpful when the history is suggestive but
radiographs are equivocal.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Diffuse idiopathic skeletal hyperostosis
(Forestier disease)
Noninflammatory back pain (A clinical algorithm for the evaluation of back pain is
described in Section III.)
Table A1-55 compares ankylosing spondylitis
and related disorders.
Compensatory
hyperextension
of neck
Exaggerated
thoracic
kyphosis
Loss of lumbar
lordosis
Vertebrae fused
together
Fixed flexion
of hips
Compensatory
flexion of knees
Normal posture
FIGURE A1-88 Ankylosing spondylitis. Typical posture in advanced cases compared with normal posture.
(From Ballinger A: Kumar & Clarks essentials of clinical medicine, ed 6, Edinburgh, 2012, Saunders.)
FIGURE A1-87 Loss of lumbodorsal spine mobility in a boy with ankylosing spondylitis.The
lower spine remains straight when the patient bends
forward. (From Behrman RE: Nelson textbook of pediatrics, ed 17, Philadelphia, 2005, Saunders.)
Feature
Ankylosing
Spondylitis
Psoriatic
Arthritis
Reactive
Arthritis
Enteropathic
Arthropathy
Gender (M:F)
Age at onset
Sacroiliitis or spondylitis
Symmetry of sacroiliitis
Peripheral arthritis
Distribution
HLA-B27
Uveitis
2-3:1
<40
100%
Symmetric
25%
Axial and lower limbs
85%-95%
25%-40%
1:1
35-55
20%
Asymmetric
95%
Any joint
25%
25%
1:1
Young adult
<20%
Symmetric
15%-20%
Variable
7%
10%-36%
121
Diseases
and Disorders
SYNONYMS
Marie-Strmpell disease
Ankylosing Spondylitis
122
Ankylosing Spondylitis
ALG
are efficacious and may be better tolerated.
One study suggested that continuous NSAID
therapy may retard the radiographic progression of ankylosing spondylitis.
Sulfasalazine may be efficacious in some
patients, especially for peripheral arthritis
Tumor necrosis factor (TNF) antagonists such
as etanercept, infliximab, and adalimumab
have been shown to be very effective for
relieving symptoms of spinal inflammatory
arthritis in numerous controlled studies. AntiTNF therapy should be recommended for
patients whose symptoms are not completely
controlled with NSAIDs, and it sometimes
results in dramatic improvement in symptoms, range of motion of the spine, and quality of life for these patients. There is evidence
suggesting that anti-TNF therapy slows the
radiographic progression of the disease.
FIGURE A1-89 Ankylosing spondylitis. A, Fusion of the facet joints and ossification of the adjacent soft
tissue have produced a trolley track appearance (arrows). The sacroiliac joints are fused. Syndesmophytes
are present. B, In another patient, there is a prominent fusion of the interspinous ligaments producing a saber
sheath appearance. (From Harris ED: Kelleys textbook of rheumatology, ed 7, Philadelphia, 2005, Saunders.)
DISPOSITION
Most patients have a normal life span but many
suffer significant disability from loss of spinal
mobility.
REFERRAL
All patients with seronegative spondyloarthropathy should be referred to a rheumatologist for
consideration of anti-TNF therapy.
PEARLS &
CONSIDERATIONS
A family history of seronegative spondyloarthropathy increases the specificity of testing
for HLA-B27.
TREATMENT
NONPHARMACOLOGIC THERAPY
Exercises primarily to maintain on flexibility
and aerobic activity are important
Postural training
1.
Patients must be instructed on spinal
extension exercises to avoid fusion in a
flexed position
CHRONIC Rx
NSAIDs: Patients with ankylosing spondylitis
should be prescribed full-dose continuous
NSAID therapy. There is anecdotal evidence
suggesting that indomethacin may be more
effective than other NSAIDs, but other NSAIDs
SUGGESTED READINGS
Available at www.expertconsult.com
RELATED CONTENT
Fig. 3-194 Spondyloarthropathy, diagnosis
(Algorithm)
Fig. 3-195 Spondyloarthropathy, treatment
(Algorithm)
Ankylosing Spondylitis (Patient Information)
AUTHOR: BERNARD ZIMMERMANN, M.D.
Ankylosing Spondylitis
SUGGESTED READINGS
Brown J: Ankylosing spondylitis, Lancet 369:13791390, 2007.
Davis JC Jr etal.: Health-related quality of life outcomes in patients with active
ankylosing spondylitis treated with adalimumab: results from a randomized
controlled study, Arthritis Rheum 57(6):1050, 2007.
Haroon N etal.: The impact of tumor necrosis factor inhibitors on radiographic
progression in ankylosing spondylitis, Arthritis Rheum 65:2645, 2013.
Heiberg MS etal.: The comparative one-year performance of anti-tumor necrosis
factor alpha drugs in patients with rheumatoid arthritis, psoriatic arthritis, and
ankylosing spondylitis: results from a longitudinal, observational, multicenter
study, Arthritis Rheum 59:234, 2008.
Oosttveen J etal.: Early detection of sacroiliitis on magnetic resonance imaging
and subsequent development of sacroiliitis on plain radiography: a prospective, longitudinal study, J Rheumatol 26:1952319528, 1999.
Wanders A etal.: Nonsteroidal antiinflammatory drugs reduce radiographic
progression in patients with ankylosing spondylitis: a randomized clinical trial,
Arthritis Rheum 52(6):1756, 2005.
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