Ankylosing spondylitis

Pathogenies:

Ankylosing spondylitis (AS) is an autoimmune disease and is a type of spondyloarthropathy (SpA). It

is characterised by progressive spinal rigidity, back pain, and inflammation of joints. This
inflammation of peripheral joints is seen in elbows, shoulders, wrists, ankles, fingers, and toes but is
most common in the sacroiliac joint (SIJ) and lumbar region. It can present with enthesitis which is
inflammation that affects the attachment sites of ligaments and tendons to bone. In worse cases the
presence of inflammation can cause a production of subsequent bone formation further, causing
ankylosis and fusion of the bones. Its pathogenesis is not fully understood and is quite complex. (1)
However, investigations have found that 1 st degree relatives of AS patients are 10 to 20 times more
likely to develop the condition opposed to the general population. (2)

Ankylosing spondylitis tends to be more prevalent in males than females and generally effects late
teens to early adults but can occur in the older population. The disease primary involvement site is
the SIJ followed by thoracolumbar and in later stages can spread to rib cage and cervical spine. (2)

Features that are common in the presentation of AS are low back, pelvis, hip, mid thoracic, chest,
ribs and cervical pain. Thoracolumbar pain that is worse after long periods of inactivity or in the
morning can also be an indicator of AS. (3) Women have been found to not be affected as much as
men and they experienced a less severe progression with longer asymptomatic periods. (4) Further,
ankylosing spondylitis has been found to present with extra-articular manifestations including fever,
uveitis, irritable bowel disease including Crohn’s disease, and ulcerative colitis. (3, 5)

Laboratory results have been found to have a correlation with Ankylosing spondylitis and it is found
that 90% of AS patients are positive for the human leukocyte antigen HAL-B27. However, only 10%
of people who are positive for HAL-B27 develop AS. Thus, it can be a diagnostic tool that can help
confirm the condition if other testing and history leads to the diagnosis of AS. However, this
leukocyte antigen has found different ethnicities have a differing prevalence particularly between
Caucasian and Eastern Asian descents. (1)

DDX:

In the early pathogenesis of Ankylosing spondylitis, it shares similar clinical features to other
spondyloarthropathies including psoriatic arthritis, reactive arthritis, and diffuse idiopathic skeletal
hyperostosis (DISH). Of these conditions clinical features include back pain, inflammation of
peripheral joints and entheses, inflammatory arthritis, sacroiliitis and enthesitis. (6)

Psoriatic arthritis is often listed in differential diagnosis (ddx) of AS due to its similarities. It shares
similar manifestation including inflammatory arthritis with sacroiliitis, spondylitis or peripheral
arthritis, enthesitis, psoriasis and can involve back or SIJ pain. However, where psoriatic arthritis
differs from AS is its involvement of smaller joints of the wrists, fingers, and feet. (7)

Reactive arthritis has been found in differential diagnosis due to similarity in features of spondylitis
and uveitis. It can be differentiated by its minimal involvement of the SIJ and spinal joints whereas
that is a key feature of AS. (4)

Diffuse idiopathic skeletal hyperostosis can present in the differentials due to it resembling AS
features. Particularly, it shares the involvement of the axial skeleton, reduced spinal mobility,
enthesitis and postural abnormalities that are seen in AS. Noticing clinical features that differentiate
it from AS is key to rule it out in the diagnosis of AS. Where it differs is it mainly affect mid-age to
elderly people and does not generally have SIJ erosion. DISH also frequently has ossification of the
anterior longitudinal ligament (ALL) compared to AS that generally does not involve this. (8)

Therefore, it becomes important to identify if the patient has any extra-articular manifestations that
can be associated with AS including anterior uveitis and inflammatory bowel disease. Neurological
testing can be included in more chronic cases of AS where studies have found it affecting peripheral
nerve pathways in the lumbar and sacral regions.

Neurological assessment:

Neurological conditions that have been found alongside Ankylosing Spondylitis although it is quite
minimal. If it occurs, it tends to be seen in longstanding AS patients and are rare complications.

Conditions that have been found alongside AS include: (9)

- Cauda equina
- Peripheral neuropathy
- Sensory neuropathy
- Low back pain with radiculopathy
- Multiple Sclerosis (MS)
- Vertebrobasilar insufficiency

Although neurological symptoms are not common in the presentation of AS a study of 45 patients
found 10 patients presenting with neurological disorders. Peripheral neuropathies are rare in AS
cases but has been found in patients. Thus, neurological testing through sensory, motor and reflexes
(SMR) is relevant for both upper and lower limbs due to AS involving predominately the SIJ and
lumbar regions. However, in later stages of AS it can be found within the cervical spine. This will not
diagnose or help the diagnosis of AS however, suggest if there has been in entrapment of the nerves
exiting at the corresponding spinal level. Caution should be taken when doing deep tendon reflexes
due to the occurrence of enthesitis. (9)
References:

1. Zhu W, He X, Cheng K, Zhang L, Chen D, Wang X, et al. Ankylosing spondylitis: aetiology,

pathogenies and treatments. Bone res [internet]. 2019. [cited 2021, May 27]; 7(22): 1-11.
Available from: https://www.nature.com/articles/s41413-019-0057-8#citeas

2. Grace K. PowerPoint: 3.4 Thoracic Spine OA/DJD and other common arthropathies.
CHIR12007: Clinical Assessment and Diagnosis 1. [e-Units on Moodle]. Brisbane, QLD:
CQUniversity; 2020 [cited 2021 May 27]. Available from:
https://moodle.cqu.edu.au/course/view.php?id=8641

3. McVeigh CM, Cairns AP. Diagnosis and management of ankylosing spondylitis. BMJ
[internet]. 2006 Sep [cited 2021 May 27]; 333(7568): 581-85. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1570004/

4. Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: an overview. Ann

Rheum Dis [internet]. 2002 [cited 2021 May 27]; 61(suppl III): 8-18. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1766729/pdf/v061p0iii8.pdf

5. Atay K, Eyvazov H, Bozcan S, Eskazan T, Demir N, Hatemi I et al. The effect of concomitant
ankylosing spondylitis on long-term outcome of patients with inflammatory bowel disease.
2019 Jul [cited 2021 May 27]; 30(7): 599-604. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1766729/pdf/v061p0iii8.pdf

6. Dumain T. 6 Diseases That Could Mimic Ankylosing Spondylitis — and Delay Your Diagnosis.
CreakyJoints [Internet]. 2019 [cited 2021 May 27]. Available from:
https://creakyjoints.org/diagnosis/ankylosing-spondylitis-misdiagnosis/

7. Tiwari V, Brent HL. Psoriatic Arthritis. StatPearls [internet]. 2020 Aug [cited 2021 May 27].
Available from: https://www.ncbi.nlm.nih.gov/books/NBK547710/

8. Angelopoulou F, Kraniotis P, Daoussis D. DISH vs Spondyloarthritides. Mediterr J Rheumatol

[internet]. 2020 Mar [cited 2021 May 27]; 31(1): 81-83. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219636/

9. Thomas DJ, Kendall MJ, Whitfield GWA. Nervous System involvement in Ankylosing
Spondylitis. BMJ [internet]. 1974 Jan [cited 2021 May 27]; 1(5899): 148-150. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1632999/pdf/brmedj02172-0034.pdf