ANKYLOSING SPONDYLITIS

Definition
 Ankylosing spondylitis is a chronic inflammatory disease of the joints of the axial skeleton,
manifested clinically by pain and progressive stiffening of the spine.
 An inflammatory disorder of unknown cause that primarily affects the axial skeleton;
peripheral joints and extraarticular structures may also be involved.
 A chronic, usually progressive, condition in which inflammatory changes and new bone
formation occurs at the attachment of tendons and ligaments to bone (enthesopathy)

General Considerations
 The disease usually begins in the second or third decade (The age at onset is usually in the
late teens or early 20s) {young adults}
 The incidence is greater in males than in females, and symptoms are more prominent in
men, with ascending involvement of the spine more likely to occur.
 Older names include Marie-Strumpell disease or Bechterew's disease.

Essentials of Diagnosis
 Chronic low backache in young adults.
 Progressive limitation of back motion and of chest expansion.
 Transient (50%) or permanent (25%) peripheral arthritis.
 Anterior uveitis in 20-25%.
 Diagnostic radiographic changes in sacroiliac joints.
 Accelerated erythrocyte sedimentation rate and negative serologic tests for rheumatoid
factor.
 HLA-B27 usually positive but not helpful diagnostically.

Symptoms and Signs

 The onset is usually gradual, with intermittent bouts of back pain that may radiate down
the thighs.
 Manifestations include pain on compression of the sacroiliac joints and spasm of the
paravertebral muscles
 As the disease advances, symptoms progress in a cephalad direction and back motion
becomes limited, with the normal lumbar curve flattened and the thoracic curvature
exaggerated.
 Chest expansion is often limited as a consequence of costovertebral joint involvement.
 Radicular symptoms due to cauda equina fibrosis may occur years after onset of the
disease.
 In advanced cases, the entire spine becomes fused, allowing no motion in any direction.
 Transient acute arthritis of the peripheral joints occurs in about 50% of cases, and
permanent changes in the peripheral joints-most commonly the hips, shoulders, and knees-
are seen in about 25%.
 Spondylitic heart disease, characterized chiefly by atrioventricular conduction defects and
aortic insufficiency, occurs in 3-5% of patients with long-standing severe disease.
 Anterior uveitis is associated in as many as 25% of cases and may be a presenting feature.
 Pulmonary fibrosis of the upper lobes, with progression to cavitation and bronchiectasis
mimicking tuberculosis, may occur, characteristically long after the onset of skeletal
symptoms.
 Constitutional symptoms similar to those of rheumatoid arthritis are absent in most patients.
Laboratory Findings
 The erythrocyte sedimentation rate is elevated in 85% of cases, but serologic tests for
rheumatoid factor are characteristically negative.
 Anemia may be present but is often mild.
 HLA-B27 is found in 90% of patients with ankylosing spondylitis

Imaging
 The earliest radiographic changes are usually in the sacroiliac joints
 Later, erosion and sclerosis of these joints are evident on plain radiographs.
 Involvement of the apophysial joints of the spine, ossification of the annulus fibrosus,
calcification of the anterior and lateral spinal ligaments, and squaring and generalized
demineralization of the vertebral bodies may occur in more advanced stages.
 The term "bamboo spine" has been used to describe the late radiographic appearance of the
spinal column.
 Additional radiographic findings include periosteal new bone formation on the iliac crest,
ischial tuberosities and calcanei, and alterations of the pubic symphysis and sternomanubrial
joint similar to those of the sacroiliacs

Treatment
A. Basic Program
 The general principles of managing chronic arthritis apply equally well to ankylosing
spondylitis.
 The importance of postural and breathing exercises should be stressed.

B. Drug Therapy
 The nonsteroidal anti-inflammatory agents are employed in the treatment of this disorder.
 Of these, indomethacin appears to be the most effective, though it can be quite toxic.
 The dosage of indomethacin is usually 25-50 mg TDS, but the smallest effective dose
should be used.
 Other NSAIDs are valuable alternatives and may be used as primary therapy.
 Sulfasalazine (1000 mg BD) is sometimes useful for the peripheral arthritis in patients
with spondyloarthropathies but has little symptomatic effect on spinal and sacroiliac joint
disease.
 Curiously, corticosteroids have minimal impact on the arthritis-particularly the spondylitis-
of ankylosing spondylitis.
 Either etanercept (25 mg subcutaneously twice a week) or infliximab (5 mg/kg every other
month) is reasonable for patients whose symptoms are refractory to physical therapy and
other interventions.

C. Physical Therapy
 Therapy is designed to maintain a position of function even if ossification and ankylosis
progress.
 Posturing exercises (lying flat for periods during the day, sleeping without a pillow,
breathing exercises), the judicious use of local heat, and job modification are all part of a
rational physical therapy program