ANKYLOSING

SPONDYLITIS
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 One of the Spondyloartheritis disease
 A group of disorders that share an overlapping set of features, including
inflammation of the axial skeleton, tendons, and entheses (insertion of
tendon to bone); tendon and enthesis calcification; an association with HLA-
B27; and mucocutaneous, gastrointestinal, and ocular inflammation
 90% associated with class I major histocompatibility complex molecule HLA-
B27
 Among first-degree relatives of patients with ankylosing spondylitis, the
presence of HLA-B27 confers an increased risk (approximately 10%-30%) of
developing the disease
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 Ankylosing spondylitis is more common in men than women (3:1 ratio)
 Peak age of onset is in the second to third decade of life.
 Ankylosis refers to the bony bridging of the vertebrae resulting from chronic
inflammation
 Risk factors for poor prognosis include male gender, early age of onset, tobacco
use, and the presence of hip or peripheral arthritis, psoriasis, IBD, iritis, or
elevated erythrocyte sedimentation rate (ESR).
 Mortality is increased, primarily relating to increased rates of cardiovascular
disease (coronary artery disease, aortic valve regurgitation, aortic aneurysm,
conduction disturbance), cancer, and infection.
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 Musculoskeletal: Axial involvement:
 Inflammatory low back pain of insidious onset is the hallmark of ankylosing
spondylitis, manifesting as pain and stiffness that are worse after immobility and
are better with use.
 Symptoms are prominent in the morning (>1 hour); night pain is characteristic
and may awaken the patient.
 Buttock pain is common and bilateral, and it correlates with sacroiliitis.
 Early in its course, ankylosing spondylitis almost always affects the lumbar spine;
longer and more severe disease may involve the thoracic and cervical regions as
well, it does not skip regions
 Fusion of the spine may occur over time, leading to rigidity and kyphosis.
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 Peripheral involvement: Enthesitis (e.g., Achilles tendinitis) with or without asymmetric
large-joint oligoarthritis; hip involvement can cause significant functional limitation;
shoulders can be involved
 Dermatologic: Psoriasis may coexist
 Ophthalmologic: Uveitis (typically anterior, unilateral, recurrent)
 Gastrointestinal: Asymptomatic intestinal ulcerations
 Genitourinary: Urethritis (rare)
 Cardiovascular: Aortic valve disease; aortitis; conduction abnormalities; CAD
 Pulmonary: Restrictive lung disease from costovertebral rigidity; apical fibrosis (rare)
 Bone quality: Falsely elevated bone mineral density from syndesmophytes; increased
risk of spine fracture
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 Diagnosis:

 Based on characteristic history and physical examination

 Laboratory :

 HLA-B27

 ESR, CRP Serum amyloid A correlate with disease activity.

 RF, Anti-CCP antibodies, ANA – could be negative or low positive.

 Imaging:

 X-Ray os spine and SI joint

 CT is more sensitive, detect subtle vertebral fracture .

 MRI detects early inflammation

 US to detect peripheral enthesitis and artheritis.

sacroiliac erosion initially appears as irregular
widening of the joint space, accompanied by
sclerotic changes. Later, the joint space narrows,
and eventually the sacroiliac joint may fuse.
Vertebral plain radiographic findings in
ankylosing spondylitis include sclerosis at the
attachment of annulus fibrosis to the anterior
corner of the vertebral endplate (“shiny
corner”), and erosion at the point of contact
between the disk and the vertebra. In later
disease, vertebrae may lose their normal
anterior concavity due to periosteal bone
proliferation, resulting in squaring of the
vertebral bodies. Calcification of the anterior
longitudinal ligament and bridging
syndesmophyte formation are late features,
leading to ankylosis and a “bamboo” spine
appearance.
ASSESSMENT OF
SPONDYLOARTHERITIS
INTERNATIONAL SOCIETY
(ASAS)
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 Management

 TNF-a inhibitors CI?

 MTX, sulfalazine??
 Local Glucocorticoids.
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 Monitoring:
 Monitoring of patients with ankylosing spondylitis for response to therapy or
progression of disease can include patient history, physical examination, and
laboratory testing (such as erythrocyte sedimentation rate and C-reactive
protein).
 Serial imaging can also be used to help monitor patients with ankylosing
spondylitis, but the 2010 Assessment of SpondyloArthritis international
Society/European League Against Rheumatism (ASAS/EULAR) guidelines
recommend against repeating spinal radiography more frequently than every 2
years unless absolutely necessary in specific cases.
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