ANKYLOSING SPONDYLITIS

BY : DR SHOAIB SHAIKH
ORTHOPAEDIC CONSULTANT
• The term ankylosing spondylitis,derived from
Greek words ankylos ( bent or crooked or
stiff ) and spondylitis ( inflammation of
vertebra ).
• By defination AS is chronic disease
characterised by a progressive inflammatory
stiffness of the joints with a predilection for
the joints of the axial skeleton , especially the
SI joints .
• INCIDENCE :
The risk for development of AS strongly
associated with HLA –B27 antigen .
• Sex distribution: Male 5 : 1 Female.
• Age : 20 to 35 years and is rare in onset after
the age of 40 years.
 Pathology
• SI joints are involved first
• Enthesitis or subchondral bone marrow
inflammation initially - cartilage destruction –
bony erosions
• Resultant fibrosis – fibrous ankylosis – bony
ankylosis – joint fusion
• ALL and PLL of spine may also ossify –
Permanently stiff spine
 Pathology
• Sacroilitis is one of the earliest manifestations of AS.
• In the spine, early in the process there is inflammatory
granulation tissue at the junction of the annulus fibrosis
of the disk cartilage and the margin of vertebral bone.
• The outer annular fibres are eroded and eventually
replaced by bone, bridging the adjacent vertebral
bodies causing “ Bamboo spine “ appearance on X-ray.
• Diffuse osteoporosis,erosion of vertebral bodies at the
disk margin,”squaring “ of vertebrae is seen.
 Clinical Manifestations.
• Starts with low back pain involving Sacro-iliac
joint first and spine later.
• SIJS : Pain over SI joint radiates to pubic
symphysis. SI joint is tender on palpation.Pain
may be reffered to groin,trochanter and
buttock.The patient exhibits pain on abduction
of the hip on the affected side and walk with a
Trendelenburg lurch.
• Spine manifestations : Back pain and stiffness
for more than 3 months and is nor relieved by
rest.Associated with morning
stiffness.Improves with exercises.Decrease
spine movements.In severe cases,obliterate
lumbar lordosis,buttock atrophy and thoracic
kyphosis.There is forward stoop of the neck.
• HIP and KNEE : Flexion contractures at
hip,compensated by flexion of the knees.
 Extra articular manifestations
• Prostatitis is associated with AS
• EYES :Acute anterior uveitis is common 30%.
• GIT : Inflammation of colon and ileum 60 %.
• CARDIAC : Pericarditis,Aortic incompetence.
• PULMONARY : upper lobe fibrosis with cough
and sputum,limited chest expansion.
• NEUROLOGICAL : Cauda equina syndrome.
• Subluxation of Atlanto-axial joint.
 SI joint tests
• SI joint tenderness
• SI compression
• Gaenslen’s test
• SLRT
• Pump Handle test
Affected leg
PUMP HANDLE TEST
 Cervical spine tests
• Stiffness
• Occiput to wall test or Flesche test
Thoracic spine involvement
 Investigations
• HLA-B27 is present in 90 % of cases.
• Haemogram: Mild anemia may be present.
• ESR and CRP are often elevated.
• Elevated Alkaline phosphatase in severe cases.
• Elevated serum IgA levels are common.
• X-Ray of Pelvis and Spine.
• - bamboo spine , dagger sign on x ray
ENTESOPATHY – CALCIFICATION OF ATTACHMENTS OF LIGAMENTS ,
TENDONS , MUSCLES
DAGGER SPINE
 Management
• Patients education: proper posture
sleeping on firm matress.
stop smoking.
• Physiotherapy : Back exercises.
encourage pt to take up
regular sports. ( Swimming )
prone lying for 15 min or more
on daily basis.
to practice full rib cage expansion
using manual resistance.
Rotation of spine and pelvis to be
encouraged.
Yogasanas and Suryanamaskaras to be encouraged.
Avoid single prolonged positions.
• Medical line of treatment:
• NSAIDS.
• TNF blocking drugs
:Etanercept(s/c),infliximab(iv) and
Adalimumab(s/c).
• Other drugs : Indomethacin,sulfasalazine 2-3g
per day.
Methotrexate 10-25mg/wk.
• SURGICAL :
• Hip and Knee arthroplasty.
• Spine : Osteotomy. - Osteotomy: During an osteotomy, bone is cut
to correct angular deformities. The bone ends are realigned and
allowed to heal. Spinal instrumentation and fusion may be
combined with an osteotomy to stabilize the spine during healing .
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• The goal of surgery is to eliminate compression of the nerve roots,
and the second is to stabilize and fuse the spine with grafts, screws,
and rods. The most common surgical procedure for ankylosing
spondylitis is: Laminectomy: A laminectomy is performed to relieve
pressure on the nerve roots.