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ANKYLOSING
SPONDYLITIS
BY DR IMRAN KHAN MAHER SENIOR REGISTRAR Department of Orthopedic surgery and traumatology LUMHS Jamshoro Ankylosing spondylitis. This is a generalized chronic inflammatory disease its effects are seen mainly in the spine and sacroiliac joints. It is characterized by pain and stiffness of the back, with variable involvement of the hips and shoulders and (more rarely) the peripheral joints. Complete fusion results in a complete rigidity of the spine, a condition known as BAMBOO SPINE AS is a systemic rheumatic disease and is one of the SERONEGATIVE SPONDYLOARTHROPATHIES the usual age at onset is between 15 and 25 years. Males are affected more frequently than females (estimates vary from 2:1 to 10:1) There is a strong tendency to familial aggregation association with the genetic marker HLA-B27. There is considerable evidence regarding ankylosing spondylitis (AS) as a genetically determined Immunopathological disorder. There are various theories about the ‘triggering factor’ that initiates the abnormal immune response. CAUSES may be a bacterial antigen, which closely resembles HLA-B27 that induces an antibody response, which also targets the HLA-B27 positive cells; or, as in the in the presentation of a specific antigen to the T cells HLA-B27 Human leukocyte antigen B27 is a class I surface antigen encoded by the B locus in the major histocompatibility complex on chromosome 6 and presents antigenic peptides to T cells. Pathology Synovitis of the sacroiliac and vertebral facet joints causes destruction of articular cartilage and peri- articular bone . Pathological changes proceed in three stages: (1) an inflammatory reaction with cell infiltration, granulation tissue formation and erosion of adjacent bone; (2) replacement of the granulation tissue by fibrous tissue; and (3) ossification of the fibrous tissue, leading to ankyloses of the joint. If many vertebrae are involved the spine may become absolutely rigid. Formation of syndesmophytes Clinical features The disease starts insidiously: a teenager or young adult complains of backache and stiffness. the symptoms are worse in the early morning and after inactivity. Referred pain in the buttocks and thighs may appear as ‘sciatica’ Gradually pain and stiffness become continuous. General fatigue, pain and swelling of joints. Pain in ankle, or pain and stiffness of the hip. slight flattening of the lower back and limitation of extension in the lumbar spine. Tenderness over the spine and sacroiliac joints loss of extension of spine earliest and the most severe disability Unable to perform ‘wall test’. Generalized fatigue and loss of weight. As spine fusses or stiffens their neck and low back lose their normal curve The mid back curves outward(kyphosis) and a fixed bent forward position can result leading to significant disability
Inflammation of the small joints joining the
ribs and collarbone to the breastbone Cause less expansion of the chest wall with breathing DIAGNOSIS Blood test for the HLA B27 gene….95% cases ESR and CRP mostly elevated Schobers test a useful clinical measure of flexion of the lumbar spine performed during examination X ray show characteristic spinal changes and sacroilitis. Erosion and fuzziness of sacroiliac joint later on peri articular sclerosis and bony ankyloses. Syndesmophytes and bridging of vertebrae's. X-RAYS (A) AN EARLY SIGN IS ‘SQUARING’ OF THE LUMBAR VERTEBRAE. (B,C) Bony bridges (syndesmophytes) between the vertebral bodies convert the spine into a rigid column. MRI MRI sacroiliac joints may show typical erosions and features of inflammation such as bone edema. TREATMENT
General measures to maintain satisfactory posture and preserve
movement; Anti-inflammatory drugs to counteract pain and stiffness; The use of TNF inhibitors for severe disease; Operations to correct deformity or restore mobility. NSAIDS such as ibuprofen, naproxen, and aspirin are a frequently effective and inexpensive option for treating the pain and stiffness of AS. Another class of NSAID known as COX-2 inhibitors, which includes the prescription medication Celebrex (Celecoxib), may reduce the risk of these GI side effects. Exercise exercise is a first-line treatment for AS. That’s because physical activity is key to loosening up the joints, relieving pain, and keeping your spine flexible. Biological treatment When NSAIDs and exercise are not effective enough at controlling your symptoms, or the side effects of NSAIDs become too severe
The first choice is usually a tumor-necrosis factor inhibitor (TNFi).
they’re more likely to be given as an injection directly into
inflamed joints for temporary pain relief during flares. Steroid injections are only used for peripheral joints such as the knees or the pelvis and generally aren't used in the spine disease-modifying anti-rheumatic drugs (DMARDs) work to limit tissue damage from inflammation. Azulfidine (sulfasalazine) Rheumatrex (methotrexate), a chemotherapy drug Surgery for AS Only in rare cases, surgery may be done to straighten a spine that has fused into a curved forward position because breathing is restricted.
Some AS patients may eventually need joint replacement
therapy—usually in the knees or hips—for severe damage that makes daily activities difficult. Complications Spinal fractures The spine is often both rigid and osteoporotic; The commonest site is C5–7. Hyper kyphosis Spinal cord compression Lumbosacral nerve root compression
