Ankylosing spondylitis overview

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Differentiating Ankylosing spondylitis from other Diseases

Epidemiology and Demographics

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Natural History, Complications and Prognosis

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Physical Examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Ankylosing spondylitis is a chronic, painful, degenerative inflammatory arthritis primarily affecting the spine and sacroiliac joints, causing eventual fusion of the spine. It is a member of the group of the autoimmune spondyloarthropathies with a probable genetic predisposition. Complete fusion results in a condition known as bamboo spine, which is a complete rigidity of the spine, .[1]

Historical Perspective

Ankylosing spondylitis was first recognized as a disease by Galen. In the late nineteenth century (1893-1898), however, the neurophysiologist Vladimir Bekhterev of Russia in 1893, Adolph Strümpell of Germany in 1897, and Pierre Marie of France in 1898, were the first to give adequate descriptions which permitted an accurate diagnosis of AS prior to severe spinal deformity. For this reason, AS is also known as Bechterew Disease or Marie–Strümpel Disease.

Pathophysiology

Ankylosing spondylitis is a systemic rheumatic disease, and is one of the seronegative spondyloarthropathies. About 90% of the patients express the HLA-B27 genotype. Tumor necrosis factor-alpha (TNF α) and IL-1 are also implicated in ankylosing spondylitis. Although specific autoantibodies cannot be detected, its response to immunosuppresive medication has prompted its classification as an autoimmune disease.

Causes

Ankylosing spondylitis needs to be differentiated from strain of lumbosacral joint, osteoarthritis, Forestier's disease among others.

Epidemiology and Demographics

In USA, the prevalence of ankylosing spondylitis is 250 per 100,000 and being a chronic condition, the incidence is low.

Risk Factors

Patients with HLA-B27 variant are at highest risk of developing ankylosing spondylitis.

Natural History, Complications and Prognosis

Ankylosing spondylitis can range from mild to progressively debilitating. In a long-term undiagnosed period, osteopenia or osteoporosis of AP spine may occur, causing eventual compression fractures and a back "hump" if untreated. Due to the fusion of the vertrbrae, paresthesia may develop. Other complications are Aortic regurgitation, Achilles tendinitis, AV node block, amyloidosis and lung fibrosis.

Diagnosis

History and Symptoms

Ankylosing spondylitis typically presents in a young patient with chronic pain and stiffness in lower part of spine. In 40% of cases, ankylosing spondylitis is associated with iridocyclitis (anterior uveitis, also known as iritis) causing eye pain and photophobia (increased sensitivity to light). Other common symptoms are recurring mouth ulcers (aphthae) and fatigue.

Laboratory Findings

There is no direct test to diagnose ankylosing spondylitis. There is increase in C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR).

X Ray

A clinical examination and X-ray studies of the spine, which show characteristic spinal changes and sacroiliitis, are the major diagnostic tools for ankylosing spondylitis. The findings on X Ray are presence of subchondral erosions, sclerosis, proliferation on iliac side of SI joints and squaring of the vertebral body.

CT

An option for more accurate (and much earlier) diagnosis of ankylosing spondylitis is tomography of the sacroiliac joints. Joint erosions, subchondral sclerosis, and bony ankylosis are better visualized on CT.

MRI

The findings on MRI in a patient with ankylosing spondylitis is synovial enhancement. It is superior to CT in detection of cartilage, bone erosions, and subchondral bone changes. An increased T2 signal correlates with edema or vascularized fibrous tissue.

Other Imaging Findings

Bone scintigraphy may be helpful in selected patients of ankylosing spondylitis with normal or equivocal findings on sacroiliac joint radiographs. The ratio of SI joint to sacral uptake of 1.3:1 or higher of the radionuclides is considered abnormal.

Treatment

Physical therapy and exercise, along with medication, are at the heart of therapy for ankylosing spondylitis. Physiotherapy and physical exercises are clearly preceded by medical treatment in order to reduce the inflammation and pain. NSAIDs, DMARD and TNFα blockers are the major types of medications used to treat ankylosing spondylitis. Surgery can be an option in ankylosing spondylitis in the form of joint replacements, particularly in the knees and hips. Surgical correction is also possible for those with severe flexion deformities (severe downward curvature) of the spine, particularly in the neck, although this procedure is considered risky.

References

  1. Jiménez-Balderas FJ, Mintz G. (1993). "Ankylosing spondylitis: clinical course in women and men.". J Rheumatol. 20 (12): 2069–72. PMID 7516975. 

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