Ankylosing spondylitis

ankylosing spondylitis, its causes, clinical features, investigations, treatment

1. Ankylosing spondylitis (MARIE STRUMPELL DISEASE) By- kajal sansoya

2. What is AS? AS is a chronic disease characterized by a progressive inflammatory stiffening of the joints, with a pre- dilection for the joints of the axial skeleton, especially the SI joint. This disease is common in young male adults. M:F ratio is 10:1

3. Etiology Exact cause of AS is unknown. Genetic factor include HLA-B27 gene The incidence of HLA-B27 is less than 1% in general population, it is present in more than 85% of patients with AS.

4. PATHOLOGY SI first affected followed by spine from lumbar region upwards. The hips& knees and the manubriosternal joints are also involved. Initially synovitis occurs, followed later by cartilage destruction & bony erosion. After bony fusion occurs, the pain may subside, leaving the spine permanently stiff.

5. CLINICAL FEATURES Classic presentation – the patient is young adult 15-30 years old male, presenting with a general onset of pain& stiffness of the lower back. Initially stiffness may be noticed only after a period of rest, & improves with movement. Pain may tends to be worse at night or early morning, awakening the patient from sleep. Better only after walks or does some exercises. There may be pain in the heel, pubic symphysis , manubrium sterni & costo-sternal joints.

6. In later stage, kyphotic defomity of spine & deformity of the hips may be prominent features.

7. UNUSUAL FEAURES OF AS Patient may occasionally present with involvement of peripheral joints such as shoulders, hips and knees. Smaller joints are rarely involved sometimes, patient may present with chronic inflammatory bowel disease.

8. ON EXAMINATION It is found that the patient walks with a straight stiff back patient may present with diffuse kyphosis . Stiff spine- there may be loss of lumbar lordosis . L-spine flexion may be limited.

9. INVOLMENT OF SI JOINT Following tests are positive in case of SI joint involvement. Tenderness- localized to PSIS or deep in gluteal region. SI compression- direct side-side cmpression of pelvis may cause pain at the SI joint. GAENSLEN’S TEST- the hip& the knee joints of the opposite side are flexed to fix the pelvis, & the hip joint of the side under test is hyperextended over the edge of table. This will exert a rotational strain over the SI joint & give rest to pain.

10. SLR TEST- the patient is asked to lift the leg up with the knee extended. This will cause pain at the affected SI joint. Pump-handle test- with patient lying supine, the examiner flexes his hips & knees completely and forces the affected knee across the chest, so as to bring it close to the opposite shoulder. This will cause pain on affected side.

11. INVESTIGATIONS Hazinees of the SI joint Irregular sub- chondral erosions in SI joint Sclerotic of articulating surfaces of SI joint Widening of SI joint space. Bony ankylosing of SI joint Calcification of SI joint ligament & sacro -tuberous ligaments.

12. LUMBAR SPINE SHOWS Squarring of verttebrae Loss of lumbar lordosis . Bridging osteophytes Bamboo spine

13. OTHER INVESTIGATIONS ESR elavated Hb : mild anaemia HLA-B27 +

14. TREATMENT CONSERVATIVE TREATMENT NSAID’S Physiotherapy- TENS, ULTRASOUND, HOT PACKS, STENGTHENING EXERCISES. Radiotherapy Yoga therapy Operative – spinal osteotomy , joint replacement in case of involvement of hips & knees.

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