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Ankylosing spondylitis

1. ANKYLOSING SPONDYLITIS Dr A d h u l K i r s h n a V

2. OVERVIEW Introduction Epidemiology Pathology Clinical features Diagnosis Treatment

3. INTRODUCTION Ankylosing spondylitis aka Marie Strumpell disease is a chronic progressive immune mediated inflammatory disorder that results in ankylosis of the vertebral column and sacroiliac joints Greek: Ankylos=fusion Spondylos=vertebra Itis=inflammation

4. EPIDEMIOLOGY Unknown Etiology 90% of patients have an association with HLA B27 antigen Occurs in 6 per 10,000 popoulation Male predominant (7:1) Age of onset typically between 15-35

5. PATHOLOGY Synovitis of Sacroiliac and vertebral facet joints Destruction of articular cartilage and periarticular bone leads to bony ankylosis Affects intervertebral discs, sacroiliac ligaments , symphysis pubis, manubrium sterni and bony insertion of large tendons

6. PATHOLOGY Anterior longitudinal ligaments are especially afffected Repeated process of healing and bony process leads to formation of bridging osteophytes (Syndesmophytes)

7. CLINICAL FEATURES Insidious onset Teenager or young adult complains of lower backache and stiffness of SI joint Symptoms worse in the morning or with inactivity Improvement of symptoms with exercise

8. CLINICAL FEATURES Loss of lumbar lordosis Later diminished spinal movement, increased thoracic kyphosis Loss of cervical extension Cervico thoracic kyphosis is common Fused spine involvement of appendicular skeleton

9. ASSOCIATED FEATURES Uveitis - Most common extra articular manifestation of AS.Acute in presentation anteriorly and unilateral Cardiovascular involvement - Aortitis of the ascending aorta may lead to distortion of the aortic ring resulting in aortic wall insufficiency Pulmonary involvement - Restrictive lung disease may occur in patients with late stage AS with costovertebral and costosternal involvement that limits chest expansion Neurologic involvement -Neurologic complications may occur secondary to fractures of a fused spine which may be very difficult to detect with standard radiography Extra articular manifestations

10. SIGNS AND SYMPTOMS Peripheral manifestations PERIPHERAL ARTHRITIS DACTYLITIS ENTHESITIS

11. TESTS FOR DETECTING SACRO ILIAC INVOLVEMENT Tenderness localised to the posterior superior iliac spine or deep in the gluteal region Sacroiliac compression: Direct side to side compression of the pelvis may cause pain at the sacro iliac joints

12. GAENSLEN’S TEST : The hip and the knee joints of the opposite side are flexed to fix the pelvis, and the hip joint of the side under test is hyper extended over the edge of the table. This will exert a rotational strain over the sacro iliac joint and give rise to pain

13. STRAIGHT LEG RAISING TEST: The patient is asked to lift the leg up with the knee extended. This will cause pain at the affected sacro iliac joint

14. PUMP HANDLE TEST : With the patient lying supine, the examiner flexes his hip and knee completely, and forces the affected knee across the chest, so as to bring it close to the opposite shoulder. This will cause pain on the affected side

15. DIAGNOSIS Raised ESR/CRP in 70%of AS but no clear correlation with disease activity. Secondary anemia Urinary 17-ketosteroids levels are increased HLA-B27 test positive in most cases Synovial fluid: increase of mononuclear leukocytes Patient with severe disease may show an elevated alkaline phosphatase level Elevated serum IgA levels are common Lab investigations

16. DIAGNOSIS Haziness of the sacroiliac joints Irregular subchondral erosions in SI joints Sclerosis of the articulating surfaces of SI joints Widening of sacroiliac joint space Bony ankylosis of the sacroiliac joints Calcification of the Sacroiliac ligament and sacrotubrous ligaments. DIAGNOSIS RADIOLOGICAL FINDINGS

17. Squaring of vertebrae Loss of lumbar lordosis Bridging osteophytes BAMBOO SPINE appearance

18. COMPLICATIONS Spinal fracture: It is the most serious complication of AS which may occur even after minor trauma to the rigid ,ankylosed spine especially in the cervical region. Chalk Stick # or Carrot Stick # Anderson lesion: Inflammatory spondylodiscitis that occurs in association with ankylosing spondylitis and result in a disc pseudarthrosis.

19. Cauda Equina Syndrome: Due to nerve root traction by bony over growth or arachnoiditis occurs rarely Atlanto axial sublaxation Osteoporosis of the vertebral bodies is very common in AS and contributes to fracture risk Premature atherosclerosis occurs in AS and is related to the systemic inflammatory process

20. MANAGEMENT NO CURE IS KNOWN FOR AS Treatment & medications are available to reduce symptoms and pain

21. MEDICAL MANAGEMENT NSAID’s such as Indomethacin, ibuprofen, naproxen, COX 2- inhibitors DMARD’s such as Methotrexate, sulphasalazine,cyclosporines used to reduce immune system response through immunosupression TNF-alpha blockers such as infliximab, etanercept

22. SURGICAL MANAGEMENT Vertebral osteotomy: Patient with fusion of the cervical upper thoracic spine may benefit from extension osteotomy of the cervical spine. Joint Replacement: THR, TKR

23. OTHER MANAGEMENT Patient Education: Proper posture in standing, sitting and lying, sleeping on a firm matteress without pillow, stop smoking Physiotherapy: The aim of exercise is to maintain joint movement and to build up muscles that oppose direction of the deformity with particular emphasis on the spinal extensor, intercostal and hip extensor muscle