Spondylitis
OR
Ankylosing Spondylitis
Ankylosing spondylitis (AS) is a chronic, inflammatory
disease primarily affecting the axial spine that can
manifest with a range of clinical signs and symptoms.
The hallmark features of the condition
include chronic back pain and progressive
spinal stiffness.
AS is characterized by the involvement of the
spine and sacroiliac (SI) joints and peripheral
joints, digits
AS often leads to impaired spinal mobility
and can result in postural abnormalities.
Patients can also experience buttocks pain
and hip pain.
In addition to skeletal involvement, AS can
affect various organs outside the joints.
Peripheral arthritis, enthesitis, and dactylitis
("sausage digits") are all associated with AS.
Clinical symptoms of enthesitis include
tenderness, soreness, and pain at enthuses
on palpation.
whereas dactylitis is recognized by swelling
of an entire digit that is different from
adjacent digits.
Epidemiology
Ankylosing spondylitis (AS) commonly
presents in individuals younger than 40.
More prevalent in men than women.
approximately 80% of patients experiencing
their first symptoms before age 30.
Etiology
(HLA)-B27
Some bacterial
infections like
Unknown
(Klebsella
pneumoniae)
Pathophysiology
infections and HLA B 27, unknown etiology
infiltrating immune cells such as CD4 and CD8 T lymphocytes and macrophages.
Cytokines, particularly tumor necrosis factor-α (TNF-α) contribute to inflammation
fibrosis
ossification
Ankylosing spondylitis
Extra articular manifestations
Inflammatory bowel disease ( most common)
Acute anterior uveitis
Psoriasis
Restrictive pulmonary pattern
Ocular manifestations
Chronic pain and disability
Aortic regurgitation
Pulmonary fibrosis
Cauda equina syndrome (The cauda equina is the bundle of nerve roots
located at the lumbar region of spine. Cauda equina syndrome occurs when
the nerve roots in the lumbar spine are compressed, cutting off sensation
and movement. )
Mood disorders
Diagnosis
Laboratory findings in ankylosing spondylitis
(AS) are typically nonspecific but may provide
supportive evidence for diagnosis.
erythrocyte sedimentation rate (ESR)
elevated C-reactive protein (CRP).
Radiographic
magnetic resonance imaging (MRI)
Several imaging abnormalities, especially
those affecting the spine and sacroiliac joints,
are associated with AS.
Evidence of sacroiliitis ( inflammation of
sacroiliac joint) on imaging, whether
radiographic or magnetic resonance imaging
(MRI), is considered a major inclusion
criterion for AS according to the Assessment
of Spondyloarthritis International Society
(ASAS) 2009 axial spondyloarthritis criteria.
A standardized plain radiographic grading
scale exists for sacroiliitis. This scale ranges
from normal (0) to most severe (IV), as
detailed below.
0: Normal SI joint width, sharp joint margins
I: Suspicious
II: Sclerosis, some erosions
III: Severe erosions, pseudo dilation of the
joint space, partial ankylosis
IV: Complete ankylosis
Throughout AS, a series of distinct
radiographic changes characteristics
can progressively develop.
In the early stages, a notable sign is
the "squaring" of vertebral bodies,
which is best visualized on lateral X-
rays.
This squaring occurs due to
inflammation and bone deposition,
resulting in the loss of normal
concavity of the anterior and
posterior borders of the vertebral
body.
Additionally, early-stage
radiographs may reveal Romanus
lesions, also known as "shiny corner
signs," characterized by small
erosions and reactive sclerosis at the
corners of the vertebral bodies.
The classic radiographic finding in late-stage
AS is the "bamboo spine sign," which refers to
vertebral body fusion by syndesmophytes.
The bamboo spine typically involves the
thoracolumbar or lumbosacral junctions. This
spinal fusion predisposes the patient to
progressive back stiffness.
Differential Diagnosis
Certain diseases and conditions can mimic
ankylosing spondylitis (AS) and must be ruled
out. These include, but are not limited to:
Mechanical low back pain
Lumbar spinal stenosis
Rheumatoid arthritis
Diffuse idiopathic skeletal hyperostosis (DISH)
Treatment Goals
Reduce the
pain
Improve joint
mobility
Strengthen
muscles.
Prevent
complications
Non- Pharmacological treatment
Exercise. Exercise is important for
maintaining healthy and strong muscles,
preserving joint mobility, and maintaining
flexibility.
Support or assistive devices.
Stress management.
Healthy diet.
Quit Smoking.
Surgery
A large proportion of patients with ankylosing
spondylitis develop hip arthritis. Hip
replacement should be considered in patients
with refractory pain or disability and with
radiographic evidence of structural damage,
independent of age.
Spinal surgery may be of value in selected
patients
Treatment Algorithm of AS
Pharmacological treatment
Non-steroidal anti-
inflammatory drugs
Disease modifying ant
rheumatic drugs
Corticosteroids
Tumour necrosis factor
inhibitors
NSAIDs
Regular use of NSAIDs, starting with celecoxib,
inhibits radiographic progression in ankylosing
spondylitis compared with NSAID use on
demand.
The decision on which NSAID to use should be
on an individual patient basis taking into
account risk factors, particularly for
gastrointestinal and cardiovascular disease.
Analgesics, including paracetamol and opioids,
may be considered when NSAIDs are
contraindicated or not tolerated.
Disease modifying anti rheumatic
drugs DMARDs
Sulfasalazine has inconclusive evidence for
efficacy in ankylosing spondylitis.
low dose methotrexate did suggest some
clinical benefit in ankylosing spondylitis
There is little evidence to support the use of
other traditional disease modifying
antirheumatic drugs in ankylosing
spondylitis.
TNF α inhibitors
Etanercept, a recombinant TNF receptor: administered
subcutaneously
Infliximab, a chimeric monoclonal antibody, given by
intravenous infusion
Adalimumab, a humanised monoclonal antibody to
TNF given subcutaneously.
Stopping treatment with TNF inhibitors results in rapid
relapse for most patients with longstanding disease
TNF inhibitors are powerful drugs and carry the risk of
significant adverse effects. Increased rates of infection
have been reported, including tuberculosis, and
pretreatment screening is carried out routinely as part
of assessment
TNFα inhibitors are expensive
Corticosteroids
Intra-articular or periarticular corticosteroid
injections for sacroiliitis have been shown to
be effective.
Intravenous methylprednisolone is
occasionally used in severe unresponsive
cases.
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