Ankylosing SpondylitisAnkylosing Spondylitis

SymptomsSymptoms

Chronic systemic inflammatory disease Chronic systemic inflammatory disease involving axial skeleton of younger ptsinvolving axial skeleton of younger pts

Develops in second/third decadeDevelops in second/third decade Typically dull aching pain of insidious Typically dull aching pain of insidious

onset in lower lumber/ buttock regiononset in lower lumber/ buttock region Early morning stiffness(ems) and Early morning stiffness(ems) and

nocturnal pain nocturnal pain

SymptomsSymptoms

Stiffness improves with exercises and Stiffness improves with exercises and recurs after periods of inactivityrecurs after periods of inactivity

Some pts present with painful hips, Some pts present with painful hips, shoulders, asymmetrical arthritis of lower shoulders, asymmetrical arthritis of lower limbs prior to spinal involvementlimbs prior to spinal involvement

Cervical and thoracic pain and stiffness is Cervical and thoracic pain and stiffness is frequentfrequent

SymptomsSymptoms

Enthesitis incl chest pain is common-Enthesitis incl chest pain is common-aggravated by manoeuvres increasing aggravated by manoeuvres increasing intra-thoracic pressure (eg coughing)intra-thoracic pressure (eg coughing)

Peripheral joints: shoulders, hips, Peripheral joints: shoulders, hips, costovertebral, costosternal, costovertebral, costosternal, manubriosternal, sternoclavicular joints manubriosternal, sternoclavicular joints commonly symptomatic at presentationcommonly symptomatic at presentation

M > F. 2-3.M > F. 2-3.

Symtoms and presentationSymtoms and presentation

Males: spine and pelvis more frequently involved Males: spine and pelvis more frequently involved with some involvement of hips, shoulders and with some involvement of hips, shoulders and chest wall. Tend to have a more severe disease chest wall. Tend to have a more severe disease than femalesthan females

Females: pelvis, hips, knees, and wrists with Females: pelvis, hips, knees, and wrists with less severe inv of the spineless severe inv of the spine

Enthesitis-inflammation of ligament and tendon Enthesitis-inflammation of ligament and tendon typical in seronegative arthritis. Eg achilles typical in seronegative arthritis. Eg achilles tendonitis, illiac crest pain, chest wall pain-from tendonitis, illiac crest pain, chest wall pain-from inv of costochondral, manubriosternal and inv of costochondral, manubriosternal and sternoclavicular jointssternoclavicular joints

HLA-B27HLA-B27

B27 +ve in 90-95% of AS. B27 +ve in 90-95% of AS. Lower prevalence of B27 in Lower prevalence of B27 in

african/african-american population african/african-american population associated with a lower prevalence of AS associated with a lower prevalence of AS in these populationsin these populations

B27 +ve individuals have a 2-5% chance B27 +ve individuals have a 2-5% chance of developing ASof developing AS

Male sex, B27+ve, FHx of AS + frequent Male sex, B27+ve, FHx of AS + frequent GI infections are all RFs for developing ASGI infections are all RFs for developing AS

PathogenesisPathogenesis

?development in genetically predisposed ?development in genetically predisposed individuals, triggered by an environmental individuals, triggered by an environmental factor eg gastro-intestinal infectionfactor eg gastro-intestinal infection

Reactive arthritis has a similar Reactive arthritis has a similar pathogenesis whereby chlamydia pathogenesis whereby chlamydia trachomatis, yersinia enterocolitica, trachomatis, yersinia enterocolitica, shigella flexneri, campylobactor jejunii, shigella flexneri, campylobactor jejunii, salmonella typhymurium have been salmonella typhymurium have been implicated.implicated.

PathogenesisPathogenesis

B27 +ve rats in a germ-free environment B27 +ve rats in a germ-free environment do not develop ASdo not develop AS

There is a high incidence of GI mucosal There is a high incidence of GI mucosal inflammation (both symptomatic and inflammation (both symptomatic and asymptomatic), this raises the possibility asymptomatic), this raises the possibility that the gut, with breakdown of the that the gut, with breakdown of the mucosal lining is a triggering event.mucosal lining is a triggering event.

PathogenesisPathogenesis

Activated T-cells and macrophages found Activated T-cells and macrophages found at sites of inflammation with expression of at sites of inflammation with expression of IL-1IL-1ββ, tnf-, tnf-αα and IF- and IF-γγ. These inflammatory . These inflammatory cytokines cause erosion of cortical bone, cytokines cause erosion of cortical bone, new bone formation and loss of bone new bone formation and loss of bone massmass

Associated featuresAssociated features

Extra-articular symptoms eg acute anterior Extra-articular symptoms eg acute anterior uveitis.uveitis.

Inflammatory bowel disease and/or Inflammatory bowel disease and/or psoriases may be presentpsoriases may be present

AS associated with CD/UC occurs in 5-AS associated with CD/UC occurs in 5-10% of individuals10% of individuals

Asymptomatic GI inflammation present in Asymptomatic GI inflammation present in 25-49% of AS25-49% of AS

Associated featuresAssociated features

50-60% of AS have microscopic inflammatory 50-60% of AS have microscopic inflammatory lesions at any one timelesions at any one time

Uveitis occurs in 25-40%Uveitis occurs in 25-40% Osteoporoses is a common feature-look out for Osteoporoses is a common feature-look out for

thisthis Less frequent-aortic incompetence, cardiac Less frequent-aortic incompetence, cardiac

conduction anomalies, progressive, b/l apical conduction anomalies, progressive, b/l apical cavitation/fibrosescavitation/fibroses

Other spondyloarthropathies-ReA, PsA Other spondyloarthropathies-ReA, PsA Enteropathic arthritis commoner in relativesEnteropathic arthritis commoner in relatives

ExaminationExamination

B/L sacro-illiac joint tenderness (febere B/L sacro-illiac joint tenderness (febere manoeuvre)manoeuvre)

Peripheral joint synovitis-asymmetric, Peripheral joint synovitis-asymmetric, oligoarticular pattern.oligoarticular pattern.

Dactylitis of fingers and/or toesDactylitis of fingers and/or toes Enthesopathy-thickened achilles tendon, Enthesopathy-thickened achilles tendon,

planter fascitis, chest wall tenderness etcplanter fascitis, chest wall tenderness etc

ExaminationExamination

Advanced disease; changes in posture-Advanced disease; changes in posture-flattening of normal lumber lordoses, flattening of normal lumber lordoses, thoracic kyphoses may be exaggerated.thoracic kyphoses may be exaggerated.

C-spine-limitation in ROM with fusion in C-spine-limitation in ROM with fusion in hyper-flexionhyper-flexion

PresentationPresentation

Chronic low back pain-usually as a teenagerChronic low back pain-usually as a teenager Tend to remain active as way to ease pain and Tend to remain active as way to ease pain and

stiffnessstiffness Back pain tends to become more progressive, Back pain tends to become more progressive,

symptomatic and severe-look for inflammatory symptomatic and severe-look for inflammatory back pain symptomatologyback pain symptomatology

Look for assoc chest wall tenderness, heel pain, Look for assoc chest wall tenderness, heel pain, buttock pain.buttock pain.

PresentationPresentation

Rarely may present with acute anterior uveitisRarely may present with acute anterior uveitis Look for other features of extra-axial Look for other features of extra-axial

involvement which would aid diagnoses- involvement which would aid diagnoses- asymmetrical oligoarthritis, enthesopathy.asymmetrical oligoarthritis, enthesopathy.

Sacro-illeitis; present with pain radiating to Sacro-illeitis; present with pain radiating to buttock and radiating to upper posterior thighs. buttock and radiating to upper posterior thighs. Usually U/L, intermittent or alternate from one to Usually U/L, intermittent or alternate from one to other side and eventually becomes B/L and other side and eventually becomes B/L and persistentpersistent

ExaminationExamination

Chest expansion, SIJChest expansion, SIJ Typical spinal ankyloses occurs after ~ Typical spinal ankyloses occurs after ~

10yrs10yrs Osteoporoses more likely in severe Osteoporoses more likely in severe

advanced, long-standing AS esp in pts advanced, long-standing AS esp in pts with immobile spine.with immobile spine.

Rigid osteoporotic spine susceptible to Rigid osteoporotic spine susceptible to vertebral fractures-prophylactic treatmentvertebral fractures-prophylactic treatment

Diagnoses + InvestigationsDiagnoses + Investigations

Based on clinical/blood test and radiological Based on clinical/blood test and radiological findingsfindings

Symptoms of inflammatory back painSymptoms of inflammatory back pain Family historyFamily history Extra-articular lesionsExtra-articular lesions B/L sacro-illeitis on XR or MRIB/L sacro-illeitis on XR or MRI MRI-STIR sequences show up inflammation with MRI-STIR sequences show up inflammation with

bone marrow oedema and enthesopathybone marrow oedema and enthesopathy

Diagnoses and investigationsDiagnoses and investigations

HLA B-27: in whom hx and examination is HLA B-27: in whom hx and examination is suggestive of a sero-negative spodyloarthropathy suggestive of a sero-negative spodyloarthropathy but have normal XRsbut have normal XRs

Should not be used as a routine, diagnostic, Should not be used as a routine, diagnostic, confirmatory or screening test.confirmatory or screening test.

Positive B-27 in the presence of non-inflammatory Positive B-27 in the presence of non-inflammatory back pain with –ve XRs does not confirm diagnoses back pain with –ve XRs does not confirm diagnoses and up to 8% fo normal pop are +ve. Higher in and up to 8% fo normal pop are +ve. Higher in normal relatives.normal relatives.

↑↑esr/crp in 70% of AS, but no clear correlation with esr/crp in 70% of AS, but no clear correlation with disease activity. Associated with peripheral arthritis disease activity. Associated with peripheral arthritis rather than axial arthritisrather than axial arthritis

ManagementManagement

Combination of non-pharmocologic and Combination of non-pharmocologic and pharmocological therapy depending on disease pharmocological therapy depending on disease stage and symptomsstage and symptoms

Patient education essential-life long programme Patient education essential-life long programme of exercise, use of individual, and group therapy of exercise, use of individual, and group therapy as well as self-help groupsas well as self-help groups

Functional disability in AS progresses more Functional disability in AS progresses more rapidly in smokers and less so in those with rapidly in smokers and less so in those with better social support and reg exercisesbetter social support and reg exercises

ManagementManagement

NSAIDs-essentialNSAIDs-essential DMARDs-not recommended for axial disease, DMARDs-not recommended for axial disease,

however SASP found to be useful in periopheral however SASP found to be useful in periopheral arthritisarthritis

Steroids-oral or parenteral not recommendedSteroids-oral or parenteral not recommended Anti TNF-all three effective in AS in pts with Anti TNF-all three effective in AS in pts with

persistently high BASDAI. No need to use MTX persistently high BASDAI. No need to use MTX with anti-tnf prior to commencing anti-tnfwith anti-tnf prior to commencing anti-tnf

SurgerySurgery

RareRare Hip arthroplasty-structuarl damage Hip arthroplasty-structuarl damage

causing refractory paincausing refractory pain Corrective spinal osteotomy. Fusion Corrective spinal osteotomy. Fusion

procedures in patients with segmental procedures in patients with segmental instability may be indicated.instability may be indicated.

PrognosesPrognoses

Depends on stage at diagnosesDepends on stage at diagnoses Initiation of effective therarpyInitiation of effective therarpy Worse in smokers, low socio-economic Worse in smokers, low socio-economic

classclass Worse in pts poorly compliant with Worse in pts poorly compliant with

exercisesexercises Males worse than femalesMales worse than females

Question?Question?