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8 Cards in this Set
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- Back
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Symptoms of anklyosing spondylitis
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Mid and lower back stiffness, worse in morning and after inactivity and at night, persistent buttock pain, painful sacroiliac joint
Thoracolumbar junction and SIH intitially involved but can involve whole spine Spinal restriction (decreased ROM): lumbar (decreased lateral flexion and rotation), thoracic (decreased chest wall expansion, normal > 5cm at T4), cervical (global decrease, often extension first Postural changes: decreased lumbar lordosis + increased thoracic kyphosis and increased cervical flexion = increased occiput to wall distance Asymmetrical joint arthritis, most often involving lower limb Enthesitis - lateral epicondylitis, plantar fasciitis, achillies tendinitis Extra-articular Fatigue and weight loss Atlanto-axial subluxation Anterior uveitis Apical lung fibrosis (rare) Aortic incompetence (aortitis, AR, pericarditis, conduction disturbances, heart failure) Amyloidosis (kidneys) + IgA nephropathy Autoimmune bowel disease (UC) Cauda equina syndrome (back, buttock, leg pain, saddle sensory loss, lower limb weakness, loss of sphincter control) |
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What is anklyosing spondylitis?
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Chronic inflammatory disorder of spine and sacroiliac joints --> anklyosis (stiff spine due to fusion of joints)
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What investigations should be performed in ankylosing spondylitis?
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CRP/ESR - raised or N (more likely to be raised if peripheral arthritis)
FBC (normochromic anaemia) HLA-B27 CT X-ray NB: radiological changes take 5-6 years to develop |
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What are the radiological findings of ankylosing spondylitis on x-ray?
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SI Joint:
"pseudowidening" of joint due to erosion with joint sclerosis --> bony fusion (late), symmetric sacroilitis Juxta-articular osteosclerosis Cortical outline lost early Spine: "squaring of edges" from erosion and sclerosis on corners of vertebral bodies leading to ossification of outer fibres of annulus fibrosis (bridging syndesmophytes - bony proliferations due to enthesitis between ligaments and vertebrae) --> syndesmophytes fuse with the above vertebral body causing anklyosis --> calcification of ligaments with anklyosis --> bamboo spine appearance Loss of lumbar lordosis Apophyseal joint fusion |
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Management of anklyosing spondylitis
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Exercise (NOT rest)
NSAIDs reduce pain and stiffness to allow patient to exercise Local steroid injections can provide symptomatic relief Sulfasalazine, methotrexate, TNF alpha inhibitor in severe disease Hip replacement to improve pain and mobility if the hips are involved Verterbral osteotomy for marked deformity |
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Prognosis of anklyosing spondylitis
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Most people's spine's don't fuse - 80% will continue with normal daily activities
Spontaneous remissions and relapses are common and can occur at any age function may be excellent despite spinal deformity favourable prognosis if female > 40 years |
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How should you examine someone who has ankylosing spondylitis?
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Undress to underpants and stand up
Look for kyphosis, lumbar lordosis Palpate each vertebral body for tenderness and palpate for mm spasm Test movement Modified Schober's test: Identify level of posterior iliac spine on the verterbal body (L5) - mark 5 cm below and 10cm above this point - ask patient to touch his toes - there should be an increase of 5 cm or more in the distance between the marks - AS - little separation of the marks since all the movement is taking place at the hips Test occiput to wall distance: Ask pt to place heels and back against wall and to touch the wall with the back of his head without raising his chin above carrying level - inability to touch wall suggests cervical involvement - measure distance from occiput to wall Push with heel of hand on sacrum and not presence of tenderness or springing in SI joint Examine heels for Achilles tendinitis, plantar fasciitis, evaluate other larger joints Examine chest for decreased lung expansion (< 3cm at nipple line suggests early costrovertebral involvement) and apical fibrosis Heart - AR, MVP, conduction defects Eyes - uveitis GIT - IBD, amyloid deposition (hepatosplenomegaly, abnormal UA) Psoriasis, Reiter's syndrome (DDx) Cauda equina compression NB: Tests allow you to test for progression at future clinic visits and to assess degree of deformity |
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What are the features of sponyloarthritides?
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Sacroilitis with or without spondylitis (inflammation of the vertebrae)
Large joint asymmetrical oligoarthritis (i.e. < 5 jts) or monoarthritis Rheumatoid factor -ve (seronegativity) HLA B27 Enthesopathy Extra-articular features e.g., anterior uveitis Family history of psoriasis, IBD, or sponyloarthropathy |
