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Snapshot
  • A 21-year-old man presents with severe morning back pain over the past three months. His pain improves as the day progreses and with excercise. Physical exam shows a stooped posture and diminished anterior flexion of the lumbar spine. Radiography of the lumbar spine shows bilateral sclerotic changes in the sacroiliac area. Laboratory testing shows that the patient is HLA-B27 positive.
Introduction
  • Clinical definition
    • chronic inflammatory disorder that primarily affects the sacroiliac joint and spine
  • Epidemiology
    • demographics
      • more common in men
      • peak onset age is 15-35 years of age
    • risk factors
      • HLA-B27 gene presence
  • Etiology
    • unknown but may involve both genetic (e.g., HLA B-27 positivity) and environmental factors
  • Pathogenesis
    • unclear but involves inflammation, bone erosion, and spur formation
      • can result in spinal fusion and costovertebral and costosternal
        ankylosis
    • involves the entheses
      • connective tissue between bone and a tendon or ligament
  • Associated conditions
    • psoriasis
    • inflammatory bowel disease
    • anterior uveitis
    • aortic regurgitation
  • Prognosis
    • may lead to chronic pain and stiffness
Presentation
  • Symptoms
    • back pain
      • worse in the morning and lasts approximately 30 minutes
      • improves with activity
    • stiffness of the spine
    • with anterior uveitis
      • photophobia
      • watering and redness of the eye
  • Physical exam
    • may have stooped posture
    • positive Schober test
      • demonstrates limited spine flexibility
    • decreased chest wall expansion
Presentation
  • Radiography  
    • indication
      • gold standard for evaluating and supporting the diagnosis of ankylosing spondylitis
    • findings
      • "bamboo spine" 
Studies
  • Labs
    • HLA-B27 positivity
      • seen in > 90% of patients
Differential
  • Mechanical low back pain
  • Enteropathic arthritis
  • Reactive arthritis
  • Psoriatic arthritis
Treatment
  • Conservative
    • patient education and exercise
      • indication
        • mainstay of treatment
  • Medical
    • nonsteroidal antiinflammatory drugs (NSAIDs)
      • indication
        • considered first-line treatment for managing pain and stiffness
    • tumor necrosis factor (TNF) inhibitors
      • indication
        • typically used in patients who do not respond to conservative and NSAID treatment
      • medications
        • adalimumab
        • etanercept
Complications
  • Low bone density due to inflammation and osteoporosis/osteopenia 
    • can predispose the patient to vertebral fractures 
  • Spine fracture leading to injury of the spinal cord
  • Restrictive lung disease
 

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