Updated: 11/23/2019

Ankylosing Spondylitis

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Questions
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Evidence
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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   
        • seen with PAIR (Psoriasis, Ankylosing spondylitis, Inflammatory bowel disease, Reactive arthritis)
  • 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" 
      • sacroiliac joint  
        • best initial test
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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Questions (9)
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(M3.RH.17.60) A 23-year-old man complains of lower back pain that began approximately 6 months ago. He is unsure why he is experiencing this pain and notices that this pain is worse in the morning after waking up and improves with physical activity. Ibuprofen provides significant relief. He denies bowel and bladder incontinence or erectile dysfunction. Physical exam is notable for decreased chest expansion, decreased spinal range of motion, 5/5 strength in both lower extremities, 2+ patellar reflexes bilaterally, and an absence of saddle anesthesia. Which of the following is the most appropriate next test for this patient? Tested Concept

QID: 103001
1

ESR

0%

(0/5)

2

HLA-B27

20%

(1/5)

3

MRI sacroiliac joint

20%

(1/5)

4

Radiograph sacroiliac joint

60%

(3/5)

5

Slit-lamp examination

0%

(0/5)

M 10 C

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(M2.RH.17.4867) A 27-year-old man presents to the emergency department with back pain. The patient states that he has back pain that has been steadily worsening over the past month. He states that his pain is worse in the morning but feels better after he finishes at work for the day. He rates his current pain as a 7/10 and says that he feels short of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 99% on room air. On physical exam, you note a young man who does not appear to be in any distress. Cardiac exam is within normal limits. Pulmonary exam is notable only for a minor decrease in air movement bilaterally at the lung bases. Musculoskeletal exam reveals a decrease in mobility of the back in all four directions. Which of the following is the best initial step in management of this patient? Tested Concept

QID: 109539
1

Pulmonary function tests

4%

(2/47)

2

Radiography of the lumbosacral spine

74%

(35/47)

3

MRI of the sacroiliac joint

21%

(10/47)

4

CT scan of the chest

0%

(0/47)

5

Ultrasound

0%

(0/47)

M 6 C

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(M2.RH.15.4662) A 27-year-old male presents to his primary care physician with lower back pain. He notes that the pain started over a year ago but has become significantly worse over the past few months. The pain is most severe in the mornings. His past medical history is unremarkable except for a recent episode of right eye pain and blurry vision. Radiographs of the spine and pelvis show bilateral sacroiliitis. Which of the following is the most appropriate treatment for this patient? Tested Concept

QID: 107052
1

Indomethacin

54%

(22/41)

2

Methotrexate

15%

(6/41)

3

Cyclophosphamide

0%

(0/41)

4

Oral prednisone

27%

(11/41)

5

Bed rest

0%

(0/41)

M 7 E

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Evidence (2)
Topic COMMENTS (7)
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