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Updated: Dec 28 2021

Ankylosing Spondylitis

  • 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 costosternalankylosis
      • involves the entheses
        • connective tissue between bone and a tendon or ligament
    • Associated conditions
      • psoriasis
      • inflammatory bowel disease
      • anterior uveitis
      • aortic regurgitation
  • 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
  • Imaging
    • Radiography
      • indication
        • gold standard for evaluating and supporting the diagnosis of ankylosing spondylitis
      • findings
        • "bamboo spine"
        • sacroiliac joint
          • best initial test
    • CT
      • will show bony changes but not active inflammation
      • CT is most sensitive test to diagnose cervical fractures in patients with AS
    • MRI
      • will detect inflammation, making it the best modality for early detection of AS in young patients
      • obtain with cervical fractures to look for epidural hemorrhage
  • 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
  • Prognosis
    • May lead to chronic pain and stiffness
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