CLASS

WITH PROF DHEV 30/4/19 movement –alleviated by rest and analgesic,

associated with stiffness in the morning
https://www.orthobullets.com/spine/2044/ank
, TE, S-pain score 8
ylosing-spondylitis -But still able to do his job,

ANKYLOSING SPONDYLITIS b. also associated with lower back pain
1.Prof: where do you come from? S-OC-worsen in the morning, associated with
A: Kedah stiffness, difficult to get up from the bed
Prof: very good.Where the hell in Kedah? RATES..
A: Jitra Ddx:
1.degenerative
Prof:Oh, The prime minister. What is Kedah
2.inflammatory
famous for?
-RA-must ask regarding family history
A:Padi -SLE
Prof: How does padi become rice? -
A: It’s being processed (explained in details in 3.
the correct terms)
Prof: Are you a farmer? You know the actual
words of how the farmer explains
c. multiple visits to general practitioner
#you must know the process of how paddy -given analgesic, no diagnosis given
become rice in Prof’s class -multiple visits to chiropractor-acupuncture,
-conclusion: you have to process the history massage-but the pain was not relieved
from patient to come for a conclusion -but, he was still able to do his job
From paddy to rice -the pain was progressive
Planting
Harvesting • 30 years ago
Drying
Hulling (done by hand by rolling or grinding the -able to adapt the pain and bear it, still taking
rough rice between stones) analgesic sometimes
Milling
Enriching d.had spine surgery at the lower back in
Cooking Thailand post trauma fall on the back at the
home
Read more: http://www.madehow.com/Volume- -had tingling sensation at upper limb and lower
5/Rice.html#ixzz5mYLDqnLd limb
HISTORY -post surgery, the pain resolve but the stiffness
preserved and reduced ROM.
64 y/o, Chinese man
• 40 years ago (24y/o) Guess types of surgery done in this patient?
Clue-back stiffness
#during this time, he was in Kelantan &
Principle of treatments for pain of joint
Terengganu making furnitures
during movement (arthritis)
#also frequently went to Thailand in the 1.modify activity
weekend for vacation
-swimming, don’t walk too fast
a.has neck pain -use walking stick- to distribute the weight on
S-at the neck,O-sudden, C-pulling in nature? 3 compartment as compared to 2
Continuous ,R-none, A-aggravated by 2.reduce weight
3.rest (immobilisation)

1

 4.analgesic
-medications-PCM
*if autoimmune-change the medication- b.back stiffness
steroid,DMARD etc -restricted ROM, needed to bend the knees to
-intraarticular steroid injection- was told as pick up things from the floor
not useful -difficult to cut toe nails,wear shoes
*TKR-1 knees RM1500 -but still ADL independent
-1 injection –MAY not help them. The max
time of pain relief 1m/6m/1 year (it’s not • 6 months ago
working for 95% of the people )
-physiotherapy-muscle strengthening helps -went for f/u at general surgery of Hospital
to give support to the joint & reduce pain Serdang for cholelithiasis, complained of the
neck and back pain and stiffness, hence, was
5.realignment osteotomy referred to orthopaedic clinic
-shifting the weight distribution, to even out • Day of admission
the wear so that medial and lateral articular
surface of joint are equally worn out, correct -1st f/u with ortho,
the deformity
Ddx
To buy time
Can still be
#in varus, medial articular surface will be
1.degenerative
affected
2.inflammatory
6.arthrodesis
-RA- must ask about joint swellings/stiffness
-not done anymore
elsewhere (fingers)
-can travel in bus
-Ankylosing spondylitis-history of uveitis, iritis
-need extra space because the joint can’t be
Joint stiffness of sacroiliac joint, ribs joint-
flexed
inflammation and fusion (unable to have a
7.joint replacement/arthroplasty
poper chest expansion, inadequate air entry,
-exists for 30-40 y in history
easy to get pneumonia. Hence, if the patient
-has ROM compared to arthrodesis
has cold, need to give extra attention)
-relieve the pain
-psoriatic arthritis
Ex:TKR


Less likely
If patient has stiffness, we do not do spinal
1.mets
Fusion
-because of history of 40y. Rare for

malignancy to survive post 10 years
• 10 years ago 2.TB
-also less likely because TB progression,
-developed neck & back stiffness usually will be manifested significantly in 10
-still has reduced ROM years
a.neck stiffness 3.pyogenic
-needed to turn the shoulder to lateral to -less likely because of acute progression
compensate for unable to rotate the neck
-also unable to do extension and flexion #sacroiliac joint ROM-hardly any
-worsen occasionally, especially in the morning
-due to these, he stopped driving the car due to
• he had
restricted ROM-unable to see sideways, blind
spot, to prevent accident 1.previous history of uveitis 4 times

2

 -acute sudden blurry vision of right eyes -f/u in HS
-reddish eye, but there was no pain/ 2. 10 years ago, take terazosin?
discharge
-BPH
-visits to GP, no diagnosis given, prescribed
with eye drop, 2.diagnosed with anxiety
-usually the condition resolve after 4 days -on alprazolam,escitalopram
• Otherwise, he had
In view of this patient has ankylosing
1.no neck swelling, no haemoptysis,no chest spondylitis,restricted chest expansion
pain, no haematemesis or altered bowel habit (reduce tidal volume),
or haematochezia,no LUTS, no painless SE of benzodiazepine-respiratory depression-
haematuria may worsen the patient’s condition if he has
2.no skin changes, nail changes (psoriasis) pneumonia
3.no fever. No TB contact
4.no family history
5.no shooting pain radiated to the feet- DRUG HISTORY
suggested of PID
-as mentioned
6.no bowel or urinary incontinence, no
numbness, no muscle weakness / unsteady gait, FAMILY HISTORY
no night pain
-
Patient has no neurological impairment in
which if has,usually means affecting spinal SOCIAL HISTORY
canal
-PID, tumour,TB-paravertebral abscess, spinal -
stenosis, infection Ddx now

Inflammatory
He only complains of long history of stiffness 1.RA
-but less likely because no history of small
Hand dominant-right joint swelling, not ill looking, more common
in women, more common in 3rd -4th decade of
Job-forrest inspector in a logging company- not life
doing heavy work like cutting log, income per 2.SLE
month? 3.ankylosing spondylitis
ADL-independent,sitting/squatting toilet at
home?, stairs?
Expectation-?

1.methods of inheritance for ankylosing

spondylitis
-autosomal recessive-HLAB27
=both parents need to be affected/ carrier

PAST MEDICAL & SURGICAL

1.hypertension 6 months
-on bisoprolol, compliance

3

PHYSICAL EXAMINATION 1.fix flexion of neck-around 0-30 degree-need
pillow to support the head, unable to lie flat
General: well, conscious, alert, thin built

Vital signs -feel

Peripheral -move-restricted for all ROM

1.No neck movement at all
Face 2.Forward bending-need the help of knee
Neck extension or flexion to do it
3.Unable to do lateral bending
Spine examination All of these gives clue toward ankylosing

-look
-special test
Standing
1.faber test-negative
1.Fix flexion of neck
2.loss of cervical and lumbar lordosis -if patient unable to lie supine to do Faber’s
Loss of cervical lordosis-unable to look at a test, in lateral position/ prone, do hip extension
far distance
-neurological examination-normal

Refer ASIA chart to know which nerve supply

muscles for which movement & which nerve
is tested for each reflex
PID common at
1.L4/L5- the nerve of L5 will be affected or
L5/S1-the nerve of S1 will be affected
The nerve root passess through below the
same vertebrae-L5 n. root passess through
below L5
2.if cervical-same nerve root with the
vertebrae will be affected
Ex. 7 cervical vertebrae, has 8 spinal n.
The nerve root passes through above the
vertebra- C1 n. root pasess through above C1
If C1 is affected,C1 n. root
3.increase in thoracic dorsal kyphosis
4.pectus excavatum?
5.normal gait,able to squat, walk on heel/ tip
toe
6. during inspiration & expiration- no chest
expansion or movement, only has abdominal
movement,
7.From supine to sitting
-unable to move the back
-tried to get up from the bed with no spine
flexion or extension (straight back)
Supine

4

 INVESTIGATIONS
1.x ray of the spine
a.AP view

-vascular examination

5



-disc spaces are preserved
Thoracic- bamboo appearance
Lumbar-bamboo appearance
*because the spinous process fused together
Pelvis-fused sacroiliac joint
b.Lateral view

spine-bamboo appearance
-disc spaces are preserved

USES OF BAMBOO
1. Bamboo is used for building roads.
2. Bamboo is used for medicinal purposes
3. Bamboo is used to build houses and
schools
4. Bamboo is used to make clothes.
5. Bamboo is used to make accessories
6. Bamboo is used to feed people and
animals
7. Bamboo is used for scaffolding
8. Bamboo is used to make furniture
9. Bamboo is used to make toys.
10. Bamboo is used to make durable utensils
11. Bamboo is used to make musical
instruments

https://matadornetwork.com/change/15-
creative-uses-of-bamboo/
15 creative uses of bamboo
How many ways have you seen bamboo
used?

2.CXR normal, no cannon ball appearance, heart
shadow is ok

6

3.HLA B27-pending, send to IMR
4.done MRI only if want to do surgery

-to confirm the site to operate, which level

MANAGEMENT

At early stage
1.we can only slower the progress
2.
Since patient comes at the late stage
Only can offer
1.pain management

*can’t do physio because of fused spinous
process

2.preserve distance of vision to look forward
-only use one pillow during lying spine. The
pillow can’t be too high

3.maintain the current spine mobility that he
has, prevent from it becomes reduce, loss
more ROM, prevent muscle wasting
-due to reduce ROM secondary to fused
spinous process-will have muscle wasting of
the back, shoulder-hence, must do muscle
exercise that he is able to do to preserve the
muscle
-If too severe restricted ROM, can do op
4.regular eye check up for glaucoma, uveitis,
iritis
* SPLINT/BRACES does not bring any
difference