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ANKYLOSING

SPONDYLITIS

TANU TUESE

Musculoskeletal System

OVERVIEW:

Epidermiology

Etiology and Risk factors

Clinical manifestations

Complications

Differential diagnosis

Diagnosis

Management

Epidemiology

Prevalence:

4%-5% of patient-lowback pain. 5% to 6% in HLA-B27 postive persons. 0.1% to 1.4% depending on the population studied.

Demographic:

Most common between the ages of 16 40 3 times more frequent in men than in women Common in white patients HLA-B27 positive 5% to 6% chance of developing ankylosing spondylitis

Etiology

No specific cause Risk factors:

HLA-B27 (genetic association). Age ( adolescence or early childhood). Sex 2 to 3 times common in men than in women.

Chronic inflammatory disease

Risk Factors

Pathophysiology

Pathophysiology

Pathophysiology

Pathophysiology

Clinical features

Clinical features • Insidious onset (over months or years) • Episodes of low back pain and

Insidious onset (over months or years)

Episodes of low back pain and muscle stiffness

Radiates to the buttocks or posterior thighs.

Axial and symmetrical in distribution.

Most in the early morning and after inactivity.

Relieved by movement.

Physical signs:

lumbar lordosis

– – Pain on sacroiliac compression

restriction of chest expansion

Clinical features • Insidious onset (over months or years) • Episodes of low back pain and

Extraspinal features

Rare features

Anterior uveitis (25%) and

conjunctivitis(20%)

Prostatitis(80% men)-

usually asymptomatic Cardiovascular disease

Aortic incompetence

Mitral incompetence

Cardiac conduction defects

Pericarditis

Amyloidosis

Atypical upper lobe

pulmonary fibrosis

Differential diagnosis

Other spondyloarthropathies. Enteropathic arthritis Psoraitic arthritis Reactive arthritis

Degenerative disk disease Diffuse idiopathic skeletal hyperostosis syndrome

Sarcoidosis

Infectious sacroiliitis

Complications

Neurological complication Kidneys- Amyloidosis Heart complication Lung problems

Investigations

Physical Examination

Schobers test Chest expansion Cervical mobility

Laboratory findings:

ESR and CRP : usually raised. Serum rheumatoid factor (RF) is negative. Renal function test FBC

Imaging:

Spine X-rays- lateral thoracolumbar view

MRI and CT scan

Physical examination

Vital signs and check for fever and signs of weight loss

Examine the skin and nails and

check for psoraisis

Examine the eyes for signs of inflammation

Auscultate the chest

Examine the spine

Schober test

Faber test

Range of movement

Physical examination • Vital signs and check for fever and signs of weight loss • Examine
Physical examination • Vital signs and check for fever and signs of weight loss • Examine

Imaging

Imaging

Diagnosing

Clinical criteria:

Low back pain with inflammatory characteristics

Limitation of lumbar spine motion in the sagittal and frontal planes

Decrease chest expansion

Radiographic criteria:

Bilateral sacroiliitis of grade 2 or higher

Unilateral sacroiliitis of grade 3 or higher

Radiologic criteria (grade 1 = suspicious change of the sacroiliac joints; grade 2 = minimal change consistent with sacroiliitis; grade 3 = unequivocal change in the sacroiliac joints; grade 4 = severe sacroiliitis with marked ankylosis).

Need one clinical and one radiographic criterion

Management

Primary management

NSAIDs (naproxen and indomethacin) Muscle relaxants

DMARDs Exercise therapy

Tobacco discontinuation

Surgical therapy

Indication :

sagittal plane deformity

Severe back pain

Upper cervical instability

Management(spine)

Opening wedge surgery

• Opening wedge surgery

Management(spine)

Closing wedge surgery

• Closing wedge surgery

Management(spine)

A. PREOPERATIVE B. POSTOPERATIVE
A.
PREOPERATIVE
B.
POSTOPERATIVE
Management(spine) A. PREOPERATIVE B. POSTOPERATIVE CERVICOTHORACIC KYPHOSIS

CERVICOTHORACIC

KYPHOSIS

Management(spine)

Management(spine) THORACOLUMBAR KYPHOSIS
Management(spine) THORACOLUMBAR KYPHOSIS

THORACOLUMBAR KYPHOSIS

Reference

Goldman’s Cecil Medicine, 24 th edition

Rothman Simeone The spine, 6 th edition

Nelson textbook of Pediatrics,19 th edition

Davison’s Priniciples and Practice of Medicine,21 st edition