Definition
ankylosing spondylitis, Marie-Strümpell disease;
rheumatoid spondylitis; arthritis of the spine, resembling
rheumatoid arthritis, that may progress to bony ankylosis with
lipping of vertebral margins; the disease is more common in the male
often with the rheumatoid factor absent and the HLA antigen present.
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Radiographic Appearance
Anteroposterior Pelvis XRay
Usually sufficient as only XRay confirmation
Reveals Bilateral and symmetric sacroiliitis
Spine XRay other findings
Bony sclerosis appears as squaring of vertebrae
Syndesmophytes between vertebrae
Classic "Bamboo" spine (<10%) appearance
Special XRay views
Ferguson's View (specialized sacroiliac view)
Other studies with limited indications
Bone Scan
CT or MRI spine
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Pathology
Ankylosing spondylitis (AS) is a rheumatic disease that
causes arthritis of the spine and sacroiliac joints and can cause
inflammation of the eyes, lungs, and heart valves. It varies from
intermittent episodes of back pain that occur throughout life to a
severe chronic disease that attacks the spine, peripheral joints and
other body organs, resulting in severe joint and back stiffness,
loss of motion and deformity as life progresses.
AS is a member of the family of diseases that attack the spine
called spondylarthropathies
The cause of AS is not known, but all of the spondylarthropathies
share a common genetic marker, called HLA-B27, in most affected
individuals. In some cases, the disease occurs in these predisposed
people after exposure to bowel or urinary tract infections.
Diagnosis: Criteria
Onset before age 40 years
Insidious onset
Duration longer than 3 months
Pain worse in the morning
Morning stiffness lasts longer than 30 minutes
Pain decreases with Exercise
Pain provoked by prolonged inactivity or lying down
Pain accompanied with constitutional Symptoms
Anorexia
Malaise
Low grade fever
Articular Symptoms and Signs
Monoarticular arthritis or oligoarticular arthritis
Asymmetric and nonerosive arthritis
Common joint involvement
Inflammatory low back back (esp. Sacroilliitis)
Large joints:
Shoulders
Hips (Hip Flexion contractures with rigid gait)
Costosternal pleuritic Chest Pain
Heel Pain
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Treatment:
Management: Non-pharmacologic
Regular therepeutic Exercise
Erect posture
Firm mattress (without a pillow)
Deep breathing Exercises
Maintain normal chest expansion
Spinal extension Exercises
Range of Motion Exercises
Cervical spine
Shoulders
Hips
Knees
Consider physical therapy
Management: Medications
First Line: NSAIDS
Indomethacin (up to maximum of 50 mg PO tid)
Tolmetin 400 mg PO tid-qid
Second Line: NSAID Adjuncts
Sulfasalazine 2-4g/day divided doses
Effective for axial and peripheral arthritis
Methotrexate
Effective for peripheral but not axial arthritis
Local Corticosteroids injection
For persistent synovitis and enthesopathy
Medications to avoid
Avoid Long term Systemic Corticosteroids
Avoid gold and Penicillamine
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