ANKYLOSING SPONDYLITIS

(Marie-Strümpell disease/ Bechterew's

disease )
 Inflammatory disorder of unknown cause that primarily affects the axial
skeleton; peripheral joints and extra-articular structures may also be involved .

 AS causes pain, stiffness, disability, decreased spinal mobility, and decreased

quality of life

 Autoimmune disease

 Disease usually begins in the second or third decade.

 M:F= 3:1

 HLA-B27 present in > 90% cases

 Sacroiliitis is usually one of the earliest manifestations.

 Pathogenesis of AS
 Incompletely understood, but knowledge increasing

 Interaction between HLA-B27 and T-cell response

 Increased concentration of T-cells, macrophages, and proinflammatory

cytokines
 Role of TNF

 Inflammatory reactions  produce hallmarks

of disease

 In some cases, the disease occurs in these predisposed people after

exposure to bowel or urinary tract infections.

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 PATHOLOGY
 The enthesis, the site of ligamentous attachment to bone, is thought to
be the primary site of pathology.

 Enthesitis is associated with prominent edema of the adjacent bone

marrow and is often characterized by erosive lesions that eventually undergo
ossification.

 Synovitis follows and may progress to pannus formation with islands

of new bone formation.

 The eroded joint margins are gradually replaced by fibrocartilage

regeneration and then by ossification. Ultimately, the joint may be
totally obliterated.
 Clinical Features of AS

Skeletal Axial arthritis (eg, sacroiliitis and spondylitis)

Arthritis of ‘girdle joints’ (hips and shoulders)
Peripheral arthritis uncommon
Others: enthesitis, osteoporosis, vertebral,
fractures, spondylodiscitis, pseudoarthrosis
Extraskeletal Acute anterior uveitis
Cardiovascular involvement
Pulmonary involvement
Cauda equina syndrome
Enteric mucosal lesions
Amyloidosis, miscellaneous
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 CLINICAL FEATURES
Initial symptom-
 Insidious onset dull pain in the lower lumbar or gluteal region
 Low-back morning stiffness of up to a few hours duration that
improves with activity and returns following periods of inactivity.
 Pain usually becomes persistent and bilateral. Nocturnal exacerbation
+.
 Predominant complaint- Back pain or stiffness.
 Bony tenderness may present at- costosternal junctions, spinous
processes, iliac crests, greater trochanters, ischial tuberosities, tibial
tubercles, and heels.
 Neck pain and stiffness from involvement of the cervical spine : late
manifestations
 Arthritis in the hips and shoulders (“root” joints) : in25 to 35% of patients.
 Arthritis of other peripheral joints: usually asymmetric.
 Pain tends to be persistent early in the disease and then becomes intermittent,
with alternating exacerbations and quiescent periods.
 In a typical severe untreated case- the patient's posture undergoes
characteristic changes, with obliterated lumbar lordosis, buttock
atrophy, and accentuated thoracic kyphosis. There may be a forward
stoop of the neck or flexion contractures at the hips, compensated by
flexion at the knees.
Cervical mobility Thoracic mobility Lumber mobility

 Occiput-to-wall  Chest expansion Modified schober index

distance
 Tragus-to-wall Finger-to-floor distance
distance
 Cervical rotation Lumber lateral flexion
Occiput To Wall Distance / Flesche Test
 The occiput to wall distance should be
zero
 Tragus-to-wall distance
 Maintain starting position i.e.
ensure head in neutral position
(anatomical alignment), chin
drawn in as far as possible. Measure
distance between tragus of the ear
and wall on both sides, using a
rigid ruler. Ensure no cervical
extension, rotation, flexion or side
flexion occurs.

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 Cervical rotation
 Patient supine, head in neutral
position, forehead horizontal (if
necessary head on pillow or foam
block to allow this, must be
documented for future
reassessments).
 Gravity goniometer / bubble
inclinometer placed centrally on the
forehead. Patient rotates head as far
as possible, keeping shoulders still,
ensure no neck flexion or side Normal ROM: 70-900
flexion occurs.
Chest expansion
 Measured as the difference between maximal inspiration and
maximal forced expiration in the fourth intercostal space in
males or just below the breasts in females. Normal chest
expansion is ≥5 cm.
 Lumbar flexion (modified Schober)

 With the patient standing upright,

place a mark at the lumbosacral
junction (at the level of the dimples
of Venus on both sides). Further
marks are placed 5 cm below and
10 cm above. Measure the
distraction of these two marks
when the patient bends forward as
far as possible, keeping the knees
straight
• The distance less than 5 cm is
abnormal

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 Finger to floor distance
 Expression of spinal column mobility
when bending over forward; the
dimension that is measured is the
distance between the tips of the fingers
and the floor when the patient is bent
over forward with knees and arms fully
extended.
 Lateral spinal flexion
Patient standing with heels and buttocks touching the wall, knees
straight, outer edges of feet 30 cm apart, feet parallel. Measure minimal
fingertip-to-floor distance in full lateral flexion and without flexion,
extension or rotation of the trunk or bending the knees.

Greater than 10cm is normal.

>>>> >>>>

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 Range of motion
Cervical Spine
 Forward flexion: 0 to 45 degrees
 Extension: 0 to 45 degrees
 Left Lateral Flexion: 0 to 45
 Right Lateral Flexion: 0 to 45
 Left Lateral Rotation: 0 to 80
 Right Lateral Rotation: 0 to 80

Thoracolumbar spine
 Forward flexion: 0 to 90 degrees
 Extension: 0 to 30 degrees
 Left Lateral Flexion: 0 to 30
 Right Lateral Flexion: 0 to 30
 Left Lateral Rotation: 0 to 30
 Right Lateral Rotation: 0 to 30
 TESTS FOR SACROILITIS
 Pelvic compression test
 Faber test
 GaenslenTest
 Pump Handle test

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 GAENSLEN TEST

Gaenslen test stresses the

sacroiliac joints,
Increased pain during this
test could be indicative of
joint disease.
 PELVIC COMPRESSION TEST
 Test irritability by compressing the pelvis with the patient prone.
Sacroiliac pain will be lateralised to the inflamed joint.
Patrick's test or FABER test
 The test is performed by
having the tested leg
flexed, abducted and
externally rotated. If pain
results, this is considered
a positive Patrick's test.
LAB. TESTS
 HLA B27: present in ≈ 90% of patients.
 ESR and CRP – often elevated.
 Mild anemia.
 Elevated serum IgA levels.
 ALP & CPK raised.
 X-RAY
Sacroiliitis-
 Early: blurring of the cortical margins of the
subchondral bone
 Followed by erosions and sclerosis.
 Progression of the erosions leads to “pseudo
widening” of the joint space
 As fibrous and then bony ankylosis
supervene, the joints may become
obliterated.
 The changes and progression of the lesions
are usually symmetric.
 Seen in Ferguson's View (specialized
sacroiliac view).
 Dynamic MRI is the procedure of choice
for establishing a diagnosis of sacroiliitis.
Lumbar spine:
 Loss of lordosis/ straightening
 Diffuse osteoporosis
 Reactive sclerosis- caused by osteitis of
the anterior corners of the vertebral
bodies with subsequent erosion
(Romanus lesion), leading to
“squaring” of the vertebral bodies.
 Ossification os supraspinous &
interspinous ligaments “ dagger Sign”.
 Formation of marginal
syndesmophytes,
 Later Bamboo spine appearance
when ankylosis of spine occurs.

 Odontoid erosion.
 DIAGNOSIS
 Modified Newyork Criteria (1984) 4 + any of 1/2/3

1. Inflammatory low back pain > 3 months

(Age of onset < 40, 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)

2. Limited motion of lumbar spine in sagittal & frontal planes

3. Limited chest expansion (<2.5cm at 4th ICS)

4. Definite radiologic sacroiliitis

 Disease Specific Instruments For The Measurement In
Ankylosing Spondylitis

Instrument Measures

Bath ankylosing spondylitis disease activity index (BASDAI) Disease activity

Bath ankylosing spondylitis functional index (BASFI) Function

Dougados functional index (DFI) Function

Bath ankylosing spondylitis metrology index (BASMI) Function

Modified stoke ankylosing spondylitis spinal score (m- Structural damage

sasss)
 TREATMENT
1. Regular physical therapy
2. NSAIDS
3. Sulfasalazine, in doses of 2 to 3 g/d- Effective for axial and peripheral
arthritis
4. Methotrexate, in doses of 10 to 25 mg/wk- primarily for peripheral
arthritis
5. Local Corticosteroids injection- for persistent synovitis and
enthesopathy 6. Medications to avoid- Long term Systemic
Corticosteroids, gold and Penicillamine
7. Anti-TNF-α therapy - heralded a revolution in the management of AS.
Infliximab (chimeric human/mouse anti-TNF-α monoclonal antibody)
Etanercept (soluble p75 TNF-α receptor–IgG fusion protein)
have shown rapid, profound, and sustained reductions in all clinical and
laboratory measures of disease activity.
8. Pamidronate, thalidomide, α-emitting isotope 224Ra
9. Most common indication for surgery - severe hip joint arthritis, total hip
arthroplasty.