ANKYLOSING

SPONDYLITIS
ANKYLOSING
SPONDYLITIS
• The word ANKYLOSING and spondylitis are Greek origin. Ankylos means bent or crooked and
refers to the stooped or bent posture that may occur in AS patients. Spondylos means spinal
vertebrae, itis means inflammation. Spondylitis then is an inflammation in the vertebrae.

• According to Zhu et al, (2019) Ankylosing spondylitis (AS), a type of SpA, is an autoimmune
disease that mainly involves spine joints, sacroiliac joints (SIJs) and their adjacent soft tissues,
such as tendons and ligaments. In more advanced cases, this inflammation can lead to fibrosis and
calcification, resulting in the loss of flexibility and the fusion of the spine, resembling “bamboo”
with an immobile position. The main clinical manifestations include back pain and progressive
spinal rigidity as well as inflammation of the hips, shoulders, peripheral joints and fingers/toes. In
addition, there are extra-articular manifestations, such as acute anterior uveitis and inflammatory
bowel disease (IBD). However, these extra-articular manifestations differ between East Asian and
Caucasian populations. In a study involving 988 patients with ankylosing spondylitis in east Asia,
only 0.4% developed inflammatory bowel disease. However, in some analyses performed in
Western countries, ~5%–10% of patients with AS present with inflammatory bowel disease.
LEARNING OBJECTIVES

At the end of discussion, the students will be

able to :
• Introduce Ankylosing Spondylitis (AS)
• State the Etiology of AS
• Describe the Pathophysiology of AS
• State the Clinical Manifestation of AS
• Identify Complications of AS
• Describe Treatments of AS
• Describe the Medical Management of AS
• Describe the Surgical Management of patients with AS
TOPIC OUTLINES

• Bekhterew's disease, Bechterew's syndrome, –Marie Strümpell– disease,

Marie's disease, Marie–Strümpell arthritis, Pierre–Marie's disease
 TOPIC CONTENTS
ETIOLOGY / RISK CLINICAL DIAGNOSTIC
DEFINITION PATHOPHYSIOLOGY
FACTOR MANIFESTATIONS PROCEDURES

MEDICAL SURGICAL NURSING

COMPLICATIONS
MANAGEMENT MANAGEMENT MANAGEMENT
DEFINITION
• Ankylosing spondylitis is an inflammatory disease that, over time, can cause some of the small
bones in your spine (vertebrae) to fuse. This fusing makes the spine less flexible and can result in a
hunched-forward posture. If ribs are affected, it can be difficult to breathe deeply.

• It is a form of arthritis that is long-lasting (chronic) and most often affects the spine. It affects joints
in the spine and the sacroilium in the pelvis, causing eventual fusion of the spine. Complete fusion
results in a complete rigidity of the spine, a condition known as bamboo spine.

• AS is a systemic rheumatic disease and is one of the seronegative spondyloarthropathies. The

typical patient is young, aged 18-30 Men are affected more than women by a ratio about of 3:1.
Traditional Types of Spondylitis
• 1.Enteropathic arthritis (EnA)

This type of spondylitis is characterized by pain and inflammation in the intestines. You may have back and joint pain.

Other symptoms include:

• stomach pain

• chronic diarrhea

• weight loss

• blood in bowel movements

2. Psoriatic arthritis (PsA)

This type of spondylitis causes back pain and stiffness. It’s associated with psoriasis of the skin.
Psoriatic arthritis mostly causes pain and swelling in smaller joints, like in the fingers and toes.

Symptoms include:

• pain and swelling in the hands, fingers, and feet.

• skin rash (psoriasis flare-up)

• dactylitis (toe or finger swells between joints, sometimes called “sausage fingers”)
3.Reactive arthritis/Reiter’s syndrome (ReA)

ReA is a type of spondylitis that usually occurs after a bacterial infection. It could be due to a sexually transmitted infection, such as chlamydia,
or a gastrointestinal infection from food contaminated with Salmonella.

ReA may cause pain and inflammation in the peripheral joints (like the knees and ankles), spine, and sacroiliac joints. These are located on each
side of your lower spine.

You may experience:

• joint pain and swelling

• skin rash

• eye inflammation

• bladder and genital pain and inflammation

4.Juvenile spondylitis (JSpA)

• JSpA is a type of arthritis that occurs in children and teenagers. This kind of arthritis
usually affects the leg joints. One leg may be affected more than another.

• JSpA can look like other kinds of spondylitis. The main symptoms are pain and
inflammation around the joints and in the spineThis type of spondylitis affects areas
where the muscles, ligaments, and tendons are attached to bone.
5.Undifferentiated spondylitis

This type of spondylitis is called undifferentiated because it doesn’t meet the criteria for a diagnosis of ankylosing spondylitis or related
disease.

If you have undifferentiated spondylitis, you’ll likely not have the usual symptoms of back pain, skin rash, or digestive problems. Instead, you
may have:

• inflammatory back pain

• buttock pain

• enthesitis (heel pain)

• peripheral arthritis

• dactylitis

• fatigue

• eye inflammation
A new way to classify spondylitis diagnosis.
6. Axial spondylitis

These are types of spondylitis that cause symptoms in the back and groin or hip area. This group is further divided into
spondylitis that causes bone and joint changes that can be seen on an X-ray or scan and those that can’t.

Axial spondylitis types may include:

• ankylosing spondylitis

• reactive arthritis

• enteropathic arthritis

• undifferentiated spondylitis

• psoriatic arthritis
7.Peripheral spondylitis

• This group covers types of spondylitis that cause symptoms in the arms and legs. Common affected areas include joints
in the:

• knees

• ankles

• feet

• hands

• wrists

• elbows

• shoulders
Etiology
 Unknown

 Genetic link
  Gender. About four times more
common in males

RISK FACTOR
 Age. Usually begins in late
Adolescence or early adulthood; onset
rare over the stage of 45.

 Genetics. Sometimes runs in families.

 CLINICAL MANIFESTATIONS

Lower back stiffness

Low back pain, which Pain in the other joints
that may be worse in Pain and tenderness in
spreads down into the such as the hips, knees,
the morning and the heels
buttocks and thighs. and shoulders
improves with exercise.

Tiredness, weight loss, Limited chest

Eye inflammation
and mild fever. expansion
 PATHOPHYSIOLOGY
Modifiable Risk Factor: Non-Modifiable Risk Factor:
-Inflammation in the eye -Gender -Race
-Low back pain -Age
-Heel pain -Hereditary

Both genetic & environmental factors appear

to be involved

HLAB27 presents an antigen to the CD8+ T

cells & in turn activates the immune system.

(TNF)-α & (IL-1) are thought to play role in

the inflammatory reaction.

to attack the fibrocartilage, AS involves

inflammation, cartilage erosion.

enthesis, which is the site of major histologic

changes is affected resulting in enthesitis.

In addition, there is seen to be mild and

destructive synovitis.

As the disease progresses it destroys the nearby

articular tissues or joint tissues

new cartilages are replaced by bone through

fusion, Resulting in stiffness and immobility.
DIAGNOSTIC
PROCEDURES
• Test and measurement for AS

1. Occiput To Wall Distance / Flesche Test

• The severity of cervical flexion deformity in ankylosing spondylitis can be

assessed by measuring the occiput to wall distance (Flesche test).

• With the patient standing erect, the heel sand the buttocks are placed against a
wall; the patient is then instructed to extend his or her neck maximally to
touch the wall with the occiput.

• The distance between the occiput and the wall is a measure of the degree of
flexion deformity of the cervical spine.

• The occiput to wall distance should be zero.

• 2. 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.
• 3. 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 Normal
ROM: 70-900 flexion or side flexion occurs.
Thoracic mobility
4. 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 mobility
5. 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 16.
6. 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.
• 7. Lateral spinal flexion

• Patient standing with heels and buttocks touching thewall,

knees straight, shouldersback, outer edges of feet 30 cm apart,
feet parallel.Measure minimal fingertip-to-floor distance in
full lateralflexion without flexion, extension or rotation of the
trunkor bending the knees. Greater than 10cm is normal.
• 8. Schober’s Test

• A useful clinical measure of flexion of the lumbar spine

performed during examination.
• 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
 • Reducing pain & inflammation
Pharmacological

MEDICAL  NSAIDs

MANAGEME  Anti-TNF medication

NT  Corticosteroids

 DMARDs (Disease- modifying anti-

rheumatic drugs)
  Joint replacement surgery

People who have hip, shoulder, and knee problems related to

SURGICAL ankylosing spondylitis may consider joint replacement surgery. Joint

replacement surgery involves replacing the cartilage and bone
MANAGEMEN surfaces of a joint with man-made materials typically metal or plastic.

T  Total hip joint replacement is usually performed for severe hip

disease.
NURSING DIAGNOSIS
• Pain related to inflammatory and stiffness in joints

• Ineffective breathing pattern related to reduced chest expansion secondary to vertebral

spine involvement.

• Impaired physical mobility related to hip joint inflammation and pain.

• Risk for injury related to improper gait and balance

• Fatigue related to pain and fever

  Reducing pain and inflammation

 Apply heat packs at the affected area.

 Give anti-inflammatory analgesics as prescribed.

 Encourage diversional activities.

 Promoting effective breathing

NURSING
 Ongoing assessment of chest wall expansion.

 instructions in deep breathing exercises, and the avoidance of

smoking and respiratory depressants can help the client to maintain

MANAGEMENT 
optimal breathing.

Promoting mobility

 Suggest that the client perform exercise in the shower because warm,
moist heat prompts mobility.

 Stress the importance of following the prescribed physical therapy

and exercise program to maintain mobility.

 Assist with range of motion exercises 3 times in a day.

• Advice on using following principles:

 Use assistive devices (such as cane/walker)

 Use the joints in their most stable positions.

 Avoid maintaining the same position for long periods of time.

 Employ appropriate body posture & moving and handling

techniques.

 Maintain muscle strength and ROM.

 COMPLICATIONS
• Spine-In rare cases, your vertebrae may become weak, making them more likely to fracture or break. Damaged vertebrae can press on or irritate a group of
nerves in the bottom of your spinal cord called the cauda equina. You might have trouble controlling your bowels or bladder, sexual problems, or a loss of
reflexes.

• The jaw -about ten percent of people with spondylitis experienced inflammation of the jaw. This can be particularly debilitating causing difficulty in fully
opening the mouth to eat.

• Eyes-About 40% of people with AS have an eye problem called uveitis. It is a kind of eye inflammation that is painful and can blur your vision and make
you sensitive to bright light. If you have uveitis, your doctor might check for AS even if you do not have any other symptoms.

• Heart valve-Rarely, AS can enlarge your aorta, the largest artery in your body. This can change the shape of your aortic valve, allowing blood to leak back
into your heart. Your heart will not pump as well, which can leave you tired and short of breath.

• Spinal rigidity

• Paraspinal calcification

• Respiratory complication
 REFERENCE:
• Michael W. Smith MD (2020) Ankylosing Spondylitis Retrieved from: https://www.webmd.com/ankylosing-spondylitis/what-is-ankylosing-
spondylitis Accessed on: June 14, 2021.

• Mayo Clinic (2019) Ankylosing Spondylitis Retrieved from: https://www.mayoclinic.org/diseases-conditions/ankylosing-

spondylitis/diagnosis-treatment/drc-20354813 Accessed on: June 14, 2021.

• Shristi Shrestha (2016) Ankylosing Spondylitis Retrieved from: https://www.slideshare.net/shristishrestha14/ankylosis-spondylitis Accessed

on: June 14, 2021.

• Ananya Mandal (2019) Ankylosing Spondylitis Pathophysiology Retrieved from: https://www.news-medical.net/health/Ankylosing-

Spondylitis-Pathophysiology.aspx Accessed on: June 14, 2021.

• Michael H. Weisman (2010) Ankylosing Spondylitis Retrieved from: https://books.google.com.ph/books?id=S6eBHfkgsv0C&dq=spondylitis

Accessed on: June 16, 2021.

• Joachim S, Jurgen B., (2010) Ankylosing Spondylitis in Clinical Practice Retrieved from: https://books.google.com.ph/books?
id=Nq4wKaP4pc4C&dq=spondylitis Accessed on: June 16, 2021

• Brenda B. Spinggs, MD (2019) Understanding the types of Spondyliltis. Retrieved from: https://www.healthline.com/health/spondylitis-
types. Accessed on: June 16, 2021. 

• Booked Based

• Smith, T. (2000). The British Medical Association Complete Family Health Guide. Strand, London.: A Penguin Company.
Thank you!