Ankylosing Spondylitis Visually Explained — Transcript

Ankylosing spondylitis is a chronic inflammatory spine disease causing fusion and stiffness, explained with key features, diagnosis, and management.

Key Takeaways

Ankylosing spondylitis causes chronic inflammation leading to spinal fusion and stiffness.
Strong genetic association with HLA-B27 and primarily affects young men.
Diagnosis relies on clinical features, physical tests, characteristic x-ray findings, and selective HLA-B27 testing.
Management combines lifestyle interventions and pharmacological treatments, mainly NSAIDs.
Extra-articular features like acute anterior uveitis require urgent attention.

Summary

Ankylosing spondylitis is a chronic inflammatory disease of the axial skeleton leading to spinal fusion and rigidity.
It belongs to the group of seronegative spondyloarthropathies known as the 'pear diseases' along with psoriatic arthritis, enteric arthritis, and reactive arthritis.
Strongly associated with the HLA-B27 gene on chromosome 6, which encodes an MHC class 1 protein involved in immune response.
Typically affects men under 40 with symptoms lasting more than 3-4 months, starting at the sacroiliac joints and progressing along the spine.
Hallmark features include enthesitis, morning stiffness, night pain improved by exercise, and extra-articular manifestations like acute anterior uveitis.
Physical exams include the FABER test and Mennel sign to assess sacroiliac joint involvement.
Pelvic x-rays reveal characteristic signs such as the dagger sign, syndesmophytes, and bamboo spine appearance.
HLA-B27 testing can support diagnosis but is not definitive and should be reserved for classic cases with normal radiographs.
Management includes lifestyle changes like smoking cessation and regular exercise, NSAIDs as first-line pharmacological treatment, corticosteroid injections for enthesitis, and DMARDs for refractory cases.
A mnemonic for ankylosing spondylitis is the 'disease of four': four seronegative spondyloarthropathies, affects men under 40, symptoms last over four months, and four assessment methods (FABER, Mennel, x-ray, HLA-B27).

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Ankylosing spondylitis is a chronic inflammatory disease of the axial skeleton that leads to the fusion and rigidity of the spine. It's described as a seronegative spondyloarthropathy, which is a group of four conditions with overlapping clinical manifestations. I remember them as the pear diseases.

Speaker A

They include psoriatic arthritis, enteric arthritis, ankylosing spondylitis, and reactive arthritis. They are seronegative because in the blood or serum there is a negative rheumatoid factor and are spondyloarthropathies because they all cause arthropathy or joint disease in the vertebral column. Before we continue,

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don't forget to hit that notification bell and subscribe. Let's discuss its etiology. All the pear diseases are strongly associated with the gene HLA-B27 on chromosome 6.

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HLA stands for human leukocyte antigen, which is a complex of genes that encodes for major histocompatibility proteins or MHC proteins. We have two main classes of these molecules, and HLA-B27 encodes for a specific type of MHC class 1 protein.

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And although we're not entirely sure why, this is thought to be the cause of these autoimmunities. In general, MHC class 1 is expressed on all nucleated cells and acts to present intracellular antigens like viruses to cytotoxic T cells.

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If they're infected or if something is in the cell that shouldn't be there, these cytotoxic T cells can then induce apoptosis. Let's focus on the presentation of ankylosing spondylitis. It follows a chronic relapsing and remitting course that typically affects

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men under 40 years old with symptoms that last for more than three or four months. It's important to consider articular and extra-articular features. It usually affects the sacroiliac joints first and then progresses to other areas of the spine. This causes morning

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stiffness and night pain, which is improved by exercise. People often forget that one of its hallmark features is enthesitis, which is the inflammation at the site of tendons and ligament attachment to bone. For example, it can cause Achilles

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tendonitis. Following inflammation and ossification, the spine progressively stiffens, leading to an abnormal posture or kyphosis. This is an exaggerated forward rounding of the back. If the costovertebral joints are involved, it can lead to reduced chest expansion.

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The most common extra-articular feature of ankylosing spondylitis is acute anterior uveitis, which is experienced by up to 30 percent of patients at some point. Conjunctival injection around the rim of the iris is a characteristic feature. This requires an urgent referral to an

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ophthalmologist. Other extra-articular manifestations can include constitutional symptoms like weight loss and aortitis, which can cause aortic insufficiency. Other than a good history, one physical examination to perform is the FABER test. This is when pain in the sacroiliac

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joint occurs on flexion, abduction, and external rotation. Another is called Mennel sign. This is positive when there's tenderness to palpation of the sacroiliac joint when it is displaced. The most important initial investigation is an anterior-posterior pelvic x-ray.

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One classic feature to look for is the dagger sign, which is a single central radiodense line caused by the ossification of the supraspinous and interspinous ligaments secondary to enthesitis. Another feature is the formation of syndesmophytes, which are paravertebral

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ossifications running parallel to the spine. This, along with the squaring of vertebral bodies, gives the impression of a bamboo spine, which is a patho-mnemonic radiographic feature only seen in ankylosing spondylitis. Finally, another important investigation to consider is testing for HLA-B27

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itself, although it's not a diagnostic test and should not be tested in all patients with back pain. It might be helpful in patients with a classic presentation but normal radiographs. Management should include serious lifestyle interventions and pharmacological treatment if necessary.

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One consequential change patients can make to improve prognosis is smoking cessation. This is because smoking is associated with greater disease activity. Regular exercise is not only important for improving strength and mobility, but it's also good for our patients' mental

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health too. Pharmacologically, NSAIDs are a cornerstone of the management of ankylosing spondylitis. Corticosteroid injections have a much more limited role but still may be beneficial for enthesitis. Finally, disease-modifying anti-rheumatic drugs can be considered in patients not responsive to the above.

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One good way to remember some of these features is that ankylosing spondylitis is the disease of four. It is one of four seronegative spondyloarthritis or pear diseases. It affects men under 40.

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Its symptoms last more than four months. Finally, it can be assessed with four things: the FABER test, Mennel sign, a pelvic x-ray, and HLA-B27. Thank you for watching Townsend Teaching. Don't forget to hit that alarm button, like, comment, and subscribe.

Topics:Ankylosing spondylitisseronegative spondyloarthropathyHLA-B27axial skeleton inflammationbamboo spineenthesitisFABER testMennel signNSAIDsautoimmune arthritis

Frequently Asked Questions

What is ankylosing spondylitis and who does it commonly affect?

Ankylosing spondylitis is a chronic inflammatory disease of the axial skeleton causing spinal fusion and stiffness. It typically affects men under 40 years old with symptoms lasting more than three to four months.

What are the key diagnostic features of ankylosing spondylitis?

Key diagnostic features include chronic back pain with morning stiffness, positive FABER and Mennel tests, characteristic pelvic x-ray findings such as the dagger sign and bamboo spine, and HLA-B27 gene association.

How is ankylosing spondylitis managed?

Management includes lifestyle changes like smoking cessation and regular exercise, pharmacological treatment primarily with NSAIDs, corticosteroid injections for enthesitis, and disease-modifying anti-rheumatic drugs for resistant cases.

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