1. Ankylosing Spondylitis
DR NARESH SHETTY
M.S.Ramaiah Medical College & Hospital. Bangalore

2. Anklosing Spondylitis
Known also as
Bechterew’s Disease
Bechterew’s Syndrome
Marie Strumpell Disease

3. Etiology Chronic Inflammatory disease of unknown etiology.
Occurs in 6 per 10,000 population
Male predominant ( 7:1)
Autosomal inheritance, Incidence in relatives of affected subject is times that of general population

4. Etiology 90% of patients have an association with HLA B27 antigen
Alternately presence of this antigen is associated with increased susceptibility to AS
Lower frequency in Blacks

5. The Cause of Ankylosing Spondylitis is unknown,
Causes of AS
The Cause of Ankylosing Spondylitis is unknown,
but a tendency to develop the condition may be Genetic

6. Synovitis of Sacroiliac and vertebral facet joints
Pathology:
Synovitis of Sacroiliac and vertebral facet joints
Destruction of articular cartilage and periarticular bone
Leads to bony ankylosis
Costovertebral involvement can lead to diminished respiratory excursion

7. Pathology
Affects intervertebral discs, sacroiliac ligaments, symphysis pubis, manubrium sterni and bony insertion of large tendons
Ant. Longitudinal ligament are especially affected
Leads to bony bridging – bamboo spine

8. Clinical Features: Starts insidiously
Teenager or young adult complains of low backache & stiffness or SI joint pain
Symptoms are worse in the morning and after inactivity
General fatigue, weight loss
Involvement of hips, knees and shoulder
There is symmetric involvement of large joints with changes in the hands which are similar but less severe than RA.

9. Spine - Clinical Findings:
Loss of lumbar lordosis
Later diminished spinal movement, increased thoracic kyphosis,
loss of cervical extension
Cervico-thoracic kyphosis is common
Fused spine involvement of the appendicular skeleton (i.e. the limbs) is eventually seen in about 50% of the patients

10. Other Clinical findings
May have diminished chest expansion due to involvement of costochondral & costovertebral joints
B/L sacra-iliac joint involvement
May involve Hip & Knee Joints
Disease is slowly progressive over a few years with SI fusion, hip & Knee involvement and ankylosis of spine

11. Associated features Extra-articular symptoms
Uveitis occurs in 25-40%. Need to be treated early or may cause visual impairment.
Inflammatory bowel disease and/or psoriasis may be present
Osteoporosis is a common feature
Cardiac -aortic incompetence, cardiac conduction anomalies
Chest Progressive, B/l apical cavitations/fibroses
Asymptomatic GI inflammation present in 25-49% of Ankylosing Spondylitis

12. Rome, 1961* Clinical Criteria
1. Low back pain and stiffness for more than 3 months, not relieved by rest
2. Pain and stiffness in the thoracic region
3. Limited motion in the lumbar spine
4. Limited chest expansion
5. History or of iritis or its sequelae
6.Radiologic Criterion - bilateral sacroiliac changes characteristic of Ankylosing Spondylitis

13. Modified New York Classification -1984
Clinical Criteria
Low back pain (3months) improved with exercise and not improved with rest.
Limited movement of lumbar spine
Chest expansion decreased < 2.5 cm
Radiological criteria; Sacroiliitis grade> 2 bilateral or grade > 4 unilaterally
Grade 0- Normal,
Grade 1- suspicious,
Grade 2- sclerosis with little erosion
Grade 3- severe erosions
Grade 4 – Complete Ankylosis
Definite AS is present if radiological criteria is associated with at least one clinical criteria S

14. To consider Ankylosing Spondyltis if:
Inflammatory spinal pain :
Onset before age 40   
Insidious onset   
Persistence for at least 3 months   
Morning stiffness that improves with exercise
Chest pain
Alternate buttock pain
Acute anterior uveitis
Other joints pain

15. Progressive Disability
• Functional –
Important predictors
age, social support,
lack of back exercise and smoking
– Ward et al Arthritis Rheum 2002
Work
AS patients 3X more likely than the normal population to leave the work force
– Boonen et al Ann Rheum Dis 2001

17. Diagnosis

18. Laboratory tests Lab investigations
Raised ESR/CRP in 70% of AS, but no clear correlation with disease activity.
Secondary anaemia
Urinary 17-ketosteroids levels are increased
HLA-B27 test: positive in most cases
Synovial fluid : increase of mononuclear leukocytes
( in RA increase in polymorphonuclear leukocytes)

19. HLA-B27: DISEASE ASSOCIATIONS
Ankylosing Spondylitis >90%
Inflammatory Bowel Disease 50%
Reiter's Syndrome 80 %
Reactive Arthritis 85%
Psoriatic Arthritis
With Spondylitis 50%
With Peripheral Arthritis 15%
Whipple's Disease 30%

20. Radiological findings-SI joint
• Initial changes are a bilateral sacroiliitis
The stages of sacroiliitis are as follows;
Initially affects lower and middle thirds of SI joint with the iliac side more severely affected
Then sacral— periarticular osteoporosis, erosions and subchondral sclerosis
Further erosion leads to widening of joints
Progresses to bony ankylosis

21. Radiological findings-Spine
Earliest vertebral change is flattening of the normal anterior concavity of the vertebral body (‘squaring’)
Disease first affects lumbar spine and then ascends to thoracic spine affecting apophyseal joints,costotransverse joints, costovertebral joints and posterior ligaments.

22. ‘Bamboo Spine’ – bridging at several levels
Osteoporosis
Hyperkyphosis of the thoracic spine

23. X-RAY Cervical Spine
Osteoporosis is a feature of longstanding disease. Because of the immobility and fragility of the spine.
Cervical lordosis lost
Ant. Bony bridging
Cervical fractures following minor trauma are quite common. Unstable because they involve all three columns
Atlantoaxial instability

24. CT more sensitive than X-ray in detecting early changes
Radiology
CT more sensitive than X-ray in detecting early changes
MRI – useful to detect disease activity
DEXA is useful for diagnosis of Osteoporosis
Reliability of these Tests are still unclear

25. MRI T1-Aweighted spin- echo image.
Erosions of vertebral-body endplates surrounded by low- signal-intensity bone-marrow oedema.

26. Hip Joints Protrusio and hip flexion contractures are common.
Hip ankylosis
Heterotropic ossification may follow THR;
Heterotrophic ossification occurs in % of hip replacements and is more common with trochanteric osteotomy
To avoid heterotropic ossification consider insertion of a cemented acetabular component followed by 750 rads around the component

27. Treatment & Medications are available to reduce Symptoms & Pain
Management
No Cure is known for AS
Treatment & Medications are available to reduce Symptoms & Pain

28. Management
Combination of non-pharmocologic and pharmocological therapy depending on disease stage and symptoms
Patient education essential- life long programme of exercise, use of individual, and group therapy as well as self-help groups
Functional disability in AS progresses more rapidly in smokers and less so in those with better social support and regular exercises

29. Three major Types 1.Anti-inflammatory 2.DMARDs 3. TNF Blockers
Medications
Three major Types
1.Anti-inflammatory
2.DMARDs
3. TNF Blockers

30. Anti-Inflammatory drugs
Control pain and counteract soft-tissue stiffness
Reduces inflammation
Includes NSAIDs such as Aspirin, ibuprofen, Indomethacin,
naproxen,
COX-2 inhibitors
Cortisone effective in relieving pain & inflammation

31. Has their own side effects
DMARD’S
DMARD’s Such as Cyclosporines, methotrexate, Sulfasalazine, steriods
Used to reduce immune system response through immunosupression
Has their own side effects

32. BIOLOGICS TNF-a blockers • Infliximab
TNF blockers have shown to be the most promising treatment , slowing the progress of AS in majority of cases
They also have been effective in treating arthritis of joint but also the spinal arthritis associated with AS
TNF-a blockers
• Infliximab
– IV 5mg/kg induction and 8 weekly intervals
• Etanercept
– SC 25mg/twice weekly
• Humira

33. Surgical Management Spinal correction for deformities
Spinal osteotomies; not easy
Problems
Positioning of patient
Anaesthesia difficulty
Injury to Cord
Injury to major vessel like Aorta & Vena cava
Cervical spine injury
Paralytic Ileus

34. Surgical Management Arthroplasty Surgery
THR ; Good pain relief, improves posture, improvement in range of movement
Problems in surgery; Dislocation may be difficult, osteotomy of neck may be needed and head removed piecemeal.
Edges of acetabulum need to be identified
Heterotrophic ossification 20-40%
TKR

35. Rehabilitation Exercises Respiratory exercises Heat Therapy
Avoid excessive physical activity during acute phase

36. Differential Diagnosis
Other Spondyloarthropathies
Lumbar strain
DISH(Forestier’s disease)-
Degenerative joint disease
Osteitis condensans illi(asymptomatic sclerosis of subchondral bone in parous women-only illiac area is involved)

37. Complications Spinal fractures
Spine rigid + osteoporotic: Commonest site for fracture C5-7
Spinal Cord Compression , Atlanto-axial subluxation; Posterior Longitudinal Ligament Ossification
Hyperkyphosis -may be difficult to lift head enough to walk and see
Typical spinal ankylosis occurs after 10yrs
Osteoporoses more likely in severe advanced, long- standing

38. Prognosis
Depends on stage at diagnoses & Initiation of effective therapy
Worse in males
Worse in patients poorly compliant with exercises
Patients with peripheral arthritis take more sick leaves than those with axial involvement
Worse for patients exposed to cold temperatures
Worse in smokers, low socio-economic class

39. Thank You