Ankylosing Spondylitis

Ankylosing Spondylitis: Excerpt from The 5-Minute Pediatric Consult

Eric Hanson, MDRandy Q. Cron, MD, PhD

Ankylosing Spondylitis - BASICS

Ankylosing Spondylitis - description

An inflammatory arthritis that tends to be asymmetric peripherally and involve the insertion of tendons and ligaments and the sacroiliac joints and spine

Ankylosing Spondylitis - epidemiology

• Typically affects adolescent boys
• Much less common in blacks:
  • HLA-B27 occurs in 70–90% of patients, and is present in 8% of whites and 6% of blacks in the general population.

Ankylosing Spondylitis - prevalence

~1/10,000 white boys

Ankylosing Spondylitis - risk factors

Ankylosing Spondylitis - genetics

• HLA-B27 associated
• Usually a family history of a male relative with disease

Ankylosing Spondylitis - pathophysiology

Inflammatory synovitis of joints and calcification of the anterior and posterior longitudinal ligaments of the spine

Ankylosing Spondylitis - etiology

Idiopathic

Ankylosing Spondylitis - DIAGNOSIS

Ankylosing Spondylitis - signs & symptoms

• Inflammatory back pain (better with exercise, not relieved by rest) of insidious onset that has been present for at least 3 months.
• Inactivity stiffness resulting in gelling of peripheral joints and back

Ankylosing Spondylitis - history

• Pain
• Family history

Ankylosing Spondylitis - physical exam

• Sacroiliac tenderness:
  • Indicates site of inflammation
• Pain on direct palpation at insertion of Achilles tendon and plantar fascia at calcaneal insertion (location of enthusis):
  • Indicates site of inflammation

Ankylosing Spondylitis - tests

Schober test of lumbar spine flexibility:

• Mark 15-cm span at mid-lower back at level of iliac crest while patient is standing.
• Have patient flex back as far as possible.
• Remeasure span.
• Abnormal if <5 cm increase in span

Ankylosing Spondylitis - lab

CBC, erythrocyte sedimentation rate (ESR), HLA-B27, rheumatoid factor (RF), and antinuclear antibody (ANA) tests:

• ESR is occasionally not elevated.
• RF and ANA are typically negative.

Ankylosing Spondylitis - imaging

Sacroiliac views:

• Demonstrate evidence of pseudo-widening, erosions, and/or sclerosis, with fusion being a late finding. Because X-ray findings may take years to develop in the presence of disease, MRI is supplanting X-ray as the initial modality to assess SI involvement in some centers.

Ankylosing Spondylitis - differencial diagnosis

• Caution:
  • Overdiagnosis in HLA-B27–positive individuals in whom other causes for joint swelling should be considered
• Infection:
  • Reiter syndrome caused by enteric pathogens or Chlamydia species
  • Whipple disease
  • Intestinal-bypass–associated arthritis
  • Discitis
  • Pott disease
• Tumors:
  • Osteoid osteoma
• Trauma:
  • Traumatic injury causing lower back pain/spasm
  • Herniated disc
• Metabolic:
  • Ochronosis
• Congenital:
  • Kyphosis
• Immunologic:
  • Inflammatory bowel disease–associated arthropathy
  • Oligoarticular juvenile idiopathic arthritis
• Psychologic:
  • Feigning lower back pain/stiffness
• Miscellaneous:
  • Psoriasis-associated arthritis

Ankylosing Spondylitis - TREATMENT

Ankylosing Spondylitis - general measures

• Therapy may need to be lifelong.
• After initiation of therapy, should see some improvement in stiffness, synovitis, and range of motion over weeks to several months

Ankylosing Spondylitis - diet

• Food intake should be good with NSAIDs
• Ensure folate intake with methotrexate

Ankylosing Spondylitis - activity

As tolerated. In cases of severe/advanced disease, modify behaviors accordingly in consideration of reduced spine flexibility and subsequent risk of serious injury.

Ankylosing Spondylitis - special therapy

Ankylosing Spondylitis - phys therapy

• Physical therapy is an essential component of treatment.
• Must encourage range-of-motion exercises and avoid prolonged neck flexion.

Ankylosing Spondylitis - medication

• NSAIDs:
  • Naproxen
  • Indomethacin
  • Diclofenac
• Disease-modifying drugs:
  • Sulfasalazine
  • Methotrexate
  • Leflunomide
  • Tumor necrosis factor inhibitors, in particular, infliximab

Ankylosing Spondylitis - surgery

In advanced cases, total hip replacement, C-spine fusion, and/or spinal wedge osteotomy (the latter if posture is severely affected).

Ankylosing Spondylitis - FOLLOW UP

Ankylosing Spondylitis - prognosis

Poor if disease remains active for 10 years or more

Ankylosing Spondylitis - complications

• Acute anterior uveitis
• Aortic insufficiency
• Worsening stiffness
• Ankylosis with risk of vertebral subluxation, fracture, and nerve damage, including cauda equine syndrome
• Acute or chronic eye pain
• Chest pain or shortness of breath

Ankylosing Spondylitis - bibliography

1. Bukulmez H, Colbert RA. Juvenile spondyloarthropathies and related arthritis. Curr Opin Rheumatol. 2002;14:531–535.
2. Burgos-Vargas R. The juvenile-onset spondyloarthritides. Rheum Dis Clin North Amer. 2002;28:531–560.
3. Burgos-Vargas R, Rudwaleit M, Seiper J. The place of juvenile onset spondyloarthropathies in the Durban 1997 ILAR classification criteria of juvenile idiopathic arthritis. International League of Associations for Rheumatology. J Rheumatol. 2002;29:869–874.
4. Homeff G, Burgos-Vargas R. TNF-alpha antagonists for the treatment of juvenile-onset spondyloarthritides. Clin Exp Rheumatol. 2002;20[suppl 28]:S137–S142.
5. Sherry DD, Sapp LR. Enthesalgia in childhood: Site-specific tenderness in healthy subjects and in patients with seronegative enthesopathic arthropathy. J Rheumatol. 2003;30:1335–1340.
6. Tse SM, Laxer RM. Juvenile spondyloarthropathy. Curr Opin Rheumatol. 2003;15:374–379.
7. Tse SM, Laxer RM, Babyn PS, et al. Radiologic improvement of juvenile idiopathic arthritis-enthesitis-related arthritis following anti-tumor necrosis factor-alpha blockade with etanercept. J Rheumatol. 2006;33:1186–1188.

Ankylosing Spondylitis - CODES

Ankylosing Spondylitis - icd9

720.0 Ankylosing spondylitis and other inflammatory spondylopathies

Ankylosing Spondylitis - PATIENT TEACHING-MED

Need for lifelong therapy

Ankylosing Spondylitis - FAQ

• Q: Should HLA-B27 be checked routinely in boys with back pain?
• A: Detection of HLA-B27 alone should not precipitate an extensive workup because it is so common in the normal healthy population. However, the risk for developing a spondyloarthropathy is 16 times greater than in HLA-B27–negative individuals.
• Q: Can affected individuals play contact sports?
• A: This is probably not a good idea because as the spine fuses, the risk for fracture of the spine (especially the cervical spine) increases. However, children with milder forms of disease, such as enthesitis related arthritis, should not be discouraged.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Ankylosing Spondylitis

• Back to disease: Ankylosing Spondylitis: Introduction
• Next Book Extract About Ankylosing Spondylitis: Surveys relating to Ankylosing Spondylitis
• More Book Extracts: All Online Books for Ankylosing Spondylitis

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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