2. Essentials of Diagnosis
1. Inflammatory back pain in young adults.
2. Radiographic demonstration of sacroiliitis.
3. Reductions in spinal mobility, particularly
lumbar flexion.
4. Association with anterior uveitis.
5. Increased relative risk conferred by
inheritance of HLA-B27.
6. Positive family history.
3.
4. Criteria for diagnosing ankylosing spondylitis
(Rome, 1961)
Clinical criteria
1. Low back pain and stiffness for more than 3 months
which is 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 evidence of iritis or its sequelae
Radiological criterion
6. X ray showing bilateral sacroiliac changes characteristic of
ankylosing spondylitis (this would exclude bilateral
osteoarthrosis of the sacroiliac joints)
5. Clinical criteria for ankylosing spondylitis
(New York, 1966)
(A) Diagnosis
1. LIMITATION OF MOTION OF THE LUMBAR
SPINE in all THREE PLANES-anterior
flexion,lateral flexion, and extension
2. History or the presence of PAIN at the dorso-
lumbar
junction or in the lumbar spine
3. LIMITATION OF CHEST EXPANSION to 1 in.
(2 5 cm.) or less, measured at the level of the
fourth
intercostal space
6. (B) Grading
DEFINITE AS:
1. Grade 3-4 bilateral sacroiliitis with at least one clinical
criterion.
2. Grade 3-4 unilateral or Grade 2 bilateral sacroiliitis
with Clinical criterion I (limitation of back movement
in all three planes) or with both Clinical criteria 2 and3
(back pain and limitation of chest expansion)
PROBABLE AS:
Grade 3-4 bilateral sacroiliitis with no clinical
criteria
7.
8.
9. SYMPTOMS AND SIGNS
The typical presenting symptom in ankylosing
spondylitis is the insidious onset of
inflammatory low back pain due to sacroiliitis.
The pain is dull and located in the lower
lumbar regions.
Some describe a deep alternating buttock
pain.
10. The pain worsens with rest, improves with
activity, and is accompanied by morning
stiffness that lasts 30 minutes or longer.
Patients often describe awakening from sleep
and pacing in order to relieve nocturnal pain—
a rare complaint in patients with mechanical
back pain.
11. Involvement of the spine (spondylitis) is the
major source of morbidity.
Ankylosing spondylitis can involve the lumbar,
thoracic, and cervical spine.
Over time the accumulation of pathologic
changes can lead to loss of spinal mobility,
particularly of the lumbar spine.
12. Clinical tools for the measurement of spinal mobility
Schober test
1. Two marks are made on the
patient's back: one at the
level of the sacral dimples
(approximately at the fifth
lumbar spinous process)
and the other 10 cm above.
2. The patient then bends
forward as far as possible
(ie, attempts to touch toes
with knees extended), and
the distance between the
two marks is again
measured.
3. In normal individuals, the
overlying skin will stretch to
15 cm; values less than this
can be indicative of reduced
lumbar mobility.
13. The modified Schober test
1. In this test marks are made 5 cm below and
10 cm above the sacral dimples;
2. The distance between these marks should
increase from 15 cm to at least 20 cm with
lumbar flexion.
3. Reductions in lumbar lateral bending and
rotation are also commonly observed.
14. Lateral lumbar flexion.
1. The patient bends
laterally to push the
middle finger down
the rule without
flexing forward or
bending the knees.
2. The difference
between start and
endpoint is recorded
and the mean
calculated; normal:
>10 cm.
15. Cervical rotation.
The mean of the left
and right cervical
rotation is recorded;
normal:>70
degrees.
16. Occiput to wall distance.
Patient stands, with
heels and buttocks
against the wall; the
head is placed back
as
far as possible,
keeping the chin
horizontal; normal =
0.
17. Tragus to wall distance.
1. Patient stands,
with heels and
buttocks against
the wall.
2. The head is placed
back as far as
possible, keeping
the chin
horizontal;.
3. Normal: <15 cm.
18. Intermalleolar distance.
Patient stands with
legs separated as
far as possible.
The distance
between the medial
malleoli is
measured.
Normal: >100 cm.
19. With advancing disease, as the spine fuses in
flexion.
This leads to loss of lumbar lordosis,
exaggeration of thoracic kyphosis, an inability
to extend the neck, and compensatory hip
flexion deformities .
The extent of spondylitis varies greatly, from
minimal to complete fusion of the cervical,
thoracic, and lumbar spine.
20. Involvement of the costovertebral and
costochondral joints commonly leads to
impaired chest expansion (<5 cm difference
between full inspiration and full expiration
when measured at the fourth intercostal
space)
Occasionally this produces pain with deep
breathing, coughing, or sneezing
21. Peripheral Joint
Manifestations
Monarticular or asymmetric oligoarticular.
Develops in approximately one-third of
patients.
Most often affects large joints of the lower
extremities.
Hip disease develops in approximately 50% of
patients and is a major source of morbidity.
22. Anteroposterior view of the pelvis in a patient with long-standing
AS. There is generalized osteoporosis, and there is also ankylosis of the
sacroiliac joints, pubic symphysis, and both hips. A normal rounded contour of
the femoral head is seen through the bone ankylosis .
23. Enthesitis
Involvement of insertion sites around the
pelvis (the ischial tuberosities, iliac crests, and
greater trochanters) is common and appears
on radiographs as bony "whiskering" at these
sites of attachment.
Achilles tendinitis and enthesitis at the site of
the insertion of the plantar fascia onto the
calcaneus can cause unilateral or bilateral
heel pain, although not as often as in reactive
arthritis.
24. Ocular
The most common extra-articular
manifestation of ankylosing spondylitis is acute
anterior uveitis.
It is heralded by the acute or subacute onset of
unilateral eye pain, photophobia, blurred
vision, and increased lacrimation.
Anterior uveitis can precede the onset of
ankylosing spondylitis by several years,.
Anterior uveitis is strongly associated with
HLA-B27.
25. Osteoporosis
Spinal immobility and persistent inflammation to
contribute to the increased prevalence of
osteoporosis in ankylosing spondylitis and other
spondyloarthropathies.
The formation of syndesmophytes in these
diseases creates a unique problem in evaluation
of bone mineral density.
For example, in an ankylosed spine with
paravertebral calcification, anteroposterior
measurement of bone density by dual energy x-
ray absorptiometry can lead to spuriously
increased values for bone mineral density of the
spine.
26. Other Organs
Ascending aortitis, aortic regurgitation,
conduction abnormalities, and myocardial
disease--- 10% of patients with ankylosing
spondylitis.
Secondary amyloidosis.
Retroperitoneal fibrosis.
Apical fibrobullous disease --radiographically
resembles reactivation of tuberculosis
27. LABORATORY FINDINGS
Routine Studies
Mild, normocytic, normochromic anemia,
reflective of chronic disease.
About half of patients with active disease will
have elevations of the erythrocyte
sedimentation rate or C-reactive protein.
No association with rheumatoid factor,
antibodies to cyclic citrullinated peptides, or
antinuclear antibodies.
28. HLA-B27
Interpretation of the HLA-B27 test.
1. Inheritance of HLA-B27 is not sufficient to
produce ankylosing spondylitis.
2. Inheritance of HLA-B27 is not absolutely
essential for the development of ankylosing
spondylitis.
3. Ethnicity influences the prevalence of HLA-
B27 in disease populations.
29. HLA-B27 is present in 8% of the general white
population, and 90% of whites with ankylosing
spondylitis are HLA-B27–positive.
In contrast, HLA-B27 is present in 2% of the
African American population and only 50% of
African Americans with ankylosing spondylitis
are HLA-B27–positive
30. IMAGING STUDIES
Sacroiliac Joints
The most distinctive finding is inflammation
of both sacroiliac joints.
A standard anteroposterior radiograph of the
pelvis is commonly used to evaluate these S-
shaped joints.
A superior image is achieved with the
Ferguson view, in which the radiograph is
taken at a 15-degree angle to the prone pelvis.
31. Anteroposterior view of sacroiliac Anteroposterior Ferguson view of the sacroiliac
joints in a patient with AS.
joint. The white cortical line is The area of the sacroiliac joint inferior to the
intact on the sacral side. It is ill arrows is imaged by the Ferguson view and not
by an anteroposterior view.
defined on the iliac side (arrows). Note the bilateral, symmetric involvement with
erosions and eburnation.
33. The first radiographic finding is the
appearance of iliac erosions.
With time erosions become more prominent
and produce "pseudowidening" of the
sacroiliac joint.
Progressive inflammation leads to fusion, and
the end result can be complete obliteration of
the sacroiliac joint by bone and fibrous tissue.
34. Anteroposterior Ferguson view of the sacroiliac joints in a patient
with AS. There is bilateral, symmetric involvement with succinct
erosions
(arrows).
35. Anteroposterior view of the sacroiliac joints in long-standing AS
shows total ankylosis. Ossification of the ligaments connecting the posterior
superior aspect of the sacroiliac joints is evident (arrows).
36. The pattern of sacroiliac joint involvement is
bilaterally symmetric in ankylosing spondylitis
and enteropathic arthritis, in contrast to the
unilateral changes observed in early psoriatic
and reactive arthritis.
37. The method that is most sensitive and specific
for the diagnosis of sacroiliitis is Magnetic
Resonance Imaging with gadolinium- DPTA or
fat suppression.
In clinical practice, a reasonable initial
evaluation of patients with symptoms of
inflammatory back pain is to obtain a plain
radiograph of the pelvis.
If this study fails to demonstrate sacroiliitis,
then magnetic resonance imaging should be
considered, particularly if the patient is HLA-
38. MR image of the sacroiliac joints in a patient with undifferentiated
spondyloarthropathy. Axial T1-weighted image with fat suppression after
intravenous administration of Gd-DTPA demonstrates increased signal intensity
in the subchondral bone marrow within the iliac and sacral sides of the right
joint and early erosions of the left joint .
39. Spine
Romanus lesions : Radiographic
appearance of vertebral "shiny corners.―
These are a reaction to inflammation at the
site where the annulus fibrosus of the disks
inserts onto the vertebral bodies.
With progressive erosions and formation of
new periosteal bone, the lumbar vertebral
bodies become "squared off" in the lateral
view.
40. Lateral view of the lumbosacral spine showing shiny corners
(arrowheads), squaring of the vertebral bodies, and early syndesmophyte
formation (arrows) in a patient with AS.
41. Syndesmophytes
Bony bridges between vertebral bodies due to
gradual ossification of the edges of the
annulus fibrosus.
The vertical orientation of syndesmophytes
and preservation of the disk space distinguish
these from osteophytes associated with
degenerative disease of the spine.
42. Lateral view of the lumbosacral spine showing syndesmophytes of
AS, giving it a bamboo appearance
43. Ankylosing spondylitis and enteropathic
arthritis exhibit symmetric delicate-appearing
syndesmophytes that are marginal,(
completely vertical in their alignment) and
arise from the margins of the vertebral body.
Psoriatic arthritis and Reactive arthritis
typically have more bulky, asymmetric bony
growths that tend to initially protrude laterally
before progressing vertically (nonmarginal
syndesmophytes).
44. Peripheral Joints
Radiographic changes in the peripheral joints
mainly result from disease of the synovium or
entheses.
Hip involvement can produce symmetric
narrowing of the joint space.
Enthesitis can result in a faint periosteal
reaction at bony prominences, such as the
greater trochanters, calcaneus, and malleoli.
