Ankylosing spondylitis
Ankylosing spondylitis: Excerpt from Handbook of Diseases
A chronic, usually progressive inflammatory disease, ankylosing spondylitis primarily affects the sacroiliac, apophyseal, and costovertebral joints and adjacent soft tissue. Generally, the disease begins in the sacroiliac joints and gradually progresses to the lumbar, thoracic, and cervical regions of the spine. Deterioration of bone and cartilage can lead to fibrous tissue formation and eventual fusion of the spine or peripheral joints. Prevalence of ankylosing spondylitis among whites is estimated at 0.5% to 1.0%, affecting five times as many males as females. (See Ankylosing spondylitis in women.)
Causes
Recent evidence strongly suggests a familial tendency in ankylosing spondylitis. The presence of histocompatibility antigen HLA-B27 (positive in over 90% of patients with this disease) and circulating immune complexes suggests immunologic activity. A possible link to underlying infection is being investigated.
Signs and symptoms
The first indication is intermittent low back pain that’s usually most severe in the morning or after a period of inactivity. Other signs and symptoms depend on the disease stage and include:
stiffness and limited motion of the lumbar spine
CLINICAL TIP: To test for lumbar mobility, perform the Schober test: With the patient standing erect, make a pen mark over the lumbar spine at L5 (even with the dimples of Venus). Measure 3.9 "(10 cm) upward along the spine and make a second mark. Then ask the patient to bend forward as far as he can while keeping his knees straight. Measure the distance between the two marks while the patient is flexed. In normal lumbar mobility, the distance between the marks should increase by at least 5.85"(15 cm).
pain and limited expansion of the chest due to involvement of the costovertebral joints
peripheral arthritis involving shoulders, hips, and knees
kyphosis in advanced stages, caused by chronic stooping to relieve symptoms, and hip deformity and associated limited range of motion (ROM)
tenderness over the site of inflammation
pain or tenderness at tendon insertion sites (enthesitis), especially the Achilles’or patellar tendon
mild fatigue, fever, anorexia, or loss of weight; unilateral acute anterior uveitis; aortic insufficiency and cardiomegaly; upper lobe pulmonary fibrosis (mimics tuberculosis)
severe neurologic complications, such as cauda equina syndrome and paralysis, which can occur secondary to fracture of a rigid cervical spine or C1-C2 subluxation.
These signs and symptoms progress unpredictably, and the disease can go into remission, exacerbation, or arrest at any stage.
Diagnosis
Typical symptoms, a family history, and the presence of HLA-B27 strongly suggest ankylosing spondylitis. However, confirmation requires these characteristic X-ray findings:
blurring of the bony margins of joints in the early stage
bilateral sacroiliac involvement
patchy sclerosis with superficial bony erosions
eventual squaring of vertebral bodies
“bamboo spine” with complete ankylosis.
Erythrocyte sedimentation rate and alkaline phosphatase and creatine kinase levels may be slightly elevated. A normal test result for rheumatoid factor helps rule out rheumatoid arthritis, which produces similar symptoms.
Treatment
Because ankylosing spondylitis’ progression can’t be stopped, treatment aims to delay further deformity by good posture, stretching and deep-breathing exercises and, in some patients, braces and lightweight supports. Patients must understand that a long-term daily exercise program is essential to delaying loss of function. An anti-inflammatory analgesic (such as indomethacin and sulfasalazine) is given to control pain and inflammation.
Severe hip involvement usually necessitates surgical hip replacement. Severe spinal involvement may require a spinal wedge osteotomy to separate and reposition the vertebrae. This surgery is performed only on selected patients because of the risk of spinal cord damage and the long convalescence involved.
Special considerations
Ankylosing spondylitis can be an extremely painful and crippling disease, so the caregiver’s main responsibility is to promote the patient’s comfort while preserving as much mobility as possible. Keep in mind that his limited ROM makes simple tasks difficult. Offer support and reassurance.
Apply local heat and provide massage to relieve pain. Assess mobility and degree of discomfort frequently.
Teach and assist with daily exercises as needed to help the patient maintain strength and function. Stress the importance of maintaining good posture.
If treatment includes surgery, provide postoperative care.
To minimize deformities, advise the patient to:
avoid any physical activity that places undue stress on the back, such as lifting heavy objects
stand upright; sit upright in a high, straight chair; and avoid leaning over a desk
sleep in a prone position on a hard mattress and avoid using pillows under the neck or knees
avoid prolonged walking, standing, sitting, and driving
perform regular stretching and deep-breathing exercises and swim regularly, if possible
have height measured every 3 to 4 months to detect any tendency toward kyphosis
seek vocational counseling if work requires standing or prolonged sitting at a desk
contact the local Arthritis Foundation chapter for a support group. Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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» Next page: Juvenile rheumatoid arthritis (Handbook of Diseases)
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