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
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:
- Trauma:
- Traumatic injury causing lower back pain/spasm
- Herniated disc
- Metabolic:
- Congenital:
- 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
- Bukulmez H, Colbert RA. Juvenile spondyloarthropathies and related arthritis. Curr Opin Rheumatol. 2002;14:531–535.
- Burgos-Vargas R. The juvenile-onset spondyloarthritides. Rheum Dis Clin North Amer. 2002;28:531–560.
- 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.
- Homeff G, Burgos-Vargas R. TNF-alpha antagonists for the treatment of juvenile-onset spondyloarthritides. Clin Exp Rheumatol. 2002;20[suppl 28]:S137–S142.
- 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.
- Tse SM, Laxer RM. Juvenile spondyloarthropathy. Curr Opin Rheumatol. 2003;15:374–379.
- 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
More Medical Textbooks Online about Ankylosing Spondylitis
Review other book chapters online related to Ankylosing Spondylitis:
Medical Books Excerpts
- NECK PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- NECK PAIN
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
- Neck pain
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Neck pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Neck Pain
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Neck pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Neck pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Neck pain
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- NECK PAIN
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
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
|
|
» Next page: Surveys relating to Ankylosing Spondylitis
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
