Ankylosing spondylitis
Ankylosing spondylitis: Excerpt from Professional Guide to Diseases (Eighth Edition)
A chronic, usually progressive inflammatory disease, ankylosing spondylitis primarily affects the sacroiliac, apophyseal, and costovertebral joints, along with adjacent soft tissue. The disease (also known as rheumatoid spondylitis and Marie-Strümpell disease) usually begins in the sacroiliac joints and gradually progresses to the spine’s lumbar, thoracic, and cervical regions. Deterioration of bone and cartilage can lead to fibrous tissue formation with eventual fusion of the spine or peripheral joints.
Ankylosing spondylitis may be equally prevalent in both sexes. Progressive disease is well recognized in men, but the diagnosis is commonly overlooked or missed in females, who tend to have more peripheral joint involvement.
Causes and incidence
Evidence strongly suggests a familial tendency in ankylosing spondylitis. The presence of human leukocyte antigen (HLA)-B27 (positive in more than 90% of patients with this disease) and circulating immune complexes suggests immunologic activity.
One out of 10,000 people has ankylosing spondylitis. It affects more males than females and usually emerges between ages 20 and 40, although it may develop in children younger than age 10.
Signs and symptoms
The first indication of ankylosing spondylitis 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 may include:
❑ hip deformity and associated limited range of motion
❑ kyphosis in advanced stages, caused by chronic stooping to relieve symptoms
❑ mild fatigue, fever, anorexia, or weight loss; occasional iritis; aortic insufficiency and cardiomegaly; and upper lobe pulmonary fibrosis (mimics tuberculosis)
❑ pain and limited expansion of the chest due to involvement of the costovertebral joints
❑ peripheral arthritis involving shoulders, hips, and knees
❑ stiffness and limited motion of the lumbar spine
❑ tenderness over the inflammation site.
These signs and symptoms progress unpredictably, and the disease can go into remission, exacerbation, or arrest at any stage.
Diagnosis
Typical symptoms, family history, and the presence of HLA-B27 strongly suggest ankylosing spondylitis.
CONFIRMING DIAGNOSIS 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 serum immunoglobulin A levels may be elevated. A negative rheumatoid factor helps rule out rheumatoid arthritis, which produces similar symptoms.
Treatment
No treatment reliably stops progression of this disease, so management aims to delay further deformity through good posture, stretching and deep-breathing exercises and, in some patients, braces and lightweight supports. Anti-inflammatory analgesics, such as aspirin, indomethacin, sulfasalazine, and sulindac, control pain and inflammation.
Tumor necrosis factor inhibitors have been shown to improve symptoms. Corticosteroid therapy or medication to suppress the immune system may be prescribed to control various symptoms. Cytotoxic drugs that block cell growth have been used in patients who don’t respond well to corticosteroids or those who are dependent on high doses of corticosteroids.
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 your main responsibility is to promote the patient’s comfort. When dealing with such a patient, keep in mind that limited range of motion makes simple tasks difficult. Offer support and reassurance.
❑ Administer medications as ordered. 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 maintain strength and function. Stress the importance of maintaining good posture.
❑ If treatment includes surgery, provide good postoperative nursing care. Because ankylosing spondylitis is a chronic, progressively crippling condition, a comprehensive treatment plan should also reflect counsel from a social worker, visiting nurse, and dietitian.
❑ 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; to sit upright in a high, straight chair; and to avoid leaning over a desk
– sleep in a prone position on a hard mattress and to avoid using pillows under neck or knees
– avoid prolonged walking, standing, sitting, or driving
– perform regular stretching and deep-breathing exercises and to 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.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Juvenile rheumatoid arthritis (Professional Guide to Diseases (Eighth Edition))
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