ankylosing spondylitis, its causes, clinical features, investigations, treatment

1. Ankylosing spondylitis
(MARIE STRUMPELL DISEASE)
By-kajal sansoya

2. What is AS?
AS is a chronic disease characterized by a
progressive inflammatory stiffening of the
joints, with a pre-dilection for the joints of the
axial skeleton, especially the SI joint.
This disease is common in young male adults.
M:F ratio is 10:1

5. Etiology
• Exact cause of AS is unknown.
• Genetic factor include HLA-B27 gene
• The incidence of HLA-B27 is less than 1% in
general population, it is present in more than
85% of patients with AS.

6. PATHOLOGY
• SI first affected followed by spine from lumbar
region upwards.
• The hips& knees and the manubriosternal
joints are also involved.
• Initially synovitis occurs, followed later by
cartilage destruction & bony erosion.
• After bony fusion occurs, the pain may
subside, leaving the spine permanently stiff.

7. CLINICAL FEATURES
• Classic presentation – the patient is young adult
15-30 years old male, presenting with a general
onset of pain& stiffness of the lower back.
• Initially stiffness may be noticed only after a
period of rest, & improves with movement.
• Pain may tends to be worse at night or early
morning, awakening the patient from sleep.
• Better only after walks or does some exercises.
There may be pain in the heel, pubic symphysis,
manubrium sterni & costo-sternal joints.

8. • In later stage, kyphotic defomity of spine &
deformity of the hips may be prominent
features.

9. UNUSUAL FEAURES OF AS
• Patient may occasionally present with
involvement of peripheral joints such as
shoulders, hips and knees. Smaller joints are
rarely involved sometimes, patient may
present with chronic inflammatory bowel
disease.

10. ON EXAMINATION
• It is found that the patient walks with a
straight stiff back patient may present with
diffuse kyphosis.
• Stiff spine- there may be loss of lumbar
lordosis. L-spine flexion may be limited.

11. INVOLMENT OF SI JOINT
• Following tests are positive in case of SI joint
involvement.
• Tenderness- localized to PSIS or deep in gluteal
region.
• SI compression- direct side-side cmpression of
pelvis may cause pain at the SI joint.
• GAENSLEN’S TEST- the hip& the knee joints of
the opposite side are flexed to fix the pelvis, &
the hip joint of the side under test is
hyperextended over the edge of table. This will
exert a rotational strain over the SI joint & give
rest to pain.

12. • SLR TEST- the patient is asked to lift the leg up
with the knee extended. This will cause pain at
the affected SI joint.
• Pump-handle test- with patient lying supine,
the examiner flexes his hips & knees
completely and forces the affected knee
across the chest, so as to bring it close to the
opposite shoulder. This will cause pain on
affected side.

13. INVESTIGATIONS
• Hazinees of the SI joint
• Irregular sub-chondral erosions in SI joint
• Sclerotic of articulating surfaces of SI joint
• Widening of SI joint space.
• Bony ankylosing of SI joint
• Calcification of SI joint ligament & sacro-
tuberous ligaments.

16. LUMBAR SPINE SHOWS
• Squarring of verttebrae
• Loss of lumbar lordosis.
• Bridging osteophytes
• Bamboo spine

18. OTHER INVESTIGATIONS
• ESR elavated
• Hb: mild anaemia
• HLA-B27 +

19. TREATMENT
• CONSERVATIVE TREATMENT
NSAID’S
Physiotherapy- TENS, ULTRASOUND, HOT
PACKS, STENGTHENING EXERCISES.
Radiotherapy
Yoga therapy
• Operative – spinal osteotomy, joint
replacement in case of involvement of hips &
knees.

20. THANK YOU
HAPPY READING