Join us for an enlightening seminar delving into the intricate world of Ankylosing Spondylitis (AS). This event aims to provide a deep understanding of AS, a chronic inflammatory arthritis primarily affecting the spine and pelvis.
Seminar Highlights:
Introduction to Ankylosing Spondylitis:
Definition, prevalence, and demographic insights.
Clinical Features and Diagnosis:
Recognizing early symptoms and the diagnostic journey.
The role of imaging and laboratory tests.
Understanding the Pathophysiology:
In-depth exploration of the immune system's role.
Genetic factors and their impact on AS.
Treatment Modalities:
Current pharmacological interventions.
Physical therapy and lifestyle management.
Quality of Life and Mental Health:
Addressing the holistic impact of AS on daily life.
Strategies for maintaining mental and emotional well-being.
Research Advances and Future Directions:
Overview of cutting-edge research in AS.
Promising avenues for future treatments and interventions.
5. WHY ARE THEY GROUPED
TOGETHER?
⢠Genetic basis
⢠Environmental trigger like GIT & GUI
⢠Spine
⢠Oligoarthritis of Large Joints
⢠Enthesitis (inflammation of site of insertion of
tendons and ligaments into bone
⢠New aberrant bone formation along with bone loss
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6. DEFINITION
Ankylosing spondylitis is a potentially disabling
inflammatory arthritis of the spine, usually presenting
as chronic back pain, typically before age of 45yrs.
Often associated with extraspinal and extra-articular
features.
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7. EPIDEMIOLOGY
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⢠Incidence and prevalence correlate with frequency of HLA-B27 in the
population
⢠6-9% in population
⢠Out of the HLA-B27 positive individual 5-7% will develop Ankylosing
spondylitis.
⢠On the other hand 80-95% of Ankylosing spondylitis shall have HLA-B27
positivity
⢠Shows wide geographical variation in occurrence across region and race
⢠31.9 per 10,000 population in US
⢠While 7 per 10,000 population in India
⢠AS and HLA-B27 are nearly absent (<1%) in African blacks and Japanese
Population
9. GENETIC FACTOR
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⢠Genetic factors have Overwhelming importance
⢠Relative Risk of AS in:
⢠First degree- 94
⢠Second degree- 25
⢠Third degree- 4
10. GENETICS CONT..
⢠HLA-B27
⢠First recognised in 1973
⢠Strongest association with disease
⢠Overall contribution to AS heritability is approximately 20%
⢠Most frequent subtype are HLA-B2705 and HLA-B2704
⢠Only two subtypes are considered not to be associated- HLA-B2706 and HLA-
B2709
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13. GUT MICROBIOME
⢠Total number of Micro-organisms,
(bacteria, viruses, protozoa and fungi) and
their collective genetic material living in
our GIT
⢠Normally the microbiome is separated
from host by the gut epithelial barrier and
gut vascular barrier
⢠However, when the integrity of the
barriers is compromised the microbes
become capable of initiating a systemic
immune response.
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14. ⢠Composition of Gut Microbiome is influenced by genetic and other factors.
⢠Differs in AS patients from healthy individuals
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15. MECHANICAL STRESS
⢠In AS, inflammation is observed mostly in
anatomic regions subjected to mechanical stress
⢠Axial skeleton, Joints of lower limbs, heels,
especially at entheses
⢠Studies indicate that mechanical stress activates
mesenchymal cells to release chemokines which
attract inflammatory cells towards these
entheses
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16. COEXISTING BONE EROSION AND
NEW BONE FORMATION
⢠Still not fully understood.
⢠Initial changes is
inflammation in which
cytokines such as TNF and IL-
17 directly or indirectly
activates osteoclast precursor
cells.
⢠Thus flexibility is lost.
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18. ⢠Inflammatory backpain
⢠Corresponds to location of Sacro-iliac joint (back pocket of trouser)
⢠Alternates between two sides but sometimes remains only one sided.
⢠Frequently but not invariably has characteristics of inflammatory
nature
⢠Typically before 40yrs
⢠Often associated with extraspinal features like peripheral
arthritis, enthesitis and dactylitis.
⢠May also be associated with extra-articular features like
uveitis, psoriasis and inflammatory bowel disease.
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19. ASSESSMENTS OF SPONDYLARTHRITIS
INTERNATIONAL SOCIETY (ASAS) CRITERIA
⢠For inflammatory backpain.
⢠At least four of the five features to be positive:
⢠Age <40 years
⢠Insidious Onset
⢠Improvement with exercise
⢠No improvement with rest
⢠Pain at night. (canât turn at night)
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20. CLUES TO BACKPAIN
SUGGESTIVE OF
INFLAMMATORY DISEASE
⢠Early onset <40yrs
⢠Gradual onset
⢠Morning stiffness
⢠Improvements with exercise
⢠Early morning awakening
⢠Alternating buttocks
⢠Uveitis, Mouth ulcers, Inflammatory
peripheral arthritis, Urethritis,
Psoriasis, IBD
NOT SUGGESTIVE OF
INFLAMMATORY DISEASE
⢠Older age >40yrs
⢠Abrupt onset
⢠H/O trauma, Cancer
⢠Radiculopathy
⢠Weight loss, Generalized aching
⢠Night Sweats
⢠Fever
⢠Worsen with exercise
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21. CAN BE CLASSIFIED AS TWO
SUBTYPES
RADIOGRAPHIC AXIAL
SPONDYLOARTHRITIS
SI joint changes and Xray changes
present
NON RADIOGRAPHIC AXIAL
SPONDYLOARTHRITIS
Only MRI changes are present
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22. OTHER MUSCULOSKELETAL
FEATURES
⢠Groin Pain: Hip arthritis and shoulder joint involvement
⢠Chest and Neck Pain: Costovertebral, manubriosternal, sternoclavicular and
costochondral inflammation
⢠Restricted Spinal Mobility: Inflammation of extraspinal entheses
⢠Dactylitis
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23. OTHER FEATURES
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ENTHESES AT
ACHILLES TENDON
SAUSAGE DIGIT
(6%)
Diffuse swelling of toes
and fingers
HYPERKYPHOSIS OF
BACK (HUNCH
BACK)
Flexion deformity of
neck
Thoracic wedging hyper
kyphosis
Loss of normal lumbar
lordosis
Flexion deformity of the
hip
25. EXTRA-ARTICULAR MANIFESTATION
⢠Fatigue weight loss
⢠Anterior uveitis 25-30% with longer disease (acute ocular pain later glaucoma or
cataract)
⢠Inflammatory Bowel disease 50% cases but rarely clinical
⢠Psoriasis 10% cases with peripheral joints but weaker association with HLA-B 27
⢠Psychosocial Issue with depression and sleep disorder
⢠Cardiovascular risk for IHD, ACS, strokes, VTE
⢠Pulmonary changes like fibrosis
⢠Neurological features due to PLL ossification, instability leading to even cauda
equina syndrome and in some cases arachnoiditis
⢠Renal involvement as IgA nephropathy, Haematuria and Amyloidosis later
⢠Osteoporosis is seen early with symptomatic osteoporotic fractures
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28. TRAGUS WALL
DISTANCE
⢠Patients heel and back rests on the
wall with no flexion and extension
at knee or hip
⢠Chin usually at the usual carrying
level. Maximum effort to touch the
head against the wall
⢠Report the better of two tries
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30. CERVICAL
ROTATIONS
⢠Patient sits straight on chair, chin
level, hands on knees
⢠Assessor places goniometer on the
top of the head in line with the
nose (A)
⢠The assessor asks to rotate the
neck maximally to left, follows with
goniometer and records the angle
in between the sagittal plane and
the new plane after rotation (B)
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31. CHEST WALL
EXPANSION
⢠Patients hands resting on or
behind the head
⢠Measure at 4th IC level anteriorly
or just below nipple in females
⢠The difference between maximal
inspiration and expiration in cms is
recorded
⢠~5cms
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32. MODIFIED
SCHOBERâS TEST
⢠Patient should be erect. Make an
imaginary line connecting both
posterior superior iliac spines
(close to the dimples of venus (A)
⢠Next mark 10cms above (B).
⢠The patient bends forward
maximally (without bending the
knee) measure the difference (C)
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33. LUMBAR FLEXION
TEST
⢠Using a goniometer parallel to the
spine and asking the patient to
flex laterally on either side and the
angle subtended is measured.
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34. INTERMALLEOLAR
DISTANCE
⢠Patient lying down supine and the
legs are separated with knees
straight and toes pointing upwards
⢠Alternatively the patient stands
and the legs are separated as far
as possible
⢠Distance between medial malleoli
measures
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36. LAB FINDINGS
⢠Elevated ESR and CRP in approximately 50-70%
⢠Less frequent with non radiographic axial spondylitis patient (30%)
⢠Normochromic normocytic anemia in very active patients
⢠Serum bone specific alkaline phosphatase may be elevated
⢠Synovial fluid findings are typical of inflammatory arthritis
⢠HLA B 27 is present in 80-95%
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37. RADIOLOGIC FEATURES
SACROILIITIS
⢠Erosions
⢠Ankylosis
⢠Juxta articular osteopenia
⢠Ossification of ligamentous
attachment to the ischial tuberosity
or the iliac crest or the GT
SPINE
⢠Erosions of vertebral corners (Shiny
Corners)
⢠Squaring of vertebral bodies
(Romanus Lesion)
⢠Syndesmophytes
⢠Ossification of Annulus fibrosis and
Longitudinal Ligaments
⢠Erosion of disco-vertebral junction
⢠Pseudoarthrosis
⢠Juxta articular bone oedema
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38. IMAGING
⢠sacroiliitis is usually the first manifestation and is
symmetrical and bilateral
⢠the sacroiliac joints first widen before they
narrow
⢠subchondral erosions, sclerosis, and
proliferation on the iliac side of the SI joints
⢠at end-stage, the SI joint may be seen as a thin
line or not visible
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39. NEW YORK CRITERIA
⢠grade 0: normal
⢠grade I: suspicious changes (some blurring of the joint margins)
⢠grade II: minimum abnormality (small localized areas with erosion or sclerosis,
with no alteration in the joint width)
⢠grade III: unequivocal abnormality (moderate or advanced sacroiliitis with
erosions, evidence of sclerosis, widening, narrowing, or partial ankylosis)
⢠grade IV: severe abnormality (complete ankylosis)
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41. MRI CHANGES OF SACROILIAC
JOINT
⢠Bone marrow
oedema, fatty
changes and
structural changes can
be picked up
⢠Important in Non
Radiographical Axial
spondylitis
⢠False positive finding
might be present with
healthy individuals
(female and post
partum period)
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42. CT CHANGES
⢠More sensitive than
Xray
⢠Low Radiation Ct is
sufficient
⢠Limitation of CT
include the inability to
assess the activity of
inflammation
⢠Better to see marginal
erosions
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43. PREDICTORS FOR RADIOGRAPHIC
PROGRESSION OF SACROILIITIS
⢠Human Leukocyte Antigen (HLA)-B27 positivity
⢠Smoking
⢠Male Sex
⢠Elevated C-Reactive Protein (CRP)
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44. SPINE RADIOGRAPH
⢠Best imaging in lateral view
⢠Squaring of vertebral bodies due to anterior
and posterior inflammation and bone erosion
and deposition is relatively early radiographic
signs of spinal involvement in AS
⢠Syndesmophytes
⢠Shiny corner sign: AKA Romanus Lesions
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47. HIPS
⢠Hip involvement is generally bilateral
and symmetric
⢠Uniform joint space narrowing,
⢠Axial migration of the femoral head
sometimes reaching a state
of protrusio acetabuli, and
⢠A collar of osteophytes at the femoral
head-neck junction.
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48. PELVIS
⢠Whiskering of the pelvic bones
primarily affects the ischial
tuberosities, resulting from
ossification of the ligamentous
origins.
⢠There can be bridging or fusion
of the pubic symphysis.
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56. PHARMACOLOGIC
⢠NSAIDS
⢠Conventional DMARDS (csDMARDs)
⢠Biological DMARDS (bDMARDs)
⢠No role of Low dose glucocorticoids but intra-articular injections may be
helpful in selected patients.
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57. NON PHARMACOLOGIC
⢠Patient Education:
⢠Need for lifelong exercise and posture training program
⢠Importance of regular follow up and management of comorbidities
⢠Smoking cessation
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58. PHYSICAL THERAPY
⢠Range of Motion exercises
⢠Stretching
⢠Recreational activities
⢠Hydrotherapy
⢠Spinal manipulation should be avoided in patients with spinal fusion or
advanced spinal osteoporosis
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59. PRE-TREATMENT EVALUATION
⢠Baseline CBC, Sr Creat., LFT, ESR, CRP
⢠Hep B and Hep C screening must be done before starting DMARDS
⢠Testing for latent TB- Mantoux or IGRA must be done before starting
DMARDS
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64. bDMARD
⢠IL-17 Antagonists: Secukinumab
Ixekizumab
⢠To be avoided in patients with concomitant IBD (may cause flare up)
⢠S/E:
⢠Hypersensitivity
⢠Increased risk of infections
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65. 2019 UPDATE OF THE AMERICAN COLLEGE OF
RHEUMATOLOGY/SPONDYLITIS ASSOCIATION OF
AMERICA/SPONDYLARTHRITIS RESEARCH AND
TREATMENT NETWORK RECOMMENDATIONS FOR
THE TREATMENT OF ANKYLOSING SPONDYLITIS
AND NON-RADIOGRAPHIC AXIAL
SPONDYLARTHRITIS
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68. GENERAL PRINCIPLES
⢠Severe hip and knee arthritis can be managed by TKR and THR respectively
⢠If flexion deformity is severe the patientâs field of vision is limited to a small
area near the feet and walking is extremely difficult
⢠This is evident by looking at the chinbrow to vertical angle
⢠Respiration becomes almost completely diaphragmatic
⢠Gastrointestinal symptoms resulting from pressure of the costal margin on
the contents of the upper abdomen are common: dysphagia or choking may
occur
⢠In addition to improvement in function the improvement in appearance
made by correcting the deformity is important to the patients
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69. ⢠If extreme the deformity should be corrected in two or more stages because
of the contracture of soft tissue and the danger of damaging the aorta,
inferior vena cava and the major nerves to the lower extremities
⢠According to Law, 25-40 degrees of correction usually obtained resulting in
marked improvement functionally and cosmetically
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70. OSTEOTOMIES FOR SPINE
⢠Smith Peterson Osteotomy
⢠Pedicle subtraction Osteotomy (Thomasen)
⢠Eggshell Osteotomy
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71. SMITH PETERSON
OSTEOTOMY
⢠For correction of smaller degrees of spinal degree
⢠Bone is removed through the pars and facet joints
⢠Symmetrical resection is necessary to prevent creating a coronal deformity
⢠Removal of underlying ligament also is helpful in preventing buckling of the
dura or iatrogenic spinal stenosis
⢠Approximately 10 degrees of correction can be obtained with each 10mm of
resection
⢠Excessive resection should be avoided because it may result in foraminal
stenosis
⢠In patients with degenerative discs decreased flexibility may limit the amount
of correction that can be obtained
⢠Osteotomy is closed with compression or with in situ rod contouring and
bone graft is applied.
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72. PEDICLE SUBTRACTION
OSTEOTOMY
⢠Best suited for patients with significant sagittal imbalance of 4cm or more
and immobilize or fused discs
⢠Pedicle subtraction osteotomy is inherently safer than the Smith Peterson as
it avoids multiple surgeries
⢠Typically 30 degrees or more of correction can be obtained with single
posterior osteotomy preferably at the level of the deformity
⢠If the deformity is at the spinal cord level pedicle subtraction osteotomy can
be used but manipulation of the cord must be avoided
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73. EGG-SHELL OSTEOTOMY
⢠Requires both anterior and posterior approach and usually reserved for
severe sagittal or coronal imbalance of more than 10cms from the midline
⢠This is spinal shortening procedure with anterior decancellisation followed by
removal of posterior elements, instrumentation, deformity correction and
fusion
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74. OSTEOTOMY FOR CERVICAL
SPINE
⢠Doen in patients with chin to chest with difficult mandibular opening
⢠May be indicated:
⢠To elevate chin from sternum improving ability to see and eat
⢠Prevent atlantoaxial and cervical subluxation and dislocation, which results in weight of
the head being carried forward by gravity
⢠Relieve tracheal or oesophageal distortion
⢠Prevent irritation of spinal cord tracts causing neurological disturbance
⢠Level of osteotomy is decided by degree of ossification by ALL
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76. JUVENILE AS
⢠Before 16 yrs, more common in males
⢠80% prevalence of HLA- B27
⢠Axial skeletal involvement seen in only 12% cases and peripheral arthropathy
in 78-85%
⢠Lower limb joints frequently affected
⢠5-10% may have constitutional symptoms of anemia increased ESR
gypergammaglobulinemia
⢠CVS and respiratory diseases are uncommon
⢠Subluxation of Atlanto-axial joints leading to severe cervico-occipital pain
⢠High level of IgM, IgG are found in both the patients and their 1st degree
relatives and selective deficiency of IgA has been reported.
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Bone scans donât help as there is syndesmophytes giving false values
9.5cm
0cm
 80° to 90° of flexion, 70° of extension, 20° to 45° of lateral flexion, and up to 90° of rotation to both sides.
15-20cms
20degrees
Xray normal cant be diagnosed even early onset is lost
Score >4 is positive
Others Like ASDAS BASMI
Interferron Gamma release assay
Mtx Sulfasalazine and Leflunamide used in peripheral Ank Spond
Sulfa reduces use of NSAIDS
Infliximab: Infusions every 6 weeks after 3 induction doses. 5 mg/kg IV given at 0, 2, and 6 weeks as an induction regimen. MAINTENANCE DOSING 5 mg/kg IV given every 6 weeks thereafter as a maintenance regimen
Etanercept: 50mg SC once weekly
Adalimumab: 40-80mg SC alt week
Golimumab: 50mg SC once a month
Certolizumab: Initial: 400 mg SC (2 injections of 200 mg), repeat at 2 and 4 weeks. Maintenance: 200 mg SC q2Weeks OR 400 mg SC q4weeks
Seku: Once weekly for 5 weeks then once monthly 150mg IV
Ixeki: 160 mg SC (ie, as two 80-mg injections) at Week 0, THEN 80 mg SC q4Weeks
