for the pain physician

1. Joint Pain In Ankylosing
Spondylitis : Assessment &
Management
Moderated by : Dr Chetna Shamshery
Presented by : Dr Dibyadip Mukherjee

2. Case presentation
• A 27 year old male patient shopkeeper by profession presents to us
with 6 months history of back pain. On taking a proper history he
reveals :
• Pain in the midline lower back
• Insidious in onset
• Dull aching in character with no neuropathic features
• Radiates into the buttock region bilaterally
• Aggravated by daily activities & also awakens him frequently in the
night
• Decreases after exercises and hot shower

3. • Maximum at the morning and stiffness lasts upto 1-2 hours
• Present VAS : 50
• Past history :
• Back pain on and off
• Red eye since 1 week
• Peripheral joint pain
• No h/o
• Trauma
• Diarrhoea / dysentry / urthretis / prostratitis in preceding 1 to 4 weeks
• Oral ulcers / skin lesions / nail changes
• Pain in the chest
• Respiratory problems
• Night sweats /fever / weight loss

4. Physical examination
• Inspection :
• Posture : normal , no stooping of the neck/ spine
• ROM : decreased forward and lateral flexion of the spine.
• Modified Schober’s test showed a displacement of 3 cm
• Chest expansion : normal
• Palpation :
• Midline tenderness over the spinous processes of L2 – L5, PSIS
• No tenderness over greater trochanter, ischial tuberosity, iliac crests
• SLR , Stinchfield , Tripod tests : negative
• SIJ maneuvers : FABER, PATRICK , GAENSLENS :-ve

5. Modified Schober’s Test

6. Investigations
• RA: -VE
• Anti ccp:-ve
• HLAB27: +ve
• X-ray: inconclusive
• ESR: 35mm per hour
• CRP: 60 iu/l

7. Ankylosing
spondylitis
Reactive
arthritis
Psoriatic
Enteropathic
(IBD)
Juvenile
onset
Undifferenti
ated
Spondylo arthropathies

8. The disease
• Inflammatory disorder of unknown cause that primarily affects the
axial skeleton
• Peripheral joints & extra articular structures : frequently involved
• No specific exogenous triggers
• Primary / idiopathic : if no associated disorder present.
• Secondary : if associated with psoriasis / bowel disease.

9. 1984 Modified New York Criteria for AS
• Clinical Criteria
• Low back pain ≥ 3 months, improved by exercise and not relieved by rest
• Limitation of lumbar spine in sagittal and frontal planes
• Limitation of chest expansion (relative to normal values corrected for age
and sex)
• Radiological criteria
• Bilateral grade 2-4 sacroiliitis OR
• Unilateral 3-4 sacroiliitis
• Requirements: bilateral grade 2-4 or unilateral grade 3-4 sacroiliitis AND
any clinical criteria.

10. Why the switchover?
• Not useful for the inclusion of early cases
• Lacked sensitivity
• MRI useful to detect axial manifestations before the presence of
radiographic sacroilitis
• Axial spondyloarthritis : includes entire spectrum of patients with
predominant axial involvement regardless of the presence of
structural damage on radiographs.

13. Epidemiology
• Age : usually in the 2nd or 3rd decade
• Sex : Male : Female : 2:1 to 3:1
• Striking correlation to the presence of HLA B 27
• 90% white patients with AS possess HLA B27
• 50% black patients with AS possess HLA B27
• Aberrant presentation of self peptides by HLA molecules causes
recognition of self antigens as harmful----autoreactivity from CD8+ T
cells.
• Also has genetic associations with ERAP 1

14. Pathophysiology
• Site: junction of bone & cartilage/ ligament
• Macrophage/ Tcells/ osteoclasts erode the entheseal margin
• Replace it with fibrocartilage, causing ossification (bony ankylosis)
• Spine :
• Inflammatory granulation tissue at junction of annulus fibrosus and
vertebral bone
• Outer fibres replaced by bone
• Beginning of syndesmophyte and endochondral ossification
• Bamboo spine vertebrae

15. Pathology
• Inflammation
• Erosion
• Syndesmophytes
• Squarring
• Bamboo spine
• Osteoporosis

16. Normal SIJ
Inflammed SIJ
Fused SIJ

17. Clinical features : Skeletal manifestations
• Inflammatory back pain :
• Morning stiffness of atleast 30 minutes
• Improvement with exercises
• Awakening because of buttock pain during the second half of the night
• Alternating buttock pain
• No improvement with rest
• Insidious nature of onset
• Improvement with NSAIDS

18. • Dull in character , difficult to localise
• May localise in the SIJ or may referred to the iliac crests or greater
trochanter
• Unilateral & intermittent at first but then becomes persistent and
bilateral
• Morning stiffness upto 3 hours

19. Other joint involvements
• Hip and shoulder arthritis :25-35 %
• Asymmetric peripheral arthritis:30%
• Neck pain and stiffness :late
• Loss of spinal mobility
• Loss of chest expansion

20. Chest pain
• Due to enthesitis at costosternal and manubriosternal joints
• Accentuated by coughing and sneezing
• May be labelled as “pleuritic”

21. Clinical examination
• INSPECTION :
• Posture :
• limitation of neck movement
• Loss of lumbar lordosis eventually to
thoracic kyphosis
• Abdominal breathing
• Decreased forward and lateral flexion
of the spine

22. Physical examination
• Decreased chest expansion
• Palpation :
• SIJ maneuvers : positive
• Tenderness due to enthesitis at:
• Spinous process
• Iliac crests
• Greater trochanter
• Heels
• Costochondral & manubriosternal joints

23. Investigations
• No diagnostic test
• HLA B27+
• ESR/CRP Increased
• Mild anemia
• Increased ALP
• RF /ANTI CCP/ANA : -ve
• Synovial fluid: Inflammatory

24. Xray- spine
• Syndesmophytes
• Bamboo spine
• Squarring of vertebrae
• Diskovertebral changes
• Osteoporosis

25. MRI

26. SACROILITIS

27. Extra articular features
• UVEITIS
• IBD

28. Ocular
• Acute anterior uveitis/ iridocyclitis
• Unilateral involvement
• Red, painful eyes with photophobia & lacrimation
• Occurs in 25-30% patients
• Tend to recur
• May lead to cataract & secondary glaucoma

29. Cardiovascular
• More in patients with peripheral joint involvement
• Increased chances of myocardial infarction by 4.4% compared to 1.2%
in general population
• Abnormalities :
• Aortic incompetence
• Cardiomegaly
• Pericarditis
• Complete heart block

30. Pulmonary
• Usually rare & late
• Slowly progressive fibrosis of the upper lobe of
lungs
• Appears on an average after 2 decades of onset
of AS
• Presents with cough, dyspnoea, haemoptysis
• Vital capacity and total lung capacity are
moderately decreased

31. Neurologic
• Due to vertebral fractures /
compression
• Most commonly involved :C5-C6 & C6-
C7
• Fractures may occur even with minor
trauma
• Spontaneous atlanto axial subluxation
may be present
• Cauda equina syndrome : rare

32. Renal
• IgA nephropathy is the major complication
• Microscopic haematuria & proteinuria may be present

33. Bones
• Osteopenia occurs in early stages
• Frank osteoporosis is a late
sequelae
• Contributes to the abnormal
posture : hyperkyphosis
• Proper assessment of BMD is
difficult in presence of
syndesmophytes as they
contribute to falsely high values

35. Treatment
• Mainly aims at:
• Relieving pain, stiffness and fatigue.
• Maintain good posture.
• Maintain good physical and psychosocial functioning.
• Tailored according to:
• Current manifestations of the disease (axial/peripheral/entheseal/extra
articular signs)
• Level of current symptoms & prognostic indicators
• General clinical status (age/gender/comorbidities)

37. Exercise & physiotherapy
• Causes marked improvement in subjective & objective components
• Reduces NSAID use
• Patient associations / self help groups / supervised exercises more
beneficial
• Lying prone for 15-30 minutes once / multiple times in a day useful to
reverse the tendency towards thoracic kyphosis & flexion
contractures of hip joints.
• Should sleep fully supine on a firm mattress with a small neck support
pillow.

39. Pharmacotherapy : NSAIDs
• In adults with active AS , treatment with NSAIDs is preferred than no
treatment.
• When taken for a prolonged time e.g 1 year, may cause improvement
in spinal mobility & acute phase reactants.
• Selective COX 2 inhibitors have similar efficacy to conventional
NSAIDs.
• Nonselective NSAID eg. naproxen may be an appropriate initial trial.
• As long as 2 weeks may be required to demonstrate maximal
symptomatic benefit.

40. Pharmacotherapy : NSAIDs
• If symptomatic relief inadequate, switchover to another NSAID is
often worthwhile.
• Must be given on a regular / on demand basis based on patient & side
effect profile.
• Continuous therapy retards radiographic progression & decreases
CRP.

41. Commonly used drugs
Drugs Dosages
Naproxen
Indomethacin
Etoricoxib
500mg BD
75mg BD
90mg OD

42. Pharmacotherapy : DMARDs
• Most evidences present for sulfasalazine.
• Commonly used in dosage :2-3gm/day
• Primary indication : patients with concomitant peripheral arthritis &
inadequate response to NSAIDs & physical modalities.
• Thalidomide has also shown clinical benefits but avoided for its side
effect profile.

43. Pharmacotherapy : Corticosteroids
• Systemic corticosteroids have shown no efficacy.
• Intra articular corticosteroids eg. SIJ injections have been found to be
beneficial.
• Efficacy concluded in meta analyses : mean duration of 8-10 months
• Advanced techniques :
• Unpredictable course of lateral branches at S1-S3 levels led to the
recommendation of bipolar RF strip lesions in a “leap frog” manner.
• Cooled RF have been shown to be significantly better than traditional RF.

44. Biologic therapies
• Revolutionised the current therapy for AS.
• 5 agents of proven clinical benefit :
• Infliximab : 5mg/kg every 6 to 8 weeks after loading at 0,2 & 6 weeks.
• Etanercept : subcutaneous injection- 50 mg once weekly.
• Adalimumab
• Certolizumab
• Golimumab
• Causes improvement in symptoms in 2-4 weeks & sustained as long
as the patient is on treatment.
• Significant improvement is also observed in function, spinal mobility,
peripheral synovitis, enthesitis and quality of life .

46. Outcome
• Rather favourable prognosis
• May run a mild & self limited course
• Spontaneous remissions & exacerbations
• Life expectancy decreases after 10 years of disease.
• Onset of AS in adolescence & early hip involvement correlates with a
worse prognosis.
• Smoking is associated with an adverse outcome.

47. Undifferentiated spondyloarthropathy

48. Thank You