1) The patient is a 27-year-old male who presents with 6 months of lower back pain that is worse in the morning and improves with exercise. Examination finds reduced spinal mobility and tenderness over the lower spine. 2) Tests show a positive HLA-B27 and elevated inflammatory markers. X-rays are inconclusive for ankylosing spondylitis. 3) Ankylosing spondylitis is an inflammatory arthritis affecting the spine. Treatment includes exercises, NSAIDs, DMARDs like sulfasalazine, and biologic therapies like infliximab which have revolutionized treatment.

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