The document discusses the investigation and treatment modalities for ankylosing spondylitis. It states that each patient should receive an individualized evaluation and treatment plan to provide the best outcome. Treatment involves a team approach including orthopedists, rheumatologists, physiotherapists and others. Drug therapy aims to relieve symptoms, slow disease progression, and produce immunosuppression. Physical therapy focuses on maintaining joint movement and strengthening muscles. Surgery may be considered for severe deformities or other complications.

1. INVESTIGATION & TREATMENT
MODALITIES

2. EVERY PATIENT SHOULD BE
CAREFULLY EVALUATED AND
INDIVIDUALIZED ,IN ORDER TO
PROVIDE HIM THE BEST TREATMENT
FOR A BETTER OUTCOME.
2

3.  THE PATIENT SHOULD BE EXPLAINED
IN DETAIL ABOUT HIS CONDITION AND
THE POSSIBLE OUTCOME AND
COMPLICATIONS, AND THAT THE
TREATMENT IS ONLY DIRECTED
TOWARDS IMPROVING THE QUALITY
OF LIFE.
3

4.  MANAGING A CASE OF ANKYLOSING
SPONDYLITIS IS A TEAMWORK COMPRISING OF
:
 ORTHOPAEDISTS
 RHEUMATOLOGISTS
 PHYSICIANS
 PHYSIOTHERAPISTS
 PARENTS
4

5.  RECOGNITION OF A FULL BLOWN CASE IS NOT
DIFFICULT
5

6.  THE NEED, IS OF A EARLY DIAGNOSIS OF THE
DISEASE ,WHICH WOULD HELP IN A BETTER
PROGNOSIS AND THIS HAS BEEN MET BY THE
TWO GROUPS NAMELY:
 THE ROME CRITERIA (1963)
 THE NEW YORK CRITERIA (1968)
6

7.  ACCORDING TO THIS ,AS IS DIAGNOSED IF
B/L SACROILIITIS IS SEEN ALONG WITH ONE
OF THE FOLLOWING.
a) LBA & STIFFNESS OF 3 MONTHS DURATION NOT
RELIEVED BY REST
b) PAIN AND STIFFNESS IN THE THORACIC SPINE
c) LIMITED LUMBAR SPINAL MOVEMENT
d) LIMITED CHEST EXPANSION
e) HISTORY OR EVIDENCE OF IRITIS OR ITS SEQUELAE
7

8.  CLINICAL CRITERIA:
a) LIMITATION OF LUMBOSACRAL MOVEMENT IN
THREE PLANES
b) HISTORY OF PRESENCE OF PAIN AT DL JUNCTION
WITH OR WITHOUT LUMBAR SPINE PAIN
c) LIMITED CHEST EXPANSION OF 2.5CM OR LESS AT
4TH INTERCOSTAL SPACE.
8

9.  RADIOLOGICAL CRITERIA BASED ON
SACROILIAC JOINT RADIOGRAPHS
 GR 0 : NORMAL
 GR 1: POSSIBLY NORMAL(minimal sclerosis)
 GR 2: DEFINITE MARGINAL SCLEROSIS
 GR 3: DEFINITE EROSION AND SCLEROSIS
 GR 4: COMPLETE OBLITERATION AND ANKYLOSIS
9

10. DEFINITE AS:
 GR 3/4 BL SACROILIITIS WITH ATLEAST ONE
CLINICAL CRITERIA
OR
 GR 3 / 4 UL SACROILITIS WITH CLINICAL
CRITERION 1
10

11. 11
Index Metric
BASFI Disability level
BASDAI Disease activity level
ASAS - IC Composite sum of disease activity
BASFI = Bath Ankylosing Spondylitis Functional Index
BASDAI = Bath Ankylosing Spondylitis Disease Activity Index
ASAS - IC = ASsessment in Ankylosing Spondylitis Improvement Criteria

12. 12
 Visual analog scale (VAS) – 10 cm
 Mean score of 10 questions
 Questions level of functional disability,
including:
◦ Ability to bend at the waist and perform tasks
◦ Looking over your shoulder without turning your body
◦ Standing unsupported for 10 minutes without
discomfort
◦ Rising from a seated position without the use of an aid
◦ Exercising and performing strenuous activity
◦ Performing daily activities of living
◦ Climbing 12 to 15 steps without aid

13. 13
 A self-administered instrument (using 10-cm
horizontal visual analog scales) that comprises 6
questions:
Over the last one week, how would you
describe the overall level of:
◦ Fatigue/tiredness
◦ AS spinal (back, neck) or hip pain
◦ Pain/swelling in joints other than above
◦ Level of discomfort from tender areas
◦ Morning stiffness from the time you awake
◦ How long does morning stiffness last?

14. 14
 Clinical Criteria
◦ Low back pain, > 3
months, improved
by exercise, not
relieved by rest
◦ Limitation of lumbar
spine motion,
sagittal and frontal
planes
◦ Limitation of chest
expansion relative to
normal values for
age and sex
• Radiologic Criteria
– Sacroiliitis grade 2
bilaterally or grade 3 – 4
unilaterally
• Grading
– Definite AS if radiologic
criterion present plus at least
one clinical criteria
– Probable AS if:
• Three clinical criterion
• Radiologic criterion
present, but no signs or
symptoms satisfy clinical
criteria

15.  RADIOLOGICAL
 LAB INVESTIGATONS
 OTHER INVESTIGATIONS
15

16. 16

17. 17

18. 18

19. 19

20. 20

21. 21

22.  50 % HAVE RAISED SERUM ALKALINE PHOSPHATASE
LEVELS
 MANY HAVE RAISED SERUM PHOSPHOKINASE
 ESR IS ELEVATED
 HB IS LOW. TLC RAISED.CRP RAISED
 NORMOCYTIC NORMOCHROMIC ANAEMIA
 HLA B27 IS POSITIVE IN AROUND 90% OF CASES AND
HAS A STRONG CORROBORATIVE VALUE IN THE
DIAGNOSIS
22

23.  TO RULE OUT EXTRA ARTICULAR
MANIFESTATIONS SUCH AS
a) UVEITIS , IRIDOCYCLITIS
b) INFLAMMATORY BOWEL DISEASE
c) AORTIC INCOMPETENCE AND CONDUCTION
DEFECTS
d) RESTRICTIVE LUNG DISEASE,PULMONARY
INFECTIONS
23

24.  DRUG THERAPY
 PHYSICAL THERAPY
 SURGERY
24

25.  IT IS TARGETED :
a) GIVING SYMPTOMATIC RELIEF TO THE
PATIENT.
b) TO PRODUCE IMMUNOSUPPRESION.
c) SLOW DOWN THE DISEASE PROGRESS.
25

26.  TO RELIEVE PAIN AND INFLAMMATION :
N S A I D s :
Ibuprofen,Phenylbutazone, Indomethacin,
Diclofenac,Naproxen,Celecoxib.
Opiod analgesics in extended release
formulations for pts having chronic pain
26

27.  DMARD S SUCH AS
cyclosporin, methotrexate, sulfasalazine
 CORTICOSTEROIDS ARE USED TO REDUCE THE
IMMUNE RESPONSE AND PRODUCING
IMMUNOSUPRESSION
27

28.  MOST PROMISING AGENTS
28

29. 29
Bone
Erosions
Macrophages
Endothelium
Synoviocytes
Proinflammatory cytokines
Chemokines
Adhesion molecules
Metalloproteinase synthesis
Articular
Cartilage
Degradation
Increased Cell
Infiltration
Increased
Inflammation
Osteoclast
progenitors
RANKL expression
TNF

30. 30
 Active disease for 4 weeks
◦ BASDAI > 4 at two times, 1 month apart
 Treatment Failures
◦ All types AS – lack of response/intolerability > 2 NSAIDs
for 3 months
◦ Patients with peripheral arthritis – lack of
response/intolerability to > 1 DMARD, sulfasalazine
preferred

31. 31
 Etanercept
◦ Dose: 50 mg SC per week as two 25 mg injections
administered on same day or 3 to 4 days apart
 Infliximab
◦ Dose: 5 mg/kg IV at week 0, 2, and 6 and every 6
to 8 weeks thereafter

32. 32
Etanercept Infliximab
Mechanism of TNF
inhibition
“Decoy” receptor
for TNF
Binds to TNF and
inhibits it from binding
with TNF receptor
Terminal half-life 4.25 +/- 1.25
days
(mean+/- SD)
8 to 9.5 days
(median values)
In vitro lysis of cells
expressing
transmembrane TNF
No Yes
Mode of administration Subcutaneous IV infusion
(over 2 to 3 hours)

33. 33

34. 34
Alternative Options
• Pamidronate
• Thalidomide
*Only biologic approved for treatment of AS in US and Europe
†Approved in Europe only for treatment of AS
This treatment algorithm contains unlabeled use of infliximab, pamidronate and thalidomide.
Anti-TNF agents
• Etanercept 50 mg SC per week as two 25 mg injections in the
same day or 3-4 days apart*
• Infliximab 5 mg/kg at 0, 2, and 6 weeks and every 6 to 8 weeks
thereafter†
• Contraindicated in patients with infections, tuberculosis,
multiple sclerosis, lupus, malignancy, and pregnancy/lactation
Initiate physical therapy plan with long-
term exercise program to accompany
pharmacologic intervention
• Emphasize posture, range of motion,
and strengthening
NSAIDs or Selective COX-2 inhibitors
• Efficacy and safety comparable between non-selective agents
• Selective COX-2 efficacy comparable, better safety profile, higher
cost that non-selective NSAIDs
Failure of at least two different NSAIDs/selective COX-2 inhibitors
for minimum of 3 months

35. 35
 Current or recurrent infections
 Tuberculosis
 Multiple sclerosis
 Lupus
 Malignancy
 Pregnant or lactating

36. 36
 ASAS core set of outcome parameters to
monitor patients
◦ Physical function, pain, spinal mobility, patient’s
global assessment, stiffness, peripheral joints and
entheses, acute phase reactant, fatigue
 Assess at 6 to 8 weeks and discontinue
patients who do not meet response criteria
◦ BASDAI: Reduction of 2 units and
◦ Physician Global Assessment > 1

37.  AIM: TO MAINTAIN JOINT MOVEMENT AND TO
BUILD UP MUSCLES THAT OPPOSE THE
DIRECTION OF DEFORMITIES I.E EXTENSORS
 IT SHOULD BE STARTED ALONG WITH THE
DRUG THERAPY FOR BETTER OUTCOME OR AS
SOON AS THE PT HAS RELIEF FROM PAIN.
37

38.  SWIMMING
 BADMINTON
 JOGGING
 YOGA
 DEEP BREATHING EXERCISES
 PRONE LYING
 MODIFICATION OF WORK
38

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40. 3/13/2014
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41.  IN LATE CASES,
 TRACTION APPICATION IS USEFUL
 FOR LOWER LIMBS : TO OVER COME FIXED
FLEXION DEFORMITIES OF THE HIP AND KNEE
AND TO RELIEVE SPASM.
 FOR CERVICAL SPINE TO RELIEVE PAIN AND
SPASM
41

42.  SEVERE DEFORMITY ( KYPHOSIS)
 DEFORMITIES OF THE HIP AND KNEE
 BREATHING AND VISUAL DIFFICULTIES
 DANGER TO THE GREAT VESSELS AND THE
SPINAL CORD ALONG WITH THE NERVE
TRUNKS
 COSMETIC REASONS.
42

43.  OSTEOTOMIES OF THE LUMBAR SPINE :
1. SMITH PETERSON OSTEOTOMY
43

44.  2) . PEDICLE SUBTRACTION OSTEOTOMY OF
THOMASEN
44

45.  3) EGGSHELL OSTEOTOMY
45

46.  4) TRANSPEDICULAR DECANCELATION
CLOSED WEDGE OSTEOTOMY
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47.  INDICATIONS:
 TO ELEVATE THE CHIN FROM THE STERNUM.
IMPROVEING THE APPEARANCE,THE
GAZE,THT ABILITY TO EAT.
 TO PREVENT ATLANTO AXIAL SUBLUXATION
 TO RELIEVE THE OESOPHAGEAL AND
TRACHIAL DISTORTION
 TO RELIEVE TRACTION ON THE CERVICAL
NERVE ROOTS.
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