PPT of Ankylosing spondylitis

2.  Ankylosing spondylitis (AS) is a chronic,
inflammatory disease primarily affecting the axial
spine that can manifest with a range of clinical
signs and symptoms.
 The hallmark features of the condition
include chronic back pain and progressive
spinal stiffness.
 AS is characterized by the involvement of the
spine and sacroiliac (SI) joints and peripheral
joints, digits

3.  AS often leads to impaired spinal mobility and
can result in postural abnormalities. Patients
can also experience buttocks pain and hip
pain.
 In addition to skeletal involvement, AS can
affect various organs outside the joints.
 Peripheral arthritis, enthesitis, and dactylitis
("sausage digits") are all associated with AS.

4.  Clinical symptoms of enthesitis include
tenderness, soreness, and pain at enthuses
on palpation.
 whereas dactylitis is recognized by swelling
of an entire digit that is different from
adjacent digits.

6.  Ankylosing spondylitis (AS) commonly
presents in individuals younger than 40.
 More prevalent in men than women.
 approximately 80% of patients experiencing
their first symptoms before age 30.

10. (HLA)-B27
Unknown
Some bacterial
infections like
(Klebsella
pneumoniae)

11. ossification
Ankylosing spondylitis
fibrosis
Cytokines, particularly tumor necrosis factor-α (TNF-α) contribute to inflammation
infiltrating immune cells such as CD4 and CD8 T lymphocytes and macrophages.
infections and HLA B 27, unknown etiology

12.  Inflammatory bowel disease ( most common)
 Acute anterior uveitis
 Psoriasis
 Restrictive pulmonary pattern
 Ocular manifestations
 Chronic pain and disability
 Aortic regurgitation
 Pulmonary fibrosis
 Cauda equina syndrome (The cauda equina is the bundle of nerve roots
located at the lumbar region of spine. Cauda equina syndrome occurs when
the nerve roots in the lumbar spine are compressed, cutting off sensation
and movement. )
 Mood disorders

13.  Laboratory findings in ankylosing spondylitis
(AS) are typically nonspecific but may provide
supportive evidence for diagnosis.
 erythrocyte sedimentation rate (ESR)
 elevated C-reactive protein (CRP).
 Radiographic
 magnetic resonance imaging (MRI)

14.  Several imaging abnormalities, especially
those affecting the spine and sacroiliac joints,
are associated with AS.
 Evidence of sacroiliitis ( inflammation of
sacroiliac joint) on imaging, whether
radiographic or magnetic resonance imaging
(MRI), is considered a major inclusion
criterion for AS according to the Assessment
of Spondyloarthritis International Society
(ASAS) 2009 axial spondyloarthritis criteria.

15.  A standardized plain radiographic grading
scale exists for sacroiliitis. This scale ranges
from normal (0) to most severe (IV), as
detailed below.
 0: Normal SI joint width, sharp joint margins
 I: Suspicious
 II: Sclerosis, some erosions
 III: Severe erosions, pseudo dilation of the
joint space, partial ankylosis
 IV: Complete ankylosis

16.  Throughout AS, a series of distinct
radiographic changes characteristics
can progressively develop.
 In the early stages, a notable sign is
the "squaring" of vertebral bodies,
which is best visualized on lateral X-
rays.
 This squaring occurs due to
inflammation and bone deposition,
resulting in the loss of normal
concavity of the anterior and
posterior borders of the vertebral
body.
 Additionally, early-stage
radiographs may reveal Romanus
lesions, also known as "shiny corner
signs," characterized by small
erosions and reactive sclerosis at the
corners of the vertebral bodies.

17.  The classic radiographic finding in late-stage
AS is the "bamboo spine sign," which refers to
vertebral body fusion by syndesmophytes.
The bamboo spine typically involves the
thoracolumbar or lumbosacral junctions. This
spinal fusion predisposes the patient to
progressive back stiffness.

18.  Certain diseases and conditions can mimic
ankylosing spondylitis (AS) and must be ruled
out. These include, but are not limited to:
 Mechanical low back pain
 Lumbar spinal stenosis
 Rheumatoid arthritis
 Diffuse idiopathic skeletal hyperostosis (DISH)

19. Reduce the
pain
Improve joint
mobility
Strengthen
muscles.
Prevent
complications

20.  Exercise. Exercise is important for
maintaining healthy and strong muscles,
preserving joint mobility, and maintaining
flexibility.
 Support or assistive devices.
 Stress management.
 Healthy diet.
 Quit Smoking.

21.  A large proportion of patients with ankylosing
spondylitis develop hip arthritis. Hip
replacement should be considered in patients
with refractory pain or disability and with
radiographic evidence of structural damage,
independent of age.
 Spinal surgery may be of value in selected
patients

22. Treatment Algorithm of AS

23. Non-steroidal anti-
inflammatory drugs
Disease modifying ant
rheumatic drugs
Corticosteroids
Tumour necrosis factor
inhibitors

24.  Regular use of NSAIDs, starting with celecoxib,
inhibits radiographic progression in ankylosing
spondylitis compared with NSAID use on
demand.
 The decision on which NSAID to use should be
on an individual patient basis taking into
account risk factors, particularly for
gastrointestinal and cardiovascular disease.
 Analgesics, including paracetamol and opioids,
may be considered when NSAIDs are
contraindicated or not tolerated.

25.  Sulfasalazine has inconclusive evidence for
efficacy in ankylosing spondylitis.
 low dose methotrexate did suggest some
clinical benefit in ankylosing spondylitis
 There is little evidence to support the use of
other traditional disease modifying
antirheumatic drugs in ankylosing
spondylitis.

26.  Etanercept, a recombinant TNF receptor:
administered subcutaneously
 Infliximab, a chimeric monoclonal antibody, given
by intravenous infusion
 Adalimumab, a humanised monoclonal antibody to
TNF given subcutaneously.
 Stopping treatment with TNF inhibitors results in
rapid relapse for most patients with longstanding
disease
 TNF inhibitors are powerful drugs and carry the
risk of significant adverse effects. Increased rates
of infection have been reported, including
tuberculosis, and pretreatment screening is carried
out routinely as part of assessment
 TNFα inhibitors are expensive

27.  Intra-articular or periarticular corticosteroid
injections for sacroiliitis have been shown to
be effective.
 Intravenous methylprednisolone is
occasionally used in severe unresponsive
cases.

28. Any Doubts
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