Ankylosing Spondylitis

Ankylosing Spondylitis (AS)

• Spine is usually stiff in flexion
• Iritis (inflammation of the uveal tract) and aortic valve disease are common
• Goal of rehabilitation is to keep the patient functional as long as possible
• Exercises aim to maintain erect posture or stiffness in extension
• Exercise helps maintain aerobic capacity
• In females, involvement of the hip is common
• Arthroplasty done in AS commonly develops post-op heterotopic ossification

New York Criteria for AS (1984)

• History of inflammatory back pain
• Onset is insidious
• Duration is more than 3 months before medical consultation
• Morning stiffness
• Improvement with exercise and activity
• Limited lumbar mobility in both sagittal and frontal planes
• Limited chest expansion (less than 4 cm or more)
• Definite radiographic sacroiliitis

Epidemiology

• Affects young adults (F:3:1)
• Gradual onset

Clinical Manifestations

• Skeletal findings:
  • Axial arthritis (sacroiliitis and spondylitis)
  • Arthritis of girdle joints
  • Peripheral arthritis (uncommon)
  • Enthesopathy
• Extraskeletal findings:
  • Acute anterior uveitis
  • Cardiovascular involvement
  • Pulmonary involvement
  • Cauda equine syndrome
  • Enteric mucosal lesion

Course and Outcome

• Generally, a variable course
• Good prognosis in females
• Poor prognosis with onset in adolescence
• Severe early disease
• Presence of extraarticular complications
• Complete cervical ankylosis with kyphosis
• Lifespan is usually normal
• Potential complications:
  • Cervical spine fracture
  • Cauda equine
  • Pulmonary fibrosis
  • Prostatitis
  • Aortic insufficiency
  • Heart block

Reiter's Disease

• Classic triad of arthritis, urethritis, and conjunctivitis (now uncommon)
• Varied presentation from monoarthritis to severe multisystem disease
• History of antecedent infection or new sex partner
• Constitutional symptoms:
  • Fatigue
  • Malaise
  • Low-grade fever
  • Weight loss
• Manifestations:
  • Asymmetric, additive arthritis
  • Often affects knee, ankle, subtalar joint, MTP, toe, and IP
  • Dactylitis or sausage digit (diffuse swelling of one finger or toe)
  • Tendinitis and fasciitis (plantar fascia)
  • Low back pain
  • Urogenital lesions
  • Prostatitis
  • Ocular:
    • Conjunctivitis
    • Uveitis
  • Musculo-cutaneous lesions:
    • Oral ulcers
    • Keratoderma blenorrhagica (characteristic skin lesion of Reiter's)
  • Nail changes:
    • Onycholysis
    • Distal yellowish discoloration
    • Hyperkeratosis

Course and Outcome

• 30-60% have persistent joint symptoms
• 25% will have disabilities
• Tendency for recurrence
• Chronic heel pain
• Yersinia infection has a better prognosis

Psoriatic Arthritis

• Arthritic problem may present as tendinitis, enthesitis, or synovitis
• Affects both peripheral and spinal joints
• Often asymmetric, but symmetric involvement is not uncommon
• Spinal involvement is usually asymmetrical, so more responsive to exercise
• Prescribe high toe box if involving toes
• Heel lift and arch support are helpful for associated plantar fasciitis
• For spinal involvement:
  • Injections for costochondral joint pain
  • Superficial heating
  • Spine extension exercises
• Koebner or isomorphic phenomenon is a finding seen in dermatologic psoriasis
• X-ray findings:
  • Similar to RA: soft tissue swelling, loss of cartilage space, erosion, bony ankylosis of fingers, subluxations, and subchondral cysts
  • But less demineralization
  • Unique, highly suggestive findings:
    • Erosion at DIP joints
    • Base of terminal phalanx expanded
    • Proximal phalanx tapered
    • Distal terminal phalanx cup-like erosions and bony proliferation (pencil-in-cup appearance)
    • Proliferation of the bone near osseous erosions
    • Terminal phalangeal osteolysis, bone proliferation, and periostitis (especially of phalanges)

Outcome

• Asymmetric and spondylitic subgroups have a better prognosis
• Symmetric type: 50% develop arthritis mutilans

Inflammatory Bowel Disease (IBD)

• Refers to the enteropathic type of spondyloarthropathy
• Equal male and female predilection
• Presents as symmetric, migratory, polyarthritis affecting mainly the large joints
• Predominant spondylitis is more common in males
• May be seen in Crohn's disease, colitis, and other inflammatory bowel diseases
• Radiograph grading system for OA:
  • Grade 0: normal
  • Grade 1: doubtful
  • Grade 2: minimal
  • Grade 3: moderate
  • Grade 4: severe

Spondyloarthropathies

• Definition: a group of clinical conditions that have:
  • Spondylitis
  • Inflammatory peripheral arthritis
  • Positive HLA-B27 antigen
  • Negative Rheumatoid factor (seronegative)

Classification of Spondyloarthropathy

• 1. Primary Ankylosing Spondylitis
• 2. Secondary Ankylosing Spondylitis
  • a. Reactive arthritis (Reiter's disease)
  • b. Psoriatic arthritis
  • c. Enteropathic arthritis