Ankylosing spondylitis

Surgery > Orthopaedic

Background knowledge 🧠

Definition

Ankylosing spondylitis is chronic inflammatory arthritis primarily affecting the spine and sacroiliac joints.
Part of the spondyloarthritis group, characterised by spinal fusion due to bony growths (syndesmophytes).

Epidemiology

More prevalent in males; onset usually in early adulthood.
Strong genetic link, with about 90% of Caucasian patients being HLA-B27 positive.

Aetiology and Pathophysiology

Exact cause unknown; involves genetic, immunological, and environmental factors.
Inflammation starts at entheses (ligament and tendon attachment points).
Chronic inflammation leads to scarring and ossification, causing stiffness and fusion in the spine.

Clinical Features 🌡️

Clinical Features

Gradual onset of low back pain and stiffness, worse in the morning or after inactivity.
Pain improvement with exercise.
Potential involvement of peripheral joints.
Extra-articular manifestations like uveitis, psoriasis, and inflammatory bowel disease.

Investigations 🧪

Tests

Based on clinical signs, radiographic findings, and HLA-B27 status.
Imaging: X-ray for sacroiliitis, MRI for early changes.
Inflammatory markers (CRP, ESR) may be elevated but are not definitive.

Management 🥼

Management

Non-pharmacological: Emphasis on physiotherapy and regular exercise.
Pharmacological:
- NSAIDs as first-line for pain and stiffness.
- DMARDs (e.g., sulfasalazine) for peripheral symptoms.
- Biologics (e.g., TNF inhibitors) for refractory cases.
Surgical: Osteotomy or joint replacement in advanced cases.

Prognosis

Wide variability in symptom severity and disease progression.
Early treatment and regular monitoring can manage symptoms and slow progression.

Key Points

Ankylosing spondylitis is chronic inflammatory arthritis characterised by spinal fusion due to bony growths.
Has a strong genetic association with HLA-B27.
Patients present with low back pain and stiffness, worse in the morning or after inactivity.
Diagnosis is based on clinical signs, radiographic findings, and HLA-B27 status.
Severity and progression is varied, dictating management which includes non-pharmacological (physiotherapy), pharmacological (NSAIDs, DMARDs) and surgery interventions.

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