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Ankylosing Spondylitis

Definition and Epidemiology

  • Chronic inflammatory arthritis primarily affecting the spine and sacroiliac joints.
  • Part of the spondyloarthritis group, characterised by spinal fusion due to bony growths (syndesmophytes).
  • More prevalent in males; onset usually in early adulthood.
  • Strong genetic link, with about 90% of Caucasian patients being HLA-B27 positive.

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

  • 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.

Diagnosis

  • 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

  • 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.

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