Buths Capella Fouts Ankylosing Spondylitis

Ankylosing spondylitis : 

Ankylosing spondylitis Caroline Buths , Molly Capella , Jacob Fouts February 2012

General Description: 

General Description Ankylosis Spondylitis is a chronic disease that progresses consistently up the spine. Initial involvement usually begins at the sacroiliac and spinal joints. Disease progression leads to ossification of affected joints. 3 Characterized by inflammation of the involved sites especially the insertion point of ligaments, tendons, fascia, and fibrous joint capsules. 3 The hallmark sign of AS (ankylosis spondylitis ) is sacroiliac joint initial involvement. 4

Signs and Symptoms: 

Signs and Symptoms Are not consistent with all those who have been diagnosed. Each patient will have a unique reaction to the disease progression. 4 Initial complaints include: Stiffness/pain in low back/buttock region especially in the morning and at night. 4 Pain described as dull and diffuse. 4 Possible S & S: mild fever 4 Nausea 4 loss of appetite 4 Fatigue 4 It is important to note that women’s S & S present differently than men. Women’s symptoms are commonly reported as starting in the neck region. 4 A S & S used to help with diagnosis is pain that persist more than three months. 4

Incidence: 

Incidence Population most affected is Caucasian males. Other ethnicities and women are also affected, but these populations have a lower incidence rate. 4 A strong genetic link has been found indicating that family history of AS increases chances of diagnosis. 1 HLA-B27 in a tissue antigen that is found during blood work in 96% of Caucasian males diagnosed with AS. 3 Age of onset ranges between late teens until thirty. 4 Research has found that AS only occurs under the age of ten in 5% of those diagnosed and over the age of fifty in 5% or less of those diagnosed. 1

Diagnosis: 

Diagnosis X-Rays/MRI 4 Individual Medical History 4 Family Medical History 4 Blood Work: HLA-B27 4 Site of Inflammation and Tenderness 4 Positive response to NSAIDs 4

Prognosis: 

Prognosis Once diagnosed, disease progression is most often continuous. 3 The inflammation typically begins in the sacroiliac region and continues up the spine until reaching the neck. 3 The peripheral joints are eventually typically involved including: hips, shoulders, ankles. The most common peripheral joint involved are the hips. 3 Other common lesion sites include: eyes, lungs, heart, and prostate. 3

Treatment : 

Treatment Psycho-social 3 Therapeutic drugs 3 Radiation therapy 3 Assistive Devices 3 Physical therapy 3 Surgery 3

Impact of Function : 

Impact of Function Function is impacted later in later stages of disease progression. Once costovertebral joints are affected, the patient begins to have pain with deep breathing. Eventually, these joints will loose motion making chest expansion impossible. This change in joint mechanics causes the patient to develop a labored breathing pattern. 3 Another common injury is fracture of vertebrae. Once the vertebrae have fractured, the patient assumes a mass flexion posture, and this posture doe not allow the patient to lift their head up. 3 An important progression to note is fusion of the hips. Once the hip joints have fused, walking becomes painful and eventually impossible. 3

Role of Imaging: 

Role of Imaging There is still debate over the role of imaging. Most articles agreed that imaging was a useful tool in tracking the progress of AS. 3 Radiographs have been useful in showing narrowing of the SI joint cartilaginous space and subchondrial sclerois . 3 Unfortunately, it can take 7 years of AS before any changes can be detected on radiographs. 4

Best Imaging : 

Best Imaging Conventional radiographs will show erosion typical of sacroiliitis , which is inflammation of the sacroiliac joints 4 If signs are present in radiographs, then they have been proven as a reliable finding to support a diagnosis of AS. 2 MRI is another imaging option, but is has not been validated as a means of making a diagnosis. There is not standard for interpreting MRIs for the AS population. 4 Yu et al were able to show that MRI can be more sensitive than either radiography or CT scanning in the detection of early cartilage changes and bone marrow edema of the sacroiliac joints 2

Radiograph of Normal Pelvis: 

Radiograph of Normal Pelvis

Radiograph of AS pelvis : 

Radiograph of AS pelvis

Radiograph: ABCS: 

Radiograph: ABCS • Alignment -The bones in this image are aligned. There is no evidence of fractures, exostoses , subluxations , or dislocations. • Bone Density -Increased bone density of the left and right femoral head and acetabulum (left>right), indicating degenerative changes and subchondral sclerosis of the joints. -Increased bone density in the intervertebral disc region and in between spinous processes, indicating ossification and subsequent linkage of these structures. • Cartilage - Absent sharp outline of bilateral sacroiliac joints - There is no evidence of joint space between the ilium and the sacrum (bilaterally), most likely due to fusion of the two bones during the repair process. -Joint space between the acetabulum and the femur (bilaterally) is significantly decreased, more so on the left than right. -Note the decreased space between the lower lumbar vertebrae and intervertebral discs, as well as the lumbosacral junction. These joints likely have fused as well. -There is a lack of separation between the spinous processes (notice the solid white line running down the midline of the spine). This indicates linkage (fusion) of the spinous processes. • Soft Tissue - The intervertebral discs are no longer apparent, as there is ossification lying overtop of them.

Radiograph: Possible Biomechanical/ Physical Impairments: 

Radiograph: Possible Biomechanical/ Physical Impairments Complete loss of motion at the sacroiliac joints and lower lumbar intervertebral joints: lack of trunk flexion, extension, sidebending , and rotation, lack of nutation and counternutation of the sacrum. Decreased motion at the hip joints, possibly occurring in a capsular pattern (FAME or MEAF) Severity of physical impairments associated with AS will affect many aspects of the patient’s life, from simple ADL’s to high-level activities. Difficulty walking and abnormal gait pattern due to hip and sacroiliac stiffness Inability to dissociate trunk from pelvis: abnormal rolling, sit-to-stand, turning May have a stooped posture if the spine fuses in a kyphotic pattern (common) Muscle tightness and weakness secondary to lack of (loss) of spinal, sacroiliac, and hip mobility Tight: quadratus lumborum , hip internal and external rotators, hip adductors Weak: paraspinals , multifidi , gluteus maximus / medius / minimus

Radiograph VS MRI : 

Radiograph VS MRI

MRI: ABCS : 

MRI: ABCS Alignment The bones in this MRI image remain aligned and the vertebrae are still in their normal shape due to the disease being in the early stages. In later stages of ankylosing spondylitis the vertebral bodies will become squared. Bone Density The MRI image shows an increased signal at the anterior vertebral bodies of T3 and T5. The increase in signal represents a destructive area known as a Romanus lesion. Following the erosion sclerosis will typically appear at the edge of the vertebrae that were affected. Cartilage Due to the disease being in the early process the intervertebral joint space remains near normal. There is a small decrease in joint space at the T2/T3 intervertebral joint space. There is an increased signal for the T2/T3, T3/T4, T4/T5, and L5/S1 intervertebral disc suggesting fluid is present in the disc, which is expected for a normal intervertebral disc. Soft Tissue The soft tissues appear normal in this image due to the disease still being in the early stages.

MRI: Possible Biomechanical/ Physical Impairments: 

MRI: Possible Biomechanical/ Physical Impairments Due to the disease being in the early stages of progression the patient would typically not demonstrate significant biomechanical and physical impairments compared to what was seen on the previous radiograph showing advanced ankylosing spondylitis. Possible early signs and impairments of ankylosing spondylitis for this patient could include frequent pain and stiffness in the low back area, more so near the Romanus lesions at the T3 and T5 vertebrae. Flexion may cause more pain/discomfort for the patient due to the Romanus lesions being compressed. As the diseases progresses the patient would begin to notice increased stiffness in the vertebrae that were affected resulting in loss of mobility.

Questions: 

Questions 1. When viewing images (conventional radiographs, MRI’s, etc.) of a patient with signs of ankylosing spondylitis (AS), what are other possible diagnoses you would need to rule out, that present similarly on imaging, before confirming the AS diagnosis? 2. What is a significant imaging finding, present in the later stages of AS, that will influence the treatment plan of the physical therapist?

References : 

References 1. Masi A, Nair K, Andonian B, et al. Integrative Structural Biomechanical Concepts of Ankylosing Spondylitis. Arthritis. 2011; 2011: 10 pages. http://www.hindawi.com/journals/arth/2011/205904. Accessed February 1 , 2012. 2. Peh , Wilfred. Imaging in Ankylosing Spondylitis. http://emedicine.medscape.com/article/386639-overview#921 . Updated April 12, 2011. Accessed February 1, 2012. 3. Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System. 3 rd ed. Baltimore, MD: Lippincott Williams and Wilkins; 1999. 4. Spondylitis Association of America. http://www.spondylitis.org . Updated 2011. Accessed February 1, 2012. Imaging Pictures Websites: Radiograph of a Normal Pelvis: http://www.hss.edu/images/corporate/pelvic-fractures-0.jpg Pelvic Radiograph of a Patient with Anklyosing Spondylitis: http://images.rheumatology.org/image_dir/album75694/md_05-07-0067.jpg MRI: http://manju-imagingxpert.blogspot.com/2009/07/shiny-corner-sign-in-ankylosing.html