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Premium member Presentation Transcript PowerPoint Presentation: Ankylosing spondylitis Dr. Abdul Rasheed Chughatta M.B.B.S (PAK) DCPS (HCSM) Pak) Hebei North University, China ByPowerPoint Presentation: Greek: “ankylos” = bent “spondylos” = spinal vertebra A Chronic inflammatory disease of axial skeleton causing back pain and progressive stiffness, Leads to fusion of some of the spinal vertebrae, making the spine less flexible and resulting in a hunched-forward posture. A severe case of ankylosing spondylitis can result in impossible for lifting of head high enough to see forward. The inflammation also affects the sacroiliac joints. Ankylosing spondylitis DefinitionPowerPoint Presentation: Ankylosing spondylitis (AS) belongs to group of disorders (spondyloarthropathies,) Strong predisposition to cause inflammation at enthesis (the site of attachment of a muscle or ligament to bone), An association with HLA-B27 Other members of spondyloarthritis (SpA) family: Reactive arthritis, (Reiter's syndrome or Reiter's arthritis) Psoriatic arthritis , Arthritis associated with inflammatory bowel disease At a Glance Ankylosing spondylitisEpidemiology: Epidemiology Prevalence: The estimated prevalence is 0.2% to 1.2%, Age: Most often affects the young adults between the age of 20-30 years , may also begin in middle-aged, Gender: Males are affected more than females; ( M:F = 4:1), most women tend to experience milder symptoms Ethnicity: Mostly Caucasians race (native to Europe, North Africa, and southwest Asia, having usually light skin pigmentation) Caucasians to Blacks = 3:1 Ankylosing spondylitisPowerPoint Presentation: There is a strong familial tendency with >90% of the risk of ankylosing spondylitis determined genetically. A strong association with HLA-B27 exists, particularly in white western European populations. Approximately 1-2% of all people who are positive for HLA-B27 develop ankylosing spondylitis (AS). This increases to 15-20% if they also have an affected first-degree relative. Twin studies concordance of Ankylosing spondylitis : 63% for identical twins, However, despite much study, it is not clear how the association with HLA-B27 determines disease susceptibility. Ankylosing spondylitis GeneticsPowerPoint Presentation: In Ankylosing Spondylitis, the major histocompatibility complex (MHC) - a cell surface molecule encoded by a large gene family which mediates the actions of leukocytes - accounts for nearly half of the disease susceptibility. Other associated genetic factors include HLA-B60 and HLA-B39 (in HLA-B27-negative patients). Only small percentage of HLA-B27 individuals in population suffer from a Spondyloarthropathy (3-8% of Americans HLA-B27 positive), suggesting that other genetic and environmental factors may play a role. Ankylosing spondylitis GeneticsPowerPoint Presentation: Only small percentage of HLA-B27 individuals in population suffer from a Spondyloarthropathy (3-8% of Americans HLA-B27 positive), suggesting that other genetic and environmental factors may play a role. Recently, two more genes, ARTS1 and IL23R have been identified that are associated with ankylosing spondylitis. These genes are called. It is anticipated that by understanding the effects of each of these known genes researchers will make significant progress in discovering a cure for ankylosing spondylitis Ankylosing spondylitis GeneticsPowerPoint Presentation: Major histocompatability complex (MHC) class I allele Presents peptides from intracellular pathogens for recognition by T-cell receptors of CD8+ T cells Pathogenic link between HLA-B27 and Ankylosing spondylitis elusive despite association of over 30 years, Prevalence: 8% Caucasians; 4% African Americans; 0.1-0.5% Japanese Northern Scandinavia: 24% HLA-B27 positive; Ankylosing spondylitis prevalence: 1.8% HLA-B27PowerPoint Presentation: Characterized by chronic inflammation and progressive ankylosis Commonly accepted that inflammation is driving force for structural damage in Ankylosing spondylitis Current research shows that tumor necrosis factor (TNF) is important cytokine contributing to inflammation in Ankylosing spondylitis . PathophysiologyPowerPoint Presentation: Hallmark of structural abnormality in Ankylosing spondylitis is bony ankylosis, As the disease worsens, new bone forms as part of the body's attempt to heal. The new bone gradually bridges the gap between vertebrae and eventually fuses sections of vertebrae together, Fused vertebrae can flatten the natural curves of spine and force it into an inflexible, hunched posture PathophysiologyPowerPoint Presentation: PathophysiologyPowerPoint Presentation: PathophysiologyPowerPoint Presentation: Fusion Inflammation Normal Spine Early Ankylosing Spondylitis Advanced Ankylosing Spondylitis PathophysiologyPowerPoint Presentation: PathophysiologyPowerPoint Presentation: Normal Posture Advanced Ankylosing SpondylitisPowerPoint Presentation: Progressive deformity due to Ankylosing Spondylitis over a period of 36 yearsPowerPoint Presentation: Inflammatory back pain Onset before age 40 years Insidious onset Improvement with exercise No improvement with rest Pain at night (with improvement upon arising) Patient has a 25% probability of having ankylosing spondylitis if four of five of the above symptoms are present. HistoryPowerPoint Presentation: Signs and symptoms of Ankylosing Spondylitis typically begin in early adulthood, The initial symptoms are those of stiffness and low grade back pain which is worst in the morning. it could affect any part of the spine, i.e. the lumbar , the thoracic , and the cervical spine. The thoracic cage is also frequently affected by the inflammation and consequent pain and stiffness. Clinical FindingsPowerPoint Presentation: Inflammation also can occur in other parts of body — such as eyes and bowels . There is no cure for ankylosing spondylitis, but treatments can decrease pain and lessen symptoms. Clinical FindingsPowerPoint Presentation: Insidious onset of low back pain and stiffness Poor chest expansion Stiffness Exaggerated dorsal kyphosis HLA-B 27 positive in >90% Clinical FindingsPowerPoint Presentation: 5 major symptoms of Ankylosing Spondylitis: Fatigue Spinal/ Back pain in 70% of all adults (2nd most common symptomatic visit to physicians, next to upper respiratory infections), Only 14% have an episode that lasts more than 2 weeks, Joint pain / swelling, Areas of localized tenderness (also called enthesitis , or inflammation of tendons and ligaments), Morning stiffness ≈ duration/severity Clinical FindingsPowerPoint Presentation: Location Axial skeleton and large, usually central, appendicular joints Sacroiliac joint involvement Hallmark of disease Only synovial portion of SI joint is involved Inferior and anterior portion of joint Other enthesopathies like DISH can cause bridging of upper, non-synovial part of joint Usually site of initial involvement Bilaterally symmetric Widened with erosions at first Then ankylosis Clinical FindingsPowerPoint Presentation: Spine Usually begins at either thoracolumbar or lumbosacral junctions Extends symmetrically without skip areas Reiter’s and psoriasis characteristically are asymmetric and have skip areas Marginal syndesmophyte formation = thin vertical dense spicules bridging the vertebral bodies Ossification of outer fibers of annulus fibrosus Not anterior longitudinal ligament Clinical FindingsPowerPoint Presentation: AP view of the lumbosacral spine showing classic changes of ankylosing spondylitis. Note bilateral symmetric sacroiliac erosive changes with sclerosis. Characteristically, delicate vertical syndesmophytes bridge multiple vertebra causing a "bamboo spine"PowerPoint Presentation: AP view (magnified segment) of the lumbosacral spine with ankylosing spondylitis. showing characteristic “ syndesmophytes”PowerPoint Presentation: Syndesmophytes (arrows) in the spine of a patient with ankylosing spondylitisPowerPoint Presentation: Spine (continued) Trolley-track sign on AP view = central line of ossification (supraspinous and interspinous ligaments) with two lateral lines of ossification (apophyseal joints) Clinical FindingsPowerPoint Presentation: “Trolley Track Sign” in Ankylosing Spondylitis – combination of bamboo spine and ossification of the interspinous ligaments.PowerPoint Presentation: Central linear vertical ingle radiodense line is related to ossification of supraspinous and interspinous ligaments . Two lateral vertical linear lines represent ossification of the apophyseal joint capsules. AP radiograph of the lumbar spine with classic “Trolley Track Sign”PowerPoint Presentation: Bamboo spine on AP view = undulating contour due to syndesmophytes Prone to fracture resulting in pseudarthrosis Straightening / squaring of anterior vertebral margins Osteitis of anterior corners Reactive sclerosis of corners of vertebral bodies = shiny-corner sign Symmetric erosions of laminar and spinous process at level of lumbar spine Apophyseal and costovertebral ankylosis Clinical FindingsPowerPoint Presentation: Lateral view of the lumbosacral spine showing classic changes of ankylosing spondylitis. Note annular calcification causing the appearance of “squared vertebral bodies”PowerPoint Presentation: The typical “ shiny corner” sign: Lateral radiograph showing anterior corner erosions at the T12 and L1 vertebral bodies. (arrows) Clinical FindingsPowerPoint Presentation: Periosteal whiskering (short, linear spiculations of irregular bone ~ enthesophytes ) Sites of tendinous insertion Ischial tuberosity Iliac crest Ischiopubic rami Greater femoral trochanter External occipital protuberance Calcaneus Patella Dorsal arachnoid diverticula in lumbar spine with erosion of posterior elements Atlantoaxial subluxation Clinical Findings: A term referring to the short, linear spiculations of irregular bone (enthesophytes) seen by plain films at the sites of muscle insertion and osseous stress, variably accompanied by osteosclerosis, cystic changes and dystrophic calcification; It is most common in the iliac, ischial and calcaneus bones, due to spondyloarthropathies—e.g., ankylosing spondylitis, DISH in renal osteodystrophy, and degenerative joint disease Periosteal whiskeringPowerPoint Presentation: Enthesophytes ( yellow arrows ): Irregular outgrowths (whiskering) seen most commonly at the iliac crests, ischial tuberosities, and the trochantersPowerPoint Presentation: Peripheral Arthritis (40%) Hip Joint (most frequently involved) Concentric joint narrowing Few erosions Protrusio acetabuli Temporomandibular joint Joint space narrowing Erosions Osteophytosis Hand (33%) Target area (MCP, PIP, DIP) Exuberant osseous proliferation Osteoporosis / Joint space narrowing Osseous erosions (deformities less striking than in rheumatoid arthritis) Clinical FindingsPowerPoint Presentation: Chest Bilateral upper lobe pulmonary fibrosis (1%) with upward retraction of hila, Resembles tuberculosis. Associated with: Ulcerative colitis Regional enteritis Clinically the SI joint involvement is identical to Inflammatory Bowel Disease (IBD) Clinical FindingsExtra-axial manifestations: Extra-axial manifestations Acute Anterior uveitis (20-30%) Of all patients presenting with acute anterior uveitis, 33-50% have or will go on to develop AS. Cardiovascular (<10% ) Aortic insufficiency and atrioventricular conduction defect, Prognosis: 20% progress to significant disability Clinical FindingsExtra-axial manifestations: Extra-axial manifestations Pulmonary involvement : Restrictive lung disease may occur in later stages, with costovertebral and costosternal involvement limiting chest expansion. Pulmonary Fibrosis of the upper lobes. Renal involvement : Amyloidosis (very rare complication) May cause renal dysfunction with proteinuria and renal insufficiency or failure. Immunoglobulin A (IgA) nephropathy is another association. Clinical FindingsExtra-axial manifestations: Extra-axial manifestations Neurological involvement : Usually occurs secondary to fractures of a fused spine. Patients with AS are prone to atlanto-axial subluxation, which may lead to cervical myelopathy . Cauda equina Syndrome may occur in patients with severe long-standing disease. Metabolic bone disease : Osteopenia and Osteoporosis; may occur in patients with long-standing spondylitis, further increasing risk of fracture. Clinical FindingsPowerPoint Presentation: ExaminationPowerPoint Presentation: Examination Schober’s test Gaenslen Test Chin-Brow Measurement Lateral spine flexion test Chest expansion test Range of MotionPowerPoint Presentation: The Schober test measures the degree of lumbar forward flexion as the patient bends over as though touching their toes. Progressive loss of spinal motion is correlated with x-ray findings. Schober's TestPowerPoint Presentation: A mark is made at the level of the posterior iliac spine on the vertebral column, i.e. approximately at the level of L5. Make another mark 5cm below this mark, Make another mark at about 10cm above the first mark. Schober's Test The patient is then instructed to bend at waist to touch his toes. Increase in distance between the upper and lower marks less than 5cm is indicative of a limitation of lumbar flexion.PowerPoint Presentation: Gaenslen test (Gaenslen's maneuver) stresses the sacroiliac joints, Increased pain during this maneuver could be indicative of joint disease. Gaenslen Test Sacroiliac pain is often found in the early stage of Ankylosing Spondylitis.PowerPoint Presentation: Examiner stands at the side of the table Patient’s knees flexed to the chest until the lower back assumes physiologic lordosis, Contralateral leg is fixated, A light pressure applied to the ipsilateral leg causing hyperextension of the hip. Gaenslen Test Patient supine (on back), affected side close to the edge and partially off the examination table,PowerPoint Presentation: Patient with AS often have necks that angle forward sharply as the spine stiffens. Chin-brow measurement is used to monitor this angle, The first measurement is called the "baseline." Each successive measurement is compared to the baseline to see if the angle is getting worse. Chin-Brow Measurement Used to measure the curve of cervical spine.PowerPoint Presentation: An expansion less than 2.5cm is abnormal. Chest Expansion Test Measured at level of 4th intercostal space, The difference between maximum inspiration and expiration is measured,PowerPoint Presentation: Heel and back against wall Measure distance from middle finger to floor Bend sideways without bending knees and repeat measurement Greater than 10cm is normal. Lateral Spinal FlexionPowerPoint Presentation: To test how well and far your joints allow you to move, the doctor measures the degree to which you can perform movements of flexion, extension, lateral bending, and spinal rotation. Asymmetry may also be noted. Range of MotionPowerPoint Presentation: X-ray is standard for diagnosing sacroiliitis and differentiating Ankylosing Spondylitis from undifferentiated spondyloarthritis (SpA) Poor sensitivity in early stages of disease. Radiographic DiagnosisSacroilitis grading: Grade 0 : Normal, Grade 1 : Some blurring of the joint margins – suspicious, Grade 2 : Minimal sclerosis with some erosion, Grade 3 : Severe erosions with widening of joint space +/- ankylosis, Grade 4 : Complete ankylosis. Radiographic Diagnosis Sacroilitis gradingPowerPoint Presentation: Normal http://radiopaedia.org/articles/sacroiliitis_grading Grade - 0PowerPoint Presentation: X-ray of the n ormal lumbar spine and pelvis: Yellow arrows point to posterior aspect of the sacroiliac jointsPowerPoint Presentation: Some blurring of the joint margins – suspicious Grade - 1 2 Minimal sclerosis with some erosion 3 Severe erosions with widening of joint space +/- ankylosis http://radiopaedia.org/articles/sacroiliitis_gradingPowerPoint Presentation: Bilateral Sacroiliitis Grade - IIIPowerPoint Presentation: Grade - 2 vs 3 Comparison Sacroiliitis Grade - II Sacroiliitis Grade - III LPowerPoint Presentation: Complete ankylosis Grade - 4 http://radiopaedia.org/articles/sacroiliitis_gradingPowerPoint Presentation: Grade – 4 Sacro Iliitis Pelvis – AP view, showing Bilateral Grade – 4 Sacro Iliitis (Complete Ankylosis)PowerPoint Presentation: Pelvis AP View, showing classic changes of Ankylosing Spondylitis Obliterated Sacroiliac joints with osseous fusion Hip Joint Space narrowing Hip Joint Space narrowingPowerPoint Presentation: Progression of Sacroiliitis in Ankylosing Spondylitis Pelvis (AP View) - 1975 Normal Pelvis (AP View) - 1981 Irregularity of the Sacroiliac joints , more so on the iliac sides. Pelvis (AP View) - 1982 Evident erosion and sclerosis of Sacroiliac joints, o n both the sacral & iliac sidesPowerPoint Presentation: X-ray showing “bamboo spine” in a patient with Ankylosing Spondylitis. X-ray showing “bamboo spine” in a patient with Ankylosing Spondylitis .PowerPoint Presentation: BAMBOO SPINE Lateral radiograph of neck showing “bamboo spine” in a patient with Ankylosing Spondylitis.PowerPoint Presentation: A 44 year old man, with ankylosing spondylitis of 19 years duration. Ossification of the posterior longitudinal ligament (OPLL) is present from C3 to C5 (white arrow).PowerPoint Presentation: Ossification of the posterior longitudinal ligament in Cervical SpinePowerPoint Presentation: CT scan of a normal SI joint The Joint space is considered normal between 2.0 and 4.0 mmPowerPoint Presentation: X-ray of a normal Sacro Iliac joint Normal Sacro Iliac Joint space X-ray of a Fused Sacro Iliac joint Fused Sacro Iliac Joint spacePowerPoint Presentation: Ankylosing spondylitis- Note fusion of both SI joints and thin, symmetrical syndesmophytes bridging the intervertebral disc spacesPowerPoint Presentation: T1-weighted MRI with fat suppression after administration of gadolinium contrast showing sacroiliitis in a patient with ankylosing spondylitis Most sensitive imaging for detection of inflammation. MRIPowerPoint Presentation: Fat-suppressed MRI of sacroiliac joints(coronal view) Thick arrows point to subchondral marrow inflammationPowerPoint Presentation: MRI showing the presence of ankylosing spondylitis in the upper part of Lumbar SpinePowerPoint Presentation: Rheumatoid arthritis - predominantly affects peripheral joints and is rheumatoid factor positive. Psoriatic arthritis - usually accompanied by skin and nail disease Reactive arthritis (Reiter's syndrome or Reiter's arthritis) - follows a genitourinary or intestinal infection (“Can’t pee, can’t see, can’t bend at the knee”) Inflammatory bowel disease arthritis - usually follows GI symptoms. Differential DiagnosisPowerPoint Presentation: The following conditions may also be considered during differential diagnosis for Ankylosing Spondylitis; Mechanical back pain. Infection, e.g. tuberculosis Neoplasms, primary or secondary. Referred pain. Congenital spinal deformity. Trauma. Differential DiagnosisPowerPoint Presentation: One clinical criterion Inflammatory back pain (Calin 1977) Reduced mobility of the lumbar spine in two planes (<3 cm) Limitation of chest expansion (<3 cm ) Radiologic criterion Radiologic sacroiliitis of ≥ grade 2 bilaterally OR Radiologic sacroiliitis of grade 3-4 unilaterally Limitations: Radiographic evidence may not show up for years. Restriction of spinal mobility also may be a late finding. Modified New York Criteria - 1984 For Diagnosis / Classification of ANKYLOSING spondylitis > 95% of AS patients have definite changes in SI JointsA case for early diagnosis: A case for early diagnosis In the past, treatment options were limited to physical therapy and NSAIDs. In the past, a delay in diagnosis did not affect patient due to lack of highly effective therapeutic medications. Recently, tumor necrosis factor (TNF) blocking agents have shown a strong response. Ankylosing Spondylitis patients with short disease duration and good functional status respond better to TNF blocking agents.PowerPoint Presentation: InvestigationsPowerPoint Presentation: No laboratory tests are diagnostic. At the initial presentation, investigations may be more useful to exclude other conditions than to positively confirm ankylosing spondylitis. Nevertheless, some tests can support the diagnosis of ankylosing spondylitis: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): provide evidence of inflammation if they are elevated, but they may be within normal limits or only mildly elevated. Full blood count: A mild normochromic normocytic anaemia also provides evidence of inflammation. Investigations Blood TestsPowerPoint Presentation: Rheumatoid factor and anti-nuclear antibodies: Are NOT useful for diagnosing ankylosing spondylitis in primary care, Are usually negative in ankylosing spondylitis. HLA-B27: Testing is usually done in secondary care. Sensitivity and specificity for ankylosing spondylitis were about 90% in one study However, for a condition with low prevalence (e.g. about 5% of people presenting with back pain) the HLA-B27 test is not thought to be accurate enough to be helpful in a primary care setting. Testing unaffected or asymptomatic relatives for HLA-B27 status is not justified as there is no preventive or curative therapy Investigations Blood TestsPowerPoint Presentation: The sacroiliac joints X-rays are the most helpful imaging modality in established disease, although they may be normal in early disease. Look for sacroiliitis or enthesitis (particularly of the annulus fibrosus). Sacroiliitis initially shows as blurring in the lower part of the joint, then bony erosions or sclerosis occur and widening or eventual fusion of the joint. Investigations Imaging - X-RaysPowerPoint Presentation: The Spine The vertebral bodies may become 'squared'. In later stages, bony bridges ( syndesmophytes ) form between adjacent vertebrae, there is ossification of spinal ligaments, In late disease, there may be complete fusion of the vertebral column ( bamboo spine ). Spinal osteopenia is common. Investigations Imaging - X-RaysPowerPoint Presentation: MRI scanning may be useful in sacroiliitis. MRI of the sacroiliac joints is more sensitive than either plain X-ray or CT scan in identifying early sacroiliitis. It has a growing role in diagnosis, prognostication and selection of patients for biological treatment. MRI/CT scans - useful in making the diagnosis of a spinal fracture in patients with late-stage spinal disease. Investigations Imaging - MRI ScanningPowerPoint Presentation: Dual-Energy X-Ray Absorptiometery (DEXA) scans are used to assess for osteoporosis but may underestimate the fracture risk in AS, due to new bone formation in the spine. Musculoskeletal ultrasound scanning can help in diagnosing enthesitis. Investigations Imaging - DEXAPowerPoint Presentation: ManagementPowerPoint Presentation: Ankylosing spondylitis affects people differently. With this condition, like other types of arthritis, it is advisable to keep fit and get plenty of exercise. The optimal management of ankylosing spondylitis involves; Medications (to reduce inflammation or suppress immunity), Physical therapy, Exercise. ManagementPowerPoint Presentation: Treatment usually combines medication with exercise (e.g. swimming) or physiotherapy . Exercises that help maintain flexibility and improve posture are recommended. It is also advisable to maintain a suitable weight for height and eat healthily. Heat packs will often help to relieve pain and stiffness. Although no cure is currently available, a number of medication options are available to treat AS. Non-prescription analgesics (e.g. paracetamol) can be used to relieve pain, and other medications are use to treat inflammation. ManagementPowerPoint Presentation: NSAIDs Non-steroidal anti-inflammatory drugs (NSAIDs) are used frequently to relieve pain and stiffness . Numerous studies show that NSAIDs provide rapid improvement in back pain and physical function Toxic side-effects on GI tract A 2 year RCT (n=215) showed reduced radiographic progression in AS patients treated with continuous (celecoxib) compared to on demand treatment. ManagementPowerPoint Presentation: DMARDs A group of medications called disease-modifying anti-rheumatic drugs are used to treat individuals with severe AS e.g. sulfasalazine and methotrexate. ManagementPowerPoint Presentation: Biologic drugs /Tumor Necrosis Factor blocking agents (anti-TNFs) Newer, effective medications for spine disease, Attack a messenger protein of inflammation called “Tumor Necrosis Factor (TNF). Provide excellent and quick symptomatic relief, by stopping disease activity, decreasing inflammation, and improving spinal mobility, Withdrawal often results in relapse, Long-term use decelerates but does not inhibit structural deterioration in patients with AS. Long term side effects unknown, Examples: Etanercept (Enbrel), Infliximab (Remicade), Adalimumab (Humira), and qolimumabg (Simponi). ManagementPowerPoint Presentation: Instructions - to maintain proper posture: Deep breathing for lung expansion Stretching exercises to improve spine and joint mobility. Maintain erect posture as much as possible Perform back-extension exercises. Ankylosis of the spine tends to cause forward curvature Sleep on a firm mattress and avoid the use of a pillow in order to prevent spine curvature. Expand chest maximally frequently throughout each day to minimize limited breathing capacity Ankylosing spondylitis can involve the areas where the ribs attach to the upper spine as well as the vertebral joints Management Physical TherapyPowerPoint Presentation: Exercises: Exercise programs are customized for each individual. Swimming often is a preferred form of exercise, as it avoids jarring impact of the spine. Ankylosing spondylitis need not limit an individual's involvement in athletics. Aerobic exercise - when the disease is inactive. It promotes full expansion of the breathing muscles and opens the airways of the lungs. Management Physical TherapyPowerPoint Presentation: Surgery: Rarely used in treatment but it is important in restoring movement to a damaged hip joint (e.g. hip replacement). Rehabilitation and Physical Therapy: Recent trials with a total of 561 participants showed that group and individual physical therapy leads to significant improvement in relief of symptoms and physical function. ManagementPowerPoint Presentation: Use NSAIDs and physical therapy as first-line therapy Tumor Necrosis Factor blocking agents (anti-TNFs) provide rapid and effective improvement in pain and function. Total hip arthroplasty and spinal surgery are of value in selected patients Treatment SummaryPowerPoint Presentation: The outlook for patients with ankylosing spondylitis is very much dependent upon the location and severity of its manifestations. The prognosis is best for those who maintain close monitoring with the treating doctors and who incorporate physical activities designed to maintain mobility. Quitting Smoking is essential for the best long-term outcome. PrognosisPowerPoint Presentation: Early age of onset- disease is often more severe when it occurs early in life; Male gender Hip arthritis Prevalence of any three of following with in 2 years of diagnosis: ESR > 30 mm/hr NSAID unresponsiveness Limitation of lumbar spine movement Sausage-like digits Oligoarthritis Smoking Extra-articular features Prognostic FactorsPowerPoint Presentation: Diagnosis & treatment Algorithm for Ankylosing Spondylitis Kruszka PS. Ankylosing Spondylitis. In: Ebell MH, Ferenchick G, Smith M, Barry H, Slawson D, Shaughnessy A, Forsch R, Li S, Wilkes M, Usatine R, eds. Essential Evidence. John Wiley and Sons: Hoboken, NJ, 2009.PowerPoint Presentation: Onset of back pain before age of 40 yrs 4 of 5 criteria: Insidious onset, Persistence for at least 3 months, Associated with morning stiffness, or Improvement with exercise? No Consider another diagnosis 25% probability of Ankylosing Spondylitis 5% prevalence of Ankylosing Spondylitis (Assumed in chronic low back pain. YesPowerPoint Presentation: 25% probability of Ankylosing Spondylitis 5% prevalence of Ankylosing Spondylitis (Assumed in chronic low back pain. Anterior spine flexion of <5 cm. (Schober’s test) Chest expansion of <2.5 cm. (often absent in early disease) Order sacroiliac x-ray. Radiologic criterion of Grade II sacroiliitis (B/L) or Grade III or IV (U/L) Yes Definite diagnosis; treat as Ankylosing Spondylitis No Patient still has possible early Ankylosing Spondylitis. Order HLA-B27. Negative Possibility of Ankylosing Spondylitis (< 3%) Consider another diagnosis. Positive Early Ankylosing Spondylitis (80%) . Consider a trial of NSAIDs & physical therapy or Refer to reumatologistPowerPoint Presentation: Prevention measures are directed toward preventing complications of the disease with optimal treatments and monitoring for side effects of the treatments. Can ankylosing spondylitis be prevented? “There is no prevention for this inherited (genetic) disease”PowerPoint Presentation: The future for patients with Ankylosing Spondylitis? Active Research in Progress Rresults of ongoing research very hopeful Effects of these genes being understood Infectious agents trigger chhronic inflammation Factors perpetuating "auto -immunity " Recent discovery of genes, RTS1 & IL23R Seven different subtypes of HLA-B27More information about Ankylosing Spondylitis: More information about Ankylosing Spondylitis For more information about ankylosing spondylitis, please visit the Arthritis Foundation (http://www.arthritis.org/) and contact local branches of the Arthritis Foundation and/or Spondylitis Association of America for support group information.PowerPoint Presentation: Ankylosing spondylitis (AS) is an autoimmune disease of unknown aetiology. It presents in young adults, often in an insidious manner with pain and stiffness in lower back associated with gradual loss of spinal mobility. Ankylosing spondylitis (AS) is a form of seronegative spondyloarthropathy. Illness may cause inflammation in uveal tract (iritis in 25%) & in intima of aorta, Symptoms are typically worse in the morning and in the middle of the night, It is an uncommon condition, with a prevalence of 0.05 - 0.23% in the general population. Ankylosing spondylitis Summary It has been estimated that up to 90% of patients with AS possess the tissue , HLA B27 (Human Leukocyte Antigen B27) . AS only develops in 1% of individuals who have HLA-B27 antigen. The disease is thought to be triggered by an unrecognised environmental factor, in genetically predisposed individuals. AS is an uncommon cause of back pain, however it is important to consider in the younger patient. Early diagnosis and initiation of treatment, especially now with the use of TNF alpha drugs, can prevent severe fixed deformities of the spine.PowerPoint Presentation: THANK YOU You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.