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Ankylosing Spondylitis

on Saturday 20 December 2008
by Sanjay Jain

Ankylosing Spondylitis

The Ankylosing Spondylitis is charactized by progressive stiffness and pain in multiple joints usually starting from back/spine and later spreading to other joints like hip, knee, shoulder extras. The diagnosis of AS is based on clinical and radiographic features. The patient's symptoms, the family history, and the articular and extra-articular physical findings offer the best clues to diagnosis and raise the index of suspicion. Radiographic evidence of sacroiliitis provides the best nonclinical indicator of the presence of the disease. However, the status of the sacroiliac joints on routine pelvic radiographs may not always be easy to interpret in the early phase of the disease, especially in children and adolescents. These patients may require magnetic resonance imaging (MRI), which produces, without any ionizing radiation, excellent but more costly computer-generated imaging. Dynamic MRI or the use of short tau inversion recovery (STIR) and other fat suppression techniques can demonstrate the inflammatory response associated with sacroiliitis and other sites of enthesitis. MRI is also very useful in detecting and evaluating complications of fractures or pseudoarthrosis, as well as changes in the dura mater, soft tissue and spinal ligaments. HLA-B27 typing can be of value in minimizing the degree of uncertainty of the diagnosis in certain clinical situations where an early, unusual, or atypical clinical presentation of AS is suspected, or in the diagnosis of early undifferentiated SpA. As a rule, in those patients in whom history and physical examination suggest AS but whose radiographic findings do not permit this diagnosis to be made, the HLA-B27 test may allow the presumptive diagnosis of AS to be accepted or rejected with less uncertainty. But this test cannot be thought of as a 'routine,' 'diagnostic,' 'confirmatory,' or 'screening' test for AS in patients presenting with back pain or arthritis. HLA-B27 testing is inappropriate in patients with back pain or arthritis in whom neither the history nor the physical examination suggests the presence of AS. A positive result in this clinical situation would still not permit the diagnosis of AS to be made because up to 8% of the general population possesses this gene. An elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) is present in up to 70% of patients with active AS. However, there is a lack of clear correlation with clinical disease activity, and levels of these acute phase reactants seem to have only limited clinical usefulness. They both may relate more to peripheral arthropathy than to the axial disease in AS. A normal ESR and/or CRP do not exclude the presence of clinically active AS. Patients with AS do not show any association with rheumatoid factor and antinuclear antibodies.

Treatment

Optimal management requires a combination of nonpharmacologic and pharmacologic treatments, with appropriate monitoring, depending on disease symptoms, severity, and drug treatment. Patient education is an essential part of the nonpharmacologic treatment for AS and should include recommendation of a life-long program of regular exercise. The usefulness of individual and group physical therapy, as well as patient associations and self-help groups, is also emphasized. Functional disability in AS progresses more rapidly in smokers and less rapidly in those who have better social support and are able to perform back exercises regularly. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is essential to the effective treatment of AS The traditional disease-modifying antirheumatic drugs (DMARDs), including methotrexate, leflunomide, and sulfasalazine, are not recommended for the treatment of axial disease. The recommendations state that sulfasalazine "may be considered in patients with peripheral arthritis rather than for patients with axial disease, but a recent study of patients with early-stage AS reported that sulfasalazine was beneficial only to those patients who did not have peripheral arthritis. Oral or parenteral use of corticosteroids use is not supported by the evidence. Numerous factors influence the overall prognosis, such as the stage of AS disease at diagnosis; initiation of appropriate therapy; the severity of disease activity, particularly at the early stages; the quality of medical management; and the degree of patient compliance with the suggested treatment. Total hip arthroplasty deserves consideration in patients with structural damage causing refractory pain or disability, irrespective of age; there is no need to discontinue NSAID therapy before surgery. Corrective spinal osteotomy and fusion procedures for segmental instability may be indicated in selected patients.