Ankylosing Spondylitis Remission
Ankylosing spondylitis (AS) is one of the group of seronegative forms of arthritis, which also includes Reiter's syndrome and psoriatic arthritis. There is a close association with the HLA-B27 type, and the disease is more than three times more common in men than in women. In many patients, the disease seems to progress slowly for years, primarily with back pain, and then stabilizes without much disability. In some cases the disease progresses to total spinal fusion, producing a typical bamboo spine on x-ray criteria. In all patients, the presence of sacroiliac joint disease on radiographs is required to make the diagnosis. There are two major neurological complications of AS a cauda equina syndrome of unclear etiology, and several types of cervical spinal cord compression due to dislocation or deformity. Ankylosing spondylitis is less common in black populations and in people of Japanese ancestry, in parallel with the lower expression of HLA-B27 in these groups. There is a...
Ankylosing spondylitis (AS) is a seronegative inflammatory arthritis of the spine of unknown etiology. It presents in the early stages with an inflammatory arthritic pain that typically involves the sacroiliac joints initially and later the other spinal regions. The classic feature of AS is enthesopathy (inflammation at the attachments of ligaments, tendons, and joint capsules to bone). Initially, range of motion is normal or mildly limited. Disease progression leads to spinal ossification, osteoporosis, and altered spinal biomechanics. The spine may eventually fuse in a kyphotic position. The lack of spinal flexibility causes the spinal column to be vulnerable to fractures following minor trauma. AS may affect the lumbar, thoracic, and cervical spinal regions. Other skeletal manifestations include dactylitis (sausage-shaped digits), heel pain (Achilles tendon insertion), and hip arthritis. Extraskeletal manifestations occur and involve the eyes (anterior uveitis), as well as cardiac,...
Are Unable To Make A Diagnosis From This Chart And Your Back Pain Is Severe Or If The Nature Of Longstanding Back Pain
Spondylitis (inflammatio the vertebrae, resulting gradually becoming har is especially likely if you Consult your doctor. ACTION Your doctor will examine you and arrange for you to have a blood test and x-rays (p.39) of your back and pelvic areas. If you are found to have ankylosing spondylitis, you will probably be given nonsteroidal antiinflammatory drugs. You will also be referred to a physiotherapist, who will teach you exercises to help keep your back mobile. These mobility exercises are an essential part of the treatment for this disorder and can be supplemented by other physical activities, such as swimming.
There seems to be a connection between the gut and spondyloarthropathies. Of patients with inflammatory bowel disease (IBD ulcerative colitis and Cohn's disease), 10 to 20 have a peripheral arthritis different from other defined arthritides. Migratory arthralgias, especially of the knees, ankles, and feet, often coincide with periods of GI disease flares. Other joints, including the spine and sacroiliac joints, might be involved but are seemingly less coincident with bowel exacerbations. HLA-B27 is found in 50 of patients with IBD-associated spondylitis but is not found in a higher percentage than in the general population for this type of spondylitis. RF and ANA are negative. NSAIDs are normally used but must be taken with caution given the patient's underlying GI disease. As noted earlier, dietary factors might increase the patient's baseline inflammatory state, so a trial of dietary manipulation or the addition of omega-3 fatty acids is reasonable.
Aorta and the aortic root may be involved in the disease process, which may lead to significant dilatation of the aortic root (42,43). The latter will stretch the aortic valve ring and make the cusps incompetent. The list of entities that can result in such a process include congenital aneurysm of the sinus of Valsalva, syphilitic aortitis, which is now quite uncommon, cystic medial necrosis with and without overt Marfan's syndrome, spondylitis, rheumatoid arthritis, Paget's disease, osteogenesis imperfecta, and hypertensive atherosclerotic aneurysm ofthe ascending aorta. The pathology will vary according to the disease entity involved. In many of these entities, the elastic tissue in the media of the aorta is destroyed, leading to expansion of the aorta. For instance, in the atherosclerotic aneurysm it has been shown that the media becomes infiltrated with macrophages, which elaborate metalloproteinases, leading to the destruction of the elastic tissue. Occasionally the aortic medial...
Ankylosing spondylitis may also present problems with tracheal intubation, but these result from rigidity of the cervical spine rather than instability. The use of the laryngeal mask airway is a suitable option for many procedures. If tracheal intubation is necessary, it may be difficult or impossible to obtain a view of the larynx by direct laryngoscopy. In many patients, tracheal intubation may be undertaken with the aid of a gum elastic bougie, but in some it is necessary to resort to the use of the intubating laryngeal mask airway or fibreoptic intubation. Ankylosing spondylitis
Ankylosing spondylitis is a chronic hereitable disease characterized by progressive inflammation of the spine with early sacroiliac joint involvement, followed by hardening of the anulus fibrosus and surrounding connective tissue and arthritic changes in the facet joints.5 6 The disease eventually results in a loss of segmental mobility and stiffening of the spinal tissues.
Stern, there appear to be several important diagnoses. Inflammatory bowel disease (IBD), irritable bowel syndrome, traveler's diarrhea, pseudomembranous colitis, celiac disease, and giardiasis are certainly in the differential diagnosis. The history of iritis and low back pain makes the diagnosis of IBD a strong possibility. IBD, consisting of Crohn's disease and ulcerative colitis, is very common, with an annual incidence in the United States of approximately 3 to 10 new cases per 100,000 people. Extraintestinal inflammatory manifestations are common. Ocular manifestations occur in 5 of patients with IBD, and ankylosing spondylitis, in 5 to 10 . The most common extraintestinal manifestation is a peripheral, large-joint, asymmetric, nondeforming arthritis this occurs in 20 of patients with IBD. Mr. Stern does not have a history of this type of arthritis. Genetic disorders seem unlikely, inasmuch as the appearance of this patient's problem started at age 27 or 28....
The offending bacterial organism of the infectious spondylitis can be varied, with staphylococci, streptococci, Escherichia The most common location for spinal tuberculosis is the lower thoracic and upper lumbar regions. The granulomatous process usually begins in the anterior third of the vertebral bodies and spreads along the spinal axis beneath the paraspinal ligaments. The intervertebral disc space in tuberculous spondylitis remains relatively intact for a longer period of time than in pyogenic infections. In untreated chronic cases of spinal tuberculosis, paraspinal, paravertebral, and psoas abscesses frequently occur. The psoas abscess may calcify.
Few well-controlled studies of androgen therapy have been reported in other rheumatological disorders. This is not just due to paucity of cases in the female-preponderant autoimmune diseases as there are no controlled studies of androgen therapy even in ankylosing spondylitis or gout, the male preponderant rheumato-logical diseases.
Mediated diseases of the connective tissue (systemic lupus erythematosus SLE , scleroderma, polyarteritis nodosa, rheumatic fever, ankylosing spondylitis, and Reiter's syndrome) are discussed. Ankylosing Spondylitis Patients with ankylosing spondylitis have limited mobility of the spine (Schober test) (120), which eventually becomes rigid (bamboo spine). The mobility of the sacroiliac joint is reduced and chest expansion limited. Aortic regurgitation is seen in 3-10 of cases of longstanding ankylosing spondylitis (120). Complete heart block is very rarely seen (120).
There is a tendency toward disc herniation in some families, such as those with congenital spinal anomalies, including fused and malformed vertebrae and lumbar spinal stenosis due to short pedicles. Patients with increased weight and tall stature are at increased risk for this condition. Also, acquired spinal disorders, such as common degenerative arthritis and ankylosing spondylitis, predispose to disc degeneration. Various behaviors that increase risk include sedentary occupations, physical inactivity, motor vehicle use, vibration, and smoking. In younger women, pregnancy and delivery are associated with lumbosacral herniation, and new symptoms of cervical disc herniation may occur in part because of the bending and lifting involved in child rearing. Differential Diagnosis. Disc herniations must be differentiated from other causes of acute and chronic neck, back, and extremity pain, radiculopathy, and myelopathy. Malignant and benign tumors affecting the spine, infection, epidural...
Moderate impairment of testicular function has been observed in periarteritis nodosa, during acute flares of rheumatoid arthritis and in active ankylosing spondylitis (Gordon etal. 1988 Tapia-Serrano etal. 1991). In the elderly, as in the young, Leydig cell function may be adversely affected by endocrine diseases such as Cushing's syndrome (Luton etal. 1977 McKenna etal. 1979) and pituitary tumors, in particular prolactinomas.
Apart from the nearly ubiquitous osteoarthritic spondylosis seen in geriatric patients, other etiologies of severe cervical and thoracic spine ankylosis can alter the biomechanics of the cervical spine, causing increased susceptibility to fracture from minor traumatic events. These include ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH). Both conditions result in a stiff and often osteoporotic spine. With injury, both the anterior and posterior columns may be completely disrupted, causing frank instability. Fractures of the ankylosed spine are associated with 50 morbidity and 30 mortality.2 For this reason, a high level of suspicion is required not to overlook potentially unstable fracture patterns. ANKYLOSING SPONDYLITIS Ankylosing spondylitis (AS) is a seronegative (RF-negative) spondylo-arthropathy that predominantly affects the sacroiliac joints and spine. It typically, but not exclusively, affects HLA-B27 seropositive patients. The 2. P. Whang, et...
The number of involved joints and presence or absence of symmetry are criteria for further diagnosis of articular pain (Figs. 32-1 and 32-2). Monoarticular (one joint) or oligoarticular (several joints) arthritides can be caused by conditions such as osteoarthritis (OA), gout, pseudogout, or septic arthritis. Asymmetric polyarthritis occurs in ankylosing spondylitis, psoriatic arthritis, Reiter's disease, and spondyloarthropathies. Symmetric arthritis, meaning that the same joint is affected on the contralateral side but not necessarily to the same degree, is characteristic of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjogren's syndrome, polymyositis, and scleroderma. Fibromyalgia, reflex sympathetic dystrophy, and predominantly psychological
By contrast, other arthritic disorders such as ankylosing spondylitis, osteoarthritis, and spinal hyperostosis have been recognized in skeletons thousands of years old and appear to be unchanged from the present condition. In fact, given the lack of evidence of the existence of rheumatoid arthritis until relatively recent times, L. Klepinger (1979) and others have suggested that rheumatoid arthritis has evolved from ankylosing spondylitis. Suffice it to say that the uncertainty about the antiquity of rheumatoid arthritis is at least partly due to the methods by which we have examined the evidence of a disease whose current definition includes a combination of clinical, radiological, and serologic criteria. Nonetheless, a search for evidence of rheumatoid arthritis in the literature, art, and bones of the past is an intriguing one.
Genetic factors have been identified for several arthritides. Presence of the human leukocyte antigen (HLA) system's HLA-DR4 antigen is associated with increased incidence and severity of RA. The HLA-B27 antigen is found in a higher percentage in patients with ankylosing spondylitis and other spondyloarthropathies than in the general population. Other factors are apparently involved,
Although the halo is the most restrictive of the various CTOs, significant motion may occur due in part to difficulty in fitting the brace securely to the chest. Both supine and upright radiographs should be assessed to ensure that cervical alignment and restriction of cervical motion are maintained with changes in posture. A phenomenon termed snaking may occur, in which there is movement between individual cervical vertebra without significant motion between the head and the spine. Use of the halo orthosis is not well tolerated in senior citizen patients, patients with severe rheumatoid arthritis and coexistent hip and knee arthritis, or patients with severe kyphotic deformities (e.g. ankylosing spondylitis). Such patients experience difficulties with ambulation, balance, feeding, and self-care. In such patients rigid internal fixation of the spine to avoid halo use is the preferred treatment option when feasible.
This is a controversial entity whose existence has been questioned. Pain from cervical structures is referred to the head through the C1 to C4 cervical roots. Accepted causes of head pain from the neck include developmental abnormalities, tumors, ankylosing spondylitis, rheumatoid arthritis, and osteomyelitis. Controversial causes include cervical disc herniations, degenerative disc disease, and whiplash injuries. y Occipital neuralgia is thought by some to occur as a result of an injury to the occipital nerve, which may be vulnerable to compression as it passes through the semispinalis capitis muscle. Referred pain of cervical origin has often been referred to as occipital neuralgia, modifying the definition of this disorder. The prevalence of cervicogenic headache and occipital neuralgia is unknown. Risk factors include whiplash injury.
Preoperative assessment is perhaps one of the most important in neurosurgical anaesthetic practice, because an unstable cervical spine is a major reason for the proposed surgery. In many patients, the neck is relatively unstable as soon as it is either flexed or extended, and the patient may be in a cervical collar or even neck traction. Bony degeneration from rheumatoid or osteoarthritis produces severe cord compression. However, with regard to tracheal intubation, the neck tends to be unstable in flexion and relatively stable in extension in most patients. It is essential to assess the range of neck movement fully with the collar removed, either in the ward or in the anaesthetic room, in addition to the assessment of the ease of tracheal intubation. It is doubly unlucky to have a difficult intubation in a patient with an unstable neck If problems are anticipated, the normal 'difficult intubation' drill should be followed, using the methods with which the anaesthetist is most...
Patients may manifest signs and symptoms of disease in areas outside the GI tract. These extraintestinal manifestations may occur in various body regions.5,13 Painful joint complications associated with IBD include sacroiliitis and ankylosing spondylitis. Ocular involvement with episcleritis, uveitis, or iritis may manifest as blurred vision, eye pain, and photophobia. Associated skin findings include pyoderma gan-grenosum (involving papules and vesicles that develop into painful ulcerations) and erythema nodosum (red nodules of varying size typically found on the lower extremities). Nephrolithiasis may also develop at a higher rate in patients with IBD. Oxalate stones are more common in CD, and uric acid-containing stones are more common in UC.13
Bartleson JD, Cohen MD, Harrington TM, et al Cauda equina syndrome secondary to longstanding ankylosing spondylitis. Ann Neurol 1983 14 662-669 10. Fox MW, Onofrio BM, Kilgore JE Neurological complications of ankylosing spondylitis. j Neurosurg 1993 78 871-878 12. Confavreux C, Larbre JP, Lejeune E, et al Cerebrospinal fluid dynamics in the tardive cauda equina syndrome of ankylosing spondylitis. Ann Neurol 1991 29 221-223
Inflammatory conditions may be seen in the joints of the symphysis and sacroiliac joints. Sacroiliitis is not uncommon in outdoor winter sports. Sacroiliitis can also be a symptom in a generalized disease such as rheumatoid arthritis or Bechterew's disease. Pain and or discomfort may radiate to the groin, to the hip joint, or to the thigh. Changes in the sacroiliac joints may be present without the athlete feeling any pain. The symptoms may be vague and most pronounced in the morning. Long intervals without symptoms may be present. The diagnoses are made by clinical exami
What special considerations should be given to patient positioning and anesthesia for cervical osteotomy procedures in
The chin-brow to vertical angle is used to measure the degree of flexion deformity of the spine in ankylosing spondylitis. A, For thoracolumbar deformity. B, For cervical deformity. C, For postoperative assessment. The chin-brow to vertical angle is the angle between a line connecting the brow to the chin and a vertical line with the patient standing with the hips and knees extended and the neck in a fixed or neutral position. (From Simmons ED Jr, Simmons EH. Ankylosing spondylitis. Spine State Art Rev 1994 8 589-604, with permission.)
Outline of area of bony resection for a cervical osteotomy. The lines of resection of the laterally fused facet joints are beveled slightly away from each other, extending posteriorly so that the two surfaces will be parallel and in apposition following correction. The pedicles must be undercut to avoid impingement on the C8 nerve roots. The midline resection is beveled on its deep surface above and below to avoid impingement against the dura following extension correction. (From Simmons ED Jr, Simmons EH. Ankylosing spondylitis. Spine State Art Rev 1994 8 589-604, with permission.)
In the past, a distinction was made between discitis (infection involving the disc space) and osteomyelitis (infection in the vertebral body). Studies have shown that in children the vascular supply crosses the vertebral endplate from vertebral body to the disc space. As a result, discitis and vertebral osteomyelitis are considered to represent a continuum termed infectious spondylitis. Hematogenous seeding of the vertebral endplate leads to direct spread of infection into the disc space. Subsequently, infection involving the disc space and both adjacent vertebral endplates may progress to osteomyelitis. Vertebral fracture and epidural abscess may occur if the infection is permitted to progress without treatment. Staphylococcus aureus is the most frequently isolated bacteria. Tuberculosis is prevalent in developing countries and should be considered in children who have traveled outside of the United States to endemic areas.
A specific abnormality or disease is not identified in up to 85 of patients who present with LBP resulting in the diagnosis of nonspecific LBP. In another subset of patients, LBP is associated with specific spine pathology such as compression fracture, spondylolisthesis, ankylosing spondylitis, malignancy, or infection. LBP may be a presenting symptom in patients with spinal stenosis or lumbar disc herniation. LBP may also originate from nonspinal causes such as
Sagittal imbalance syndrome may occur for many reasons in addition to Harrington instrumentation for scoliosis treatment. Sagittal plane malalignment may occur after lumbar fusion for degenerative spinal disorders when adequate lumbar lordosis is not restored during the initial surgery. Transition syndrome (breakdown of spinal segments above or below a solid spinal fusion) is another frequent cause of sagittal imbalance. Autofusion of the spine as a result of Forestier's disease (diffuse idiopathic skeletal hyperostosis, DISH) or ankylosing spondylitis may also lead to spinal imbalance. Osteoporotic compression fractures are a common cause of sagittal imbalance. Additional etiologies include spinal tumors, spinal trauma, spinal infections, and iatrogenic deformities following instrumented spinal fusion surgery.
Diffuse idiopathic skeletal hyperostosis (DISH) is seen in older individuals, predominantly, involving the thoracic spine with flowing anterior ossification (at least four levels) and associated with enthesophytes elsewhere (especially pelvis). Patients are at increased risk for heterotopic bone formation after joint replacement. Differentiated from ankylosing spondylitis by age (older) location (C, T spine L spine, no sacroiliac involvement) and morphology (loosely flowing ossification on lateral view). Left image, lateral thoracic radiograph shows classic osteophyte pattern seen in DISH. Upper right image, anteroposterior pelvis radiograph shows pelvic enthesophyte. Center image, lateral cervical radiograph shows classic osteophyte pattern noted in DISH. Lower right image, lateral knee radiograph shows patella enthesophyte. (From Morrison W, Sanders T. Problem Solving in Musculoskeletal Imaging. 1st ed. Philadelphia Mosby 2008).
Discuss key points to consider in the initial assessment of a patient with AS following a traumatic spinal injury
Fractures associated with ankylosing spondylitis typically involve the disc space and run obliquely through the fused segments. Left image, lateral cervical radiograph depicts an extension-distraction injury resulting in extreme cervical instability. Center image, lateral thoracic radiograph shows a three-column fracture typical for AS. Right image, magnified view depicting the three-column thoracic fracture. (From Morrison W, Sanders T. Problem Solving in Musculoskeletal Imaging. 1st ed. Philadelphia Mosby 2008). Figure 69-4. Fractures associated with ankylosing spondylitis typically involve the disc space and run obliquely through the fused segments. Left image, lateral cervical radiograph depicts an extension-distraction injury resulting in extreme cervical instability. Center image, lateral thoracic radiograph shows a three-column fracture typical for AS. Right image, magnified view depicting the three-column thoracic fracture. (From Morrison W, Sanders T. Problem...
This category includes a wide range of conditions which affect the lung and chest wall. Lung diseases include sarcoidosis and fibrosing alveolitis, while lesions of chest wall include kyphoscoliosis and ankylosing spondylitis. Pulmonary function tests reveal a decrease in both FEVi and FVC, with a normal FEVj q FVC ratio and a decreased FRC and total lung capacity (TLC). Small airways closure occurs during tidal ventilation, with resultant shunting and hypoxaemia. Lung or chest wall compliance is decreased thus, the
The spondyloarthropathies are a group of multisystem inflammatory disorders that affect predominantly the spine but also other joints and extra-articular tissues. Most are linked to the HLA-B27 gene, but HLA-B27 by itself does not explain the development of these diseases pathogenesis of these conditions is still unknown. They include ankylos-ing spondylitis, reactive arthritis (Reiter's syndrome), pso-riatic arthropathy, enteropathic arthropathy, juvenile-onset arthropathy, and undifferentiated spondyloarthropathy. Both genetic and environmental factors probably contribute to the onset and progression of these diseases. Most people with HLA-B27 do not develop these diseases, and these diseases occur in the absence of HLA-B27. Ankylosing Spondylitis Key Points The male predominance for ankylosing spondylitis is 5 1. Primary or uncomplicated ankylosing spondylitis (AS) is a systemic inflammatory disorder predominantly affecting the sacroiliac joints and the spine. Patients with...
The range of ossification in the ligaments of the cervical spine that can be examined using imaging include ossification of the posterior longitudinal ligament (OPLL), ossification of the yellow ligament (ligamentum flavum) (OYL), ossification of the anterior longitudinal ligament, and ankylosing spondylitis. OPLL is one of a group of diffuse idiopathic skeletal hyperostoses that can affect the various spinal ligaments. Cervical OPLL is the most common among this group and often leads to compression myelopathy. Clinical guidelines for diagnosing and treating OPLL were published in 2005 by a committee within the Japanese Orthopedic Association and funded by the Japanese Ministry of Public Health and Welfare 1 . This section describes the diagnostic imaging for cervical OPLL based on those clinical guidelines and on the research referred to by the guidelines.
More research is needed on the value of humor in medicine so that we will know when and how to use it effectively. Norman Cousins, former editor of the Saturday Review, had ankylosing spondylitis. He received 3 hours of pain relief after watching comedy videotapes of The Three Stooges and Abbott and Costello but obtained only V2 hour of pain relief from an oral analgesic. Some physicians write prescriptions for patients to laugh out loud three times each day. In India, Laughter Clubs convene at the beginning of each day to laugh out loud. Even a fake laugh makes one feel better throughout the day.
Cyriax, prominent in the field of physical medicine and rehabilitation Movement does occur at the sacroiliac joint at the extremes of trunk flexion and extension, rotation takes place between the sacrum and the ilium No muscles span the joint. There is no intra-articular meniscus. All in all, there is little that can go wrong. The only condition encountered with any frequency is ankylosing spondylitis (20).
A variant of spinal degenerative arthritis known as spondylosis (spondylitis) deformans is reported among some populations, such as the Late Stone Age inhabitants of the Baltic Coast (V. Y. Derums 1964), as well as those of Neolithic Jericho (Kurth and Rohrer-Ertl 1981), Neolithic Greece (Dastugue 1974), Third Dynasty Egypt (c. 2750-2680 B.C. Ruffer and Rietti 1912 Ruffer 1918), and Bronze Age Latvia, USSR (c. 2000-1000 B.C. V. J. Derums 1987). A second general category of arthritis is that of the inflammatory erosive joint diseases. This category includes such syndromes as Reither's syndrome, psoriatic arthritis, and three that are examined in this paper rheumatoid arthritis, ankylosing spondylitis, and gout. Some syndromes of inflammatory erosive joint disease have a known association with bacterial infection of the bowel or genitourinary track. Lyme disease, for example, is initiated by a tick bite that introduces a bacteria (spirochete) into the host. If untreated, the disease...
'Other' categories include osteoporosis, ankylosing spondylitis, Scheuermann's disease, mechanically inconclusive, or chronic pain state. Osteoporosis and ankylosing spondylitis are reviewed in Chapter 8 and elsewhere (McKenzie and May 2003, Chapter 12). These are conditions whose management may involve physiotherapy, but they require special consideration and appropriate diagnosis. The description of the latter two is as in Chapter 9. Scheuermann's Ankylosing Spondylitis
The thoracic spine is prone to the usual range of degenerative and maturation changes that affect other areas of the spine, plus some that principally affect this region. With age the thoracic kyphosis tends to increase, a process that is accentuated by reduced physical activity, postural habit and female gender (Singer 2004). A number of specific pathologies, some asymptomatic, can exacerbate this these include ankylosing spondylitis, Scheuermann's disease, diffuse idiopathic skeletal hyperostosis, Pagets disease and osteoporosis (Sparkes 2004). An exaggerated thoracic kyphosis can have repercussions on the cervical spine and respiratory function (Singer 2004).
Patients suspected of an anterior uveitis should be referred to an ophthalmologist for consultation and treatment. The most common cause of anterior uveitis is idiopathic other common causes include ankylosing spondylitis, inflammatory bowel disease, sarcoidosis, juvenile rheumatoid arthritis, Reiter's syndrome (urethritis, polyarteritis, and ocular inflammation), herpetic keratitis, and Lyme disease.