• Clinical science

Ankylosing spondylitis (Bekhterev's disease…)

Abstract

Ankylosing spondylitis (spondyloarthritis) is a chronic inflammatory disease of the axial skeleton that leads to partial or even complete fusion and rigidity of the spine. Males are disproportionately affected and upwards of 90% of patients are positive for the HLA-B27 genotype, which predisposes to the disease. The most characteristic early finding is pain and stiffness in the neck and lower back, caused by inflammation of the vertebral column and the sacroiliac joints. The pain typically improves with activity and is especially prominent at night. Other articular findings include tenderness to percussion and displacement of the sacroiliac joints (Mennell's sign), as well as limited spine mobility, which can progress to restrictive pulmonary disease. The most common extra-articular manifestation is acute, unilateral anterior uveitis. Diagnosis is primarily based on symptoms and x-ray of the sacroiliac joints, with HLA-B27 testing and MRI reserved for inconclusive cases. There is no curative treatment, but regular physiotherapy can slow progression of the disease. Additionally, NSAIDs and/or tumor necrosis factor-α inhibitors may improve symptoms. In severe cases, surgery may be considered to improve quality of life.

Epidemiology

  • Sex: > (3:1)
  • Age: 15–40 years
  • Lifetime prevalence in the US: ∼0.5%

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[1]

Clinical features

Articular symptoms

  • Most common presenting symptoms: back and neck pain
    • Gradual onset of dull pain that progresses slowly
    • Morning stiffness that improves with activity
    • Pain is independent of positioning; , also appears at night
    • Tenderness over the sacroiliac joints
  • Limited mobility of the spine (especially reduced forward lumbar flexion)
  • Inflammatory enthesitis (e.g., of the Achilles tendon, iliac crests, tibial tuberosities): painful on palpation
  • Dactylitis
  • Arthritis outside the spine: hip, shoulder, and knee joint

Extra-articular manifestations

References:[1][2]

Diagnostics

Diagnostic approach

  1. Physical examination, patient history, and pelvic x-ray: If results are conclusive, no additional testing is required!
  2. If inconclusive → HLA-B27 testing
  3. If still inconclusive → pelvic MRI

Clinical tests

  • Chest expansion measurement: in full expiration and inspiration
    • Pathological difference: < 2 cm
    • Physiological difference: > 5 cm
  • Spine mobility tests
    • Wall test: ability of heels, buttocks, and scapulae to touch the wall
    • Chin-jugulum measurement: difference between the chin and suprasternal notch
    • Schober's test : Mark two points, L5 and another point 10 cm above → patient touches toes (without bending the knees) → distance between the two points increases by ≥ 4 cm → physiological test result
    • Ott's test : Mark two points, C7 and another point 30 cm below → patient touches toes (without bending the knees) → distance between the two points increases by ≥ 3 cm → physiological test result
  • Examination of the hip[3]
    • Mennell sign: tenderness to percussion and pain on displacement of the sacroiliac joints
      • Supine position
      • Lateral position
      • Prone position
    • FABER test: FABER (Flexion, ABduction, and External Rotation) provokes pain in the ipsilateral hip

Laboratory findings

Imaging

X-ray

  • Can help confirm a diagnosis or evaluate the severity of disease, but is not required for the diagnosis
  • Changes are generally more evident in later disease
  • Sacroiliac joints: signs of sacroiliitis, including ankylosis of sacroiliac joints
  • Spine
    • Loss of lordosis with increasing abnormal straightening of the spine
    • Sclerosis of the vertebral ligamentous apparatus
    • Syndesmophytes resulting in a so-called 'bamboo spine' in anteroposterior radiograph in the later stages (see the table in “Differential diagnosis” below)
    • Signs of spondyloarthritis, including ankylosis of intervertebral joints[4]

Mild courses may only exhibit inflammatory changes in the sacroiliac joints on x-ray after a number of years.

MRI[5]

  • More sensitive method of detecting sacroiliitis
  • Best method for early detection

References:[1][6][7]

Differential diagnoses

Syndesmophytes

Osteophytes
Definition
  • Lipping of vertebral bodies

Radiographic features

  • Symmetrical, vertical growth, directly from vertebral body to vertebral body
  • Full manifestation: "bamboo spine
  • Horizontal growth
Etiology

Syndesmophytes grow vertically, as opposed to osteophytes, which grow horizontally!
References:[9][10][11]

The differential diagnoses listed here are not exhaustive.

Treatment

  • Physical therapy
    • Consistent and rigorous physical therapy
    • Independent exercises
  • Medical therapy
  • Surgery: in severe cases to improve quality of life
    • Indication:
      • Severe deformity of the spinal column
      • Instability of the spine
      • Neurologic deficits
    • Procedures:
      • Osteotomy
      • Joint replacement
      • Spinal fusion

Physical therapy is the most important treatment modality!
References:[1][13]

Complications

References:[1][2]

We list the most important complications. The selection is not exhaustive.

last updated 08/27/2018
{{uncollapseSections(['Aj0R1T', '-j0D1T', 'ZP0ZWT', 'YP0nWT', 'cP0adT', 'WP0PdT', 'dP0odT', 'VP0GdT'])}}