Ankylosing Spondylitis: Symptoms, Findings and Diagnosis

Ankylosing Spondylitis

Ankylosing spondylitis, also known as axial spondyloarthritis, is an inflammatory condition that can eventually lead to the fusion of some of the vertebrae in the spine. This fusion reduces the spine's flexibility and may cause a hunched posture. Breathing deeply may be challenging if the ribs are injured.

There are two forms of axial spondyloarthritis. Ankylosing spondylitis is detected on an X-ray. The disorder is known as non radiographic axial spondyloarthritis when it cannot be seen on an X-ray but is discovered based on symptoms, blood tests, and other imaging studies.

Read this blog further to get a quick overview of this important topic for orthopedics to ace your NEET PG exam preparation.

Causes of Ankylosing Spondylitis

Although there is no established etiology for ankylosing spondylitis, genetic factors may play a role. In particular, the chance of developing ankylosing spondylitis is considerably enhanced among those who carry the HLA-B27 gene. 

Symptoms of Ankylosing Spondylitis

Early adulthood is usually when symptoms first appear. Other bodily parts, most frequently the eyes, might also experience inflammation.

Back discomfort and stiffness in the lower back and hips, particularly in the morning and after periods of inactivity, are possible early signs of ankylosing spondylitis. Fatigue and neck aches are also frequent. At sporadic periods over time, symptoms may get better, get worse, or stop altogether.

The regions most frequently impacted are:

• The joint that connects the pelvis to the base of the spine.
• The lower back's vertebrae.
• The locations along bones, primarily in the spine but occasionally along the back of the heel, where tendons and ligaments attach.
• The cartilage that lies between the ribs and the breastbone.
• The shoulder and hip joints.

Risk Factors for Ankylosing Spondylitis

Early adulthood or late youth is the typical onset time. Those with ankylosing spondylitis typically carry the HLA-B27 gene. However, many individuals with this gene never experience ankylosing spondylitis.

Findings on Physical Examination

Modified Schober's Test and Lateral Spine Flexion

• Tenderness or pain at
  • Sacroiliac joint or sacroiliitis - It is the earliest involvement in the AS. Radiologically we can find  Bone marrow edema.
  • Sternoclavicular joint.
  • Tips of the spinous process of the vertebra.

If such patients are involved in body contact sports, chances of irreversible injury or even the chances of fracture of the spine are higher.

• Substantial buttock muscle atrophy- It is Presented as buttock pain. It can be Examined by Modified Schober's Test which is also known as Standard Schober's Test. The distance between the two points or markings is <4 CM.

Modified Schober's Test

Steps of the Modified Schober's Test

Select the posterior superior iliac spine of the patient. Mark a point on the midline of the PSIS and draw a line 5 cm below the point and 10 cm above the point (Making the total length of marking 15 cm). 

Ask the patient to bend forward and ask to try to touch the toes. In normal individuals, the total length of the marking may increase substantially to 21 or 22 cm as the spine is flexible, that is the distance between the markings can increase more than 5 cm. In AS patients, the total length of marking doesn't increase like normal. Spine length may increase to 18-19 cm. The distance between the markings is less than 4 cm.

Lateral bending

The lateral bending decreases in patients with ankylosing spondylitis.

Ask the patient to bend laterally and touch the knee with the palms. In AS, the patient cannot be able to touch the knee, as a normal person. As the curvature of the spine is substantially reduced.

Height of the patient 

Due to Substantial thoracic kyphosis and Loss of lumbar lordosis, there is a Decrease in the Height of the Patient 

It is due to an increase in the thoracic kyphosis and a decrease in the lumbar lordosis component. In late diagnosis (Due to myopathy or alternative traditional medicine or improper diagnosis), the following characteristics can be presented  as a Bamboo spine or Dagger sign.

Diagnosis of Ankylosing Spondylitis

Ankylosing spondylitis cannot be diagnosed with certainty by any test. Your healthcare professional will do a physical examination after going through your symptoms and family history. One or more of the following tests may be requested by your doctor to aid in diagnosis:

• Magnetic resonance imaging (MRI) scans are imaging tests that can identify spine issues earlier than conventional X-rays. Even so, your doctor might request a spine X-ray to look for arthritis or rule out other issues.
• Blood tests: Blood tests can determine whether the HLA-B27 gene is present. Only 25% of persons of European heritage who carry this gene experience ankylosing spondylitis, however, it affects only 8% of them.

Treatment of Ankylosing Spondylitis

Ankylosing spondylitis is a chronic illness. Although there is no cure, therapy can lessen joint deterioration, avoid long-term consequences, and relieve discomfort. Treatments comprise:

• Physical exercise: Regular physical activity can halt or reduce the progression of the disease. When they are inactive, many people's pain gets worse. Pain seems to subside with movement. Your doctor may suggest safe workout regimens.
• Anti-inflammatory medications that are not steroidal: NSAIDs, such as ibuprofen (Advil®) and naproxen (Aleve®), reduce inflammation and pain.
• DMARDs (disease-modifying anti-rheumatic drugs): Sulfasalazine is one of several medications that ease joint discomfort and edema. Additionally, the medications address inflammatory bowel disease-related lesions. Biologics, a newer class of DMARDs, work by altering the immune system to reduce inflammation. Interleukin-17 (IL-17) inhibitors and tumor necrosis factor (TNF) are examples of biologics.
• Injectable corticosteroids can temporarily reduce inflammation and joint discomfort.

Complications of Ankylosing Spondylitis

In cases of severe ankylosing spondylitis, the body attempts to mend by forming new bones. This new bone gradually fills the space between vertebrae, eventually joining entire vertebrae together. Those areas of the spine stiffen and lose their flexibility. Fusion can also stiffen the rib cage, limiting lung function and capacity.

There may be further issues, such as:

• Uveitis is an inflammation of the eyes. Uveitis, one of the most frequent side effects of ankylosing spondylitis, can result in sudden onset eye pain, light sensitivity, and impaired vision. When you experience these symptoms, go see your doctor straight soon.
• Fractures from compression. During the early phases of ankylosing spondylitis, some persons have bone thinning. A stooped posture can become more severe due to collapsed vertebrae. The spinal cord and the nerves that go through the spine may be compressed by vertebral fractures, which could result in injury.
• Heart issues. The aorta, the body's biggest artery, might develop issues as a result of ankylosing spondylitis. The heart's aortic valve might become so distorted by an enlarged, inflamed aorta that it loses its ability to function. Ankylosing spondylitis-related inflammation raises the risk of heart disease in general.

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