Ankylosing spondylitis: Difference between revisions
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==Background== | ==Background== | ||
*Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial skeleton with variable involvement of other joints or even nonarticular structures | *Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial skeleton with variable involvement of other joints or even nonarticular structures | ||
* | *3x more common in males than females | ||
* Often associated with other autoimmune disorders | *Typically diagnosed in young adults between the ages of 20 and 30 yrs | ||
*Often associated with other autoimmune disorders | |||
*90% of people with AS express the HLA-B27 genotype | |||
==Clinical Features== | ==Clinical Features== | ||
* Spinal pain, particularly in the lower back, is usually the first and most common symptom of AS | *Spinal pain, particularly in the lower back, is usually the first and most common symptom of AS | ||
**Begins in early adulthood (before 45 | **Begins in early adulthood (before 45 yrs) | ||
**Has a gradual onset | **Has a gradual onset | ||
**Lasts longer than three months | **Lasts longer than three months | ||
**Is worse after rest (for example, in the morning) but improves with activity | **Is worse after rest (for example, in the morning) but improves with activity | ||
**Can cause morning stiffness lasting more than 30 minutes | **Can cause morning stiffness lasting more than 30 minutes | ||
* Fatigue | *Fatigue | ||
* Can also be associated with anterior uvetitis, bowel ulcers and spinal fractures are 4 times more common in patients with AS <ref> Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. European Spine Journal. 2009;18(2):145–156 </ref> | *Can also be associated with anterior uvetitis, bowel ulcers and spinal fractures are 4 times more common in patients with AS <ref> Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. European Spine Journal. 2009;18(2):145–156 </ref> | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Lower back pain DDX}} | {{Lower back pain DDX}} | ||
==Diagnosis== | ==Diagnosis== | ||
*There is no direct test for AS | *There is no direct test for AS | ||
* ESR, CRP can be elevated but not sensitive or specific | *ESR, CRP can be elevated but not sensitive or specific | ||
* Xray lumbar/sacroiliac: The earliest changes in the sacroiliac joints shows erosions and sclerosis | *Xray lumbar/sacroiliac: The earliest changes in the sacroiliac joints shows erosions and sclerosis | ||
**Progression of | **Progression of erosions leads to pseudo widening of the joint space and bony ankylosis AKA "Bamboo Spine" | ||
* CBC | Often X-ray findings lag about 10 years from initial progression of disease [[File:5269907670e86d9b415221efa30bf166.jpg|200px|thumb|right|"bamboo spine"]] | ||
*CBC | |||
*Chem 10 | *Chem 10 | ||
* UA | *UA | ||
* Genetic testing for HLA B27 ( > 90% of people with AS have this gene, though by it's self is not specific) | *Genetic testing for HLA B27 ( > 90% of people with AS have this gene, though by it's self is not specific) | ||
==Management== | ==Management== | ||
*There is no cure for AS, although treatments and medications can reduce symptoms and pain | *There is no cure for AS, although treatments and medications can reduce symptoms and pain | ||
* Exercise and posture training should be part of the treatment program for everyone with AS | *Exercise and posture training should be part of the treatment program for everyone with AS | ||
* NSAIDS | *NSAIDS | ||
* Sulfasalazine can be used in people with peripheral arthritis | *Sulfasalazine can be used in people with peripheral arthritis, but for axial involvement, evidence does not support it <ref>Chen J, Lin S, Liu C. Sulfasalazine for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD004800. DOI: 10.1002/14651858.CD004800.pub3.</ref>. | ||
* Lack of evidence for methotrexate <ref>Chen J, Veras MMS, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004524. DOI: 10.1002/14651858.CD004524.pub4.</ref> or steroids. | *Lack of evidence for methotrexate <ref>Chen J, Veras MMS, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004524. DOI: 10.1002/14651858.CD004524.pub4.</ref> or steroids. | ||
* Tumor necrosis factor-alpha blockers, such as the biologics etanercept, infliximab, golimumab and adalimumab, | *Tumor necrosis factor-alpha blockers, such as the biologics etanercept, infliximab, golimumab and adalimumab, provide good short-term effectiveness though long term management is currently being studied | ||
==Disposition== | ==Disposition== | ||
* Often diagnosis will not be made in | *Often diagnosis will not be made in ED but if made in ED often can be discharged home with PMD f/u or rheumatology f/u | ||
==See Also== | ==See Also== | ||
*Arthritis | |||
==External Links== | ==External Links== |
Revision as of 15:20, 1 November 2015
Background
- Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial skeleton with variable involvement of other joints or even nonarticular structures
- 3x more common in males than females
- Typically diagnosed in young adults between the ages of 20 and 30 yrs
- Often associated with other autoimmune disorders
- 90% of people with AS express the HLA-B27 genotype
Clinical Features
- Spinal pain, particularly in the lower back, is usually the first and most common symptom of AS
- Begins in early adulthood (before 45 yrs)
- Has a gradual onset
- Lasts longer than three months
- Is worse after rest (for example, in the morning) but improves with activity
- Can cause morning stiffness lasting more than 30 minutes
- Fatigue
- Can also be associated with anterior uvetitis, bowel ulcers and spinal fractures are 4 times more common in patients with AS [1]
Differential Diagnosis
Lower Back Pain
- Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Thoracic and lumbar fractures and dislocations
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Spinal Infarct
- Renal disease
- Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
- Pelvic disease
- Other
Diagnosis
- There is no direct test for AS
- ESR, CRP can be elevated but not sensitive or specific
- Xray lumbar/sacroiliac: The earliest changes in the sacroiliac joints shows erosions and sclerosis
- Progression of erosions leads to pseudo widening of the joint space and bony ankylosis AKA "Bamboo Spine"
Often X-ray findings lag about 10 years from initial progression of disease
- CBC
- Chem 10
- UA
- Genetic testing for HLA B27 ( > 90% of people with AS have this gene, though by it's self is not specific)
Management
- There is no cure for AS, although treatments and medications can reduce symptoms and pain
- Exercise and posture training should be part of the treatment program for everyone with AS
- NSAIDS
- Sulfasalazine can be used in people with peripheral arthritis, but for axial involvement, evidence does not support it [2].
- Lack of evidence for methotrexate [3] or steroids.
- Tumor necrosis factor-alpha blockers, such as the biologics etanercept, infliximab, golimumab and adalimumab, provide good short-term effectiveness though long term management is currently being studied
Disposition
- Often diagnosis will not be made in ED but if made in ED often can be discharged home with PMD f/u or rheumatology f/u
See Also
- Arthritis
External Links
References
- ↑ Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. European Spine Journal. 2009;18(2):145–156
- ↑ Chen J, Lin S, Liu C. Sulfasalazine for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD004800. DOI: 10.1002/14651858.CD004800.pub3.
- ↑ Chen J, Veras MMS, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004524. DOI: 10.1002/14651858.CD004524.pub4.