Ankylosing Spondylitis

History Taking

Chief Complaint:

• Chronic low back pain

• Morning stiffness in the back that improves with exercise but not with rest

History of Presenting Complaint:

• Pain and stiffness usually begin gradually, most often between late adolescence and age 40

• Duration of symptoms is usually more than 3 months

• Pain often awakens the patient in the early morning

• Stiffness in the lower back and hips, particularly in the morning and after periods of inactivity

• Pain and stiffness in the neck, upper back and other joints may also occur

• In severe cases, the pain and stiffness may lead to a hunched-over posture

System Review:

• Fatigue

• Fever and weight loss

• Inflammation in other parts of the body: eyes (iritis or uveitis), skin (psoriasis), bowels (Inflammatory bowel disease)

• Presence of dactylitis (swollen fingers or toes)

• Presence of enthesitis (pain and swelling in the areas where tendons and ligaments attach to bones)

• Reduced chest expansion due to inflammation of joints between ribs and spine

Past Medical History:

• History of chronic back pain or inflammatory bowel disease (IBD)

• History of recurrent episodes of eye inflammation (iritis or uveitis)

• History of skin lesions suggestive of psoriasis

Drug History:

• History of use of anti-inflammatory drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs), or biologic drugs

• Assessment of response to the above medications

Family History:

• Family history of ankylosing spondylitis or other spondyloarthropathies

• Family history of psoriasis, uveitis, reactive arthritis or inflammatory bowel disease

Personal History:

• History of chronic low back pain and stiffness which may limit physical activity

• History of discomfort and fatigue affecting work or school performance

Social History:

• Impact of chronic pain and fatigue on personal relationships, hobbies and activities

• Accommodations required at work or school due to physical limitations

Physical Examination

General Examination:

• Patient may appear generally unwell, fatigue can be evident

• Reduced chest expansion secondary to costovertebral joint involvement

• Evidence of recent weight loss

Examination of Hands and Arms:

• Peripheral joint involvement may be seen, including wrists and knees

• Evidence of dactylitis (sausage-like swelling of the digits)

• Examination may show synovitis, with tender and swollen joints

Examination of the Mouth and Neck:

• Mouth: Aphthous ulcers can be present if there's an associated inflammatory bowel disease

• Neck: Reduced cervical spine movement

Cardiovascular Examination:

• Evidence of aortic regurgitation secondary to aortitis (early diastolic murmur at left sternal edge)

Respiratory Examination:

• Reduced chest expansion, particularly in the lower part due to involvement of costovertebral joints

• Decreased breath sounds, dullness to percussion, and reduced tactile fremitus if there is a pleural effusion secondary to lung involvement

• Apical fibrosis

Abdominal Examination:

• Tenderness or other signs of inflammatory bowel disease (though it's rare to have positive abdominal examination findings)

Neurological Examination:

• Examination for signs of cauda equina syndrome if there is severe disease (lower limb weakness, altered sensation in saddle distribution, bowel or bladder dysfunction)

Examination of the Spine and Pelvis:

• Reduced lumbar spine flexion and extension (Schober's test)

• Reduced lateral lumbar flexion

• FABER test (Flexion, ABduction, and External Rotation of the hip) may be positive indicating sacroiliac joint pathology

• Wall to occiput distance is increased due to flexion deformity of cervical spine

Investigations

Laboratory Investigations:

• Full Blood Count: May show a mild normocytic normochromic anaemia due to chronic disease

• ESR and CRP: Raised due to inflammation

• Rheumatoid Factor and Anti-CCP: Negative; these are more indicative of rheumatoid arthritis

• HLA-B27 antigen: Positive in majority of the cases; however, it's also seen in a proportion of the healthy population

• Urea and Electrolytes, Liver function tests: Baseline tests and to monitor for drug side effects if patient is on treatment

Imaging:

• X-ray of sacroiliac joints and spine: May show sacroiliitis, syndesmophytes (bony growths inside ligaments, usually around the vertebral bodies), "bamboo spine" (continuous ossification of the anterior longitudinal ligament of the spine)

• MRI of spine and sacroiliac joints: Can show early changes like bone marrow edema even before changes are seen on X-ray

• Chest X-ray: To look for apical fibrosis if patient has respiratory symptoms

Invasive Tests:

• Sacroiliac joint injection: To help confirm diagnosis if other investigations are inconclusive (pain relief after injection is suggestive of sacroiliitis)

Other Tests:

• Pulmonary function tests: To assess for restrictive lung disease due to chest wall involvement

• Echocardiography: To assess for aortic regurgitation or other cardiac involvement

• Ophthalmology referral for slit lamp examination: If uveitis is suspected

Specialist Referral:

• Rheumatology: For definitive diagnosis and management

• Physiotherapy: For assessment and guidance on exercises to maintain posture and mobility

• Ophthalmology: For management of uveitis, if present

• Gastroenterology: If symptoms of inflammatory bowel disease are present, for further assessment and management

• Dermatology: If symptoms of psoriasis are present, for further assessment and management

Management

General Management:

• Patient education: On condition, prognosis, and importance of regular exercise

• Physical therapy: Regular exercise for posture and flexibility maintenance, deformity prevention

• Occupational therapy: Aids in adapting daily activities to minimize pain, maximize function

• Smoking cessation: Necessary if patient is a smoker, as smoking accelerates disease progression

Medical Management:

• NSAIDs: First-line for symptomatic relief of pain and stiffness

• DMARDs: Sulfasalazine for peripheral arthritis

• TNF inhibitors: E.g., Infliximab, Adalimumab, Etanercept - if inadequate response to NSAIDs

• IL-17 inhibitors: E.g., Secukinumab, Ixekizumab - alternative to TNF inhibitors for those who can't use or haven't responded to them

• Corticosteroids: Topical or intra-articular injection for localized inflammation; systemic use generally avoided

Surgical Management:

• Joint replacement: Consider for severe peripheral joint disease (e.g., hip or knee)

• Spinal surgery: Rarely, procedures such as osteotomy for severe spinal deformity

Other:

• Eye care: Regular checks if uveitis history

• Cardiovascular risk management: Regular monitoring and management given increased cardiovascular disease risk

• Mental health support: Counseling or psychotherapy for psychological impact of chronic disease

• Regular follow-ups: Monitor disease progression and treatment response

Referrals:

• Rheumatology: Ongoing disease management and monitoring

• Ophthalmology: If uveitis symptoms are present

• Gastroenterology: For suggestive inflammatory bowel disease symptoms

• Dermatology: If psoriasis symptoms present

• Orthopedics: If surgical intervention is being considered

• Pain management: Multi-disciplinary management of chronic pain