Essentials of Clinical Rheumatology

Ankylosing Spondylitis

Sittichai Ukritchon , MD.

Division of Rheumatology , Department of Medicine
Faculty of Medicine, Chulalongkorn University
Outline

- What is ankylosing spondylitis ?

- When to suspect ankylosing spondylitis ?

- How to diagnose ankylosing spondylitis ?

- When to order HLA-B27 ?

- How to treat ankylosing spondylitis ?

What is ankylosing spondylitis ?
 Ankylosing spondylitis (AS)

- Marie-StrÜmpell disease, von Bechterew’s disease, Pelvospondylitis ossifican

- A disease in spondyloarthritis (SpA)

: Peripheral arthritis
: Sacroiliitis and Spondylitis
: Enthesitis
: Extramusculoskeletal manifestations
: HLA-B27 association
: -ve RF
 Spondyloarthritis (SpA)

Enteropathic arthritis
(ulcerative colitis,
Crohn’s disease)

Undifferentiated
spondyloarthritis (uSpA)

Juvenile
spondyloarthritis

Ankylosing spondylitis Reactive arthritis Psoriatic arthritis

(AS) (ReA) (PsA)
When to suspect ankylosing spondylitis ?
 First presenting features of AS in clinical practice

Age onset 20-40 yr. , Male : Female 2-3 : 1

- Low back pain

- Enthesitis or peripheral arthritis

- Some extra-articular manifestations or other features of secondary AS

- Incidental findings of typical radiographic changes of AS

Inflammatory low back pain (LBP) : sacroiliitis , spondylitis

Clinical feature Inflammatory LBP Mechanical LBP

Age onset < 40 years All age group

Progression of
insidious acute or insidious
disease

depend on the
Duration > 3 months
cause

Morning back
> 1 hour < 1 hour
stifffness

Exercise improve aggravate

Some patients present with alternate buttock pain instead of LBP

Physical examination in patients with inflammatory LBP or AS

AIM

- For diagnosis

- Evaluate severity of spondylitis and/or sacroiliitis

- For follow up the results of treatment

Physical examination in patients with inflammatory LBP or AS
Posture of spine
Occiput to wall distance

Neck flexion deformity

Increased thoracic kyphosis

Loss of lumbar lordosis

Compensatory hip
flexion deformity
Physical examination in patients with inflammatory LBP or AS
Spinal mobility test
- Schober’s test +ve test : limited L spinal movement in saggital plane

A B A B

- Modified Schober’s test

10 cm

A B A B
5 cm
Physical examination in patients with inflammatory LBP or AS
Spinal mobility test
Finger to floor distance Chest wall expansion (4th ICS)

- normal ≥ 5 cm,
- abnormal < 2.5 cm
 Physical examination in patients with inflammatory LBP or AS
Test for sacroiliitis

Pelvic compression

Gaenslen’s test

Patrick’s test
(FABER)
Direct compression
spinal fusion  pain disappear  renew pain  suspected Fx

REFER to Rheumatologist
 First presentation with enthesitis

Tenderness at enthesis

Enthesis - Achilles tendon, plantar fascia,

ischium, iliac crest, greater trochanter
 First presentation peripheral arthritis
- Typical features of presenting peripheral arthritis in AS

Root joints : shoulder , hip

Asymmetrical mono- or oligoarthritis of lower extremities

- Hip involvement at presentation in AS  poor prognosis

Typical features of presenting extra-articular manifestations in AS

- Recurrent unilateral anterior uveitis

 First presentation with other features of secondary AS

- Secondary AS : AS associated with psoriasis , inflammatory bowel disease,

reactive arthritis

- Secondary AS can present with skin lesion , chronic diarrhea

First presentation with incidental findings of
typical radiographic changes of AS

Trauma of spine  Film LS spine

Urologic problem  plain KUB

Review of history  inflammatory LBP

Plain film
- suggest pelvis AP > film SI joint 1
Rt olbique view Ferguson view Lt olbique view

Film SI joint
1 Battistone MJ, et al. J Rheumatol 1998;25:2395-401.
 Film SI joint at KCMH nowadays

Rt olbique view Ferguson view Lt olbique view

Plain film
- suggest pelvis AP > film SI joint 1
Grading of Sacroiliitis 2
Grade 0 - normal SI joint
Grade 1 - suspicious changes
Grade 2 - minimal abnormality (small localized area with erosion or sclerosis
without alteration in the joint width)
Grade 3 - unequivocal abnormality (moderate or advanced sacroiliitis with
erosions, evidence of sclerosis, widening,
narrowing, or partial ankylosis)
Grade 4 - severe abnormality (total ankylosis)
1 Battistone MJ, et al. J Rheumatol 1998;25:2395-401.
2 van der Linden S, et al. Arthritis Rheum 1984;27:361-8.
Grade 0 Grade 2

Grade 3 Grade 4
Female , 35 yr

- 2 months ago : back stiffness on lifting heavy stuff or prolong

sitting ; went to see the doctor and was diagnosed with Ankylosing

spondylitis

- No history of heel pain, conjunctivitis, uveitis or genital ulcer

PE. mild tenderness along L spine

SI joint : no tenderness

Schober’s test 10  16 cm.

Osteitis Condensans Ilii:
- Symmetric sclerosis of the iliac side of the sacroiliac joint found in young multiparous women.
- The sclerosis appears triangular with the base located inferiorly. Erosions are absent.
- May be painful.
Bamboo spine
Male , 70-year old
5-6 months ago : back stiffness on flexion and extension or prolong standing or sitting
1 month ago : went to see the doctor and was diagnosed with Ankylosing spondylitis
(Referral note : film LS spine - bamboo spine)
No history of heel pain, conjunctivitis, uveitis or genital ulcer
PE. slightly limited spinal flexion, mild tenderness along L spine
SI joint : no tenderness
Schober’s test 10  15 cm.
Diffuse idiopathic hyperostosis syndrome (DISH).

- Ossifications along the anterolateral aspect of 4 contiguous vertebra.

- Normal intervertebral disc, apophyseal joint and SI joint

- Unknown etiology but usually involves the lower thoracic spine.

- Association with diabetes

How to diagnose ankylosing spondylitis ?
 Diagnosis of Ankylosing spondylitis
1984 Modified New York Diagnostic criteria for AS

1. Clinical criteria
a) Inflammatory LBP more than 3 months
b) Limitation of motion of lumbar spine in both sagittal and frontal planes
c) Limitation of chest expansion (age & sex match) < 2.5 cm
2. Radiologic criterion (plain x-ray)
Sacroiliitis grade > 2 bilaterally or sacroiliitis grade 3-4 unilaterally
Definite AS : at least 1 clinical criterion plus radiologic criterion
 Current and Classic Classification of Spondyloarthritis

Classic classification Current classification (ASAS)

Ankylosing spondylitis Axial spondyloarthritis (age onset < 45 yr)
with radiographic sacroiliitis (AS)
Reactive arthritis
without radiographic sacroiliitis (nr-axSpA)
Psoriatic arthritis Sacroiliitis on MRI (imaging arm)
Enteropathic arthritis HLA-B27 plus 2 clinical criteria (clinical arm)
Peripheral spondyloarthritis (no limited age onset)
Juvenile-onset spondyloarthritis
with psoriasis
Undifferentiated spondyloarthritis
with inflammatory bowel diseases
with preceding infection
without psoriasis or inflammatory bowel diseases or
preceding infection
Taurog JD, et al. N Engl J Med. 2016;374:2563-74.
Problems of ASAS Classification criteria for Axial spondyloarthritis

Lack of specificity of the criteria, especially for nr-axSpA (clinical arm)

Heterogeneity between AS vs nr-axSpA
or even nr-axSpA (imaging arm) vs nr-axSpA (clinical arm)
Problems of ASAS Classification criteria for Axial spondyloarthritis
Lack of specificity of the criteria, especially for nr-axSpA (clinical arm)
: sensitivity and specificity of ASAS criteria = 82.9% and 84.4%
ASAS (imaging arm) = 66.2 % and 97.3%
ASAS (clinical arm) = 56.6% and 83.3 %
: ASAS criteria perform quite well as diagnostic criteria if pre-test
likelihood (prevalence) of 60% for axSpA in rheumatology setting.
: In GP clinic (low prevalence) , ASAS criteria use (as diagnostic test)
will result in a false-positive (look-alike) axSpA.
van der Linden S, et al. Curr Rheumatol Rep. 2015;17:62. doi: 10.1007/s11926-015-0535-y.
 Problems of ASAS Classification criteria for Spondyloarthritis
Heterogeneity between AS vs nr-axSpA
AS nr-axSpA
1
Prevalence 2-3 times of AS
2
Male : Female 2-3 : 1  1:1 (slightly female predominance)
2
HLA-B27 no difference between AS and nr-axSpA
Peripheral arthritis, no difference between AS and nr-axSpA
2
Dactylitis, Enthesitis
2
Anterior uveitis AS > nr-axSpA
2
Response to anti-TNF agents AS < nr-axSpA
1 van der Linden S, et al. Curr Rheumatol Rep. 2015;17:62. doi: 10.1007/s11926-015-0535-y.
2 de Winter JJ, et al. Arthritis Res Ther 2016;18:196.
 Problems of ASAS Classification for Axial spondyloarthritis
Heterogeneity between AS vs nr-axSpA or nr-axSpA imaging arm vs clinical arm

15-year follow up of 83 new-onset nr-axSpA

- 26% of nr-axSpA progress to AS
- more frequent and more rapid progression to AS among patients in the imaging arm
than in the clinical arm
Wang R, et al. Arthritis Rheumatol 2016;68:1415-21.
When to order HLA-B27 ?
 HLA-B27 test
Diagnostic Use
- No use for diagnosis of AS

- Not included in Modified New York diagnostic criteria for AS

- Should not be used for diagnosis of nr-axSpA (clinical arm according to

1,2,3
ASAS classification criteria) because of the possibility of false positive

1. van der Linden S, et al. Curr Rheumatol Rep. 2015;17:62. doi: 10.1007/s11926-015-0535-y.
2. Akkoc N, et al. Clin Rheumatol 2016;35:1415-23.
3. van der Linden S, et al. In Kelley and Firestein’s Textbook of Rheumatology 10th ed. 2017:p.1256-1279.e5
 HLA-B27 test
Prognostic Use
1
- AS with +ve HLA-B27 vs AS with –ve HLA-B27
: younger age onset, earlier age of diagnosis, more frequent acute anterior
uveitis, familial history of AS, less association with psoriasis or inflammatory bowel
disease, good response to TNF inhibitors
2
- Relatives of AS with +ve HLA-B27
16 times risk of AS in comparision with general population with +ve HLA-B27

1. Akkoc N, et al. Curr Rheumatol Rep 2017;19:26.

2. van der Linden SM, et al. Arthritis Rheum 1984;27:241-9.
How to treat ankylosing spondylitis ?
 Treatment of Ankylosing spondylitis

AIM MODE
- Relieve pain - Nonpharmacological treatment
- Suppress inflammation - Pharmacological treatment
- Prevent disability
- Improve quality of life
 Nonpharmacological Treatment
- Stop smoking
- Physical therapy and Rehabilitation
: back exercise , rage of motion exercise (neck, shoulder, hip), deep breathing exercise,
lying prone

- Sport
- Daily life activities
: posture and balance , driving , falling
Patient information of AS http://www.spondylitis.org
http://www.arthritis.org
 Pharmacological Treatment

Evaluation
- Spondylitis
- LBP, morning back stiffness, ESR or hs-CRP
- Sacroiliitis

- Peripheral arthritis
- Pain , Physical Examination
- Enthesitis
 Pharmacological Treatment
NSAIDs
- Any NSAIDs can be used
- Depends on individual response , comorbidities
1,2
- Continuous NSAIDs use may slow radiographic progression

Corticosteroids
- Local corticosteroids in cases of anterior uveitis, enthesitis,
mono-arthritis
1. Wanders A, et al. Arthritis Rheum 2005;52:1756-65.
2. Poddubnyy D, et al. Ann Rheum Dis 2012;71:1616-22.
 Pharmacological Treatment
Slow-acting antirheumatic drugs (SAARDs)
1
- Review of literatures and current recommendation
Methotrexate, sulfasalazine and leflunomide have no efficacy for
treatment of spondylitis and sacroiliitis in AS.
2
- Sulfasalazine showed efficacy in AS with peripheral arthritis
- Due to high-cost biologic agents (TNF inhibitors)  try sulfasalazine
or methotrexate after NSAIDs failure in AS

1 Ward MM, et al. Arthritis Rheumatol 2016;68:282-98.

2. Chen J, et al. Cochrane Database Syst Rev 2005:CD004800.
Guideline for Management of
Ankylosing Spondylitis
Thai Rheumatism Association 2012.
 Prognosis
- Variable natural histories in individual patients
- In general , good prognosis in AS patients
- 10-20% of patients with disabilities after follow up of 20-30 yr.
1
- Poor prognostic factors
: younger age onset
: hip involvement
: dactylitis
: anterior uveitis
: ESR > 30 mm/hr
: poor response to NSAIDs
1 Pradeep DJ, et al. Rheumatology (Oxford) 2008;47:942-5.
Thank You for Your Attention