ANKYLOSING SPONDYLITIS

● A chronic inflammatory disorder principally affecting the articulations, ligaments, and

tendons of the spine and pelvis (axial skeleton), often resulting in complete polyarticular
ankylosis.

● Less commonly known as Bechterew disease or Marie Strümpell disease

● Onset is usually between 15 and 35 years and involves males more than females.

● The cause remains unknown.

Clinical Features
● chronic low back pain, relieving with activity.

● low back, with aching and stiffness of variable intensity localized to the sacrum,

buttocks, and thighs.

● long-standing cauda equina syndrome

● Diminished chest expansion and anterior chest pain.

● Peripheral involvement of the large joints occurs in up to 50% of patients.

● Hips, shoulders, knees, and heels.

Associations (Mnemonic APICO- SAC)

1. anterior uveitis (25-40%)
2. psoriasis
3. inflammatory bowel disease: ulcerative colitis / Crohn disease
4. osteopenia
5. cardiovascular disease, aortic valve disease / aortitis
6. apical/upper lobe predominant interstitial lung disease with small cystic spaces
7. secondary amyloidosis (rare)
8. cauda equina syndrome

LAB – elevated ESR, RAF – neg and HLAB27 +

Pathologic Features
 ✔ Synovial Articulations

synovial proliferation and inflammatory cell proliferative synovial tissue forms a layer over
the articular cartilage, resulting in its destruction and subchondral erosion of bone.

✔ Cartilage Articulations

initial changes occur in the subchondral bone as an osteitis extensive replacement of the involved bone and intra-articu

Eventually, the fibrous tissue undergoes ossification, resulting in osseous trabeculae

traversing the entire joint space and creating bony ankylosis.

✔ Entheses

when an inflammatory cell infiltrate replaces the chondrified and calcified parts of the
ligament, resulting in bone erosion. Repair of the erosion is characterized by deposition of
woven bone, which projects away from the original surface, producing spur-like bony
spicules. Later, this is remodelled and replaced by lamellar bone
Radiologic Features

● early bilateral sacroiliac changes and an ascending progression of spinal alterations

● The basic changes consist of osteoporosis, erosions, and surrounding reactive sclerosis,

followed by bony ankylosis. Bilateral and symmetric.

⮚ Sacroiliac joints (4 signs)

● sacroiliitis is usually the first manifestation and is symmetrical and bilateral

● the sacroiliac joints first widen before they narrow

● changes occur in the iliac side of the SI joints

● at end-stage, the SI joint may be seen as a thin line or not visible

Stage 1. Pseudo-Widening of the Joint Space.

- subchondral osteoporosis leads to l oss of the articular cortical bone margin
produces hazy joint definition.
 Pseudo Widening on left
Stage 2. Erosive and Sclerotic Changes.
- Erosive areas in the subarticular bone joint margin becomes irregular k/a rosary
bead appearance.

-
- Reactive sclerosis, particularly in the adjacent ilium seen = most common stage
when diagnosis is first made.
Stage 3. Ankylosis.
- Narrowing and eventual obliteration of the joint space.
- Reactive sclerosis gradually dissipates replaced by generalized osteoporosis.

Occasionally, the anterior sacroiliac joint marginal cortex will remain visible through the
ankylosis and is referred to as a ghost joint.
The upper ligamentous portion of the joint will also demonstrate bridging ossification.
When prominent, it will be seen on an AP film as a triangular radiopacity (star sign)
Sacroiliitis grading (New York criteria) – based on
X-ray
Classification
● grade 0: normal
● grade I: suspicious changes (some blurring of the joint margins)
● grade II: minimum abnormality (small localized areas with erosion or
sclerosis, with no alteration in the joint width)
● grade III: unequivocal abnormality (moderate or advanced sacroiliitis
with erosions, evidence of sclerosis, widening, narrowing, or partial
ankylosis)
● grade IV: severe abnormality (complete ankylosis)
⮚ Spine (9 signs)

1. early spondylitis is characterized by small erosions at the corners of vertebral bodies

with reactive sclerosis: Romanus lesions of the spine (shiny corner sign)
Vertebral body corner erosions (Romanus lesion)
Vertebral body corner sclerosis (shiny corner)

2. vertebral body squaring

3. non-infectious spondylodiscitis: Andersson lesion
An ankylosed segment fractures fail to reankylose non-union pseudo-arthrosis
through the intervertebral disc.
Radiographically, there is a rapid loss of the adjacent endplates, sclerosis, and
fragmentation of the underlying vertebral body. The appearance is identical to an
active infection or a neurotrophic process involving the intervertebral disc space.
Surgical fusion is the treatment of choice.
4. Barrel vertebra - Accentuated convexity of anterior vertebral body
5. diffuse syndesmophytic ankylosis can give a "bamboo spine" appearance

6. syndesmophytes are classically described as paravertebral ossification running

parallel to the spine
7. linear ossification along the central spine; representing interspinous ligament
ossification can give a "dagger spine" appearance on frontal radiographs;

8. Trolley track spine - Three vertical lines seen in advanced case on the AP lumbar
film owing to ossification in the apophyseal joints and interspinous and supraspinous
ligaments
9. ossification of spinal ligaments, joints and discs (with fatty marrow within the ossified
disc, best seen on MRI)
10. apophyseal and costovertebral arthritis and ankylosis
11. enthesophyte formation from enthesopathy – whiskering enthesophytes

12. pseudoarthroses may form at fracture sites

13. dural ectasia

with dural diverticuli

● Hips

- Hip involvement is generally bilateral and symmetric, with uniform joint space
narrowing,
- axial migration of the femoral head sometimes reaching a state of protrusio
acetabuli, and
- a collar of osteophytes at the femoral head-neck junction.

● Pelvis

Whiskering of the pelvic bones primarily affects the ischial tuberosities, resulting from
ossification of the ligamentous origins.

There can be bridging or fusion of the pubic symphysis.

● Knees

Knees demonstrate uniform joint space narrowing with bony proliferation.

● Hands

Hands are generally involved asymmetrically, with smaller, shallower erosions and
marginal periostitis.

● Shoulders

demonstrates a large erosion of the anterolateral aspect of the humeral head, producing a
'hatchet' deformity
marrow oedema of the acromion process, at the site of origin of deltoid muscle, has been
described as a very specific sign of the disease
● Chest

- progressive fibrosis and bullous changes at the apices. These lesions may
resemble tuberculosis infection and bullae may become infected.

● Cardiac

- normal/ cardiomegaly.

CT
● chronic structural changes such as joint erosions, subchondral sclerosis, and bony

ankylosis are better visualized on CT

● better in demonstrating fractures.

MRI

● may have a role in early diagnosis of sacroiliitis; MRI is more sensitive than CT or plain

radiography in detecting inflammatory changes (which precede structural changes) such

as bone marrow edema (best demonstrated on STIR sequences), synovitis and capsulitis
(on gadolinium enhanced T1 weighted sequences) 16,18

● enhancement of the interspinous ligaments is indicative of enthesitis

● superior to CT in the detection of cartilage inflammation and destruction

● useful in follow-up

Bone scintigraphy
● Ratios of SI joint to sacral uptake of 1.3:1 or higher is abnormal

Complications
1. fracture
increased chance of spinal fracture also known as "chalk stick" or "carrot stick fractures"

2. Andersson lesion
3. Arachnoid Diverticula
● Generalized dural ectasia in association with diverticula formation occurs appears
to be closely linked to the development of cauda equina syndrome.
● Lumbar spine is the most common site
● most diverticula are directed posteriorly and can erode the pedicles, lamina, and
spinous process
4. rare neurological complications include transverse myelitis and/or cauda equina
syndrome

TREATMENT

DD
● general spine: enteropathic arthritis and other seronegative arthritis

● cervical spine: juvenile rheumatoid arthritis

● diffuse idiopathic skeletal hyperostosis