ANKYLOSING

SPONDYLITIS
By Sahej Verma (83)
Final year BPT
INTRODUCTION

 Ankylosing Spondylitis is a term derived from the Greek words

Ankylos meaning “stiffening” Spondylos meaning “vertebra”

INTRODUCTION
 Ankylosing Spondylitis is defined as a chronic seronegative
Inflammatory sypondyloarthropathy predominantly affecting the
axial skeleton ultimately leading to the fusion of the bones.
 Ankylosing spondylitis is highly common in genetic predisposition
meaning it is also an auto-immune disorder making it a
rheumatological disorder.
 We most commonly see the inflammations occurring at the sites of
attachments such as Tendons, Ligaments and also the Joint
capsules (facet joints) which is also called enthesitis.
 Seronegative means that there is no involvement of rheumatic
factor.
ANATOMY

 A normal vertebral Spine consists of 33 vertebral

bones :-
Cervical (7)
Thoracic (12)
Lumbar (5)
Sacral (5)
Coccygeal (4)
ANATOMY
 JOINTS:-
1. Facet joints (Vertebra to Vertebra)
2. Sacroiliac joints (Sacrum to ilium)
3. Costovertebral joints (Thoracic rib cage to
Vertebra)
 Ligaments:-
1. Anterior longitudinal ligaments
2. Posterior Longitudinal Ligaments
3. Interspinous Ligaments
4. Supraspinous Ligaments
AETIOLOGY

 There are only 2 causes of Ankylosing Spondylitis:-

1. Gene susceptibility :- So far the studies have shown that the subjects with
the human leukocyte antigen HLA B27 shows
strongest association with the rheumatological
diseases
2. Bacterial infection:- Klebsiella pneumoniae is thought to be the initiating
factor for ankylosing spondylitis
Klebsiella pneumoniae produces repeated
episodes of klebsiella – reactive arthritis.
(again, only in HLA B27 positive
patients)
The HLA B27 gene cross reacts with
Klebsiella which leads to an
immunological cascade reaction
PATHOPHYSIOLOGY
Major histocompatibility complex (MHC) class 1 molecule

Presents the cytoplasm of the cell for immune check as a sample

T-lymphocytes and CD8 + T cytotoxic cells binds to the “sample” antigen

HLA B27 GENE From chromosome 6 consisting of molecule cloning DNA

Triggers the cytotoxic cells of the immune system
PATHOPHYSIOLOGY
Immune cells like neutrophils, macrophages, fibroblasts and histamines
Are recruited and rush to the site.

Immune cells release cytokines like TNF – Alpha and Interleukin -1

Inflammation of the joints

(intervertebral, Facet, sacroiliac and costovertebral)

Fibroblasts replace the synovial joints with fibrin which causes

Osteoblasts are activated starting ossification of the fibrous tissue into bone

Enthesitis, syndesmophytes, bony ankylosis, Discal Calcification and osteoporosis

STAGES OF AS

STAGE 1 STAGE 2 STAGE 3

• Isolated SI • Pain limited to lumbar • Cauda equina

inflammation (Hip region syndrome
pain) • Not relieved by rest • Excruciating pain
• Mild and nagging • Paraspinal muscle
pain • Crippling pain and
stiffening fibrosis
• Nocturnal pain
• Dull and constant or
• Activity eases pain • Non-anginal anterior chest
• Vigorous activity intermittent pain
pain • Stiff and Reduced
causes transient • Pain at hemithorax
pain ROM.
• episodic precipitated by coughing or
laughing.
SIGNS AND SYMPTOMS

 WEIGHT LOSS
 ANTERIOR UVEITIS
 FEVER
 FATIGUE
 PAIN IN HIP REGION (SACROILIAC JOINT)
 CERVICAL / THORACIC PAIN (INTERVERTEBRAL AND FACET JOINTS

AFFECTION)
 SHORTNESS OF BREATH (COSTOVERTEBRAL JOINT AFFECTION)
 REDUCED ROM
 NOCTURNAL PAIN
 INTERMITTENT PAIN
 FLUCTUATING FREQUENCY AND INTENSITY OF SYMPTOMS FROM DAY TO DAY
SIGNS AND SYMPTOMS

 CAUDA EQUINA SYNDROME

 OSTEOPENIA
INVESTIGATIONS
• X-RAY
 At Sacrum :-
1. Bilateral inflammation in the Iliac portion (sacroiliitis)
INVESTIGATIONS
• X-RAY
 At Sacrum :-
1. Enamel erosion followed by the sclerosis resulting in the bridging of
the bony formations
2. Shows production of syndesmophytes
3. This progresses ultimately to ossification
INVESTIGATIONS
• X-RAY
 At Spine :-
1. Osteitis :- bony erosions seen on the anterior bordersx of the
vertebrae (romanus lesions)

“Shiny corner sign” (healed lesion)

INVESTIGATIONS
• X-RAY
 At Spine :-
2). Syndesmophytosis:- ossification of the outer fibres of the annulus
fibrosus, anterior longitudinal ligaments and paravertebral connective
tissue (bamboo spine appearance)
INVESTIGATIONS
• X-RAY
 At Spine :-
2). Syndesmophytosis:- ossification of the outer fibres of the annulus
fibrosus, anterior longitudinal ligaments and paravertebral connective
tissue (bamboo spine appearance)
INVESTIGATIONS
• X-RAY
 At Spine :-
3). Vertebral body squaring
INVESTIGATIONS
• X-RAY
 At Spine :-
4). Erosion/Destruction:-
non infectious spondylodiscitis (Andersson’s lesion)
(schmorl’s nodes)[if located centrally]
INVESTIGATIONS
• X-RAY
 At Spine :-
5). ossification:-
The inflammation followed by fibrosis followed by ossification of
the supraspinous ligaments and interspinous ligaments as well as the
outer fibres of the intervertebral disc (annulus fibrosus)
INVESTIGATIONS
• X-RAY
 At Spine :-
6). Trolley – track sign

The ankylosis of the costovertebral joints may hinder the chest

expansion and therefore causes problems while breathing.
INVESTIGATIONS
• X-RAY
 At Spine :-
 7). Osteoporosis:-
Reduced bone turnover
Decreased Trabechular network.
INVESTIGATIONS
• CT/MRI
 Same findings as x-ray but a bit more clearer.

• Culture testing
 For detection of klebsiella

• Gene testing
 For detection of HLA B-27 gene
SPECIAL TESTS
• SCHOBER’S TEST
 A test used to determine the lumbar spine mobility
SPECIAL TESTS
• MODIFIED SCHOBER’S TEST
SPECIAL TESTS
• MODIFIED MODIFIED SCHOBER’S TEST
SPECIAL TESTS
• WOLFSON’S MODIFIED SCHOBER’S TEST
 SPECIAL TESTS
• FLESCHE TEST (OCCIPUT TO WALL)
• While looking forward, the examinee also attempts to have the back of the head
(the occiput) touch the wall as well.
• In most normal individuals in this standard position, the occiput will touch the wall
and the OWD measurement will be zero.
• If the occiput does not touch the wall, then the OWD is measured with a ruler.
• A value greater than 2 cm. is considered to be abnormal
 SPECIAL TESTS
• CHEST EXPANSION TEST
 SPECIAL TESTS
• GAENSLEN’S TEST
 MANAGEMENT
• MEDICAL MANAGEMENT
 NSAIDS (Anti inflammatory)
 Sulfasalazines
 Methotrexate
 Skeletal muscle relaxants
 Disease modifying anti rheumatic drugs (DMARDS)
 Biologics (to inhibit cytokine production)
 MANAGEMENT
• PHYSIO MANAGEMENT
 Short term goals:-
 Control of the diffuse and intense pain secondary to joint stiffness
 Recovery of proprioception, joint stability,
 restoring normal postural patterns
 reduction of pain
 MANAGEMENT
• PHYSIO MANAGEMENT
 Long term goals:-
1. To enable the patient to maintain their residual function to
guarantee the most autonomy possible.
2. pain control
3. improvement in activities of daily living
4. general function and quality of life
 MANAGEMENT
• PHYSIO MANAGEMENT
 Electrotherapy:-
 TENS
 STEAM BATH
 HOT PACK
 CRYOTHERAPY
 INFRA RED
 HYDROTHERAPY
 MANAGEMENT
• PHYSIO MANAGEMENT
 Posture training
 Strengthening exercises
 Mobility exercises
 Flexibility and stretching exercises
 Cardiovascular endurance training
 Aquatic therapy