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« Thread started on: Mar 25th, 2007, 11:32pm »

Ankylosing Spondylitis: Description and Diagnosis
Christopher I. Shaffrey, M.D.
Professor, Department of Neurological Surgery
University of Virginia
Charlottesville, VA, USA


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What Is It?
Ankylosing Spondylitis (AS) is a chronic inflammatory disease characterized by pain and progressive stiffness. It is part of a group of rheumatic diseases termed seronegative spondyloarthropathies (vertebral joints) that share the human antigen HLA-B27. AS is seronegative (serum negative) because a rheumatoid factor is not detected in the patient's blood (serum).

AS is considered to be hereditary, although environmental factors have been suggested. Most people with the HLA-B27 antigen do not develop AS. It is known to affect white males about four times as often as females. Onset typically occurs between the ages of 15 and 45.

In the early stages of the disease, the sacroiliac joints (back of the pelvis) become inflamed and painful. As the disease progresses, ossification is triggered by the body's defense mechanism. Ossification causes new bone to grow between vertebrae eventually fusing them together increasing the risk for fracture. Further, ossification may affect spinal ligaments causing spinal canal stenosis (narrowing), which can result in neurologic deficit.

Other symptoms may include:

>Low back pain that may spread down into the buttocks and thighs. Pain varies in intensity, duration, and is episodic. Stiffness is usually worse in the morning and improves with exercise.

>Limited motion in the lumbar spine.

>As the disease progresses, the patient may notice the discomfort moves up the spine.

>The thoracic region may be affected by pain, stiffness, and limited chest expansion.

Pain, tenderness, and stiffness in the shoulders, hips, knees, and heels.

>Cauda Equina Syndrome (specific nerve compression) may develop causing bilateral lower extremity numbness, weakness, and incontinence.

>Inflammation of the intervertebral disc or disc space (spondylodiscitis) is a common complication caused by the hardening/thickening of fibrous tissue (sclerosis) affecting vertebral end plates. The resultant abnormal vertebral motion almost always causes pain.

>Spinal deformity: kyphosis (humpback), lordosis (swayback).

General health and family medical history is important because ankylosing spondylitis (AS) can be hereditary. Ankylosing spondylitis may or may not be associated with non-skeletal diseases such as uveitis (eye inflammation), prostatitis (prostate inflammation) and certain disorders affecting cardiac and pulmonary function. A blood workup will reveal the HLA-BA27 antigen. A physical examination often includes the following:

Schober Test: Limited motion in the lumbar spine is symptomatic of AS. The Schober test measures the degree of lumbar forward flexion as the patient bends over as though touching their toes. Progressive loss of spinal motion is correlated with x-ray findings.

Gaenslen Test: Sacroiliac pain is often found in the early stage of AS. Gaenslen's maneuver stresses the sacroiliac joints. Increased pain during this maneuver could be indicative of joint disease.

When AS affects the thoracic spine normal chest expansion may be compromised. The amount of chest expansion is measured from deep expiration to full inspiration. Measurements significantly less than one inch (normal chest expansion) could indicate AS.

General range of motion measures the degree to which a patient can perform movements of flexion, extension, lateral bending, and spinal rotation. Asymmetry may also be noted.

Neurologic Evaluation
A neurologic evaluation is mandatory for patients presenting with a spine disorder. The following symptoms are assessed: pain, numbness, paresthesias (e.g. tingling), extremity sensation and motor function, muscle spasm, weakness, and bowel/bladder changes.

Radiographic Evidence
Plain radiographs (x-rays) are standard for AS. A CT Scan or MRI may be ordered to evaluate bone and soft tissues (e.g. spinal canal) in greater detail. These tests reveal changes in the spine affected by AS.

>Characteristic bilateral sacroiliac changes may appear as blurry erosions (wearing away) or hardening/thickening of fibrous tissue (sclerosis) on either side of the joint(s).

>Loss of cartilage spacing in the facet joints, which fuse and become indistinguishable.

>Natural spinal curvature lost and presentation of abnormal kyphosis (humpback) and/or lordosis (swayback).

>Spinal fractures anywhere in the spinal column. A CT Scan or MRI may detect epidural bleeding common following spinal fracture. This bleeding may cause a semisolid swelling (hematoma) causing compression of neural elements. Fractures may lead to neurologic deficit and/or spinal deformity.

>Lumbar vertebrae may appear abnormally square from erosion that has occurred where bone meets fibrous tissue during the inflammatory phase.

>'Bamboo Spine' is typical of AS and results from ossification of the annulus fibrosus, the anterior longitudinal ligament, and bony bridges that form across the intervertebral spaces.

Ankylosing Spondylitis: Treatment and Recovery
Christopher I. Shaffrey, M.D.
Professor, Department of Neurological Surgery
University of Virginia
Charlottesville, VA, USA

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Treatment for ankylosing spondylitis (AS) is aimed at relieving the patient's symptoms and preventing spinal deformity. Seldom is surgery required.

Standard treatment includes nonsteroidal anti-inflammatory agents and physical therapy (PT). PT teaches the patient exercises designed to strengthen back muscles, improve posture, increase flexibility and range of motion, and techniques to enhance breathing. Activities that help to alleviate stiffness include taking a warm bath or shower, gentle stretching movements performed in bed prior to rising, or aquatics such as swimming.

Spinal fractures resulting from AS may be treated non-surgically using traction and/or bracing. Treatment for cervical fractures may necessitate a halo brace. This apparatus immobilizes the cervical spine by placement of pins into the skull secured to a metal ring (halo). The halo is combined with a well-fitted jacket. A TLSO (thoraco lumbar sacral orthotic) is a jacket-like brace (sleeveless) that stabilizes the thoracic - lumbar - sacral spinal regions. These braces may be worn for 3 months or more depending on the patient's disorder.

Most patients with ankylosing spondylitis do not require surgery. Surgery is a consideration when:

(1) The spinal deformity is in a fixed flexed position. The magnitude (angle) of the deformity is paramount. An example is forward flexion so great the chin rests near or on the chest. The functional limitations of this particular deformity are great. In the example, the patient would be unable to look forward, make visual contact, drive, and may have difficulty eating.

(2) The stability of the spine is compromised.

(3) Neurologic deficit exists.

(4) A combination of any of the above.

Several surgical procedures may be available to the spinal physician. The type of procedure is dependent on the disorder, spinal stability, neurologic compromise, and other variables.

During an osteotomy bone is cut to correct angular deformities. The bone ends are realigned and allowed to heal. Spinal instrumentation and fusion may be combined with an osteotomy to stabilize the spine during healing.

>Other procedures decompress the spinal canal and associated neural elements restoring or preventing neurologic dysfunction.

>Spinal Instrumentation and Fusion are surgical procedures used to correct spinal deformity and to provide permanent stability to the spinal column. These procedures join and solidify the level where a spinal element has been damaged or removed. Instrumentation uses medically designed hardware such as rods, bars, wires, and screws. These devices hold the spine straight during fusion. Fusion is the adhesive process joining bony spinal elements.

Following certain cervical procedures, the patient may need to wear a halo brace to immobilize the cervical spine. The halo, a metal ring, is secured to the skull with pins and combined with a well-fitted jacket. A TLSO (thoraco lumbar sacral orthosis) is a jacket-like brace worn to stabilize the thoracic - lumbar - sacral spinal regions. This brace may need to be worn for six months (or until healing occurs) following surgery.

Although ankylosing spondylitis (AS) is not curable, most people are only mildly affected. The condition tends to become less severe with age (e.g. progression). Episodic pain and stiffness will not prevent most patients from leading a productive life. Pain can be treated using medication, stiffness alleviated with exercise and modalities (e.g. heating pad), and a program of stretching can increase flexibility and range of motion.

Post-surgical patients will be given medication to control pain. At the appropriate time during recovery, the patient will begin a program of physical therapy (PT) to strengthen the spinal muscles and increase flexibility. The physical therapist will teach the patient how to incorporate principles of good posture into their everyday life.

If the patient was prescribed a brace to wear, their progress will be monitored during follow up visits with their physician.

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