Ankylosing Spondylitis Approach Stem Statement 1. Look at this patient (no apparent endocrine, rheumatology or neurological abnormalities) 2.

Examine patients gait 3. Low back pain, chest, back, neck, look at the ceiling Proceed 1. Introduce (thank you for letting me exam you, my name is how do I address you) 2. Ask if there is pain 3. Stand the patient, walk him, turn around and return to original position 4. Touch toes with his fingers 5. Look left and look right 6. Touch your chest with your chin Presentation Sir, this patient has Ankylosing Spondylitis as evidenced by a stooped, question-mark posture with loss of lumbar lordosis and a fixed kyphosis with extension of the cervical spine in an attempt to maintain a horizontal visual gaze. There is also a protuberant abdomen. Spinal movements are restricted as evidenced by the finger-to-toe test, with limited flexion and lateral movements of the cervical spine. I would like to complete the examination by doing the heels, hips and occiput test and measure the occiput-to-wall distance, as well as a modified schoebers test and chest expansion (5cm). I would like to look for shoulder and knee joint involvement extra-articular involvement and complications Differential diagnoses o Skin to rule out Psoriasis which is a possible differential diagnosis o Abdominal examination to look for signs of inflammatory bowel disease o Reiters syndrome Questions 1. Tell me about AS. a. Seronegative spondyloarthropathies, chronic inflammatory arthritis affecting the SI joints with fusion of the spinal vertebrae, associated with HLA b27 b. 3rd to 4th decades, males 3X c. Symptoms: back pain worse in the morning and with rest and improves with activity d. Signs : limited lateral flexion of the lumbar spine is the first sign of spinal involvement followed by loss of lumbar lordosis e. Investigation and management

2. What are the associated conditions? a. Anterior uveitis, iritis b. Atlanto-axial subluxation or dislocation c. Apical fibrosis d. Aortic regurgitation e. AV nodal block, arrythmias f. Amyloidosis g. Achilles tendonitis, plantar fasciitis 3. What is the heels-hips-occiput test? a. Ask the patient to place his heels, hips and occiput against a wall all at once b. Inability of the occiput to touch the wall c. Can measure the wall-occiput distance 4. What is Schoebers test? a. Draw a line joining the dimple of Venus b. 5cm mark below c. 10cm mark above d. Forward flexion e. <5 cm implies limited spinal mobility 5. Why is there a protuberant abdomen? a. This occurs as a result of restricted chest expansion from a fixed spine b. Hence resulting in a predominantly diaphragmatic breathing c. With resultant protuberant abdomen 6. What are the other types of conditions that can present with sacroilitis? a. Psoriasis b. Reiters (reactive arthritis) i. Can be urogenital (Chlamydia) or gastrointestinal (Shigella, campylobacter, salmonella) ii. Triad of urethritis, arthritis and conjunctivitis iii. Cs have circinate balanitis (small shallow painless sores) and keratoderma blenorrhagica (small hard papules on palms and soles) c. Enteropathic arthritis (these are the seronegative spondyloarthropahy which are associated with HLA B27) 7. How do you diagnose AS? a. Rome or New York Criteria b. Based on: i. Radiological features of sacroilitis ii. Symptoms of back pain (lumbar spine or dorsolumbar junction) iii. Physical signs of limited spinal mobility in all 3 planes and chest expansion <2.5cm

8. How would you investigate? a. Imaging AP views and the SI joints and AP/lat of spinal vertebrae i. Early erosions and sclerosis of the SI joints ii. Later Syndesmophytes in the margins of lumbosacral vertebrae iii. Advanced bamboo spine b. Blood test (not so important) i. Elevated ESR ii. HLA B 27 (95% AS is positive but small percentage of B27 positive develop AS) 9. How would you manage? a. Education and counseling i. Chronic disease ii. Genetic counseling (HLA positive, siblings has 30%) 1. 50% chance of transferring genes to children 2. 1/3 of children who has HLA B27 will have AS 3. Overall risk is 1/6 b. Non-pharmological i. Lifelong regular exercises ii. Involving the PT and OT c. Pharmological i. NSAIDs ii. MTX, sulphasalazine iii. Anti TNF and anti CD-20 d. Surgical therapy What are the indications for starting immunomodulators? TNF blocking agents are recommended for the treatment of active AS after having failed treatment for the patients predominant clinical manifestation