Answer

Ankylosing spondylitis: The anteroposterior and lateral radiographs of the spine

demonstrate the classic bamboo-spine finding of ankylosing spondylitis. The
images show sclerosis and erosions of the anterior surfaces of the vertebrae
corners and margins (osteitis). Bone formation extends across the anterior and
lateral margins of the intervertebral disks of the lower thoracic and lumbar spine
(syndesmophytosis). The sacroiliac joints show extensive periarticular sclerosis
and focal ankylosis.

Ankylosing spondylitis is a chronic inflammatory disorder that principally

involves the axial skeleton, but sometimes involves the appendicular skeleton
as well. Ankylosing spondylitis affects men 4-10 times more frequently than
women, and symptoms generally appear in those aged 15-35 years. More than
90% of whites with ankylosing spondylitis have the HLA-B27 gene, and only 6-
8% of those with this gene are spared the disease.

Symptoms include back pain, peripheral joint and chest pain, sciatica, anorexia,
weight loss, and low-grade fever. Back pain is typically transient at first,
becoming persistent later on, and it is usually worst in the mornings and
resolves after exercise. Ankylosing spondylitis is associated with iritis in 20% of
patients and sometimes with pulmonary fibrosis of the upper lobes, which leads
to cavitation and bronchiectasis, cardiac enlargement with pericarditis and
conduction defects, and inflammatory bowel disease.

Ankylosing spondylitis affects joints and sites where tendons and ligaments
attach to bone. Radiographic changes usually first appear in the sacroiliac
joints, followed by the thoracolumbar and lumbosacral spine. The disease
usually progresses cephalad up the spine. However, the cervical spine can be
involved without involvement of the thoracic or lumbar spine. Radiographically
evident peripheral-joint abnormalities are seen in more than 50% of patients.
Abnormalities can also be seen in the symphysis pubis and in the
manubriosternal, sternoclavicular, and temporomandibular joints. Spinal findings
include osteitis, syndesmophytosis, discovertebral erosions and destruction,
and discal calcification. On radiographs, joint involvement appears as joint-
space narrowing, periostitis, osseous erosion, and minimal periarticular
osteoporosis (less than that seen with rheumatoid arthritis). Sacroiliac joint
involvement is usually bilateral and symmetric.

Common laboratory findings are an elevated erythrocyte sedimentation rate

(during the acute phase), positive results for HLA-B27 histocompatibility
antigen, mild leukocytosis, normochromic normocytic anemia (anemia of
chronic disease), and negative results for rheumatoid factor.

The general principles of managing chronic arthritis also apply to ankylosing

spondylitis. Among the various nonsteroidal anti-inflammatory drugs (NSAIDs)
available to treat the disease, indomethacin may be the most effective. The
lowest dose that provides pain relief should be used to avoid potentially serious
complications, such as nausea and vomiting, peptic ulcer disease, and renal
insufficiency. Sulfasalazine can be useful if peripheral arthritis is present, but it
is ineffective for the spinal and sacroiliac pain that is most characteristic of this
disease. In most patients, symptoms persist for life, though in rare cases
remission does occur.

Vigorous physical therapy and exercise can help prevent axial immobility.
Specifically, spinal extension and deep-breathing exercises maintain spinal
mobility, encourage erect posture, and promote chest expansion. Maintaining
an erect posture and sleeping on a firm mattress with a thin pillow can help
reduce thoracic kyphosis. Severe hip or spinal involvement may require surgical
repair. Anti–tumor necrosis factor (anti-TNF) agents, such as infliximab
(Remicade) and etanercept (Enbrel), are relatively new therapeutic agents and
may be considered in patients with pain refractory to other interventions and
vigorous physical therapy. These agents reduce the back pain and arthritis
associated with the disease and improve patients' quality of life in the short
term. However, long-term therapy is beneficial, and whether radiologic
progression and ankylosis can be stopped remain to be seen.

For more information on ankylosing spondylitis, see the eMedicine articles

Ankylosing Spondylitis (within the Radiology specialty), Ankylosing Spondylitis
(within the Orthopedic Surgery specialty), and Ankylosing Spondylitis and
Undifferentiated Spondyloarthropathy (within the Internal Medicine specialty).

References
 Resnick D: Bone and Joint Imaging. 2nd ed. Philadelphia, PA: WB
Saunders; 1996: 246-63.
 Andreoli T: Cecil Essentials of Medicine. 4th ed. Philadelphia, PA: WB
Saunders; 1997: 620-1.
 Peh WCP: Ankylosing spondylitis. eMedicine Journal [serial online].
2005. Available at http://www.emedicine.com/radio/topic41.htm.
Accessed July 4, 2005.
 Rudwaleit M, Sieper J: Infliximab for the treatment of ankylosing
spondylitis. Expert Opin Biol Ther 2005;5(8):1095-109.
 Braun J, Breban M, Maksymowych WP: Therapy for ankylosing
spondylitis: new treatment modalities. Best Pract Res Clin Rheumatol
2002;16(4):631-51.

BACKGROUND
A 19 year-old man presents to his primary care physician with a 2-month history
of lower back pain and stiffness. The pain is intermittent, achy, and usually
worst in the morning. He also noticed a progressive inability to bend down to
pull on his pants or tie his shoelaces. The pain sometimes awakens him at night
and is relieved with exercise. He also reports a several month history of low-
grade fever, malaise, and anorexia, as well as a weight loss of 10 pounds.

On physical examination, the patient has normal vital signs. Cardiovascular

examination reveals normal findings and no murmurs. The patient has no
evidence of photophobia, redness of the eye, or decreased visual acuity.
However, flexion of the lumbar spine is decreased when he bends to touch his
toes. Percussion elicits point tenderness of both sacroiliac joints. His other
physical findings are within normal limits.

Routine laboratory investigations and plain radiographs of the back are ordered
before the patient is discharged home. After 3 days, these values are noted:
WBC count of 4600 cells/µL, hemoglobin of 13.7 g/dL, hematocrit 43%, platelet
count of 120,000/µL, negative rheumatoid factor, erythrocyte sedimentation rate
of 64 mm/h (normal <10 mm/h for men), and positive finding for human
leukocyte antigen (HLA)-B27.

Anteroposterior and lateral radiographs of the lumbar spine are available (see
Images 1-2).

Hint
The spine and sacroiliac joints show classic findings for the diagnosis.
Authors: Jeremy Logan, MD, Department
of Radiology, University of New
Mexico Hospital, Albuquerque

Gautam Dehadrai, MD, Staff

Physician, Department of
Radiology, Veterans
Administration Hospital,
Albuquerque, NM

eMedicine Editor: Rick Kulkarni, MD, Attending

Physician, Department of
Emergency Medicine, Olive View
- UCLA Medical Center, Assistant
Professor of Medicine, David
Geffen School of Medicine at
UCLA