Spondyloarthropathies: Ankylosing Spondylitis

Table 4: Inflammatory vs degenerative spinal disease: A comparison of features

The patient may first feel pain from the sacroiliac joints deep in the gluteal regions. This pain is insidious in onset. It is dull and difficult to localize and is often worse on awakening.

The Schober test measures spinal mobility with bending, although a positive test is not specific for ankylosing spondylitis. Spinal mobility with bending can be seen to improve with treatment.

Buttock pain is typically either unilateral or alternating from side to side. With subsequent involvement of the thoracic spine, including costovertebral, costosternal, and manubriosternal joints, patients may experience chest pain that is accentuated by coughing or sneezing and is sometimes characterized as "pleuritic". Mild to moderate reduction of chest expansion may occur.

Peripheral skeletal involvement
Tenderness may occur over sites of enthesitis, including costosternal junctions, spinous processes, iliac crests, greater trochanters, ischial tuberosities, tibial tuberosities, or heels at the insertion of the Achilles tendon or plantar fascia.

Hips and shoulders are the most frequently involved peripheral joints in ankylosing spondylitis. Asymmetric peripheral arthritis occurs in 35% of patients, whereas enthesitis occurs in 20%. Hip and ankle pain are more common initial presentations if the disease starts in childhood. Temporomandibular joint involvement occurs in about 10% of patients.

Extra-articular manifestations
Anterior uveitis or iridocyclitis (inflammation of the iris and ciliary body) is the most common extra-articular manifestation of ankylosing spondylitis, occurring in 25% to 30% of patients at some time during the course of the disease. Anterior uveitis in the absence of spondylitis is also associated with the B27 antigen.

Other extra-articular manifestations are uncommon and usually occur late in the course of the disease:

Cardiac involvement may include ascending aortitis, aortic insufficiency, conduction abnormalities, cardiomegaly, and pericarditis.

Lung involvement is characterized by slowly progressive fibrosis of the upper lobes that appears, on average, 2 decades after the onset of ankylosing spondylitis. The lesions may cavitate and be colonized by Aspergillus species.

Neurologic complications can be caused by fracture, instability, or compression of the spine. Cauda equina syndrome is a rare but serious complication of long-standing ankylosing spondylitis.

Diagnostic considerations
Clinical manifestations of ankylosing spondylitis usually begin in late adolescence or early adulthood. In rare cases, they begin after age 40 or in childhood. Two features of the history are critically important: inflammatory-pattern back pain with stiffness and a family history of ankylosing spondylitis.

The diagnosis is usually established by radiographic evidence of bilateral sacroiliitis, (19,20) in addition to a clinical feature such as inflammatory back pain, limitation of lumbar spine motion, or decreased chest expansion. Testing for the B27 antigen has no value in routine screening and should not be regarded as diagnostic or confirmatory in patients with back pain.(21)

Cleveland Clinic Journal of Medicine
Volume 71, Number 3, March 2004

This paper discusses therapies that are experimental or are not approved by the U.S. Food and Drug Administration for use under discussion.