Ankylosing Spondylitis Treatment with Expert

Presenting complaints: This is a disease of young adults, more common in males (M : F=10 : 1). The following clinical presentations may be seen:

1. Classic presentation: The patient is a young adult 15-30 years old male, presenting with a gradual onset of pain and stiffness of the lower back. Initially, the stiffness may be noticed only after a period of rest, and improves with movement. Pain tends to be worst at night or early morning, awakening the patient from sleep. He gets better only after he walks about or does some exercises. There may be pain in the heel, pubic symphysis, manubrium sterni and costo-sternal joints. In later stages, kyphotic deformity of spine and deformity of the hips may be prominent features.
2. Unusual presentations: Patient may occasionally present with involvement of peripheral joints such as the shoulders, hips and knees. Smaller joints are rarely involved. Sometimes, a patient with ankylosing spondylitis may present with chronic inflammatory bowel disease; the joint symptoms follow.

   On examination it is found that the patient walks with a straight stiff back. There may be a diffuse kyphosis. Following clinical signs may bepresent:

   • Stiff spine: There may be a loss of lumbar lordosis. Lumbar spine flexion may be limited.
   • Tests for detecting sacro-iliac involvement: Following tests may be positive in a case with sacro-iliac joint involvement:
     • Tenderness, localised to the posterior superior iliac spine or deep in the gluteal region.
     • Sacro-iliac compression: Direct side to side compression of the pelvis may cause pain at the sacro-iliac joints.
     • Gaenslen’s test: The hip and the knee joints of the opposite side are flexed to fix the pelvis, and the hip joint of the side under test is hyperextended over the edge of the table. This will exert a rotational strain over the sacro-iliac joint and give rise to pain.
     • Straight leg raising test: The patient is asked to lift the leg up with the knee extended. This will cause pain at the affected sacroiliac joint.
     • Pump-handle test: With the patient lying supine, the examiner flexes his hip and knee completely, and forces the affected knee across the chest, so as to bring it close to the opposite shoulder. This will cause pain on the affected side.
   • Tests for cervical spine involvement: In advanced stages, the cervical spine gets completely stiff.
     • The Fle’che test may detect an early involvement of the cervical spine.
     • Straight leg raising test: The patient is asked to lift the leg up with the knee extended. This will cause pain at the affected sacroiliac joint.
     • Fle’che test: The patient stands with his heel and back against the wall and tries to touch the wall with the back of his head without raising the chin. Inability to touch the head to the wall suggests cervical spine involvement.
     • Thoracic spine involvement: Maximum chest expansion, from full expiration to full inspiration is measured at the level of the nipples. A chest expansion less than 5 cm indicates involvement of the costo-vertebral joints.
     • Extra-articular manifestations: In addition to articular symptoms, a patient with ankylosing spondylitis may have the following extra-articular manifestations:
       • Ocular: About 25 per cent patients with ankylosing spondylitis develop at least one attack of acute iritis sometimes during the natural history of the disease. Many patients suffer from recurrent episodes, which may result in scarring and depigmentation of the iris.
       • Cardiovascular: Patients with ankylosing spondylitis, especially those with a long standing illness, develop cardiovascular manifestations in the form of aortic incompetence, cardiomegaly, conduction defects, pericarditis etc.
       • Neurological: Patients may develop spontaneous dislocation and subluxation of the atlanto-axial joint or fractures of the cervical spine with trivial trauma, and may present with signs and symptoms of spinal cord compression.
       • Pulmonary: Involvement of the costo-vertebral joints lead to painless restriction of the thoracic cage. This can be detected clinically by diminished chest expansion, or by performing pulmonary function tests (PFT). There may also occur bilateral apical lobe fibrosis with cavitation, which remarkably simulates tuberculosis on X-ray.
       • Systemic: Generalised osteoporosis occurs commonly. Occasionally, a patient may develop amyloidosis.