Examine this patient's back.
Examine this patient.
· Back stiffness and back pain - worse in the morning, improves on exercise and worsens on rest.
· Symptoms in the peripheral joints (in -40%), particularly shoulders and knees.
· Onset o! symptoms is typically insidious and in the third to lburth decade.
· Extra-articular manifestations: red eye (uveitis), diarrhoea (Gl involvement), history of aortic regurgitation, pulmonary apical
fibrosis (worse in smokers).
· 'Question mark' posture (due to loss of lumbar lordosis, fixed kyphoscoliosis of the thoracic spine with compensatory extension
of the cervical spine).
· Protuberant abdomen.
Proceed as follows:
· Ask the patient to look to either side - the whole body turns when the patient does this.
· Examine the cervical, thoracic and lumbar spines (remember that cervical spine involvement occurs later in the disease and
results in pain and a grating sensation on movement of the neck).
· Measure the occiput-to-wall distance (inability to make contact when heel and back are against the wall indicates upper
thoracic and cervical limitation).
· Perform Schober's test - this involves marking points 10 cm above and 5 cm below a line joining the 'dimple of Venus' on the
sacral promontory. An increase in the separation of less than 5 cm during full forward flexion indicates limited spinal mobility.
Note, Finger-floor distance is a simple indicator but is less reliable because good hip movement may compensate for back limitation.
· Examine for distal arthritis (occurs in up to 30% of patients and may precede the onset of the back symptoms). Small joints of
the hand and feet are rarely affected.
· Measure chest expansion with a tape (less than 5 cm suggests costovertebral involvement).
· Tell the examiner that you would like to examine the following:
-Eyes for iritis, anterior uveitis (seen in 20% of patients).
Heart for aortic regurgitation (seen in 4% of patients who have had the disease for over 15 years), cardiac conduction defects.
-Lungs for mild restrictive disease, apical fibrosis, apical cavities and secondary
-Central nervous system such as tetraplegia, etc.
-Foot for Achilles tendinitis and plantar fasciitis.
· The four 'A's of ankylosing spondylitis: apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendinitis.
· That psoriasis and Reiter's syndrome can also cause sacroiliitis.
This patient has fixed kyphoscoliosis of the thoracic spine with loss of lumbar lordosis (lesion) due to ankylosing spondylitis
(aetiology) on Schober's test; spinal movements are severely diminished (functional status).
What investigations would you like to perform in this patient?
Anteroposterior view of sacroiliac joints and lateral radiographs of lumbar spine: the earliest changes are erosions and sclerosis of the sacroiliac joints.
Later in the disease syndesmophytes may be found in the lumbosacral spine. In severe disease, involvement progresses up the spine, leading to a
'bamboo spine'. The New York criteria (1966) for the diagnosis of ankylosing spondylitis require a combination of clinical and radiographic features, but
the diagnosis should be suspected on the basis of inactivity, spinal stiffness, and pain, with or without additional features.
In which other seronegative arthritic disorders is Iow back pain a
fca ture ?
Sacroiliitis is often seen in Reiter's syndrome, psoriatic arthritis, juvenile chronic arthritis and intestinal arthropathy.
How would you manage a patient with ankylosing spondylitis?
· Encourage exercise, particularly physical therapy, to preserve back extension.
· NSAIDs, in particular indometacin (indomethacin). Phenylbutazone is reserved for resistant cases.
· Surgical therapy, consisting of vertebral wedge osteotomy, is occasionally indicated.
What genetic counselling would you give this patient?
In HLA-B27 positive patients, the siblings have a 30% chance of developing this disease. Hence children of such patients who develop symptoms
such as joint pains or sore eyes should be referred to a rheumatologist.
What is the natural history of the disease?
About 40% go on to develop severe spinal restriction; about 20% have significant dis-ability: early peripheral joint disease, particularly of the hip,
indicates a poor prognosis.
What is the risk in those with a 'bamboo' cervical spine when driving?
Increased susceptibility to whiplash injury and restricted lateral vision.
What therapy may the patient have received in the past if the blood film shows a leukaemic picture?
In the past, patients were treated with irradiation of the spine. However, such patients tend to develop leukaemia several years after therapy.
The term 'ankylosing spondylitis' derives from the Greek words, ankylos (bent or crooked) and spondylos (vertebra). Past names have included
Marie-Str0mpell disease and von Bechterew's disease.
The first clinical report of ankylosing spondylitis (1831) concerned a man from the Isle of Man. Vladimir von Bechterew of St Petersburg, Russia,
described a series of cases between 1857 and 1927. Adolf Str0mpell (1853-1926) of Erlangen, and Pierre Marie (1853-1940) of Paris, independently
described this condition in 1897 and 1898 respectively.
H.C. Reiter (1881-1969), a German physician.
Achilles is a figure from Greek mythology who was a hero of the Trojan War. His mother dipped him into the rwer Styx, holding him by his heel, to
make him invulnerable to attack. He slew Hector in this war, but was himself slain, wounded in his vulnerable heel by Paris.