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Ankylosing Spondylitis

 

Thank you for asking to examine Harry who presented with back pain.

 

Examples of introduction:

  • A forward stooped posture with decrease lumbar lordosis, exaggerated kyphosis with fixed flexion deformity of the axial spine, most consistent with a deformity axial spondyloarthropathy such as AS, affecting the cervical/thoracic/lumbar spine with/without enthesopathy, psoriasis or other extra-articular features. My findings in further detail...

  • My findings were consistent with an axial spondyloarthropathy, most likely ankylosing spondylitis affecting the cervical/thoracic/lumbar spine with/without enthesopathy, psoriasis or other extra-articular features.

 

I will now present my findings in further detail with commentary on severity, extra-articular manifestations, complications, and differentials.

 

On general inspection, Harry was comfortable and there were no apparent gait aids.

 

There was/was not thoracic kyphosis, and loss of lumbar lordosis. (There was loss of lumbar lordosis, thoracic kyphosis, and compensatory cervical lordosis - the question mark sign)

 

The occiput to wall test was normal / abnormal.

 

On assessment of movement:

  • In the lumbar spine, the modified Schober’s test was normal / abnormal with ___ cm of flexion. Extension and lateral flexion were / were not reduced (Normal is greater than 10 cm as per UTD but notes considerable variability based on age, sex, etc).

  • In the thoracic spine, there was / was not reduced range of motion in rotation. Chest expansion was normal / reduced at ____ (<5cm).

  • The cervical spine did / did not show reduced range of motion in flexion (45 degrees), extension, lateral bending (45 degrees) and rotation.

 

On palpation, there was / was not tenderness in the spinous processes and facet joints.

 

There was / was not tenderness in the SI joints (pain suggests active disease).

 

On examination of extra-axial features:

  • There was / was not evidence of small joint of the hand arthropathy, knee or hip involvement

  • There were / were not psoriatic changes

  • There was / was not enthesitis and dactylitis

  • There was / was not uveitis, pulmonary fibrosis, cardiac involvement with AR, signs of psoriasis, or signs of inflammatory bowel disease.

 

In terms of complications of possible immunosuppression:

  • There was / was not signs of steroid complications, such as a Cushingoid appearance, bruising, skin atrophy, cataracts, or proximal myopathy. 

  • There were no particular injection marks suggestive of biological use

 

In summary my findings are in keeping with an axial spondyloarthropathy. This is most likely ankylosing spondylitis with / without extra-axial features. Whilst this may require immunosuppression, I could/could not ascertain specific evidence for these.

 

Differential include other seronegative spondyloarthropathies including:

  • Psoriatic arthritis, but there were no stigmata of psoriasis, peripheral joint involvement, or dactylitis.

  • Reactive arthritis

  • Enteropathic arthritis, although there were no features of IBD and axial involvement is less common.

 

I would proceed from here by:

  • Confirming my diagnosis with an x-ray of the sacro-iliac joints, HLA-B27 status

  • Completing an assessment of disease activity by:

    • Reviewing current symptoms

    • CRP, ESR, FBE (anaemia), albumin (chronic inflammation)

  • Assessing for complications of disease:

    • FBE, UEC, LFT (treatment toxicity)

    • BMD (osteoporosis)

    • Steroid related if relevant

    • CV risk assessment

    • CXR, PFTs, HRCT – ILD

    • ECG, TTE – AR, heart block 

 

How is disease activity assessed?

  • We can use the Bath AS Disease Activity Index (BASDAI) - a questionnaire

 

What is inflammatory back pain?

  • < 40, insidious onset, improvement with exercise, no improvement with rest, pain at night

 

What are the XR changes?

  • SIJ - cortical outline loss, juxta-articular sclerosis, erosions, ankylosis

  • Lumbar - loss of lordosis, squaring of vertebrae, syndesmophytes, bamboo spine with bone bridging of vertebrae anteriorly, OP, apophyseal joint fusion

  • SIJ can be graded using the New York Criteria (Grade 0 to 4)

    • 0 = normal

    • 1 - some blurring of joint margins

    • 2 - minimal sclerosis with some erosion, no change in joint width

    • 3 - erosions and pseudo-widening

    • 4 = ankylosis

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