In a middle aged male having back pain, syndesmophytes involving4 continous vertebrae are seen on Xray. The patient has -
Ans. is 'b' i.e., Ankylosing spondylitiso Back pain with syndesmatophytes in a middle aged man suggest the diagnosis of ankylosing spondylitis.Ankylosing spondylitis (marie-strumpell disease)o Ankylosing spondylitis is a chronic progressive inflammatory disease of the sacroiliac joints and the axial skeleton,o Prototype of seronegative (absence of rheumatoid factor) spondyloarthropathies,o Inflammatory disorder of unknown cause.o Usually begins in the second or third decade with a median age of 23, in 5% symptoms begin after 40.o Male to female ratio is 2-3 :1o Strong correlation with HLA-B27o 90-95% of cases are positive for HLA - B27.Joints involved in ankylosing spondylitiso Ankylosing spondylitis primarily affects axial skeleton.o The disease usually begins in the sacro-iliac joints and usually extends upwards to involve the lumbar, thoracic, and often cervical spine.o In the worst cases the hips or shoulders are also affected. Hip joint is the most commonly affected peripheral joint,o Rarely knee (Ebenzar 4th/6 593) and ankle (Apley's 9th/e 67) are also involved. Pathologyo Enthesitis i.e. inflammation of the insertion points of tendons, ligaments or joint capsule on bone is one of the hallmarks of this entity of disease.o Primarily affects axial (spinal) skeleton and sacroiliitis is often the earliest manifestation of A.S..o Involvement of costovertebral joints frequently occur, leading to diminished chest expansion (normal > 5 cm)o Peripheral joints e.g. shoulders, and hips are also involved in l/3rd patients.o Extraarticular manifestations like acute anterior uveitis (in 5%); rarely aortic valve disease, carditis and pulmonary fibrosis also occur.o Pathological changes proceed in three stages-Inflammation with granulation tissue formation and erosion of adjacent bone.Fibrosis of granulation tissueOssification of the fibrous tissue, leading to ankylosis of the joint.Radiological features of ankylosing spondylitiso Radiographic evidence of sacroiliac joint is the most consistent finding in ankylosing spondylitis and is crucial for diagnosis. The findings areSclerosis of the articulating surfaces of SI jointsWidening of the sacroiliac joint spaceBony ankylosis of the sacroiliac jointsCalcification of the sacroiliac ligament and sacro-tuberous ligamentsEvidence of enthesopathy - calcification at the attachment of the muscles, tendons and ligaments, particularly around the pelvis and around the heel.o X-ray of lumbar spine may showSquaring of vertebrae : The normal anterior concavity of the vertebral body is lost because of calcification of the anterior longitudinal ligament.Loss of the lumbar lordosis.Bridging kosteophytes' (syndesmophytes)Bamboo spine appearance
DISH
Ankylosing spondylitis
Rheumatoid arthritis
Osteoarthritis
Arthritis