A 65 yrs old man with H/O back pain since 3 months. ESR is raised. On examination marked stiffness and mild restriction of chest movements is found. On x-ray, syndesmophytes are present in veebrae. Diagnosis is
Ankylosing spondylitis (Ref: Apley's 9/e, p 66-70, 477; Harrison 17/e, p 2109-2112, 1 1 1 Turek's ohopedics 6/e ,p158, 168] The clinical profile of the given case fits into Ankylosing spondylitis (A.S.) except, for the age. A.S. is usually seen in 2nd or 3rd decades of age with a median age of 23. However "in 5% of patients, symptoms begin after 40" - Harrison All other features, i.e. raised ESR, marked stiffness, restriction of chest movements & syndesmophytes are seen in A.S. Syndesmophvtes Syndesmophytes are thin, slender veical radiodense spicules bridging the veebral bodies, giving the spine `bamboo' appearance. They are actually ossification of outer. fibres of annulus fibroses. Syndesmophytes are seen in: - Ankylosing spondylitis - Psoriatic ahritis - Reiter's disease - Ahritis assoc. with Inflammatory bowel disease Before discussing A.S. lets see other options: Diffuse idiopathic skeletal hyperostosis (DISH): Also k/a Forestier's disease, ankylosing hyperostosis DISH is a syndrome of excessive calcification and ossification of soft tissues. mainly ligaments and entheses, that develops with aging. There is a marked predilection to the axial skeleton, paicularly the thoracic spine. It may also involve the peripheral joints. The most characteristic radiographic abnormality of DISH is calcification and ossification of the anterior longitudinal ligament of the spine. The diagnosis is made by, spinal radiographs that show "flowing" calcifications along the anterior and lateral poion of at least four contiguous veebral bodies without loss of disc height and without typical radiographic findings of ankylosing spondylitis. (no syndesmophytes). DISH commonly occurs in men in their fifth to sixth decade of life. Patients are often asymptomatic but may have spinal pain or limited spinal motion. DISH can be ruled out as in DISH there is no raised ESR and syndesmophytes. (ESR is raised in inflammatory spondyloahropathies like Ankylosing spondylitis. But DISH and degenerative osteoahritis are non-inflammatory conditions, so ESR would be normal.) Apley's writes- "Although DISH bears a superficial resemblance to AS, it is not an inflammatory disease; spinal pain and stiffness are seldom severe, the sacroilitis joints are not eroded and the ESR is normal." Harrison writes- "Diffuse idiopathic skeletal hyperostosis which occurs in middle aged and elderly is usually not symptomatic." Degenerative osteoahritis of spine: It is a disease of elderly characterised by formation of large osteophytes along the anterior and lateral aspects of spine with decreased interveebral disc spaces. Lumbar canal stenosis: It is ruled out as - Neurogenic claudication or pseudoclaudication is the usual symptom, consisting of back and buttock or leg pain induced by walking or standing and relieved by sitting. It can be congenital (achondroplasia) or acquired in degenerative diseases, trauma, spine surgery, metabolic or endocrine disorders and Paget's disease. S/s of the case Ankylosing spondylitis (AS) . Ankylosing hyperosteosis/Diffuse idiopathic skeletal hyperosteosis (DISH) Degenerative osteoahritis of spinelspondylosis deformation 65 yrs age in 5% common common 3 months history + insidious long duration insidious long , ,,, duration Back pain ++ +/- (may be asymptomatic) - +/ (may be asymptomatic) Marked stiffness ++ - (Stiffness is mild) TESR + inflammatory - non-inflammatory - non-inflammatory Restriction of chest movements + _ ? Syndesmo phytes + "flowing wax" like calcification or hyperostoses, no 1 of interveebral disc space Osteophytes 1 of interveebral disc space * No raised ESR or syndesmophytes are seen. Ankylosing spondylitis Introduction Prototype of seronegative (absence of rheumatoid factor) spondyloahropathies. Inflammatory disorder of unknown cause. Usually begins in the second or third decade with a median age of 23, in 5% symptoms begin after 40. Male to female ratio is 2-3 : 1 Strong correlation with HLA-B27 Pathology Enthesitis i.e. inflammation of the inseion points of tendons, ligaments or joint capsule on hone is one of the hallmarks of this entity of disease. Primarily affects axial (spinal) skeleton and sacroiliitis is often the earliest manifestation of A.S.. Involvement of costoveebral joints frequently occur, leading to diminished chest expansion (normal 5 cm) Peripheral joints for e.g. shoulders, and hips (root joints) are also involved in 1/3rd patients. Extraaicular manifestations like acute anterior uveitis (in 5%); rarely aoic valve disease, carditis and pulmonary fibrosis. Pathological changes proceed in three stages? 1)Inflammation with granulation tissue formation and erosion of adjacent bone. 2)Fibrosis of granulation tissue 3)Ossification of the fibrous tissue, leading to ankylosis of the joint. Clinical features Low back pain of insidious onset Duration usually less than 3 months Significant morning stiffness and improvement with exercise Limited chest expansion Diffuse tenderness over the spine and sacroiliac joints Loss of lambar lordosis, increased thoracic kyphosis Decreased spinal movements (especially extension) in all directions. Radiological features Cardinal and earliest sign is erosion and fuzziness of the sacroiliac joints Squaring of veebral bodies Syndesmophytes (described earlier) giving the appearance of a "bamboo spine". Other investigations ESR and CRP are usually elevated HLA-B27 is present in 95% of cases. Treatment General measures to maintain satisfactory posture and preserve movement. NSAIDs TNF inhibitors for severe disease Operations to correct deformities Complications Spinal fractures Hyperkyphosis Spinal cord compression Lumbosacral nerve root compression
Ankylosing spondylitis
Degenerative osteoahritis of spine
Ankylosing hyperosteosis
Lumbar canal stenosis