Medical symptom checker- Back pain cause- Ankylosing spondylitis ( question mark posture )
Ankylosing spondylitis affects the large proximal joints as well as the axial skeleton. It is known as seronegative inflammatory arthropathy.
The aetiology remains unknown but it is triggered with infection by bacteria known as klebsiella which leads to an antigen cross reactivity with human self peptide. It is also associated/link with individual with HLA- B27 gene. More than 90% of individual with HLA- B27 may suffer from ankylosing spondylitis. It affects around 8 % of general population.It is also associated with strong family history and people with HLA- B27 allele.
In terms of epidemiology, it is common.Affect 0.25%-1% of population in the UK. It is more common in caucasian and common in male than female with at 16 years old 6 :1 and at 30 years old the ratio is 2:1.
Other investigations include lung function test which is used for kyphosis patient to assess any impairment in the mechanical ventilatory function and if apical fibrosis is present chest x- ray is performed.
The management includes medical and physiotherapy treatments. The medical treatment involves symptomatic reliever such as NSAIDS. The second line treatment such as immunospressant ( sulfasalazine) can also be used. Involvement of peripheral joints and joints which are acutely inflamed may required the intra articular injection of corticosteroid. Other durgs include biological agent is producing promising result and include etanercept. Etanercept will inhibit the action of TNF- alpha as it is a tumor necrosis factor ( TNF )- alpha receptor fusion protein.
The aims of physiotherapy treatment is to maximizes the range of movement by educating the patient on proper posture and exercise.
The complication of ankylosing spondylitis includes heart valve disorder such as aortic regurgitation, apical lung fibrosis ( respiratory impairment ), systemic amyloidosis and Achilles tendinitis , cauda equina syndrome and aortitis.
In term of prognosis around 10 % will develop onto a crippling disease while other will leads a normal life with regular surveillance of the complication and continuous intensive physiotheraoy.
Patient with ankylosing spondylitis may present with sacroiliac or back pain which disturb sleep and it is worst on resting or early in the morning and better with exercise.There is also a loss of spinal movement progressively. Patient may complains that he suffers from symptoms of asymmetrical peripheral arthritis.Plantar fasciitis may lead to heal pain while costovertebral joint involvement may lead to pleuritic chest pain ( sharp chest pain ).Other complains includes feel tired( fatigue ) or malaise( weak).
The examination performs on the patient include Schober' test. In Schober's test, a mark is made on the back at the middle of line between posterior iliac spines. later another mark is made 10 cm above the mark in the middle line between posterior iliac spine. Then, the patient is asked to bend forward and if the distance between both marks are more than 5 cm it is normal ( on forward flexion ). less than 5 cm , is abnormal and indicates ankylosing spondylitis. It is confirms with reduction on the occiput to wall distance when you asked the patient to stands next to the wall. Besides that reduction on lateral spinal flexion may also confirm the diagnosis of ankylosing spondylitis. Any tenderness or pain may also be felt on palpating the sacroiliac joints. On later stage, patient may develop question mark posture, thoracic kyphosis as well as fusion of the spine ( spinal fusion).
Other signs that may present includes heart valve problems such as aortic regurgitation that present with diastolic murmur and red eye syndrome or anterior uveitis as well as reduction in lung expansion due to costovertebral joint fusion and apical lung fibrosis.
The pathology behind ankylosing spondylitis involves the spine and sacroiliac joints. In spine, there is an inflammation which initially begins at the entheses which is the sites where the ligaments attach the vertebral bodies.The inflammation will persists ( persistent inflammatory ethesitis) and continue with reactive new bone formation. The changes in the structure of the bone will begins in the lumbar region before progressing onto thoracic region and finally ended in cervical region. The chronology are:
1) - The vertebral bodies begin to square ( squaring of the vertebral bodies)
2) - ossification of the vertebral that bridges the margin/ border of the vertebrae adjacently. Syndesmophytes are formed.
3) - The facet joints and syndesmophytes will fused. This will leads to immobility of the spine and ankylosis of the bone.
4)- Finally there will be a calcification of the spinal ligament anteriorly and laterally.
The investigations needed include blood and radiography. Blood test involves full blood count, to detect ant signs of anemia of chronic disease , rheumatoid factor which supposed to turn out to be rheumatoid factor negative in case of ankylosing spondylitis and ESR and CRP which increases in level due to inflammation. HLA typing is also needed.
Radiography investigation includes lateral view and anteroposterior view of the spine which shows an evidence of the bamboo spine. Radiography investigation also includes lateral and anteroposterior views of the sacroiliac joint. It will show the blurring of the symmetrical joint which is symmetrical. Then , the radiograph will show erosion, sclerosis and fusion of the sacroiliac joint. Inflammation of the sacroiliac joint or sacroiliitis also present in other seronegative inflammatory arthropathies such as psoriatic arthorparthy,Reiter's syndrome ( reactive arthritis and inflammatory bowel disease.
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