| Ankylosing Spondylitis | ||
Gregory F. Keenan
| Database Differential Diagnosis Data Gathering Physical Examination Laboratory Aids Therapy Follow-Up Common Questions and Answers Bibliography |
| DATABASE | ||
DEFINITION
Ankylosing spondylitis is an inflammatory arthritis that tends to be asymmetric peripherally and to involve the insertion of tendons, ligaments, as well as the sacroiliac joints and spine.
CAUSES
PATHOLOGY
EPIDEMIOLOGY
GENETICS
COMPLICATIONS
| DIFFERENTIAL DIAGNOSIS | ||
INFECTION
TUMORS
TRAUMA
METABOLIC
CONGENITAL
IMMUNOLOGICAL
PSYCHOLOGICAL
MISCELLANEOUS
| DATA GATHERING | ||
HISTORY
Question: Ankylosing spondylitis
Significance: Signified by
back pain of insidious onset that has been present for at least 3 months. There
is usually a familial history of a male relative with disease and inactivity
stiffness resulting in gelling of peripheral joints and back.
| PHYSICAL EXAMINATION | ||
Finding: Sacroiliac tenderness
Significance: Indicates site
of inflammation
Finding: Pain on direct palpation at insertion of Achilles tendon and
plantar fascia at calcaneal insertion
Significance: Indicates site of
inflammation
Finding: Schober test of lumbar spine
flexibility
Significance: Mark 15-cm span at mid-low back at level of
iliac crest while patient is standing. Have patient flex back as far as
possible. Remeasure span. Abnormal if less than 5 cm increase in
span.
| LABORATORY AIDS | ||
Test: CBC, ESR, HLA-B27, rheumatoid factor (RF), and antinuclear
antibody (ANA) tests should be done.
Significance: Note that ESR is
occasionally not elevated. RF and ANA are typically negative.
Test: Imaging
Significance: Sacroiliac views should be
obtained to demonstrate evidence of pseudowidening and/or sclerosis.
Test: False Positives
Significance: HLA-B27 occurs in 8% of
whites and 6% of blacks.
| THERAPY | ||
DRUGS
PHYSICAL THERAPY
Physical therapy is an essential component of treatment. Must encourage range-of-motion exercises and avoid prolonged neck flexion.
DURATION OF THERAPY
DIET
| FOLLOW-UP | ||
WHEN TO EXPECT IMPROVEMENT
Over weeks to several months should see some improvement in stiffness, synovitis, and range of motion.
SIGNS TO WATCH FOR TO INDICATE PROBLEMS
PROGNOSIS
PITFALLS
Overdiagnosis in HLA-B27-positive individuals in whom other causes for joint swelling should be considered.
| COMMON QUESTIONS AND ANSWERS | ||
Q: Should HLA-B27 be checked routinely in boys with back
pain?
A: Detection of HLA-B27 alone should not precipitate an
extensive work-up because it is so common in the normal healthy population.
However, the risk for developing a spondyloarthropathy is 16 times greater than
in the HLA-B27-negative individual.
Q: Can affected individuals play contact sports?
A: This is
probably not a good idea because as the spine fuses, the risk for fracture of
the spine (especially the C-spine) increases.
ICD-9-CM 720.0
| BIBLIOGRAPHY | ||
Cabral DA, Malleson PN, Petty RE. Spondyloarthropathies of childhood. Pediatr Clin North Am 1995;42(5):1051–1070.
Case records of the Massachusetts General Hospital. Weekly clinicopatholgical exercises. Case 17-1990. A 16-year-old boy with painful swelling of the left knee joint and calf. N Engl J Med 1990;322:1214–1223.
Flato B, Aasland A, Vinje O, Forre O. Outcome and predictive factors in juvenile rheumatoid arthritis and juvenile spondyloarthropathy. J Rheumatol 1998;25(2):366–375.
Spondyloarthropathies and psoriatic arthritis in children. Curr Opin Rheumatol 1993;5:634–643.
Copyright
© 2000 Lippincott Williams & Wilkins
M. William
Schwartz, Louis M. Bell, Jr., Peter M. Bingham, Esther K. Chung, David F.
Friedman and Andrew E. Mulberg, The 5 Minute Pediatric Consult