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Diagnosis of

Ankylosing spondylitisHuda A.K. Hamouda

MBBS 3rd year

Internal MedicinePBL

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HistoryO General health and family medical history

Hereditary

O Non-skeletal diseases

{ uveitis , prostatitis and certain disorders

affecting cardiac and pulmonary function}

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Physical ExaminationO Schober Test:

it measures the degree of lumbar forward flexion asthe patient bends over as though touching their toes.

O Gaenslen Test:

Gaenslen's maneuver stresses the sacroiliac joints.

O When ankylosing spondylitis affects the thoracicspine normal chest expansion may becompromised..

O General range of motion measures the degree

to which a pa

tient can perform movements offlexion, extension, lateral bending, and spinalrotation. Asymmetry may also be noted.

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Neurologic EvaluationO A neurologic evaluation is mandatory for patients

presenting with a spine disorder. The following

symptoms are assessed:pain, numbness, paresthesias (e.g. tingling), extremity

sensation, and motor function, muscle spasm,

weakness, and bowel/bladder changes.

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Radiographic EvaluationO Plain radiographs (x-rays) are standard for

AS. A CT Scan or MRI may be ordered to

evaluate bone and soft tissues (e.g. spinalcanal) in greater detail. These tests reveal

changes in the spine affected by AS.

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O Characteristic bilateral sacroiliac changes may appear as blurry erosions or

thickening of fibrous tissue (sclerosis) on either side of the joint(s).

O Loss of cartilage spacing in the facet joints, which fuse and becomeindistinguishable.

O Natural spinal curvature lost and presentation of abnormal kyphosis and/or

lordosis .

O spinal fractures anywhere in the spinal column.

O A CT Scan or MRI may detect epidural bleeding common following spinal

fracture. This bleeding may cause a semisolid swelling (hematoma) causing

compression of neural elements. Fractures may lead to neurologic deficit

and/or spinal deformity.

O Lumbar vertebrae may appear abnormally square from erosion that has

occurred where bone meets fibrous tissue during the inflammatory phase.

O Bamboo Spine' is typical of ankylosing spondylitis and results from

ossification of the annulus fibrosus, the anterior longitudinal ligament, and

bony bridges that form across the intervertebral spaces.

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G0 Normal

G1 Suspicious

G2 Sclerosis , some erosions

G3 Severe erosions . Widening of the joint space ,some ankylosis

G4 Complete ankylosis

Radiographic grading of sacroiliac changes in

ankylosing spondylitis

S0 Normal , no lesions

S1 Mild enhancement and bone marrow oedema , covering less than 25% of a VU

S2 Moderate bone marrow oedema , less than 50% of a VU

S3 Severe bone marrow oedema , covering more than 50 % of a VU

S4 bone marrow oedema and erosion covering less than 25% of a VU

S5 bone marrow oedema and erosion covering less than 50% of a VU

S6 bone marrow oedema and erosion covering more than 50% of a VU

ASspiMRI-a

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Modified New York Criteria for

the Diagnosis of ASO Clinical Criteria

O Low back pain, > 3months, improved byexercise, not relievedby rest

O Limitation of lumbarspine motion, sagittaland frontal planes

O Limitation of chestexpansion relative tonormal values for ageand sex

Radiologic Criteria

Sacroiliitis grade 2bilaterally or grade 3 4

unilaterally Grading

Definite AS if radiologiccriterion present plus atleast one clinical criteria

Probable AS if:

Three clinical criterion

Radiologic criterionpresent, but no signs orsymptoms satisfy clinicalcriteria

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Blood tests CRP

ESR

Serum RF- / LOW TITER

Variations of HLA-B gene

ARTS1 & IL23R

To exclude kidney conditions

Urinalysis

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Disease Activity Assessment

Index Metric

BASFI Disability level

BASDAI Disease activity level

ASAS - IC Composite sum of disease activity

BASFI = Bath Ankylosing Spondylitis Functional Index

BASDAI = Bath Ankylosing Spondylitis Disease Activity Index

ASAS - IC = ASsessment in Ankylosing Spondylitis Improvement Criteria

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Thank You