questions 7

Ankylosing Spondylitis

Topic updated on 09/22/17 9:24pm

  • A 21-year-old man presents with severe morning back pain over the past three months. His pain improves as the day progreses and with excercise. Physical exam shows a stooped posture and diminished anterior flexion of the lumbar spine. Radiography of the lumbar spine shows bilateral sclerotic changes in the sacroiliac area. Laboratory testing shows that the patient is HLA-B27 positive.
  • Clinical definition
    • chronic inflammatory disorder that primarily affects the sacroiliac joint and spine
  • Epidemiology
    • demographics
      • more common in men
      • peak onset age is 15-35 years of age
    • risk factors
      • HLA-B27 gene presence
  • Etiology
    • unknown but may involve both genetic (e.g., HLA B-27 positivity) and environmental factors
  • Pathogenesis
    • unclear but involves inflammation, bone erosion, and spur formation
      • can result in spinal fusion and costovertebral and costosternal
    • involves the entheses
      • connective tissue between bone and a tendon or ligament
  • Associated conditions
    • psoriasis
    • inflammatory bowel disease
    • anterior uveitis
    • aortic regurgitation
  • Prognosis
    • may lead to chronic pain and stiffness
  • Symptoms
    • back pain
      • worse in the morning and lasts approximately 30 minutes
      • improves with activity
    • stiffness of the spine
    • with anterior uveitis
      • photophobia
      • watering and redness of the eye
  • Physical exam
    • may have stooped posture
    • positive Schober test
      • demonstrates limited spine flexibility
    • decreased chest wall expansion
  • Radiography  
    • indication
      • gold standard for evaluating and supporting the diagnosis of ankylosing spondylitis
    • findings
      • "bamboo spine" 
  • Labs
    • HLA-B27 positivity
      • seen in > 90% of patients
  • Mechanical low back pain
  • Enteropathic arthritis
  • Reactive arthritis
  • Psoriatic arthritis
  • Conservative
    • patient education and exercise
      • indication
        • mainstay of treatment
  • Medical
    • nonsteroidal antiinflammatory drugs (NSAIDs)
      • indication
        • considered first-line treatment for managing pain and stiffness
    • tumor necrosis factor (TNF) inhibitors
      • indication
        • typically used in patients who do not respond to conservative and NSAID treatment
      • medications
        • adalimumab
        • etanercept
  • Low bone density
  • Spine fracture leading to injury of the spinal cord
  • Restrictive lung disease


Qbank (2 Questions)

(M3.RH.60) A 23-year-old Caucasian male complains of lower back pain that began approximately 6 months ago. He also reports pain in his hips and heels. He is unsure why he is experiencing this pain. He notices that this pain is worse in the morning after waking up, and improves with physical activity. Ibuprofen provides significant relief. He denies bowel and bladder incontinence or erectile dysfunction. Physical exam is notable for decreased chest expansion, a spinal flexion length difference of 3.5 cm on Schober's testing, 5/5 strength in both lower extremities, 2+ patellar reflexes bilaterally, and an absence of saddle anesthesia. Which of the following is the best initial diagnostic test for this patient? Topic Review Topic

1. Human leukocyte antigen (HLA) B-27 testing
2. Erythrocyte sedimentation rate (ESR)
3. MRI of the sacroiliac joint
4. Radiography of the sacroiliac joint
5. Slit-lamp examination

(M2.RH.4723) A 25-year-old man presents to his primary care physician with lower back pain. He states that he has had the pain for the past two years. The patient works as a butcher, and recently was moving heavy meat carcasses. The patient states that his pain is worse in the morning and that nothing improves it aside from swimming. The patient has a past medical history of anabolic steroid abuse, acne, hypertension and obesity. His current medications are hydrochlorothiazide, ibuprofen, topical benzoyl peroxide, and acetaminophen. On physical exam there is no tenderness upon palpation of the spine. There is limited range of motion of the spine in all 4 directions. Which of the following is most likely to confirm the most likely diagnosis in this patient? Topic Review Topic

1. Radiograph of the spine
2. MRI of the spine
3. The straight leg test and the clinical presentation
4. MRI of the sacroiliac joint
5. HLA typing

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