Ankylosing spondylitis

128 Ankylosing spondylitis



Instruction


Examine this patient’s back.


Examine this patient.



Salient features



History




• Back stiffness and back pain: worse in the morning, improves on exercise and worsens on rest


• Symptoms in the peripheral joints (in ~40%), particularly shoulders and knees


• Onset of symptoms is typically insidious and in the 3rd–4th decade


• Extra-articular manifestations: red eye (uveitis), diarrhoea (GI involvement), history of aortic regurgitation, pulmonary apical fibrosis (worse in smokers).



Examination




• ‘Question mark’ posture (as a result of loss of lumbar lordosis, fixed kyphoscoliosis of the thoracic spine with compensatory extension of the cervical spine)


• Protuberant abdomen.


Proceed as follows:



• Ask the patient to look to either side: the whole body turns when the patient does this.


• Examine the cervical, thoracic and lumbar spines (remember that cervical spine involvement occurs later in the disease and results in pain and a grating sensation on movement of the neck).


• Measure the occiput-to-wall distance (inability to make contact when heel and back are against the wall indicates upper thoracic and cervical limitation).


• Perform Schober’s test. This involves marking points 10 cm above and 5 cm below a line joining the ‘dimple of Venus’ on the sacral promontory. An increase in the separation of <5 cm during full forward flexion indicates limited spinal mobility.


Note: Finger–floor distance is a simple indicator but is less reliable because good hip movement may compensate for back limitation.

• Examine for distal arthritis (occurs in up to 30% of patients and may precede the onset of the back symptoms). Small joints of the hand and feet are rarely affected.


• Measure chest expansion with a tape (<5 cm suggests costovertebral involvement).


• Tell the examiner that you would like to examine the following:


• Eyes for iritis, anterior uveitis (seen in 20% of patients)

• Heart for aortic regurgitation (seen in 4% of patients who have had the disease for over 15 years), cardiac conduction defects

• Lungs for mild restrictive disease, apical fibrosis, apical cavities and secondary fungal infection; look for cyanosis (patients with rigid spine syndrome often have underlying hypoventilation)

• CNS, such as tetraplegia, etc.

• Foot for Achilles tendinitis and plantar fasciitis.

Remember:



• The four ‘A’s of ankylosing spondylitis: apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendinitis


• That psoriasis and Reiter syndrome can also cause sacroiliitis.

Related posts:

  1. Permanent cardiac pacemaker/implantable cardioverter-defibrillator
  2. Cauda equina syndrome
  3. Anaemia
  4. Superior vena caval obstruction

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Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Ankylosing spondylitis

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