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Ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic, progressive inflammatory arthritis primarily affecting spine and sacroiliac joints, causing eventual fusion of the spine; it is a member of the group of the spondylarthropathies. Complete fusion results in a complete rigidity of the spine, a condition known as bamboo spine. more...

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Treatment is with physiotherapy and medication. Some cases remain mild, while other result in marked disability.

Signs and symptoms

The typical patient is a young man of 15-30 years old (although women are also affected) with pain and stiffness in the spine. It is also associated with iridocyclitis (anterior uveitis), ulcerative colitis, psoriasis and Reiter's disease, through HLA-B27 (see below).

Osteopenia or osteoporosis of AP spine, causing eventual compression fractures and a back "hump" if untreated.

Organs affected by AS, other than the axial spine, are the hips, heart, lungs, heels, and other areas (peripheral).

Ankylosing spondylitis affects the eyes in up to 40 percent of cases, leading to episodes of eye inflammation called acute iritis. Acute iritis causes eye pain and increased sensitivity to light (photophobia).

Diagnosis

The diagnosis is by X-ray studies of the spine, which show characteristic spinal changes and sacroiliitis. A normal X-ray does not exclude the disease.

Variations of the HLA-B gene increase the risk of developing ankylosing spondylitis, those with the HLA-B27 variant are at highest risk of developing the disorder. HLA-B27, demonstrated in a blood test, is occasionally used as a diagnostic, but does not distinguish AS from other diseases and is therefore not of real diagnostic value. Effective Diagnosis can also happen via MRI scans. Unattended cases normally lead to knee pain, resulting in a fair assumption of normal rheumatism.

Pathophysiology

AS is a systemic rheumatic disease, and about 90% of the patients are HLA-B27 positive. HLA-DR and IL1ra are also implicated in ankylosing spondylitis. Although specific autoantibodies cannot be detected, its response to immunosuppresive medication has prompted its classification as an autoimmune disease.

Hypotheses on its pathogenesis include a cross-reaction with antigens of the Klebsiella bacterial strain (Tiwana et al. 2001). Particular authorities argue that elimination of the prime nutrients of Klebsiella (starches) would decrease antigenemia and improve the musculoskeletal symptoms. On the other hand, Khan (2002) argues that the evidence for a correlation between Klebsiella and AS is circumstantial so far, and that the efficacy of low-starch diets has not yet been scientifically evaluated. Similarly, Toivanen (1999) found no support for the role of kebsiella in the etiology of primary AS.

Epidemiology

The sex ratio is 3:1 for men:women. In the USA, the prevalence is 0.25%, but as it is a chronic condition, the number of new cases (incidence) is fairly low.

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TREATMENT OF LOWER CERVICAL SPINE FRACTURES IN PATIENTS WITH ANKYLOSING SPONDYLITIS
From Journal of Bone and Joint Surgery, 1/1/04 by Gille, O

Purpose: A retrospective study of 17 fractures of the cervical spine in patients with ankylosing spondylitis is reported. The purpose of this study was to search for risk factors of fracture in ankylosing spondylitis an to assess treatment outcome.

Material and methods: Seventeen patients treated between 1982 and 2201 were reviewed with a mean follow-up of five years. There were three women and fourteen men, mean age 60 years at trauma. Fifteen patients underwent surgery and two were treated orthopaedically.

Results; This group of patients with ankylosing spondylitis with fracture of the cervical spine was homogeneous: age 60 years, disease duration 30 years, fracture due to fall. The fracture was at the C6/C7 level in 47% of the patients where the lever arm is the greatest and also a level that is difficult to explore, explaining the late diagnosis in 35% of the patients. Sixty percent of the patients were in Frankel classes D or E and 23% in classes A or B. Anterior fixation was used for M patients, posterior fixation in one. A long ostcosynthesis involving several levels was used in all cases. Major kyphosis had developed in three patients after fracture which was not recognised initially; at fixation, an anterior wedge graft was inserted in the fracture line for correction. Mean correction was 20° with good restoration of the lordosis and rehorizontalization. Bone healing was achieved in all operated patients without loss of the reduction of the kyphosis at last follow-up. The neurological status did not worsen in any patient. Anterior fixation was insufficient to reduced an old fracture-dislocation in one patient who required posterior decompensation. Orthopaedic treatment was used in two patients: the first (Frankel A) died at two months and the second healed with a 10° aggravation of the cervical kyphosis. all the Frankel A and B patients in this series died.

Conclusion: all patients with severe neurological involvement died. The anterior approach, used alone, provided good stabilisation of the cervical spine. For the patients without neurological involvement, reduction of the cervical kyphosis should he associated with a stabilisation procedure in case of fracture with kyphosis.

O. Gille. C. Schaeldele, V. Pointillart. J.M. Vital

Unite de Pathologie Rachidienne, Hopital Pellegrin,

place Amelie-Raba-Leon, 33076 Bordeaux cedex,

France

Copyright British Editorial Society of Bone & Joint Surgery 2004
Provided by ProQuest Information and Learning Company. All rights Reserved

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