Ankylosing spondylitis (AS) is a chronic progressive spondyloarthropathy that mainly affects the medial bones (spine) and is characterized by ossification of the ligamentous attachments of the spine, eventually leading to ankylosis, stiffness and deformity of the spine. -The cause is unknown and may be related to genetics, infection, or injury.
I. These patients usually present with the following symptoms.
1. Low back pain or discomfort is the most common symptom of this disease. The incidence is about 90%. Low back pain in this disease cannot be relieved by rest, but the symptoms can be improved by activity. Patients may only feel stiffness or muscle pain in the lower back, or paravertebral pressure pain, which can be easily misdiagnosed as “rheumatic pain”. Hip and posterior thigh pains are often misdiagnosed as “sciatica”, but those caused by ankylosing spondylitis are less likely to radiate below the knee.
2, morning stiffness is one of the common early symptoms of ankylosing spondylitis. The patient wakes up in the morning and feels stiffness in the lower back, which can be relieved by activity, hot compresses and hot baths can also relieve morning stiffness.
3. Tendon attachment point lesion
This is an inflammation of the tendon/ligament bone attachment point, which is a characteristic pathological change of ankylosing spondylitis. Inflammation of the attachment points of the sternocostal joints, stalk-thoracic joints, etc. Patients may experience chest pain that is aggravated by coughing or sneezing. Cervical spine stiffness and pain usually occur several years after the onset of the disease, but in a few cases such symptoms may also appear early. Tendon attachment point lesions can also be seen in the rib-thoracic junction, vertebral eminence, iliac crest, greater trochanter, sciatic tuberosity, tibial tuberosity and heel as early manifestations of the disease.
4. Peripheral joint symptoms
In more than half of the cases, peripheral joint symptoms appear during the course of the disease. If the peripheral joints are involved as the first symptom, peripheral joint involvement is more common in the large joints of the lower extremities such as the hip, knee and ankle, and can also involve the large joints of the upper extremities such as the shoulder and wrist, and less common in the small joints of the periphery such as the fingers and toes. The involvement of peripheral joints in ankylosing spondylitis is less likely to be persistent and destructive, one of the features that distinguishes it from rheumatoid arthritis.
Second, some patients may also present with some extra-articular manifestations.
1, systemic symptoms are mostly seen in the early stage, mainly manifested as weakness, weight loss, anemia, and acute temporal reactions such as elevated blood sedimentation and c-reactive protein. Generally speaking, the systemic symptoms are milder in those with mainly axial joint symptoms; while those with more serious peripheral joint involvement have more prominent systemic symptoms.
2.Acute anterior uveitis or iritis
3, cardiovascular manifestations are rare. Clinically, they include episodic aortitis, subaortic fibrosis, aortic valve closure insufficiency, mitral valve prolapse and mitral valve closure insufficiency, cardiac enlargement, atrioventricular block and bundle branch block, dilated cardiomyopathy and pericarditis.
4. Pulmonary manifestations are common extra-articular manifestations in the late stage of the disease, which usually occur in those with a disease duration of more than 20 years. There may be no obvious clinical symptoms, but there may be cough, sputum, shortness of breath and even hemoptysis. The progressive fibrosis and herpetiform changes in the upper lungs.5. The neurological and muscular manifestations of spinal ankylosis are usually complicated by severe osteoporosis and are therefore very prone to fracture. Chronic progressive cauda equina syndrome is a rare but important complication of late ankylosing spondylitis.
6. Kidney damage
Ankylosing spondylitis kidney damage is less common, mainly lgA nephropathy and renal amyloidosis.
7, prostatitis
Chronic prostatitis has been reported to be more common in this disease than in the normal population.
Ankylosing spondylitis laboratory indicators are few and lack diagnostic significance and are mainly used to determine disease activity and estimate the efficacy of.
(1) Blood tests: mild elevation of leukocytes, anemia and thrombocytosis may be present, the incidence generally does not exceed 20%.
(2) Acute phase reaction: elevated sedimentation, C-reactive protein
(3) Other biochemical tests: alkaline phosphatase; phosphocreatine kinase.
(4) Immunochemical tests: immunoglobulins; clear complement; anti-peptidoglycan antibodies; anti-93kD antibodies; rheumatoid factor: circulating immune complexes.
(5) Joint fluid examination: the following three points can be distinguished from rheumatoid synovial fluid: complement is generally normal; CPM cells (cytophagcytic mononuclear cell); Rago cells (Ragocyle).
(6) tissue typing: because about 90% of ankylosing spondylitis HLA-B27 positive, so HLA-B27 examination has a reference value for diagnosis. However, about l0% of ankylosing spondylitis are HLA-B27 negative, so a negative test cannot exclude this disease. On the other hand, 48% of the normal population is also HLA-B27 positive, so HLA-B27 alone cannot diagnose this disease.
(7) Synovial histological examination: Ankylosing spondylitis synovium is not significantly different from rheumatoid arthritis synovium under ordinary microscopy, but the histochemical examination is significantly different: plasma cell infiltration in ankylosing spondylitis is mainly IgG, lgA type, while rheumatoid arthritis is mainly IgM type.
Third, the imaging examination
Typical sacroiliac joint involvement is bilateral and symmetric and usually precedes spinal involvement. Initially, the white, thin subchondral bone plates of the sacroiliac joint become indistinct and discontinuous. These changes can develop into severe bone erosion, and the gold standard for imaging ankylosing spondylitis is now considered to be sacroiliac joint MRI.
IV. Diagnostic criteria for ankylosing spondylitis (AS)
The “New York (NY) criteria” established in 1966: 1.
1, 3 aspects of the lumbar spine activities are limited (forward flexion, lateral bending, back extension);
2. pain in the lumbar spine or at the thoracolumbar junction;
3, limited thoracic movement (≤2.5 cm of mobility measured at the 4th intercostal space).
Graded according to the above clinical criteria and x-ray changes of sacroiliac arthritis.
V. Diagnosis.
1, Definite AS. bilateral grade III-IV sacroiliitis plus 1 or more clinical criteria; or unilateral grade III-IV or bilateral grade II sacroiliitis plus the 1st or 2+3 clinical criteria.
2, may AS. bilateral grade III-IV sacroiliac arthritis without clinical criteria.
In view of the overly strict NY criteria, vander Linden et al. proposed the modified New York criteria (MNY criteria) in 1984 based on family and population surveys, which improved the sensitivity of the diagnosis of AS.
1. Low back pain and morning stiffness for more than 3 months, with improvement by activity and no improvement by rest;
2.Limited anterior, posterior and lateral flexion of the lumbar spine;
3, thoracic mobility is lower than that of normal people of the same age and sex.
Radiological criteria: bilateral sacroiliac arthritis ≥ grade II; unilateral sacroiliac arthritis grade III-IV.
Diagnosis: Definite AS. meeting radiological criteria and more than 1 clinical criteria; probable AS. meeting 3 clinical criteria; or meeting radiological criteria without any clinical criteria, except for those with other causes of sacroiliac arthritis.
MNY criteria still do not meet the need for early diagnosis of AS.
VI. The treatment of ankylosing spondylitis includes the following components.
1, general treatment
General treatment is easy to ignore in most patients, but is very important to prevent unnecessary surgery.
Patients should be physically active to obtain and maintain the best position of the spinal joints, strengthen the paravertebral muscles and increase lung capacity, which is no less important than drug therapy. When standing, one should try to maintain a posture with the chest up, abdomen tucked in and eyes level in front. The sitting position should also keep the chest upright. One should sleep on a hard bed and take more supine positions to avoid positions that promote flexion deformity. The pillow should be short, and once the upper thoracic or cervical spine is involved, the pillow should be stopped.
2.Medication
Non-steroidal anti-inflammatory drugs (Loxone, Cilazol, Ankangxin, etc.)
3.Surgical treatment
If the spinal fusion leads to flexion deformity and the eyes cannot look forward, osteotomy orthopedic surgery is required. If the fusion of hip and knee joint affects the walking function, joint replacement is required.
4.Treatment after fracture
The treatment of fractures in patients with ankylosing spondylitis is more complicated than that of normal fractures. Fortunately, most fractures are not combined with severe neurological deficits. However, if not treated properly, severe neurological deficits can occur.