Overview.
Ankylosing spondylitis is a chronic progressive inflammatory disease that primarily affects the spine and involves the sacroiliac and peripheral joints.
Epidemiology.
The prevalence of this disease varies widely among different races in different regions depending on the period of investigation and the criteria used. The incidence of AS in China is 0.3%.
Etiology.
The etiology of ankylosing spondylitis is not yet completely clear, and recent research findings suggest that it is related to genetic qualities, infection and immunity. Liu Kechun, Department of Orthopedics and Traumatology, The First Affiliated Hospital of Tianjin University of Traditional Chinese Medicine
Pathogenesis.
The etiology of AS has not yet been fully elucidated. The positive rate of HLA-B27 in patients with ankylosing spondylitis is over 90%, proving that AS is genetically related. Most scholars believe that it is related to genetics, infection, immunity, and environmental factors.
1.Heredity
Genetic factors play an important role in the development of AS. According to epidemiological surveys, the HLA-B27 positivity rate of AS patients is as high as 90%-96%, while the HLA-B27 positivity rate of the general population is only 4%-9%. However, it should be noted that, on the one hand, not all HLA-B27-positive individuals develop spondyloarthropathy, and on the other hand, about 5% to 20% of patients with spondyloarthropathy test negative for HLA-B27, suggesting that, in addition to genetic factors, there are other factors affecting the development of AS, so HLA-B27 is an important genetic factor in the expression of AS, but not the only factor affecting the disease .
2.Infection
Recent studies have suggested that the incidence of AS may be related to infection. The carriage rate of Klebsiella enterica pneumoniae and the IgA-type antibody titer against the bacterium in the serum of AS patients during the active phase of AS were found to be higher than those of controls, and were positively correlated with disease activity.
3.Other
It has been found that 60% of
of patients with AS had increased serum complement levels, most cases had IgA-type rheumatoid factor, significantly higher serum C4 and IgA levels, and circulating immune complexes in the serum, but the antigenic nature was not determined. The above phenomena suggest that immune mechanisms are involved in the pathogenesis of the disease. Trauma, endocrine, metabolic disorders and metabolic reactions are also suspected to be factors in the pathogenesis. In conclusion, the etiology of the disease is still unknown and there is no single theory that can fully explain all the manifestations of AS. It is likely that the disease is caused by environmental factors (including infection) and other factors on the basis of genetic factors.
4.Pathology
The basic pathological changes in the early stage of the disease are lesions of tendons and ligamentous bone attachment points. The onset of the disease is often earliest in the sacroiliac joint, and later joint adhesions, fibrous and bony ankylosis may occur. The histological changes are chronic inflammation of the joint capsule, tendons, and ligaments. The disease differs from rheumatoid arthritis pathologically in that there is a tendency for significant calcification of joint and para-articular tissues, ligaments, intervertebral discs, and annular fibrous tissue. Synovial inflammation is rarely associated with extensive erosive and deforming changes.
Sacroiliac arthritis is the pathological hallmark of ankylosing spondylitis and is often one of its earliest pathological manifestations. Erosion of bone and destruction of cartilage follows, followed by progressive replacement by degenerating fibrocartilage and eventually bony ankylosis. The initial damage to the spine is the formation of granulation tissue at the junction between the fibrous ring of the disc and the vertebral bone rim. The outer layer of the fibrous ring may eventually be replaced by bone, forming a ligamentous osteophyte, and further progression will result in the bamboo-like spine seen on x-ray. Other injuries to the spine include diffuse osteoporosis, destruction of the vertebral body adjacent to the disc rim, squared changes in the vertebral body, and sclerosis of the intervertebral disc.
Clinical manifestations.
1, clinical overview
These diseases start as tendon end inflammation, finger/toe inflammation, or oligoarticular inflammation, and in some cases may progress to sacroiliac arthritis and spondylolisthesis. Inflammation of the beginning end of the tendon occurs in the foot (plantar fasciitis and/or heel osteochondritis and Achilles tendonitis can cause heel pain) and tibial tuberosity. Ankylosing spondylitis is notable for its high incidence of mid-axis myotendinitis and synovitis, and ultimately leads to fibrosis and advanced bony ankylosis of the sacroiliac joints and spine.
Although all patients with ankylosing spondylitis have varying degrees of sacroiliac joint involvement, it is uncommon to see a true complete fusion of the spine in clinical practice. Sacroiliac arthritis causes inflammatory low back pain that is insidious, difficult to localize, and felt deep in the buttocks. The pain is often unilateral and intermittent at the beginning of the disease, gradually becoming bilateral and persistent after a few months, and is also present in the lower lumbar region. Typical symptoms are prolonged fixation in a certain position or worsening upon awakening in the morning (“morning stiffness”), which can be improved by somatic activity or hot baths. Tendonitis, the main feature of spondyloarthropathies, is inflammation originating in the ligaments of the affected joint or in the area where the joint capsule attaches to the bone, near the joint ligaments, and in the synovium, cartilage, and subchondral bone. Synovitis in spondyloarthropathies is often associated with clinically undetected tendon telangiectasia, and at least in some joints, this synovitis is only a secondary inflammatory condition.
Painful extra-articular or near-articular bone pressure due to tendon telangiectasia at the thoracic rib junction, sphenoid, iliac crest, sciatic tuberosity, and heel bone sites is an early feature of this type of disease. Very few patients have no or very mild low back symptoms, while others may simply complain of low back stiffness, muscle pain, and tendon tenderness. Cold or dampness may aggravate the symptoms, and this group of patients is often misdiagnosed as having fibromyalgia syndrome. Early in the disease, some patients may also present with mild systemic symptoms such as anorexia, fatigue, or low-grade fever, and these symptoms are especially common in patients with a juvenile onset of disease. Rib cartilage and rib cage, tendinitis at the transverse joint of the rib cage can cause chest pain, which is easily misdiagnosed as a result of pleurisy because it worsens with coughing or sneezing.
The ratio of male to female incidence is 7:1 to 10:1. The onset of the disease is mostly in men aged 15 to 30 years old, and is rare in children and people over 40 years old. The difference in the prevalence of ankylosing spondylitis between men and women has not yet been satisfactorily explained. Occupation and pregnancy have no major impact on the disease, and the role of sex hormones is not yet certain.
The average age of onset in women is 26.8 years, 6 years later than the average age of onset in men, as reported by Peking Union Medical College Hospital. Another characteristic of ankylosing spondylitis in women is peripheral arthritis, especially knee joint involvement, which occurs more frequently than in men. In addition, pubic symphysis involvement was more common in women than in men. However, the involvement of the median joint is relatively rare and mild, and thus often misdiagnosed as other rheumatic diseases. In terms of disease severity, women are generally considered to have a milder disease and a better prognosis. Most patients have an insidious onset, with early symptoms of intermittent dull pain in the upper back, hips and hips, with stiffness or sciatica. The pain is intermittent and mild at first. As the disease progresses, it may become persistent or even more severe after several months or years. Sometimes the pain can occur higher up in the back, in and around the shoulder joint, but soon the lower back symptoms can appear. Patients often feel that the pain is worse in the morning and after a day of work, but less severe at other times. Symptoms worsen in cold and humid weather and may be relieved by salicylic acid preparations and local heat. Other patients first present with iritis of unknown origin, and the typical manifestations of ankylosing spondylitis appear years or months later, with more children than adults having this onset. Occasionally, heel pain due to palmar fasciitis or Achilles tendinitis may be an early symptom. Systemic symptoms include fatigue, malaise, anorexia, weight loss, and hypothermia. Ankylosing spondylitis is a systemic disease with both arthritic and extra-articular manifestations.
2, arthritis manifestations can involve any joint, but the spinal joints are involved more often.
(1) sacroiliac arthritis most patients first appear sacroiliac joint involvement symptoms, individual patients may also first appear higher spinal arthritis symptoms, manifested as lower back straightness and pain, often radiating to one or both sides of the hip, occasionally radiating to the thigh, further can develop to the dorsal side of the knee joint, and may even extend below the knee joint. The lower extremity extension and elevation sign is usually negative due to local inflammation of the sacroiliac joint. Pain can be induced by direct pressure on the diseased joint or by straightening the affected lower extremity. Restriction of lower back motion and mild paravertebral muscle spasm of the sacroiliac joint can occur early in the course of the disease. Pain may also be induced by finger pressure on the pubic symphysis, iliac crest, and sciatic tuberosity. The sacroiliac joint is symmetrically involved and the pubic symphysis may also be involved. The patient may be fixed in a certain position.
(2) Lumbar spine arthritis: Although the sacroiliac and lumbar joints are involved at the same time, most patients have back pain and discomfort and motor dysfunction caused by lumbar spine joint lesions. Diffuse pain appears in the back at first, and then gradually concentrates in the lumbar region. Severe lumbar ankylosis may sometimes occur, causing the patient to fear bending, standing upright and turning, as these movements can cause severe pain. Spinal ankylosis may be caused by spasm of the paravertebral muscles due to lumbar osteoarthritis. On examination, there may be tenderness in the lumbar osteoarthritic joints, marked spasm of the paravertebral muscles, straightening of the lumbar spine, restriction of movement, and loss of normal physiological curvature of the lumbar region.
(3) Thoracic arthritis spondylitis progressive upward development, the thoracic spine joints can also be involved. At this time the patient has upper back pain, chest pain and a sense of restricted movement of thoracic expansion. These symptoms can occur early in the course of the disease in some patients, but most patients do not develop them until 6 years after the onset of the disease. Chest pain is usually present on inspiration. Restriction of thoracic expansion is mainly due to involvement of the cribriform joints, the sternal stalk-sternal body joints, the rib and rib cartilage joints, and the sternoclavicular joints. Thoracic expansion restriction can cause dyspnea, especially during exercise. Pulmonary function measurements are not significantly altered in most patients, as the increased amplitude of diaphragmatic motion compensates for the restricted thoracic expansion. Tenderness can be induced by finger pressure on the sternal stalk-sternal body joint, the rib and rib cartilage junction, and all thoracic vertebrae. As the disease progresses, significant kyphosis and limited thoracic movement may occur.
(4) Cervical arthritis: A few patients may have cervical arthritis only as an early manifestation, but with progressive development of the disease, severe cervical lordosis or lateral lordosis may occur, and finally the head may be in a fixed forward flexion position, posterior flexion, rotation and lateral flexion, which may be partially or completely restricted, and the spatial field of vision may become significantly smaller. Pain due to cervical spine lesions may be limited to the neck or may radiate to the head along the paracervical structures, with severe spasm of the cervical muscles beginning and eventually atrophy and radicular pain involving the head and arms. Due to the ankylosis and osteoporosis of the entire spine, fractures can easily occur due to trauma, especially in the neck. Once a traumatic fracture of the neck occurs, paraplegia can result.
(5) Peripheral arthritis: more than 1/3 of patients may have shoulder and hip joint involvement, which further aggravates the disabling consequences. Joint pain is often mild, while joint movement restriction is obvious, such as inability to comb hair or difficulty in squatting. As the disease progresses, cartilage degeneration and fibrosis of the periarticular structures may occur, leading to joint ankylosis. Early in the course of the disease, the limitation of joint motion is mainly due to spasm of the muscles surrounding the joint. Hip contracture and compensatory flexion of the knee joint may cause the patient to be in a forward bowing and flexing position, and a duck walk may occur. Extensive lesions of the spinal joints can also cause flat chest and severe hunchback.
In advanced stages of ankylosing spondylitis, the joints are painless because the inflammation has largely disappeared, and spinal fixation and ankylosis are the main manifestations. The cervical spine is fixed in an anterior tilt, the spine is kyphotic, the thorax is often fixed in an expiratory state, the lumbar spine loses its physiological curvature, the hip and knee joints are severely flexed and contracted, the eyes are fixed on the ground when standing, and the body weight is shifted forward. Individual patients may be severely disabled, bedridden for a long time and unable to take care of themselves.
3. Extra-articular manifestations
There are many extra-articular manifestations of ankylosing spondylitis, which can be primary, but most are secondary. In a small number of patients, these manifestations can occur months to years before the spondylitis. In some cases, extra-articular manifestations may overlap with other diseases, for example, aortitis, which can occur in both ankylosing spondylitis and Ritter syndrome, so ankylosing spondylitis can overlap with Ritter syndrome; heel pain is a common feature of psoriatic arthritis, Ritter syndrome, and ankylosing spondylitis, and all three patients have a high rate of HLA-B27 positivity, suggesting that these three diseases can overlap with each other. overlap.
(1) Cardiac lesion autopsy revealed that about 1/4 of the patients had ascending aortic root abnormalities. However, aortic valve insufficiency due to inflammation of the aorta and aortic valve is mostly seen in patients with long duration of disease, peripheral arthritis and significant systemic symptoms (fever and anemia), so clinically only 5% of patients present with cardiac symptoms, and most patients have no conscious symptoms and only a weak diastolic tone can be heard in the second auscultatory region of the aortic valve at the left sternal border on physical examination. Occasionally, complete atrioventricular block or an episode of A-Syndrome may occur. As the disease progresses, angina pectoris may occur, and congestive heart failure may develop later in the course of the disease. In addition to aortitis, ankylosing spondylitis may be complicated by pericarditis, myocarditis, and polyarteritis nodosa.
(2) Pulmonary lesions: Because diaphragmatic movement can compensate for respiratory function, dyspnea rarely occurs although thoracic expansion is limited during inspiration. Pulmonary radiographs show dense, patchy shadows in the upper fields of both lungs, fibrosis in some patients, cavitation in others, and Aspergillus parasites. Sputum culture can be cultured with Aspergillus, which can be accompanied by mycetoma formation. In advanced patients, the thoracic expansion is limited and the lung capacity is significantly reduced.
(3) Iriditis can be recurrent in about l/4 of patients and is more likely to occur the longer the course of the disease. The iritis is a non-granulomatous anterior uveitis and is usually unilateral. Ocular lesions are related to the severity and activity of the spondylitis and are most often seen in patients with peripheral arthritis or a previous history of urinary tract infection, which can lead to glaucoma or blindness if left untreated. If left untreated, glaucoma or blindness may result. In some patients, ocular symptoms may precede joint symptoms.
(4) Neurological lesions: Ankylosing spondylitis can cause many neurological complications, such as spontaneous atlantoaxial dislocation, which manifests as severe pain in the neck, often radiating to the temporal, occipital, or retro-orbital regions. It can also lead to vertebral collapse, vertebral fractures due to trauma, and can even cause spinal cord compression resulting in paraplegia. When the cauda equina of the spinal cord is compressed, urinary incontinence, impotence, numbness in the perineum and weakened Achilles tendon reflexes may occur.
(5) Urinary lesions: amyloidosis can occur in the kidneys, the incidence of which is similar to that of rheumatoid arthritis, and proteinuria can occur. A small number of patients can die from uremia. The incidence of prostatitis is also higher than that of the general population.
4.Special physical signs
(1) Tests reflecting inflammation and injury of sacroiliac joint: such as positive “4” test, positive sacroiliac joint separation test or positive sacroiliac joint compression test, etc.
(2) Signs of restricted spinal movement: e.g. positive Schober test, restricted lateral bending, positive occipital wall test.
The ability to touch the ground with the fingers when fully extending the knee alone cannot be used to assess spinal mobility, because good hip function can compensate for the obvious limitation of lumbar motion, and the Schober test can more accurately reflect the degree of limitation of lumbar anterior flexion motion. Anterior lumbar convexity is progressively lost as the disease progresses.
Direct pressure on the inflamed sacroiliac joint often causes pain, and sometimes sacroiliac pain can also be caused by the following tests: compression of the iliac wings on both sides of the patient in the supine position; maximum flexion of one hip while trying to abduct the other hip (Gaenslen test, Figure 5); maximum flexion, abduction, and external rotation of the hip (4-character test or Patrick test); compression of the patient’s pelvis in the lateral position; or compression of their pelvis; or direct compression of their sacrum in the prone position. Some patients may not have any of these signs because, on the one hand, the sacroiliac joint is surrounded by strong and sturdy ligaments with minimal motion, and on the other hand, in the advanced stages of the disease, the inflammation has been replaced by fibrous or bony ankylosis.
(3) The difference between deep inspiration and deep expiration at the end of the flat 4th rib thorax is less than 2.5 cm.
Complications.
(1) When the sacroiliac and lumbar joints are involved at the same time, the paravertebral muscles spasm significantly, the lumbar spine straightens, movement is restricted, and the normal physiological bending of the lumbar region disappears. When the thoracic vertebral joints are also involved, the restricted expansion of the thorax can cause respiratory difficulties. In severe cases of cervical kyphosis or scoliosis, a traumatic fracture of the neck may result in paraplegia. In advanced stages of ankylosing spondylitis, individual patients can be severely disabled.
2. In severe cases of cardiac lesions, aortic valve insufficiency, heart enlargement and conduction abnormalities may occur. Aortitis can also be combined with pericarditis, myocarditis and polyarteritis nodosa. In pulmonary lesions, some patients may develop fibrosis, and some others develop cavitation with Aspergillus parasites. Peripheral arthritis or a history of previous urinary tract infections can cause glaucoma or blindness if left untreated. Ankylosing spondylitis can cause many neurological complications, such as spontaneous atlantoaxial dislocation, which manifests as severe pain in the neck, often radiating to the temporal, occipital, or retro-orbital regions. Urinary lesions The kidneys can develop amyloidosis with proteinuria. A small number of patients may die from uremia.
Laboratory tests.
Routine blood count and sedimentation. The blood count may be approximately normal, and some patients may have orthocytic hypochromic anemia and leukocytosis. Most patients have a rapid sedimentation rate in the early or active phase and a normal sedimentation rate in the later phase. The increased sedimentation rate is useful in the diagnosis of patients with suspicious clinical and radiographic findings. Urine routine When amyloidosis occurs in the kidneys, proteinuria may be present.
1. Blood biochemical tests
There are no diagnostic or specific tests for ankylosing spondylitis. Blood tests may include a mild increase in white blood cells and platelets and a mild orthocytic orthochromic anemia in 15% of patients. 75% or more of patients have an increased erythrocyte sedimentation rate and an elevated C-reactive protein in the acute phase or in those with a heavy inflammatory response.
2.Immunological examination
The rate of rheumatoid factor positivity is not high. Serum IgA may be mildly to moderately elevated and is associated with the activity of AS, IgG and IgM may be elevated in patients with peripheral joint involvement, and it has been reported that AS patients may have elevated serum complement C3 and C4, increased levels of anti-peptidoglycan antibodies, anti-Drosophila 93000 antibodies, anti-Klebsiella pneumoniae nitrogenase reductase antibodies, and anti-histone 3 subunit antibodies are closely associated with iritis. HLA typing examination was positive for HLA-B27 in about 90% of patients.
3, Microbiological examination The detection rate of fecal Klebsiella pneumoniae in AS patients was higher than normal.
4.HLA-B27 test
The HLA-B27 test is helpful in the diagnosis of ankylosing spondylitis, but in the vast majority of patients the diagnosis can only be made by history, signs and X-rays. Although the test has a high diagnostic sensitivity for some races, it is not used as a routine test or as a screening test for diagnosis and exclusion of diagnosis in patients with ankylosing spondylitis who have low back pain, and its clinical use depends heavily on the context of the test.
Other ancillary tests.
1, X-ray examination of ankylosing spondylitis
(1) Sacroiliac joint changes: This is the main basis for the diagnosis of the disease. It can be said that a normal x-ray of the sacroiliac joint can almost exclude the diagnosis of this disease. Early sacroiliac joint changes are more characteristic and easier to recognize than those of the lumbar spine. Generally speaking, the sacroiliac joint can have three stages of changes.
(1) Early stage: joint margins are blurred and slightly dense, and the joint space is widened.
(2) Middle stage: the joint space is narrowed, and the joint edges are jagged with bone erosion and dense hyperplasia.
(iii) Late stage: the joint gap disappears, and there are bone trabeculae passing through, showing bony fusion.
However, some scholars still follow the 1966 New York radiological criteria and classify the sacroiliac arthritis of ankylosing spondylitis into five grades: grade 0 is normal; grade I is suspicious; grade II is mildly abnormal; grade III is obviously abnormal; grade IV is severely abnormal and the joint is completely ankylosed.
(2) Spinal changes: lesions developed to the middle and late stages can be seen as.
(1) formation of ligamentous osteoid (i.e., ossification of the intervertebral disc fibrous ring), or even a bamboo-like spinal fusion (Figure 6).
②Square vertebrae.
(iii) Generalized osteoporosis.
④Erosion, narrowing, and bony ankylosis of the articular synovial joint.
⑤ ossification of the paravertebral ligaments, with ossification of the ligamentum flavum, interspinous ligament and intervertebral fibrous ring being the most common (advanced bamboo-like spine).
(6) Spinal deformities, including: loss of anterior convexity or retroconvexity of the lumbar and cervical spine; increased physiological retroconvexity of the thoracic spine, and hunchback deformity occurring mostly in the lumbar and lower thoracic segments.
(7) Fatigue fractures of the intervertebral discs, vertebral arches and vertebral bodies and atlantoaxial subluxation.
(3) Hip and knee joint changes: hip joint involvement is often bilateral, with early osteoporosis, closed hole narrowing, and joint capsule expansion; in the middle stage, joint gap narrowing, cystic changes at the joint edges or osteophytes at the outer edge of the acetabulum and femoral head edges (ligamentous bone superfluity formation) are seen; in the late stage, joint gap disappears, with bone trabeculae passing through, and the joint is bony ankylosis.
(4) Changes in tendon attachment points: mostly bilateral, with dense bone infiltration and surface erosion seen in the early stage and ligamentous redundancy formation (osteophyte and edge irregularity) seen in the late stage.
The radiographic manifestations of primary AS and concomitant spondylitis secondary to inflammatory bowel disease, Reiter syndrome, and psoriatic arthritis are similar, but the latter is distinguished by asymmetric sacroiliac arthritis with irregular jumping lesions of the spine.
Other radiographic manifestations of extra-spinal joints include osteoporotic, mildly erosive destructive lesions of the shoulder joint, narrowing of the joint space, destruction of the joint surface, and finally bony ankylosis. Osteitis and osteochondritis can occur at the attachment of ligaments, tendons, and bursae, most commonly in the heel bone, sciatic tuberosity, and iliac crest. Similar radiographic changes may occur in other peripheral joints.
When early X-rays are negative, radionuclide scans, CT and MRI are feasible to detect early symmetrical sacroiliac joint lesions. It is important to note, however, that a simple posterior anterior radiograph is usually sufficient to diagnose the disease.
CT, MRI and imaging in ankylosing spondylitis
X-rays are easy to diagnose the more typical sacroiliac arthritis, but it is more difficult to diagnose early sacroiliac arthritis, and it is easy to miss the diagnosis. CT or MRI of sacroiliac joint is highly sensitive and can detect sacroiliac joint lesions at an early stage; CT can show the sacroiliac joint space and joint surface bone more satisfactorily and find minor joint surface bone erosion and subchondral cystic changes that cannot be shown by X-ray plain film. MRI can directly display the articular cartilage, which is superior to CT for early detection of sacroiliac joint cartilage changes and for estimating the condition and determining the efficacy of sacroiliac arthritis. Emission computed tomography (ECT) radionuclide scan lacks specificity, especially 99mTc-methylene diphosphate (99mTc-MDP) bone scan, where radionuclides are non-specifically concentrated near the sacroiliac joint, easily causing false positives, so it has little diagnostic significance for sacroiliac arthritis. However, it has been suggested that single photon emission electron computed tomography (SPECT) bone scan may also be useful for the diagnosis of AS. Vertebrograms are indicated in patients with neurological deficits in the lower extremities and are useful for complete decompression at the time of surgery.
Diagnosis.
1. Historical features Based on the medical history, inflammatory spondylosis should be considered when the following manifestations are present.
(1) Low back discomfort vaguely present.
(2) Age <40 years.
(3) Persistent for more than 3 months.
(4) Stiffness in the early morning.
(5) Symptoms improve with activity.
With the above history and signs of sacroiliac arthritis on X-ray, the diagnosis of spondylosis is confirmed; further exclusion of psoriasis, inflammatory bowel disease or Reiter syndrome arthritis will make the diagnosis of primary AS, rather than waiting until the spine is clearly ankylosed to make a definitive diagnosis.
2. Common clinical diagnostic criteria for AS
(1) Rome criteria (1963).
(1) Low back pain and lumbar stiffness for more than 3 months, not relieved by rest.
(ii) Pain and stiffness in the chest.
(iii) Restriction of lumbar spine movement.
④ Restriction of thoracic expansion activities.
⑤ History, phenomenon or sequelae of iritis.
The presence of bilateral sacroiliac arthritis plus one of the above clinical criteria can be considered as the presence of ankylosing spondylitis.
(2) New York criteria (revised in 1984).
(1) Restriction of lumbar spine movement in all areas (anterior flexion, posterior extension, lateral flexion).
(②The thoracolumbar segment or lumbar spine has been painful in the past and is still painful.
(③The thoracic expansion mobility is equal to or less than 2.5 cm, measured at the 4th intercostal space.
Definite spondylitis established: 3 to 4 degrees of bilateral sacroiliac arthritis plus at least one clinical index; 3 to 4 degrees of unilateral or 2 degrees of bilateral sacroiliac arthritis plus the 1st or 2nd and 3rd clinical index.
Possible spondylitis was established: only 3 to 4 degrees of bilateral sacroiliac arthritis without clinical indicators.
Both of the above diagnostic criteria emphasize the importance of lumbar pain, limitation of lumbar spine movement, chest pain, limitation of thoracic movement and sacroiliac arthritis in the diagnosis, and the disease is not difficult to diagnose by mastering the above points. Young men who present with lumbar stiffness and low back pain that cannot be relieved after rest should be suspected of this disease, and a high-quality orthopantomolecular pelvic X-ray should be taken promptly. Many scholars believe that the presence of low back pain plus bilateral sacroiliac arthritis (X-ray manifestation) can be diagnosed as this disease.
Differential diagnosis.
1. Lumbosacral joint strain
Chronic lumbosacral joint strain is persistent and diffuse lumbar pain, with the lumbosacral region being the heaviest, with no restriction of spinal movement and no special changes on X-ray. Acute lumbosacral joint strain, pain is aggravated by activity, and can be relieved after rest.
2. Osteoarthritis
Often occurs in the elderly, characterized by bone and cartilage degeneration, synovial thickening, more common in the weight-bearing spine and knee joints. If the spine is involved, chronic low back pain is often the main symptom, which is easily confused with AS; however, joint ankylosis and muscle atrophy do not occur, and there is no systemic symptom, and the X-ray shows the generation of bone redundancy and narrowing of the vertebral space.
3. Forestier’s disease
Forestier disease (age-related ankylosing bone hypertrophy) patients also form continuous bone redundancy in the spine, similar to the bamboo-like changes in the spine of AS, but the sacroiliac joint is normal and the small intervertebral joints are not invaded.
4. Tuberculous spondylitis
The clinical symptoms are similar to AS, but X-ray examination can be used to differentiate. In tuberculous spondylitis, the vertebral margins are blurred, the intervertebral space is narrowed, the anterior wedge is changed, there is no ligamentous calcification, sometimes there is a shadow of paravertebral tuberculosis abscess, and the sacroiliac joint is unilaterally involved.
5. Rheumatoid arthritis
It has been confirmed that AS is not a specific type of rheumatoid arthritis (RA), and there are many differences between the two. RA is more common in women, usually invades the small joints of the hands and feet first, and is bilaterally symmetrical, while the sacroiliac joints are usually not involved.
6. Enteropathic arthropathy
Ulcerative colitis, restrictive enteritis, or enterogenic fat metabolism disorder (Whipple’s disease) can occur in spondylitis, and enteropathic arthropathy involves joints and radiographic changes similar to AS that are not easily differentiated, so it is necessary to look for intestinal signs and symptoms for differentiation. Colonic mucosal ulceration, edema and bloody diarrhea in ulcerative colitis; abdominal pain, nutritional disorders and fistula formation in restrictive enterocolitis; steatorrhea and acute wasting in Whipple’s disease all contribute to the diagnosis of primary disease. The HLA-B27 positivity rate is low in patients with enteropathic arthropathy, and IgG is increased in intestinal lavage fluid in patients with Crohn’s disease, while IgG is basically normal in intestinal lavage fluid in patients with AS.
7. Reiter syndrome and psoriatic arthritis
Spondylitis and sacroiliac arthritis can occur in both diseases, but spondylitis generally occurs later and is milder, with less calcification of paravertebral tissues and non-marginal type of ligamentous bone redundancy (calcification of fibrous tissues outside the fibrous ring), forming partial bone bridges between two adjacent vertebrae unlike the bamboo-like spine of AS; sacroiliac arthritis is generally unilateral or bilateral asymmetric, with rare osteoarthritic lesions and no generalized osteoporosis. In addition, Reiter syndrome has conjunctivitis, urethritis, mucosal and skin damage; psoriatic arthritis has skin psoriasis damage and other distinguishable features.
Prognosis.
The evolution of the course of ankylosing spondylitis varies widely and is characterized by alternating spontaneous remissions and exacerbations, with a generally good, self-limiting prognosis. A minority of patients suffer rapid bone loss and develop severe disability early in life, with hip involvement and complete ankylosis of the cervical spine.
Survival of patients with mild forms is not different from the general population. However, concomitant spinal fractures, cardiovascular involvement, renal amyloidosis, and other serious complications can shorten survival in some patients. Loss of function occurs in most patients within the first 10 years of disease onset and is associated with peripheral arthritis, radiographic changes in the spine, and a “bamboo spine”. In patients with a disease duration greater than 20 years, 80% of patients still have pain and stiffness, and more than 60% of patients require drug therapy. About 85% of patients have a good prognosis, even if severe deformity or disability occurs, they can still take care of themselves with surgical treatment. A small number of patients may die from heart failure, uremia and cervical fractures complicated by paraplegia.
Prevention.
AS has a genetic basis, and it is difficult to control the relationship between HLA-B27 and the human body. The pathogenesis of AS due to infection is still under study, and Chinese medicine believes that the onset of ankylosing spondylitis is due to congenital deficiency of endowment or acquired disorders of regulation, indisposition of the room, panic, depression and anger, and post-illness disorders, resulting in deficiency of the liver and kidneys, and the onset of wind, cold and dampness, so attention should be paid to The following aspects should be noted.
1. strengthen physical exercise, reasonable life rules, maintain a happy mood to improve the body’s immune function.
2. Avoid the attack of wind, cold and dampness, prevent colds and infections.
3. Quit smoking and drinking, and pay attention to maintaining normal posture and mobility.