Ankylosing Spondylitis (Free Trial)

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

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Doctor Instruction:

You are a doctor working in family medicine. Your next patient is Derek Love, a 25-year-old male presenting with back pain. Please take a history and perform a relevant examination.

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Patient History:

Derek Love (Derek), 25y/o M, a master's student studying sports science.

You have been experiencing back pain for 5 months, but it isn't causing any trouble for you. You decide to see a doctor as it has gradually worsened to the point where you have difficulty getting out of bed. You can't remember if it has happened suddenly or gradually. Aching lower back pain starts on and off and worsens in the morning when you wake up, but it gets better throughout the day. Pain doesn't radiate and is rated at 4/10. It also gets slightly better following taking ibuprofen.

You have been having poor sleep as sometimes pain wakes you up early in the morning. You, therefore, feel tired all the time.

No neurologic symptoms/fever/ weight loss/ dyspnoea.

Only mention if asked: You had 2 episodes of a random painful red eye over the last 5 months, which you remember you were given steroid drops at the eye casualty and a pupil dilator which you need to store in the fridge.

Ideas, Concerns, Expectations:

• You think you might have possibly injured your back as you are a gym fanatic – you are not sure if you have injured yourself after squatting too hard at the gym. You have stopped going to the gym since then because of this. You are worried that you need surgery to fix your back. You want to know what might be causing the problem and better painkillers.

Past Medical History:

• Psoriasis

Drug History:

• Topical Steroids to control psoriasis (currently well controlled), currently taking ibuprofen for back pain. NKDA

Family History:

• Your father occasionally also suffers back pain since he was young, but you are no longer in contact with your father, so you do not know what happened to him.

Social History:

• Smoker – 20 cigarettes/day for 1 year

• Drink socially e.g. a pint of beer every week when going out with friends

• Not an IVDU

• Occupation: student

• Live alone – managing well.

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Examination Findings:

• Abnormal Schober’s test with reduced lumbar flexion

• Reduced spinal lumbar rotation, extension, lateral flexions

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Differentials:

1. Ankylosing Spondylitis

2. Back Injury

3. Psoriatic arthritis

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Investigations:

Bedside:

• Basic observations

• Full neurological assessment – to rule out spinal cord injury

Bloods:

• FBC (may show anaemia in AS)

• LFT (Baseline)

• U&E (Baseline)

• Bone Profile

• CRP/ESR (raised in AS)

• HLA-B27 (may be positive in AS)

Imaging:

• Spine/Sacrum X-Ray – may show fusion of sacroiliac, facet or costovertebral joints. Other features include squaring of the vertebral body, syndesmophytes, ossification of ligaments, joints and discs, and subchondral sclerosis/ erosion. The classical appearance of “bamboo spine”.

• MRI Spine – may show sacroiliitis, and bone marrow oedema in AS. Also, to rule out other spinal pathologies.

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Management:

Conservative:

• Physiotherapy

• Stop smoking

• Encourage exercise and stretching

Medical:

• Rheumatology referral/review

• NSAID e.g. ibuprofen

• Steroids during flares (oral, IM or joint injection)

• Anti-TNF e.g. etanercept/ infliximab

• Anti-Interleukin e.g. Secukinumab

• Bisphosphonates (those with osteoporosis)

Surgery:

• May be required to fix spine/joint deformity

• Treatment of complications

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Viva Questions:

What are the associated complications of Ankylosing Spondylitis?

• Spinal Fusion: AS can cause inflammation and new bone formation in the spine, leading to the vertebrae fusing together. This can result in reduced flexibility, stiffness, and a stooped posture, limiting mobility.

• Joint Damage: Over time, chronic inflammation can damage the sacroiliac joints and other peripheral joints, leading to pain, stiffness, and reduced mobility.

• Eye Inflammation: Some individuals with AS might experience uveitis or iritis, which are eye inflammations. These conditions can cause eye pain, redness, and sensitivity to light.

• Breathing Difficulties: In severe cases, AS can lead to decreased chest expansion due to spinal fusion. This restriction can cause breathing difficulties.

• Heart Problems: Individuals with AS might have a higher risk of heart disease due to chronic inflammation.

• Osteoporosis: People with AS might be at an increased risk of osteoporosis due to reduced mobility and the chronic inflammatory process.

• Psychological Impact: Living with chronic pain and reduced mobility can lead to psychological stress, affecting mental health.

• Fatigue: Chronic pain and inflammation can lead to persistent fatigue, affecting daily activities and quality of life.

What are the associations of HLA-B27?

• Ankylosing Spondylitis (AS): Strongest association with this inflammatory spinal condition.

• Spondyloarthropathies: Linked to other forms of spinal arthritis.

• Anterior Uveitis: Higher risk of developing eye inflammation in HLA-B27 carriers.

• Inflammatory Bowel Disease (IBD): More common in individuals with IBD, such as Crohn's disease and ulcerative colitis.

• Reactive Arthritis: Often found in cases of reactive arthritis, especially following infections.

What is the most common age/gender of onset?

Ankylosing Spondylitis (AS) typically begins between late teens and mid-30s, more commonly affecting men, though it can also occur in women.