Ankylosing Spondylitis

Ankylosing Spondylitis

>previously known as Bechterew's disease, Bechterew syndrome, Marie Strümpell disease

It is a form of arthritis that is long-lasting (chronic) and most often affects the spine.

It affects joints in the spine and the sacroilium in the pelvis, causing eventual fusion of the spine.

Complete fusion results in a complete rigidity of the spine, a condition known as

bamboo spine

AS is a systemic rheumatic disease and is one of the seronegative spondyloarthropathies.

The typical patient is young, aged 18-30

Men are affected more than women by a ratio about of 3:1

What causes ankylosing

spondylitis?

The cause of ankylosing spondylitis is unknown, but a tendency to develop the condition may be

genetic.

>HLA-B27 genotype. -90% of patients

>Tumor necrosis factor-alpha (TNF α)

>IL-1

HLA-B27 Human Leukocyte Antigen B*27 (subtypes B*2701-2724) is a class I surface antigen encoded by the B locus in the major histocompatibility complex (MHC) on chromosome 6 and presents microbial antigens to T-cells. HLA-B27 is strongly associated with a certain set of autoimmune diseases referred to as the “seronegative spondyloarthropathies.”

TNF Tumor necrosis factor (TNF, cachexin or cachectin and formally known as tumor necrosis factor-alpha) is a cytokine involved in systemic inflammation. The primary role of TNF is in the regulation of immune cells. TNF is also able to induce apoptotic cell death, to induce inflammation, and to inhibit tumorigenesis and viral replication.

IL-1Interleukin-1 (IL-1)The original members of the IL-1 superfamily are IL-1α, IL-1β, and the IL-1 Receptor antagonist (IL-1RA).

IL-1α and -β are pro-inflammatory cytokines involved in immune defense against infection.

The IL-1RA is a molecule that competes for receptor binding with IL-1α and IL-1β, blocking their role in immune activation.

The Ankylosis Process

SIGNS AND SYMPTOMS:>mild to severe back and buttock pain that is often worse in the early morning hours.

-This pain usually gets better with activity.

>Continued inflammation of the: -ligaments,-tendons, -joint capsules (soft tissues surrounding the joint), -and joints of the spine

-cause the spine to fuse together (ankylose) as the joints and disc spaces are replaced by bone.

-leading to less motion in the neck and low back

>As the spine fuses, or stiffens,-the neck and low back lose their normal curve,-the mid-back curves outward (kyphosis),-and a fixed bent-forward position can result

-leading to significant disability.

>Inflammation of the small joints joining the ribs and collarbone to the breastbone

--cause less expansion of the chest wall with breathing

In 40% of cases,

>ankylosing spondylitis is associated with an inflammation of the white of the eye (iridocyclitis)

-causing eye pain and photophobia.

Another common symptom is generalized fatigue.

Less commonly aortitis, apical lung fibrosis and ectasia of the sacral nerve root sheaths may occur.

As with all the seronegative spondarthropathies, lifting of the nails (onycholysis) may occur

Diagnosis

>a blood test for the HLA-B27 gene

>X-ray -which show

characteristic spinal changes and sacroiliitis.

>tomography and magnetic resonance imaging of the sacroiliac joints

-but the reliability of these tests is still unclear

>Schober's test -a useful clinical

measure of flexion of the lumbar spine performed during examination.

X-ray demonstrating in ankylosing spondylitis

Treatment>No cure is known for AS! >treatments and medications are available to reduce symptoms and pain.

Medication

There are three major types of medications used for ankylosing spondylitis.

1. Anti-inflammatory drugs-includes NSAIDs such as

aspirin, ibuprofen, phenylbutazone, indomethacin, naproxen and COX-2 inhibitors, -reduce inflammation, and consequently pain

2. DMARDs -such as cyclosporin,

methotrexate, sulfasalazine, and corticosteroids,

-used to reduce the immune system response through immunosuppression;

3. TNFα blockers (antagonists)-such as etanercept,

infliximab and adalimumab (also known as biologics) -indicated for the treatment of and are effective immunosuppressants in AS as in other autoimmune diseases

>TNFα blockers have been shown to be the most promising treatment, slowing the progress of AS in the majority of clinical cases.

>They have also been shown to be highly effective in treating not only the arthritis of the joints but also the spinal arthritis associated with AS.

Surgical Management:

>may include OSTEOTOMY for marked deformities of the hip/spine.

>occasionally, hip or knee ARTHROPLASTY is used.

- if there is severe arthritis of those joints.

Nursing Responsibilities:

>educate about the nature of the disease>baseline ROM including chest expansion should be advised

>pain should be managed by appropriate medications, heat, massage and gentle exercise.>excessive physical exertion during periods of active inflammation should be discouraged.

>proper positioning at rest is essential>the mattress should be firm, and pillows must be avoided.>the patient should sleep on the back and avoid positions that encourage flexion deformity.

>postural training emphasizes avoiding flexion, heavy lifting and prolonged walking, standing or sitting.

Ankylosing spondylitis