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Effective Decision Making for Ankylosing Spondylitis

Effective Decision Making for Ankylosing Spondylitis


Early diagnosis of ankylosing spondylitis (AS) and prompt institution of treatment can control its signs and symptoms. However, early diagnosis presents clinicians with a challenge because radiographic changes—the hallmark of the disease—tend to take about 7 to 10 years to develop. Sound decision making and patient interaction, such as with screening questionnaires, can help the diagnosis and result in more effective treatment.

AS is the prototype of a group of inflammatory arthritides characterized by involvement of the axial skeleton and the absence of seropositivity for antibodies, such as rheumatoid factor and antinuclear antibodies.1 Clinically recognizable subtypes grouped under the heading of seronegative spondyloarthritides also include reactive arthritis, arthritis associated with inflammatory bowel disease (IBD), psoriatic arthritis (PsA), and undifferentiated spondyloarthritis (SpA). A common feature is the tendency to involve the sacroiliac joints, large joints of the lower extremities, attachment sites of tendons and ligaments (enthesitis), and the body's skin and mucous membranes. The seronegative spondyloarthritides are thought, incorrectly, to be less common than rheumatoid arthritis. However, they may be underdiagnosed and go unrecognized as chronic back pain or possible degenerative joint disease.

Advances in MRI have helped the diagnosis of AS before radiographic changes set in. Another clue to the diagnosis is the tendency of AS to occur within families and share some genetic markers among those who are affected. In addition, primary care physicians often see patients with back pain or diffuse body pain; recognizing features of inflammatory back pain (IBP), which is common in AS, provides an important clue to proceed with diagnostic testing. Screening patients for AS is another important diagnostic tool.

In this article, we offer a clinical case scenario of a patient with AS. We use it to explore the 5 key questions that are involved in AS diagnosis and treatment decision making.

1. When should the primary care physician consider the presence of AS or the related diseases?

Clinical case scenario. Robert, a 24-year-old college student, was seen in the student health center with symptoms of low back pain (LBP) that had been present for about 2 weeks. The pain was present in the buttocks area and alternated from the right side to the left.The pain worsened at night and occasionally forced Robert to get out of bed and walk around. He also complained of stiffness in his lower back, especially in the first 2 hours after he arose from bed in the morning. The back pain and stiffness improved after progressive activity during the day.

Robert reported that he had had this back pain twice during the previous 6 months and attributed the previous episodes to athletic activity. He took over-the-counter ibuprofen and had significant pain relief. His review of systems was negative for recent bowel or genitourinary infections, and he denied any abdominal pain, diarrhea, or fever.

Robert's family history does not show any history of inflammatory arthritis of the spine. His physical examination results were unremarkable except for tenderness over the lower back on flexion. No restriction was present when he underwent a modified Schober test or when chest expansion was measured.

The modified Schober test was performed by measuring the increase in length, while bending forward maximally, of an imaginary vertical line between 2 points placed 10 cm apart, the first at the midpoint between the dimples of Venus (corresponding to the lumbosacral junction) and the second 10 cm vertically above it in the midline. The measurement was 7 cm (normal, more than 5 cm).The maximal chest expansion on inspiration was measured at the level of the nipples; it was 6 cm (normal, more than 5 cm).


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