Ankylosing Spondylitis: Visual Explanation for Students

hi this is tom from zero a noise calm in this video i'm going to be going through ankylosing spondylitis and you can find written notes on this topic at zero define as calm slash ankylosing spondylitis or in the Rheumatology section of the zeroD finals medicine book let's jump straight in ankylosing spondylitis is an inflammatory condition that mainly affects the spine that causes progressive stiffness and pain it's part of the seronegative spondyloarthropathies of conditions that are related to the HLA b27 gene and other conditions in this group are things like reactive arthritis and psoriatic arthritis the key joints that are affected in ankylosing spondylitis are the sacroiliac joints and the joints of the vertebral column and the inflammation causes pain and stiffness in these joints progressed a fusion of the joints so fusion of the spinal column and the sacroiliac joints fusion of the spine leads to the classical finding on the x-ray of a bamboo spine and this is something that will often appear in your medical exams there's a strong link with the HLA b27 gene and around 90% of patients who have ankylosing spondylitis will have this HLA b27 gene however only around 2% of people who have the gene will develop and closing spondylitis this number goes up to around 20% if they have a first-degree relative that's affected so if you have a first-degree relative and the HLA b27 gene is around a 20% chance of developing the condition so how do these patients present the tip especially in your exams is a young adult male in their late teens or twenties and affects males about three times more often than females and symptoms usually develop gradually over more than three months the main presenting features are low back pain and stiffness and sacroiliac pain which occurs in the buttock region the pain and stiffness is worse with rest and it improves with movement and the pain is worst at night and in the morning and it may even wake them up from sleep in the early hours of the morning and when you take a history the patient will describe how it takes at least 30 minutes for the stiffness to improve in the morning and then that stiffness seems to get progressively better throughout the day as they do more and more activities the symptoms can fluctuate with periods of flares of worsening symptoms and other periods where the symptoms seem to improve one of the key convocations of unclosing spondylitis is vertebral fractures so what associations are there between ankylosing spondylitis and other affected areas in the body and ankylosing spondylitis doesn't just affect the spine it can affect other organ systems and cause things like systemic symptoms such as weight loss and fatigue it can present with chest pain related to the cost over to ball joints and the cost Oh sternal joints and the situs is inflammation of the entha C's and this is where the tendons or the ligaments insert into the bone this can cause problems like plantar fasciitis and achilles tendonitis dactyl itis is a condition where there's inflammation of an entire finger or toe it can cause anemia anterior uveitis a or Titus which is inflammation of they a water the large blood vessel coming out of the heart it can cause heart block when there's fibrosis of the hearts conduction system restrictive lung disease can be caused by restricted movement in the chest wall and ankylosing spondylitis can also be associated with pulmonary fibrosis particularly at the upper lobes of the lungs and this occurs in about 1% of patients the condition that's also associated with ankylosing spondylitis is inflammatory bowel disease there's a test called showbiz test which you're expected to know about in medical school and this is a test that's used as part of a general examination of the spine to assess how much mobility there is particularly in the lumbar spine you might be asked to do this in your oski examinations so how do you do it well you have the patient stand straight you find approximately where their l5 vertebra is and then you mark a point 10 centimeters above the l5 vertebra and 5 centimeters below so the points of 15 centimeters apart then you ask the patient to bend forward as far as they can and you measure the distance between the two points if the distance between them when they're bending forwards is less than 20 centimeters this indicates there's a restriction in the lumber movement and it would help to support a diagnosis of ankylosing spondylitis what investigations can you do well you can start with some basic inflammatory markers like CRP and ESR they might go up with increased disease activity you can send off a genetic test to look for the hey tell a b27 gene you can do x-rays of the spine and the sacrum and if the x-rays are normal an MRI of the spine can show early changes and this shows up as bone marrow edema in the vertebral bodies and this is something that will appear before there's any changes on the x-ray so what x-ray changes do you get well this bamboo spine is the typical exam description of the x-ray appearance of the spine in later stages of enclosing spondylitis and it's worth remembering this term in case it appears in your mcq exams x-ray images and ankylosing spondylitis can show squaring of the vertebral bodies subchondral sclerosis and subchondral erosions sindh ESMA fights which are areas of bone growth where the ligament normally inserts into the bone and this occurs relating to the ligaments that support the intervertebral joints so where the ligaments insert into the vertebra to hold the vertebra together you can get these developments of bony growth called CIN desmo fights ossification can occur in the ligaments or discs and the joints and this is where the structures like the ligaments starts to turn into bone like tissue and he can get fusion of the facet joints the sacroiliac joints and the cost over two ball joints so there's no longer any movement at all in those joints so let's move on to the management of ankylosing spondylitis let's first start with the medical management of the condition so the first step would be non-steroidal anti-inflammatory medication like ibuprofen or naproxen and these can be used to help with the pain related to the inflammation if the improvement in the pain and the symptoms aren't adequate after two to four weeks of the maximum dose and you can consider switching to another non-steroidal anti-inflammatory and simply switching medication can sometimes lead to an improvement in symptoms steroids can be used during flares of the condition to help control the symptoms and this could be oral steroids or intramuscular slow-release injections or steroid injections directly into the affected joints the next step is medications that target tumor necrosis factor an anti TNF medications like etanercept or monoclonal antibodies against TNF such as infliximab adalimumab and cirtl ISM AB are known to be effective in treating the disease activity and enclosing spondylitis if these don't work so if you get no adequate response from NSAIDs steroids and TNF inhibitors then there's a monoclonal antibody against interleukin 7 called sec Aquino map and this is a relatively new medication that shows promising results in ankylosing spondylitis then you need to move on to additional management to support the medical management physiotherapy is really important to give them exercise and encourage them to mobilize the spine to keep that flexibility and mobilization they're avoiding smoking is important bisphosphonates can be used to treat osteoporosis if it occurs you need to offer treatment for other complications such as the heart block or the restrictive lung disease and then surgery may be required if there's deformities to the spine or vertebral fractures or deformities develop in other joints so thanks for watching I hope you found this video helpful if you did don't forget there's plenty of other resources on the zero to finals website including loads and loads of notes on various different topics that you might cover in medical school with specially made illustrations there's also a whole test section where you can find loads of questions to test your knowledge and see where you're up to in preparation for your exams there's also a blog where I share a lot of my ideas about a career in medicine and tips on how to have success as a doctor and if you want to help me out on YouTube you can always leave me a thumbs up give me a comment or even subscribe to the channel so that you can find out when the next videos are coming out so I'll see you again soon

Channel: Zero To Finals

Views: 881,293

Keywords: medical, education, medicine, doctor, rheumatology, etanercept, ankylosing spondylitis, orthopaedics, spine

Id: a23A3nAaO0E

Length: 11min 3sec (663 seconds)

Published: Thu Mar 28 2019