Figure

Plain AP film of the thoracic spine in a patient with DISH showing flowing osteophytes bridging the vertebral bodies on the right side. Note the absence of similar osteophytes on the left.

the sacroiliac joints will fuse. Subsequently ossification of the vertebral bodies and the annulus pulposus leads to the formation of thin syndesmophytes. They form bridges between the vertebral bodies, eventually leading to spine fusion (Figures 8-5 and 8-6).

The facet joints become fused as well. The disc spaces may be preserved These features can be easily seen on a CT scan. It will show the sclerotic bone, calcified discs, syndesmophytes, and fused facet joints (Figure 8-7). The fused spine will appear hypointense on T1 as well as T2 weighted images, consistent with the abundant sclerotic bones. The calcifying discs may show increased signal intensity on T1 and T2 weighted images.

AS may be, at times, confused with diffuse idiopathic skeletal hyperostosis (DISH), a commonly seen benign condition (Figure 8-8).

Table 8-1 emphasizes some of the salient differences between these two conditions.

Management

The management of AS includes patient education, a lifelong exercise program, medications, and occasionally surgery. The patient should be referred for long-term physical therapy. Mobility preservation, muscle strengthening, fitness enhancement, and improvement in the sense of well-being are the main physical therapy goals. Stretching exercises, especially of the hip and knee flexors, are incorporated into the patient's daily routine in an attempt to prevent the development of flexion contractures. Every effort is made to preserve the upright posture and prevent the spine from fusing in kyphosis. General conditioning exercises combined with underwater aerobics may prove beneficial. Nonsteroidal anti-inflammatory drugs (NSAIDs) in full therapeutic doses should be tried first. Sulfasalazine, an effective and safe medication, can be prescribed at the early stages of the disease. It may be helpful in patients who do not respond to NSAIDs. In patients with severe, progressive disease methotrexate and cyclophosphamide should be prescribed. Tumor necrosis factor alpha inhibitors (etaner-cept, infliximab, or others) may be helpful in delaying disease progression and, according to some authors, should be prescribed early in the course of the disease.

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