Clinical Course of Ankylosing Spondylitis

Low back pain and stiffness in the sacroiliac region in the early morning are often the only symptoms in the beginning of the disease. If the pain lasts for more than three months, especially in patients below the age of 40, the diagnosis of AS should be taken into account. Typically, pain and stiffness decrease during exercise. Another possible symptom is an alternating and transient pain in the anterior chest wall, the neck, in the knee joints or the heels. These complaints may be triggered by sudden movements like sneezing or stumbling. In addition to these articular and spinal symptoms, an iridocyclitis is a frequent early sign.

The clinical examination may demonstrate decreased mobility of the spine and the chest in this phase of AS. Measurements should at least contain the Ott and Schober sign as parameters of thoracic and lumbar mobility, the Fleche sign for the cervical spine, the fingertips-floor distance for anteversion of the whole spine, the Mennell sign for verifying sacroiliac involvement and thoracic excursion during breathing, as summarized in Table 1. The measurements of spinal mobility are especially important for follow-up examinations in the same patient because of interindividual differences, for example, a fingertip-floor distance of 3 cm is not pathologic per se. An increment to 10 cm, six months later, however, should be noticed very seriously.

In the later course of the disease, radiological signs of sacroiliits and increasing mineralization of ligaments and tendons are seen as a part of the modified New York criteria (12), thus leading to the final diagnosis of AS in many patients. In each patient, the diagnosis is based on both clinical signs and radiological criteria, shown in Table 2. However, the mean delay between the onset of first symptoms and the diagnosis of AS is between five and seven years (13), which is obviously too late, considering the fact that the most severe harm and loss of mobility happens during the first decade of the disease (14). Thus, approximately one-third of all AS patients are significantly impaired at the time of diagnosis (13).

The further course of the disease may be mild with only slow progress and long periods without subjective complaints. Other patients suffer from rapid

Table 1 Clinical Tests for Measuring Spine Mobility in Ankylosing Spondylitis

Sign

Afflicted area

Examination

Ott

Thoracic spine

Mark C7 and a 30-cm line in caudal direction

) Measure extension in maximum anteversion

Schober

Lumbar spine

Mark S1 and a 10-cm line in cranial direction

) Measure extension in maximum anteversion

Fleche

Cervical spine

Patient leaning against the wall in upright position ) Measure distance between occiput and wall

Mennell

Sacroiliac joint (SIJ)

Patient lying on his left side, fix the SIJ with your left hand ) Shear stress on the SIJ by extension of the right leg ) Other side vice versa

Table 2 The Modified New York Criteria for the Diagnosis of Ankylosing Spondylitis

Criteria:

Low back pain and stiffness for at least three months, not eased by resting, alleviated by exercise Limited mobility of the lumbar spine in both sagittal and frontal plane Limited thoracic excursion, adapted to age and gender Bilateral sacroiliitis stages 2-4a Unilateral sacroiliitis stages 3-4 True diagnosis of ankylosing spondylitis if Unilateral sacroiliitis stages 3 -4 or

Bilateral sacroiliitis stages 2-4 combined with any clinical sign

"Radiological stages of sacroiliitis following the New York criteria: 0 = normal; 1 = suspected sacroiliitis with blurred joint space; 2 = minimal sacroiliitis with osteolytic areas and increasing subchondral osseous thickening; 3 = intermediate sacroiliitis with sclerosis on both sides of the articular surface and partial osseous bridging; 4 = total bony ankylosis with/without bony sclerosis. Source: From Ref. 12.

and painful progressive ossifications, leading to early and severe disability. Approximately 20% of all patients with AS are at risk for severe disability and a premature withdrawal from employment (15). However, a spontaneous remission of the inflammatory and osteogenic activity is also possible in every condition of AS.

Several clinical indices were proposed to assess the disease activity during the time course of AS or for the evaluation of treatment response, as the correlation with laboratory parameters of inflammation is only weak. The most important and widely accepted indices were developed by a group of rheumatologists in Bath, England. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) mainly refers to both pain and stiffness of the spine and peripheral joints. The degree of functional impairment during the patient's daily activities is evaluated by the Bath Ankylosing Spondylitis Functional Index (BASFI) and the Bath Ankylosing Spondylitis Metrology Index (BASMI), which consist of several parameters for spinal and hip joint mobility (16).

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