Ankylosing spondylitis

Advances in musculoskeletal imaging and their clinical utility in the early diagnosis of spondyloarthritis

Interest in imaging ankylosing spondylitis (AS) and related spondyloarthropathies has increased in recent years. MRI is regarded as the most sensitive imaging modality to detect early inflammatory lesions in the sacroiliac joints and in the spine. Standard radiography plays a major role in evaluating potential disease-modifying properties of the recently introduced, symptomatically effective anti-tumor necrosis factor-alpha agents. Various radiographic scoring methods have been developed to assess and monitor spinal structural damage in AS. The modified stoke ankylosing spondylitis spine score is the method of choice based on its sensitivity to change. MRI is emerging as a useful tool to detect AS early, but this remains a challenge. Recent progress in MR technology with the advent of whole body MRI has expanded the potential role of imaging in AS. Further data are needed before MRI can replace radiographs for earlier diagnosis of AS.

Surgical management of global sagittal deformity in ankylosing spondylitis

✓ Ankylosing spondylitis (AS) is an inflammatory rheumatic disease whose primary effect is on the axial skeleton, causing sagittal-plane deformity at both the thoracolumbar and cervicothoracic junctions. In the present review article the authors discuss current concepts in the preoperative planning of patients with AS. The authors also review current techniques used to treat sagittal-plane deformity, focusing on pedicle subtraction osteotomy at the thoracolumbar junction, as well as cervical extension osteotomy at the cervicothoracic junction.

Nonsurgical management of ankylosing spondylitis

Object

The aim of this study was to review the current evidence-based nonsurgical management strategies of ankylosing spondylitis (AS) for spine surgeons. Whereas surgical management is indicated in a highly selected group, nonsurgical management is itself a useful measure for nearly all patients with AS.

Methods

The authors conducted a literature review of PubMed using relevant search words. All the articles published in English in the last 15 years were reviewed and the level of evidence provided by them was noted.

Results

Nonpharmacological treatments in the form of physical therapy and patient education have Level Ib evidence in maintaining function in AS. There is Level Ib evidence supporting the use of nonsteroidal antiinflammatory drugs (NSAIDs) and coxibs for treatment in patients with symptoms. There is not enough evidence to support the use of conventional disease-modifying antirheumatoid arthritis drugs. Tumor necrosis factor (TNF)α inhibitors (infliximab, etanercept, and adalimumab) are associated with Level Ib evidence in improving spinal pain, function, inflammatory biomarkers, and spinal inflammation detected by magnetic resonance imaging in patients in whom symptom duration has exceeded 3 months.

Conclusions

Physical therapy and patient education are useful for all patients diagnosed with AS. If symptomatic, patients are started with either a course of nonselective NSAIDs or a selective cyclooxygenase-2 inhibitor. The role of NSAIDs as a disease-modifying therapy in the treatment of AS is increasingly being understood. The central role of TNF in the pathogenesis of AS is now known, and the advent of biological treatment in the form of anti–TNFα factors has revolutionized the medical management of AS and is used in patients with axial disease whose symptoms persist despite an adequate dose of NSAIDs.