Nasal Endoscopy and FESS: maneuver, indications, aims, complications

Here is the second part of the discussion of Ankylosing spondylitis (AS), in which we are going to discuss the differential diagnosis (DD), investigations and treatment .
- Definition, causes, pathology and clinical picture of Ankylosing spondylitis is Here

Differential diagnosis of Ankylosing spondylitis (AS)

• The inflammatory back pain of AS is usually distinguished by the following features.

- Age of onset < 40 years - Insidious onset

- Duration > 3 m - Improvement with exercise.

• AS must be differentiated from other causes of bachache (see later).

• Diffuse idiopathic skeletal hyperstosis (DISH) must be differentiated from AS .as it leads to marked calcification and ossification of paraspinous ligaments.

Investigations 

1- X ray Sarco-iliac joint :  erosion, sclerosis. It is often the first abnormality.

2- X ray Spine (The disc is preserved, unlike in spondylosis).

   • Square shaped vertebrae.

   • Calcification of longitudinal ligament.

   • Bony bridging between vertebral bodies = syndesmophytes ==> bamboo spine.

3- Laboratory finding (there is no specific laboratory test).

   • Normochromic anemia.

   • ESR +++ ,+++ CRP during activity.

   • Rheumatoid factor -ve.

   • HLA Testing is rarely of value because of the high frequency of HLA-B27 in the population.

   • Alkaline Phosphatase l' with activity .

Treatment of Ankylosing spondylitis

(The principles are to relieve pain and spinal stiffness).

• The key of treatment is early diagnosis to start preventive exercise program before syndesmophytes have formed. Excercises aim to maintain spinal mobility, posture and chest expansion (swimming is recommended).

• NSAIDs :  relieve symptoms, but don't alter the course of the disease

• Local steroid :  for enthesopathy and planter fasciitis.

• Genetic counselling.

• Systemic steroid sometimes required for treatment of uveitis.

• Sulfasalazine and methotrexate may be of value for peripheral arthropathy.

• TNF blockers are effective

• Surgery: plaster jackets to correct kyphosis, hip arthroplasty.

Prognosis 

With exercise and pain relief, the prognosis is excellent and over 80% of patients are employed.

- Definition, causes, pathology and clinical picture of Ankylosing spondylitis