CASE 155

BY: Dr. Nizar Al-Nakshabandi MD, FRCPC

HISTORY: 46-year-old complaining of shoulder pain.

What are your findings?

What is the differential diagnosis?

What are the causes?

FINDINGS:

Vertebral alignment is maintained. Loss of lordosis of the cervical spine likely related to ankylosis and spasm. Evidence of vertebral body squaring with diffuse syndesmophytes giving a bamboo spine appearance. Ankylosis of the apophyseal and costovertebral joints is seen. Narrowing of the intervertebral neural foramina is present from C2 to C7 (worse on the left side).

DIFFERENTIAL DIAGNOSIS:

·         general spine: enteropathic arthritis.

·         cervical spine: juvenile rheumatoid arthritis (JRA).

·         diffuse idiopathic skeletal hyperostosis.

DIAGNOSIS:

Ankylosing spondylitis.

PEARLS AND DISCUSSION:

Ankylosing spondylitis is a seronegative spondyloarthropathy which results in fusion of the spine {ankylosis}as well as ankylosis of the sacroiliac joint. It can also affect large and small joints.

It affects males more than females by a factor of 3:1. Male patients usually in their 30s.

There is a 90% association with HLA-B27 gene. Rheumatoid factor is negative, hence the name seronegative spondyloarthropathy.

It can be associated with inflammatory bowel disease. Some patients who have it can have aortic valve disease/aortitis. In the eyes, look for uveitis and in the skin, look for psoriasis.

Sacroiliac joint is one of the first manifestations. Sacroiliac joint becomes widening before it narrows. In end-stage, the sacroiliac joint may not be seen.

In the spine, look for a vertebral body squaring, a bamboo spine, interspinous calcification [dagger spine] shiny corners in which there are erosions and sclerosis of the corners of the vertebral body is seen. In our case, there is a trapezial and costovertebral ankylosis is observed.

MRI has a significant role in early diagnosis. Bone marrow edema of the sacroiliac joints is noted with synovial enhancement when gadolinium is administered.

Treatment is with anti-TNF therapy.

FURTHER READING:

1.      Riley MJ, Ansell BM, Bywaters EG. Radiological manifestations of ankylosing spondylitis according to age at onset. Ann. Rheum. Dis. 1971;30 (2): 138-48.

2.      Resnick D, Niwayama G. Entheses and enthesopathy. Anatomical, pathological, and radiological correlation. Radiology. 1983;146 (1): 1-9.

3.      Wilkinson M, Bywaters EG. Clinical features and course of ankylosing spondylitis; as seen in a follow-up of 222 hospital referred cases. Ann. Rheum. Dis. 1958;17 (2): 209-28.