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Ankylosing spondylitis (AS)

• A chronic inflammatory disease affecting the axial skeleton resulting in the fusion of vertebrae
• Men are affected 3x as often as women
• Most often affecting patients age 20-30 years old
• Huge delays in diagnosis

Clinical Presentation

• Back pain for more than 3 months
• Back stiffness more than 3 months

Labs, Studies and Physical Exam Findings

• Diagnosis is difficult and often delayed due to late changes on X-ray
• Schober’s test
  • Mark L5 with patient standing
  • Mark 5 cm below L5 call this point 1
  • Mark 10 cm above L5 call this point 2
  • With the patient bending over the distance between point 1 and point 2 should be greater than 20 cm  If not, this indicates decreased flexion of the spine
• X-ray – changes may not be seen for up to 10 years – Bamboo spine
• Early diagnosis is achieved by demonstrating sacroiliitis on MRI or X-ray, a positive HLA-B27 and two of the following
  • Dactylitis – inflammation of the fingers
  • Enthesitis of the heel – Inflammation at the bone tendon junction
  • Family history of spondyloarthritis
  • History of inflammatory back pain
  • Arthritis
  • Psoriasis
  • Inflammatory bowel disease
  • Uveitis
  • Elevated C-reactive protein
  • Good response to nonsteroidal anti-inflammatory drugs

Treatment

• Use good posture
• NSAIDs
• Opioids
• Disease-modifying antirheumatic drug (DMARDS)
• Tumor necrosis factor-alpha
• Physical Therapy & exercise
• Surgery to correct symptomatic issues

Kyphosis (Humpback)

• A significant increase in the curvature of the thoracic spine
• Incidence increases with age
• Causes
  • Vertebral body fractures
  • Degenerative disc disease

Clinical Presentation

• Humpback

Labs, Studies and Physical Exam Findings

• Kyphosis measurements
• X-ray
• MRI
• CT

Treatment

• Bracing
• Physical therapy
• Kyphoplasty

Scoliosis

• A spinal curvature of more than 10 degrees from side to side
• Once growth has stopped the condition will usually not get worse

Clinical Presentation

• Routine physical exam
• Obvious deformity

Labs, Studies and Physical Exam Findings

• Adams forward bend test – With patient standing in front of you have the patent bend forward as far as possible  Look for one side of the ribcage to be higher than the other
• X-ray
  • Cobb angle– You draw a line that is parallel to the superior endplate of one vertebra and another line parallel to the inferior plate of another vertebra  The angle at which these two lines intersect is the Cobb angle

Treatment

• Cobb angle of < 20 – watchful waiting
• Cobb angle between 20 and 50 or increasing deformity – bracing
• Cobb angle > 50 degrees – Surgical correction with a posterior spinal fusion

Thoracic Outlet Syndrome

• Similar in concept to carpal tunnel syndrome
• There is a tunnel formed by the top ribs, the clavicle and the muscles of the neck
• The brachial plexus, subclavian vein, and subclavian artery all pass through this tunnel
• Compression of this tunnel is thoracic outlet syndrome

Risk factors

• Presence of a cervical rib
• Trauma – whiplash
• Mass effect
  • Tumor
  • Bodybuilding
  • Significant weight gain

Clinical Presentation

• Symptoms will vary depending on which structure is compressed
  • Venous compression
  • Edema
  • Pain and paresthesia
  • Possible DVT
  • Arterial compression
    • Cold or pale limb
    • Pain and tingling in the arm and hand
    • Possible aneurysm
  • Brachial plexus
    • Pain and paresthesia
    • Weakness
    • Atrophy of the limb

Labs, Studies and Physical Exam Findings

• Ultrasound
• Chest X ray looking for cervical rib
• Brachial plexus nerve block

Treatment

• Rib resection
• Brachial plexus symptoms
  • Physical Therapy
  • Botox injection
  • Surgery
• Venous & arterial occlusion
  • Blood thinners may be necessary
  • Thrombolysis
  • Surgical repair of the aneurysm