Lumbar / Pelvis

Bechterew’s Disease (ankylosing spondylitis)

Definition

Bechterew's disease is a chronic inflammatory rheumatoid disorder that, in particular, involves the axial skeleton. However, systemic involvement can also occur. Characteristically, it presents in young adults of 20-30 years of age.

Aetiology

Up until now, the exact aetiology of Bechterew's disease is unknown. There is a strong association with the HLA-B27 antigen.  In about 90% of patients, a genetic carrier has been established, in contrast to 8% in the normal population.

Signs and symptoms

The most serious complaints are neck and lower back pain, particularly in the region of the buttocks. These complaints start gradually before the age of 40 and are accompanied by morning stiffness that improves after motion. A typical symptom is nocturnal pain, especially in the second part of the night, as well as inflammation of the sacroiliac joint. In a proportion of patients, bony deformities of the spine occur, resulting in motion restriction in the cervical, thoracic and lumbar spine. Apart from these spinal complaints, inflammation of peripheral joints together with pain as a consequence of enthesitis of, for example, the Achilles tendon is a frequent occurrence. Extra-spinal and extra-articular symptoms are more common in patients with anterior uveitis, such as in ankylosing spondylitis and psoriasis.

Diagnostics

Physical Examination

In order to diagnose Bechterew's disease, careful examination of the vertebral column is essential. However, at the start of the disease, abnormalities can be sparse with minimal disorders of the mobility of the cervical and lumbar spine. Restrictions are most pronounced in the passive backward and lateral flexions and less in the forward flexion. Later on, during the course of the disease, all three motions become restricted.

As the disease progresses the lordosis of the lumbar spine flattens. The Schober test can be helpful in estimating the amount of lumbar forward flexion restriction.

Apart from the lumbar spine, the neck, thorax and peripheral joints should also be examined. Attention should be paid to the existence of enthesitis and tendinitis.

Additional Somatic Diagnostics

  • Bechterew's disease can frequently be diagnosed based on medical history and physical examination. Laboratory examinations, such as inflammation parameters.
  • CT scan can confirm the presence of inflammation of the sacroiliac joint.

Additional Psycho-cognitive Diagnostics

  • RAND-36 (quality of life)
  • VAS-Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

  • NSAID
  • Sulfasalazine
  • Methotrexate
  • Leflunomide
  • TNFα inhibitors
  • Corticosteroids

Other Treatments