eMedicine Specialties > Neurology > Inflammatory and Demyelinating Diseases

Ankylosing Spondylitis

Alan Schaffert, MD, Former Chief of Staff, Department of Medicine, Doctor's Medical Center of Modesto; Clinical Assistant Professor, University of California at Davis

Updated: Jan 8, 2007

Introduction

Background

Spondyloarthritis or spondyloarthropathy refers to a group of chronic inflammatory conditions affecting the joints, tendon and ligament attachments, and sometimes nonskeletal structures. Ankylosing spondylitis (AS) is one of these inflammatory diseases. It primarily affects the axial joints, including the spine and sacroiliac joints. It causes eventual fusion of the spine. Peripheral joints may be involved.

Pathophysiology

Inflammation at the sites of insertion of ligaments and tendons in the bones is the primary pathological process. Reactive bone growth occurs that is cumulative with each new attack. The disorder is predominantly skeletal, with ankylosis of the spine; involvement of hips, knees, and occasionally small joints; and plantar fasciitis.

Nonskeletal problems associated with AS may include iritis, uveitis, aortitis, pulmonary fibrosis, amyloidosis, and inflammatory bowel disease. Neurological complications include C1-C2 subluxation, tendency to spinal fractures with minor trauma, spinal stenosis in the cervical or lumbar regions, chronic inflammatory cauda equina syndrome, and radiculopathy secondary to fracture or compression.

Frequency

United States

In the general population, 1.4% are affected.

Sex

Male-to-female ratio is approximately 3:1.

Age

Peak onset is in adolescents and adults aged 15-30 years. A juvenile form also exists.

Clinical

History

Patients typically present in their late teens or twenties. Large joints of the lower extremities are involved more commonly in the juvenile form than in the adult form.

Patients usually describe a gradual onset of low back pain over 3 or more months. The pain is described as follows:
- Worse in the morning with improvement during the day
- Better with activity and worse with rest (helps in distinguishing AS from mechanical low back pain)
- Gradual ascending pattern from the lumbar region to the thoracic and then the cervical spine
Approximately 25% of patients present with complaints of proximal joint involvement. Rarely, small joint involvement is a presenting feature.
Patients may describe pain and stiffness of the rib cage, which may or may not be pleuritic in nature. Atypical chest pain may be present.
Presentation may be atypical or as a forme fruste.

Physical

Examine for tenderness over the sacroiliac joints. Look for loss of lumbar lordosis and limited range of lumbar motion. In early phases of the disease, range of motion limitations may be due to muscle spasm. However, later it is due to bony fusion.
Measure for limitations in chest expansion.
Range of motion of the entire spine may be limited. In chronic, untreated cases, thoracic kyphosis is increased. This results in a characteristic posture in which the patient cannot look to the horizon.
Acutely involved joints may have overlying purplish discoloration.

Causes

About 90-95% of patients have the HLA-B27 antigen.
Onset and flare-ups may be due to poorly understood environmental factors.
Presumably, a fairly benign bacterium or virus can be antigenically similar to human ligaments.
In a susceptible individual, a mild infection might stimulate an abnormal immune response.

Differential Diagnoses

Cervical Spondylosis: Diagnosis and Management
Spinal Cord Hemorrhage
Spinal Cord Infarction
Spinal Epidural Abscess

Workup

Laboratory Studies

Low-grade anemia of chronic disease may be present.
Antinuclear antibody (ANA) and rheumatoid factor (RF) are within reference ranges.
Erythrocyte sedimentation rate (ESR) is normal or mildly elevated; it is more likely to be elevated with active inflammation.
C-reactive protein may be elevated with increased disease activity but is not a better indicator of inflammation than ESR.
Serum alkaline phosphatase may be elevated when active bone remodeling is occurring.
HLA-B27 antigen is positive 90-95% of the time but, notably, is not always present. Furthermore, its presence is not sufficient to make the diagnosis. The test is most helpful when diagnosis is not clear.
Cerebrospinal fluid (CSF) protein may be elevated mildly during acute exacerbations.

Imaging Studies

Plain radiography of the pelvis shows sacroiliitis or fusion of sacroiliac joints.
Lumbar spine radiography may show ossification of the anterior longitudinal ligament and fusion of facet joints. The appearance gives rise to the term bamboo spine. With extensive fusion of the spine, a patient may have a poker spine.
CT scan will show bony fusions and eroded laminae and spinous processes.
MRI may be needed to document atlantoaxial subluxation. MRI may be indicated after trauma to evaluate the spinal cord and to rule out cauda equina syndrome or epidural hematoma.
- Cauda equina syndrome may be inflammatory or compressive.
- In inflammatory cauda equina syndrome, the spinal canal is normal to large with CSF diverticula that are best seen on MRI.
Plain films or CT scan of the spine may be indicated after trauma to evaluate for bony injury.

Other Tests

Occasionally, joint aspiration may be needed to rule out septic arthritis. With ankylosing spondylitis, synovial fluid may reveal a neutrophilic leukocytosis.

Treatment

Medical Care

General principles of management include the following:

Exercise and postural training
Medications to decrease pain and inflammation, tumor necrosis factor-alpha antagonists are valuable recent additions to the medication options. When used, they rapidly reduce symptoms and slow disease progression.
Diagnosis and treatment of potential complications

Surgical Care

Surgical treatment may be necessary for some complications of ankylosing spondylitis.

Surgical fusion may be required for stabilizing atlantoaxial subluxation.
Cervical spine fractures require rigid immobilization, usually with a halo. In the past, surgical fusion was usually not performed. With neurological deficit, early surgical intervention with fusion is often recommended. Neurological deficit often improves after surgery.
Surgery rarely is indicated for correction of uncomplicated thoracic kyphosis. If functional impairments are present, correction of the spinal deformity may be necessary; however, postoperative mortality from various complications is substantial, 4%.
Thoracolumbar fractures require reduction of displacement and stabilization, usually with rods. Laminectomy rarely is needed.
Decompression of cervical or lumbar spinal stenosis is indicated when neurological structures are involved.
If weight-bearing joints are involved, hip or knee replacement may be necessary. The most common surgical procedure in these patients is a total hip arthroplasty.

Consultations

If patients have complaints of eye pain, visual changes, or increased lacrimation, an ophthalmologist should be consulted to evaluate and treat for iritis or uveitis and rule out other causes of these conditions.
Chest pain may require evaluation by a cardiologist or pulmonologist. Aortic regurgitation, sometimes associated with heart block, may need further treatment. Because apical pulmonary fibrosis may allow for opportunistic infection, pulmonary care may be necessary.
Consultation with an orthopedist or neurosurgeon is indicated when spinal trauma occurs or in the setting of persistent pain or neurological deficit.
Orthopedic care may be needed if weightbearing or shoulder joints are involved. Plantar fasciitis may require orthopedic or podiatry consultation.
If associated inflammatory bowel disease is present, evaluation and treatment by a gastroenterologist may be necessary.

Activity

Daily bending, twisting, and gentle range of motion exercises help prevent postural deformities and restriction of joint range of motion.
Breathing exercises are recommended to prevent chest wall immobility.
Encourage good sleeping posture with a small pillow on a firm mattress in either the supine or prone position.

Medication

The goal of pharmacotherapy is to control pain and decrease inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used medications. Sulfasalazine has been shown to be effective for peripheral joint involvement. Steroids and immunosuppressive agents are used sometimes. Injections of local steroids may offer symptomatic relief for local inflammation.

Nonsteroidal anti-inflammatory drugs

These agents reduce pain and inflammation. No particular NSAID has been shown to be clearly superior for treating ankylosing spondylitis.

Ibuprofen (Motrin, Advil, Haltran, Nuprin)

Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, thus inhibiting prostaglandin synthesis.

Dosing

Adult

200-800 mg PO q6-8h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 30-70 mg/kg/d PO divided tid/qid; start at lower end of range and titrate upward; not to exceed 2.4 g/d
>12 years: Administer as in adults

Interactions

Probenecid may increase concentrations and possibly toxicity; may decrease effects of loop diuretics; may increase serum lithium levels and risks of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Coadministration with anticoagulants may prolong prothrombin time (PT); consider effects that NSAIDs have on platelet function and gastric mucosa; Monitor PT and patients closely, and instruct patients to watch for signs and symptoms of bleeding

Contraindications

Documented hypersensitivity; because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients in whom aspirin, iodides, or other NSAIDs have induced symptoms of asthma, rhinitis, urticaria, nasal polyps, angioedema, bronchospasm, or other symptoms of allergic or anaphylactoid reactions

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion are at greatest risk of acute renal failure
Low WBC counts are rare and transient; they usually return to normal as therapy continues; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuing drug
Perform ophthalmological studies in patients who develop eye complaints during therapy; effects include blurred or diminished vision, scotomata, changes in color vision, corneal deposits, and retinal disturbances (including maculae); discontinue therapy if ocular changes are noted; blurred vision may be significant and warrants thorough examination, including central visual fields and color vision testing; these changes may be asymptomatic, and thus periodic eye examinations should be performed in patients on prolonged therapy

Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)

Relieves mild to moderately severe pain and inhibits inflammatory reactions, probably by decreasing activity of enzyme cyclooxygenase, thus inhibiting prostaglandin synthesis.

Dosing

Adult

250-500 mg PO bid; may increase to 1.5 g/d for limited periods; generally, not to exceed 1.25 g/d

Pediatric

<2 years: Not established
> 2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Diclofenac (Voltaren)

Has analgesic, antipyretic, and anti-inflammatory activity. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, thus inhabiting prostaglandin synthesis.
Doses above stated maximum generally do not increase effectiveness.

Dosing

Adult

25 mg PO bid/tid; if well tolerated, increase daily dose by 25 or 50 mg at weekly intervals until satisfactory response obtained; not to exceed 150-200 mg/d

Pediatric

<14 years: Not established
>14 years: Administer as in adults

Interactions

Contraindications

Documented hypersensitivity
Because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients with hypersensitivity to aspirin, iodides, or other NSAIDs

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Tumor necrosis factor antagonists

These agents inhibit the activity of cytokine TNF-alpha. Indications are a definitive diagnosis, active and refractory disease, with failure of conservative treatment. Treatment should be discontinued for patients who do not respond within after 6-12 weeks. Before use, refer to current practice guidelines for more complete discussions.

Infliximab (Remicade)

Chimeric IgG1k monoclonal antibody that neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Reduces infiltration of inflammatory cells and TNF-alpha production in inflamed areas. May be administered with or without methotrexate.

Dosing

Adult

5 mg/kg IV infusion at 0, 2, and 6 wk as induction regimen, then 5 mg/kg q6wk for maintenance
IV infusion must be administered over at least 2 h; must use infusion set with in-line, sterile, nonpyrogenic, low-protein-binding filter (pore size <1.2 µm)

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

TNF-alpha modulates cellular immune responses; anti-TNF therapies, such as infliximab, may adversely affect normal immune responses and allow development of superinfections; more cases of lymphoma were observed in TNF-alpha blockers compared with controlled groups; may increase risk of reactivation of tuberculosis in patients with particular granulomatous infections

Etanercept (Enbrel)

Soluble p75 TNF receptor fusion protein (sTNFR-Ig). Inhibits TNF binding to cell surface receptors, thereby decreasing inflammatory and immune responses.

Dosing

Adult

25 mg SC 2 times/wk

Pediatric

Not established

Interactions

Do not administer within 3 mo of live virus vaccines (eg, MMR)

Contraindications

Documented hypersensitivity; sepsis

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Serious infections may develop and therapy should be discontinued if they occur; possible adverse effects include injection site pain, redness and swelling at injection site, and headaches; rare cases of lupuslike symptoms and heart failure have been reported (discontinue treatment if symptoms develop)

Adalimumab (Humira)

Recombinant human IgG1 monoclonal antibody specific for human TNF. Indicated to reduce signs and symptoms in patients with active AS. Can be used alone or in combination with methotrexate or other disease-modifying antirheumatic drugs (DMARDs).

Dosing

Adult

40 mg SC q2wk

Pediatric

Not established

Interactions

May interfere with immune response to live virus vaccine (MMR) and reduce efficacy; methotrexate decreases clearance (available data do not support adjusting dose of either adalimumab or methotrexate); coadministration with anakinra (an interleukin-1 antagonist that also blocks TNF) may cause additive adverse effects, particularly development of serious infections

Contraindications

Documented hypersensitivity; active infection

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Causes immunosuppression; may reactivate tuberculosis infection; increases risk for lymphoma development; associated with CNS demyelination (rare); discontinue if serious infection develops; autoantibody development may occur causing lupuslike syndrome; may cause hypersensitivity reactions, including anaphylaxis and hematologic adverse effects (ie, pancytopenia, aplastic anemia)

Antirheumatic agents

This agent relieves pain and joint swelling and treats GI lesions associated with inflammatory bowel disease.

Sulfasalazine (Azulfidine, EN-tabs)

Acts locally in colon to decrease inflammatory response; systemically inhibits prostaglandin synthesis.

Dosing

Adult

Initial dose: 1 g PO tid/qid
Maintenance dose: 2 g/d PO divided tid/qid

Pediatric

<2 years: Not established
> 2 years:
Initial dose: 40-60 mg/kg/d PO q4-8h
Maintenance dose: 20-30 mg/kg/d PO divided qid

Interactions

Decreases effects of iron, digoxin, and folic acid; increases effects of oral anticoagulants, methotrexate, and oral hypoglycemic agents

Contraindications

Documented hypersensitivity; hypersensitivity to sulfa drugs; GI or GU obstruction

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Use caution in patients with renal impairment, blood dyscrasias, impaired hepatic function, or urinary obstruction; possible adverse effects include headache, sore throat, anorexia, nausea, jaundice, reversible oligospermia, itching, skin rash, hives, hemolytic anemia, and cyanosis; Monitor CBC and microscopic urinalysis frequently

Corticosteroids

These agents relieve inflammation and joint pain associated with ankylosing spondylitis.

Prednisone (Deltasone, Orasone, Sterapred)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
May be given PO or injected into an inflamed joint, which may afford temporary relief from pain, stiffness, and swelling.

Dosing

Adult

5-60 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve

Pediatric

4-5 mg/m²/d PO; alternatively, 1-2 mg/kg qd or divided bid/qid; taper over 2 wk as symptoms resolve

Interactions

Clearance may be decreased by estrogens; when used with digoxin, may increase digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism (consider increase in maintenance dose of prednisone); monitor patients for hypokalemia when taking with diuretics

Contraindications

Documented hypersensitivity; diabetes; mental illness; hypothyroidism; cirrhosis; viral, fungal, or tubercular skin lesions

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Use caution in patients with hyperthyroidism, nonspecific ulcerative colitis, osteoporosis, peptic ulcer, and myasthenia gravis; abrupt withdrawal may cause adrenal crisis; possible adverse effects include hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections

Antimetabolites

These agents are second-line therapy to control symptoms of joint pain and inflammation in ankylosing spondylitis.

Methotrexate (Folex, Rheumatrex)

Mechanism of action in ankylosing spondylitis unknown; may affect immune function. Although clearly ameliorates symptoms of inflammation, no evidence that it induces remission.

Dosing

Adult

7.5 mg/wk PO as a single weekly dose or 2.5 mg PO q12h for 3 doses given as a course once weekly; in either schedule, dosages may be adjusted gradually to achieve optimal response; not to exceed 20 mg total weekly dose ordinarily
Alternative: 0.2-0.4 mg/kg PO once weekly

Pediatric

5-15 mg/m²/wk PO/IM as single dose or as 3 divided doses given q12h

Interactions

Concurrent NSAIDs may cause fatal interaction; oral aminoglycosides may decrease absorption and blood levels of PO methotrexate; charcoal lowers plasma levels of both PO and IV forms, which may be particularly significant with high-dose therapies; etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response to methotrexate; indomethacin and phenylbutazone can increase plasma levels (mechanism of action not known, but may involve inhibition of renal prostaglandin synthesis or competitive renal secretion); may decrease phenytoin serum concentrations; procarbazine many increase nephrotoxicity; may increase plasma levels of thiopurines
Probenecid, salicylates, and sulfonamides (including TMP-SMZ) may increase therapeutic and toxic effects; inhibition of renal tubular secretion, competition for common elimination pathway, or protein displacement may be causes; however, if protein displacement is mechanism, may involve displacement of highly bound metabolic 7-hydroxymethotrexate, since parent drug is only 50% bound

Contraindications

Documented hypersensitivity; alcoholism, alcoholic liver disease, or other chronic liver disease; laboratory evidence of immunodeficiency syndromes, preexisting blood dyscrasias such as bone marrow hypoplasia, leukopenia, thrombocytopenia, or significant anemia

Precautions

Pregnancy

X - Contraindicated in pregnancy

Precautions

Monitor blood cell counts at least monthly; liver and renal functions, q1-3 mo during therapy; during initial or changing doses, or periods of increased risk of elevated methotrexate blood levels (eg, dehydration), more frequent monitoring may be indicated; stop methotrexate immediately if blood cell counts drop significantly; aspirin, NSAIDs, or low-dose steroids may be continued, although possibility of increased toxicity with concomitant NSAIDs (including salicylates) has not been fully explored
Potential adverse effects include hepatotoxicity, interstitial pneumonitis, bone marrow suppression, severe nephropathy, opportunistic infections, ulcerative stomatitis, and diarrhea

Follow-up

Complications

Atlantoaxial subluxation may occur spontaneously and can be associated with a severe myelopathy. It is found in about 20% of patients who have a mean disease duration of 10 years. Clinically significant myelopathy requiring fusion is found in only 2%.
Cervical spinal fractures are uncommon and usually are seen in patients with advanced disease.
- Fracture usually results from minor trauma. Typically, the fracture is through the intervertebral space at level C5-C6 or C6-C7. Neurological deficits associated with spinal fracture may be delayed for 2-30 days.
- Approximately 57% have severe neurological sequelae. Overall mortality rate is 35%, about twice that of a similar fracture in healthy individuals.
Cervical myelopathy may result from cervical spinal stenosis.
Thoracic and lumbar spinal fractures are less common than cervical spinal fractures. They usually result from minor trauma and may be multiple. Severe neurological deficits are frequent.
Lumbar spinal stenosis may result in a cauda equina syndrome.
- Chronic inflammatory cauda equina syndrome occurs only in long-standing AS and may occur when other aspects of the disease are seemingly inactive.
- Patient described a gradual onset of buttock and leg pain. Sensory symptoms are often mild and symmetrical, often not noticed by the patient.
- Motor involvement and bowel or bladder dysfunction are variable.
- This condition is slowly progressive to stable for years to decades.
- Neither surgery nor steroid therapy is beneficial.
Radiculopathies may occur as a result of foraminal stenosis, disc disease, or fracture at the level of a nerve root.

Prognosis

Symptoms of pain and stiffness are common and may be moderately severe to severe. Patients have few problems with social interactions, although depression is common.
Most patients remain employed and relatively few develop severe functional disability. Disability correlates with duration of disease, disease activity, and spinal mobility. Peripheral joint involvement also results in greater impairment.
The medical cost of treating AS can be relatively low compared with the costs of other rheumatologic diseases. The use of tumor necrosis factor antagonist agents is very expensive.

Miscellaneous

Medicolegal Pitfalls

Angular kyphosis may result from a spinal fracture. Evaluation often requires imaging techniques, since neurological deficits may be delayed.
Nocturnal pain in a weight-bearing joint is atypical and should be evaluated.
Persistent neck or back pain after a seemingly minor trauma requires evaluation to rule out a fracture. Multiple fractures are a possibility, which may be difficult to see on a plain x-ray. Obtain CT or MRI scans and image the spine liberally to avoid missing an occult fracture.
With preexisting kyphosis, a suspected thoracolumbar fracture may be a contraindication to immobilization in the supine position. Severe neurological deficit may result.

References

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Keywords

ankylosing spondylitis, Marie-Strümpell arthritis, Bechterew disease, spondyloarthritis, spondyloarthropathy, chronic inflammatory conditions, AS, inflammation of the joints, inflammation of the tendons, inflammation of the ligaments, iritis, uveitis, aortitis, pulmonary fibrosis, amyloidosis, inflammatory bowel disease

Contributor Information and Disclosures

Author

Alan Schaffert, MD, Former Chief of Staff, Department of Medicine, Doctor's Medical Center of Modesto; Clinical Assistant Professor, University of California at Davis
Alan Schaffert, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, California Medical Association, and National Stroke Association
Disclosure: Nothing to disclose.

Medical Editor

Rodrigo O Kuljis, MD, Esther Lichtenstein Professor of Psychiatry and Neurology, Director, Division of Cognitive and Behavioral Neurology, Department of Neurology, University of Miami School of Medicine
Rodrigo O Kuljis, MD is a member of the following medical societies: American Academy of Neurology and Society for Neuroscience
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Associate Program Director, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

Further Reading

eMedicine Specialties > Neurology > Inflammatory and Demyelinating Diseases

Ankylosing Spondylitis

Introduction

Background

Pathophysiology

Frequency

United States

Sex

Age

Clinical

History

Physical

Causes

Differential Diagnoses

Other Problems to Be Considered

Workup

Laboratory Studies

Imaging Studies

Other Tests

Treatment

Medical Care

Surgical Care

Consultations

Activity

Medication

Nonsteroidal anti-inflammatory drugs

Ibuprofen (Motrin, Advil, Haltran, Nuprin)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Diclofenac (Voltaren)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Tumor necrosis factor antagonists

Infliximab (Remicade)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Etanercept (Enbrel)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Adalimumab (Humira)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy