Bechterew's Disease: Diagnosis

Early diagnosis of Bechterew's disease consists of an analysis of the presence of diseases associated with HLA-B27 in direct relatives of the patient. And information about the presence of episodes of uveitis, psoriasis, signs of chronic inflammatory bowel disease in the past is important for conducting a more detailed examination of the patient and determining the form of the disease.

[1],

Clinical diagnosis of Bechterew's disease

Particular attention should be paid to assessing the condition of the spine, joints and entecies, as well as those organs and systems that are commonly affected by AS (eyes, heart, kidneys, etc.).

[2], [3]

Diagnostics of Bechterew's disease: examination of the spine

Assess the posture, bends in the sagittal (cervical and lumbar lordosis, thoracic kyphosis) and the frontal plane (scoliosis). Measure the volume of movements.

To assess movements in the cervical region, the patient is asked to consistently perform maximum flexion and extension (norm not less than 35 °), lateral inclinations (norm not less than 45 °) and head turns (norm not less than 60 °).

Movement in the thoracic spine is assessed using the Ott test: from the spinous process of the 7th cervical vertebrae, count down 30 cm and apply a mark on the skin, then the patient is asked to bend down as far as possible, bending his head, and again measure this distance (normal growth is not less than 5 cm). You also measure a chest breathing excursion to assess the mobility of the rib-vertebral joints (the norm in adult men in young and middle age is at least 6 cm and at least 5 cm in women).

The mobility of the lumbar spine in the sagittal plane is assessed using the Wright-Schober test. In the patient's standing position, a point is noted at the intersection of the middle line of the back with an imaginary line connecting the posterior-superior awns of the ileum. Then a second point is marked 10 cm above the first. The patient is asked to bend forward as much as possible, without bending his knees. In this position, measure the distance between two points. Normally, it increases by at least 5 cm. The volume of movements in the frontal plane is determined by measuring the distance from the floor to the tip of the middle finger in the patient's standing position, and then during the maximum strictly lateral flexion of the trunk to both sides (without bending the knees). The distance should decrease by at least 10 cm.

[4], [5], [6]

Examination of joints

Describe the appearance (the presence of a defoguration), determine the pain on palpation and the volume of movements in all peripheral joints. Particular attention should be paid to the joints of the lower limbs, as well as temporomandibular, sternoclavicular, sternocostal joints and articulation of the sternum with its body.

[7], [8], [9]

Enthesies

Palpation is estimated (the presence of local soreness) of the attachment of tendons and ligaments in those areas from which pain is noted. More often reveal entesites in the region of the iliac crest, ischial tubercles, large trochanteres of the femurs, tuberosity of the tibia, the heel area (from below and from behind).

It has long been noted that in many patients laboratory indicators traditionally used to assess the activity of systemic inflammation (ESR, CRP and others) do not change significantly. For this reason, in order to assess the activity of this disease, they focus mainly on clinical indicators: the severity of pain and stiffness in the spine, joints and entesis, the presence of systemic manifestations, the degree of efficacy of NSAIDs administered at the full daily dose, and the rate of progression of functional and radiological changes the spine. To quantify the overall activity of AS, the BASDAI (Bath Ankylosing Spondilitis Disease Activity Index) is widely used. The questionnaire for determining the BASDAI index consists of 6 questions, to which the patient answers independently. To answer each question, a 100 mm visual analogue scale is proposed (the leftmost point corresponds to the absence of this attribute, the right extreme point corresponds to the extreme degree of the sign, and the last issue of the stiffness duration is 2 hours or more).

1. How would you rate the level of general weakness (fatigue) in the last week?
2. How would you rate the level of pain in the neck, back, or hips in the last week?
3. How would you rate the level of pain (or degree of swelling) in the joints (other than the neck, back, or hip joints) in the last week?
4. How would you undo the degree of discomfort that occurs when you touch any painful areas or pressure on them (over the last week)?
5. How would you rate the severity of the morning stiffness that occurs after waking up (over the last week)?
6. How long does the morning stiffness that occurs after waking up (over the last week)?

Using the ruler, measure the length of the marked line segments. First, the average arithmetic value of the answers to the 5th and 6th questions is calculated, then the resulting value is added to the results of the answers to the remaining questions and the average value of the sum of these five values is calculated. The maximum value of the BASDAI index is 100 units. The value of the BASDAI index of 40 or more units indicates a high activity of the disease. The dynamics of this index is considered a sensitive indicator of the effectiveness of treatment.

To quantify the extent of functional disorders in Ac, the BASFI index (Bath Ankylosing Spondilitis Functional Index) is used. The questionnaire for determining this index consists of 10 questions, each of which is attached a 100-millimeter scale. To the left of its extreme point, the answer is "easy", and the extreme right-most point is "impossible". The patient is asked to answer all questions by marking the pen on each scale.

Could you do the following in the last week?

1. wear socks or tights without assistance or devices (ancillary equipment of any object or device that is used to facilitate the performance of any action or movement):
2. bend forward, bending at the waist to lift the handle off the floor without the help of tools;
3. reach out without assistance or devices BEFORE HIGHLY located shelf;
4. stand up from a chair without armrests, without leaning on his hands, without outside help and devices;
5. to rise from the floor from the position of lying on your back without assistance or any other means;
6. stand without support or additional support for 10 minutes without experiencing discomfort;
7. climb up 12-15 steps, without leaning on a railing or cane, pann one foot for each step;
8. Turn your head and look behind your back without turning your torso;
9. engage in physically active activities (for example, physical exercise, sports, gardening):
10. keep active throughout the day (at home or at work).

Using the ruler, measure the length of the marked line segments and calculate the average arithmetic value of the answers to all questions. The maximum value of the BASFI index is 100 units. Functional violations are considered significant if the value of this index exceeds 40 units.

[10], [11], [12]

Bekhterev's laboratory diagnosis

Specific laboratory indicators that are important for the diagnosis of Bechterew's disease there. Although HLA-B27 is found in more than 90% of patients, this antigen is often found in healthy (in the European population in 8-10% of cases), therefore, its definition does not have an independent diagnostic value. In the absence of HLA-B27 ankylosing spondylitis can not be excluded. If HLA-B27 is detected, the probability of the disease increases only when there is some suspicion on the basis of the clinical picture of the presence of this disease (for example, characteristic pains in the spine, family history), but there are still no obvious radiologic signs of sakroileitis.

Laboratory diagnosis of Bechterew's disease allows to determine the indices of activity of the systemic inflammatory process, in particular, the content of CRP in the blood and ESR, are increased less than in patients with a clinically active form of the disease. The degree of increase in laboratory indices of systemic inflammation is usually low and does not correlate well with the clinical indices of disease activity and the effect of therapy, therefore, to assess the course of the disease and the results of treatment, laboratory diagnostic data have only an auxiliary significance.

A certain proportion of patients show an increase in IgA concentration in the blood, which has no significant clinical significance.

[13], [14], [15],

Instrumental diagnosis of Bechterew's disease

Among the instrumental methods, radiography of the sacroiliac joints and spine is of primary importance in the diagnosis and evaluation of AS progression. For early diagnosis of sacroiliitis, x-ray CT and MRI can be prescribed. These methods are also used to determine the state of the spine, if necessary, differential diagnosis, as well as to detail the state of individual anatomical structures of the spine with an already established diagnosis of the disease. In CT, in addition to visualization in the axial plane, it is advisable to obtain reconstructed images in the coronary plane. At MRI it is recommended to use 3 kinds of a signal: Т1, Т2 and Т2 with suppression of a signal from an adipose tissue.

All patients should regularly appoint an ECG. If noises are found in the heart area, echocardiography is indicated.

Early diagnosis of Bechterew's disease

Suspect the presence of the disease is necessary in the following clinical situations (mainly in young people).

• Chronic pain in the lower back of the mouth is inflammatory.
• Persistent monoarthritis or oligoarthritis with predominant lesion of large and middle joints of the lower extremities, especially in combination with zntesites.
• Recurrent anterior uveitis.

The inflammatory nature of chronic pain in the lower back is usually said if they last at least 3 months and have the following symptoms:

• Accompanied by morning stiffness for more than 30 minutes.
• Decrease after exercise and do not weaken at rest.
• Awakening due to pain at night (exclusively in the second half).
• Alternating pain in the buttocks.

In the presence of any two of these signs, the probability of inflammatory lesion of the spine (in patients with chronic pain in the lower part of the tire) is 10.8%, in the presence of three or four signs - 39.4%.

The likelihood of diagnosis of AS in these patients also increases when ankylosing spondyloarthritis is detected during an examination or history of ankylosing spondylitis, such as asymmetric arthritis of large and middle joints of the lower extremities, heel pain, dactylitis (a sucking-like swelling of the finger due to inflammation of the tendons of the toe or hand) anterior uveitis, psoriasis, ulcerative colitis, as well as when receiving information about the presence of AS or other seronegative spondylitis in direct relatives.

Of decisive importance in the diagnosis of Bechterew's disease are the signs of sakroileitis found during the radiography of the sacroiliac joints. The first radiologic changes characteristic of sakroileitis are the loss of continuity (blurring) of the occlusal bone plate in one or more joint regions, individual erosions or areas of expansion of the joint gap (due to osteitis), as well as banded or spotted osteosclerosis (osteitis excess formation in the zones of osteitis) . The combination of these signs is of diagnostic value. Almost always the first violations are noted from the side of the ilium. It should be borne in mind that the width of the sacroiliac joint at radiography is normal (after the ossification of the pelvis is completed) is 3-5 mm, and the width of the occlusal bone plate is not more than 0.6 mm II of the ilium and no more than 0.4 mm in the sacrum.

When detecting sakroileitis it is recommended to determine the presence of the so-called modified New York criteria of ankylosing spondylitis

• Clinical criteria.

Pain and stiffness in the lower back (for at least 3 months), decreasing after exercise, but remaining at rest.

Restrictions of movements in the lumbar spine in both the sagittal and frontal planes (Sagittarius test is used to assess the movements of the sagittal plane, and lateral torso of the trunk in the frontal plane).

Restrictions of respiratory chest excursion in comparison with while naked in healthy individuals (depending on age and sex).

• The x-ray criterium sakroileit [bilateral (II and more stages according to Kellgren's classification) or one-sided (III-IV stage according to the Kellgren classification) |.

If there is an x-ray and at least one clinical criterion, the diagnosis is considered reliable.

It should be borne in mind that these criteria are considered indicative and conducting diagnostics of Bechterew's disease it is necessary to exclude other similar diseases. X-ray stages of sacroiliitis according to Kellgren classification are presented below.

• 0 stage - no change.
• I stage - suspicion of changes (no specific changes).
• II stage - minimal changes (small, local areas of erosion or sclerosis in the absence of narrowing of the slit).
• III stage - unconditional changes: moderate or significant sacroileitis with erosions, sclerosis, enlargement, narrowing or partial ankylosis.
• IV stage - far-reaching changes (complete ankylosis).

X-ray signs of sacroileitis may appear with a "delay" of 1 year or more. In the early stages of ankylosing spondylitis, especially before the full closure of the young growth in the pelvic bones (at the age of 21), it is often difficult to interpret the condition of the sacroiliac joints. These difficulties can be overcome with the help of CT. In the same cases, when there is no x-ray evidence of sakroileitis, and suspicion of the presence of the disease persists, MRI has been shown to diagnose the sacroiliac joints (using T1, T2 regimens and T2-mode with suppression of the adipose tissue signal) edema of various structures of the iliac articulation to the development of visible radiographic changes.

In situations where the clinical picture is dominated by the symptoms of peripheral arthritis, the same signs, classification criteria and diagnostic methods for sakroileitis as described above are used to diagnose Bechterew's disease. It should be borne in mind that in children and adolescents, typical peripheral arthritis may not be accompanied by sakroileitis and spondylitis for many years. In these cases, the definition of HLA-B27 is of additional importance, the detection of which, although it has no unconditional diagnostic value, still indicates a high probability of seronegative spondylitis, including AS. In these cases, the diagnosis is clarified only in the course of subsequent observation of the patient with a regular targeted examination.

In patients with recurrent anterior uveitis, if there is no evidence of ankylosing spondylitis and other seronegative spondyloarthritis in a targeted study, the definition of HLA-B27 is shown. When this antigen is detected, further observation of the patient in a rheumatologist is shown (although isolated HLA-B27-associated uveitis is possible), and the absence of HLA-B27 is considered a sign of the etiology of uveitis.

[16]

Bechterew's Disease: differential diagnosis

In children and adolescents, pain in the spine and movement disorders and it, similar to those in AS, is noted in the case of Sheyerman-Mau (juvenile kyphosis), osteoporosis, and severe juvenile osteochondrosis of the spine. In these diseases, characteristic radiographic changes of the spine are detected, which are confirmed by osteodensitometry in the case of osseoporosis. Carrying out differential diagnostics, it is necessary to consider two circumstances.

1. In childhood, the disease usually begins not with a lesion of the spine, but with peripheral arthritis and / or enthesitis. Spondylitis usually joins only at the age of 16; AC is a rare cause of isolated pain in the spine in children.
2. In patients with a valid disease, x-ray changes in the spine, typical of the Scheierman-Mau disease (anterior wedge deformation, Schmorl's hernia), which can be an additional cause of pain and movement restrictions, are often detected.

Differential diagnosis of Bechterew's disease is performed with an infectious spondylodiscitis. Radiographic manifestations of spondylodisitis of infectious and non-infectious (for example, in AS) genesis in early stages can be similar: the rapid development of destruction of the adjacent vertebral bodies and a decrease in the height of the intervertebral disc located between them. The main differential diagnostic value is the tomographic study (mainly MRI), with the help of which it is possible to detect the spine infections characteristic of the spine infections in the formation of the near-vertebral soft tissues. Measures are also important to identify the entrance "gate" of tuberculosis or other bacterial infections. Among the chronic infections that occur with the defeat of the musculoskeletal system, it should be noted brucellosis. This disease develops spondylitis, as well as arthritis of large peripheral joints and often sacroiliitis (usually one-sided), which can be the cause of an erroneous diagnosis of Bechterew's disease. In most cases, brucellosis spondylitis and arthritis are caused by hematogenous infection with the appearance of spondylodisitis. High cytosis and neutrophilia in the cerebrospinal fluid are noted. Typically, an increase in body temperature. The diagnosis is made on the basis of laboratory tests (serological reactions).

Individual clinical and radiological manifestations of the spine, similar to those of AS, are possible with Forestia (idiopathic diffuse hyperostosis of the skeleton), acromegaly, axial osteomalacia, fluorosis, congenital or acquired kyphoscoliosis, pyrophosphate arthropathy, ochronosis. In all these cases, the criteria of AS are not noted, and X-ray changes, as a rule, only resemble changes that occur in AC, but are not identical to them.

An x-ray picture of sakroileitis is found in various diseases, including rheumatic diseases, such as RA (usually in the late stages of the disease), gout, SLE, BB, sarcoidosis and other diseases, as well as in the case of inspection of these joints. X-ray changes resembling sakroileitis are possible with osteoarthrosis of the sacroiliac joints, pyrophosphate arthropathy, condensing ileitis, Paget's bone disease, hyperparathyroidism, osteomalacia, renal osteodystrophy, polyvinylchloride and fluoride intoxication. With paraplegia of any genesis, ankylosing of the sacroiliac joints develops.

Bechterev's disease diagnosis allows attributing this disease to the seronegative spondyloarthritis group, which also includes reactive arthritis, psoriatic arthritis, spondyloarthritis in ulcerative colitis, and undifferentiated spondylitis. All these diseases are characterized by common clinical and radiological manifestations. Unlike other seronegative spondyloarthritis, AS is characterized by persistent and progressive inflammation of the spine, which prevails over other symptoms of ankylosing spondylitis. However, any other seronegative spondylitis can sometimes occur in this way, and in such cases ankylosing spondylitis is commonly considered to be one of the manifestations of these diseases.

[17], [18], [19]