Delayed Diagnosis of Ankylosing Spondylitis: A Missed Opportunity?

Abstract

Ankylosing spondylitis is an inflammatory condition involving the axial spine, often associated with the human leukocyte antigen (HLA)-B27 genotype and supporting radiographic imaging findings. Patients develop symptomatic low back and/or hip pain beginning in late adolescence or early adulthood. Diagnosis of ankylosing spondylitis is based primarily on clinical presentation and imaging studies. In this article, we are presenting a case of a 40-year-old male patient who presented to the office with chief concerns of chronic mid-thoracic back pain and restricted range of motion of his neck. The imaging study obtained was suggestive of fusion of the sacroiliac joints. This article also highlights the presence of elevated inflammatory markers in the setting of the patients chronic symptomatic complaints which could have guided in early diagnosis.

Keywords: ankylosing spondylitis; chronic low back pain; inflammatory arthritis; inflammatory markers; iritis; spondyloarthropathy; stiffness.

Figure 1. X-ray Image of the sacroiliac spine

Findings: There appears to be a fusion of the sacroiliac (SI) joints (yellow circles). There is a marked narrowing of the left hip joint (red circle). There is a hip resurfacing prosthesis on the right. Impression: There is a fusion of the SI joints. Prominent degenerative change and narrowing of the left hip joint. Resurfacing prosthesis on the right hip.

Figure 2. X-ray of the lumbar spine

Findings: The heights of the lumbar vertebral bodies are normal. There are degenerative facet changes at lumbar spinal (L) levels 4 and 5 (L4-5). Mild narrowing of lumbar spine level 5 and sacral disc 1 space (L5-S1) (image C, orange circle). There is some anterior spurring of L4-L5 (image B, blue arrow) and at L1-L2. Remaining lumbar disks are well preserved. Impression: Degenerative changes as described above. Findings are most marked in the facets at L4 and L5. There is no evidence of vertebral fracture.

Figure 3. X-ray of the cervical spine

Findings: The heights of the cervical vertebral bodies are normal. There is the mild narrowing of the cervical C2-C3 disc space. There is a mild anterior spurring at the cervical C3-C4 disc levels. There does not appear to be significant narrowing. Remaining cervical disc spaces are fairly well-preserved. There are mild degenerative facet changes in the mid and upper cervical spine. The odontoid appears intact. Impression: Mild degenerative disc changes. Degenerative facet changes. There is no evidence of cervical spine fracture.