A 40-year-old male presented with inflammatory low back pain from the past 24 years. The pain was mild and intermittent, which improved after taking non-steroidal anti-inflammatory drugs (NSAIDs). From the past 10 years, he experienced increased pain and stiffness in the neck with progressive restriction in neck movement. In addition, two episodes of unilateral acute anterior uveitis were documented last year, which were resolved after topical treatment. He had to take daily NSAID for his symptoms. On examination, Patrick test elicited posterior pain localized to bilateral sacroiliac joints, restricted flexion in his lumbar spine and reduced chest expansion (3 cm, normal ≥5 cm). The range of motion was restricted in both hips and the cervical spine. Acute phase reactants were raised (erythrocyte sedimentation rate 56 mm/hour (0–20) and C-reactive protein 26 mg/L (0–10)). Human leucocyte antigen B 27 was positive by a polymerase chain reaction. Radiography of the pelvis (anteroposterior (AP) view) showed bilateral sacroiliitis (Grade 4), reduced hip joint space, dagger sign, new bone formation near acetabular margins and diffuse syndesmophytic ankylosis leading to bamboo spine appearance (Fig. 1). A diagnosis of ankylosing spondylitis (AS) with active disease (Bath AS Disease Activity Index (BASDAI) 4.2) was made. He was managed with regular physiotherapy, naproxen and sulfasalazine. At 3 months of follow up, a significant improvement in pain, stiffness and physical activity (BASDAI 2.7) was noticed.
Figure 1
Radiography of pelvis (AP view) showing dagger sign (a), bilateral Grade 4 sacroiliitis (b), bamboo spine (c), reduced joint space bilaterally (d) and new bone formation near acetabular margins (e), which are characteristic radiographic features of AS.
Dagger sign in radiograph of spine is classically observed in advanced cases of AS. It is primarily due to ossification of supraspinous and interspinous ligaments. This causes a central dense line on AP radiograph of spine and pelvis. Otherradiographic features of AS are bilateral symmetrical sacroiliitis (first and characteristic manifestation), focal sclerosis of vertebrae (shiny corner sign), erosion especially at anterior corner of vertebral end plate (Romanus sign), spondylodiscitis (Anderson lesions), trolley track sign, squaring of vertebrae and syndesmophyte formation with gradual progression into ankylosis leading to bamboo spine appearance. The extent of radiographic progression depends upon the severity of radiographic damage
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