Ankylosing Spondylitis

Ankylosing Spondylitis is a type of arthritis which causes recurring inflammation of the spinal bones and other joints such as sacroiliac joints. It is a chronic disorder which is also known as Marie-Strümpell disease or Bechterew’s syndrome. The symptoms of this condition include pain and stiffness from the neck down to the lower back. Chronic inflammation of these leads to ankylosis (new bone formation in the spine) and spinal bones fuse together completely, resulting in a condition known as “bamboo spine”, in which the spinal column becomes completely rigid. The changes can vary from mild to severe and may cause significant deformities. For doctors, it is already not clear enough what causes Ankylosing Spondylitis.

Ankylosing Spondylitis is a systemic disease, which means that the symptoms of this condition are not just limited to the joints, It can also affect other areas of the body, such as the shoulders, ribs, pelvic bones, heels, and small joints of the upper and lower extremities. It can also affect eyes and cause inflammation (redness and pain) of the eyes, and rarely, heart and lung problems may also develop. People with the condition can also suffer from fever, fatigue, and loss of appetite.

What Causes Ankylosing Spondylitis?

There is no known reason as to what causes Ankylosing Spondylitis, but there is a lot of information available about what effects it has on the body, and why it causes the vertebrae to become stiff and rigid.

People who have the particular HLA-B27 gene have a significantly greater risk of developing AS, but there are many people who have this gene that never develops AS. Infectious agents may be involved in the development of the disease.

Ankylosing Spondylitis: Classification

There are four different types of Ankylosing Spondylitis:

• Slowly progressive
• Slowly progressive with periods of exacerbations
• Quick progressive
• Septic
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Ankylosing Spondylitis: Prevalence and Risk Factors

Ankylosing Spondylitis is more prevalent in Northern European countries and Afro-Caribbean populations. The overall prevalence of this disease is < 0.3% of the general population. Ankylosing Spondylitis is diagnosed twice as often in males as in females, but many doctors believe the number of females with the disease is underestimated because females tend to have milder symptoms. Typically, signs and symptoms of Ankylosing Spondylitis usually first appear between the ages of 15 and 25.

Ankylosing Spondylitis affects the 0.1%- 0.5% of the population. This condition usually begins in early adulthood. It can also affect children and this is known as Juvenile Ankylosing Spondylitis. It is most likely to affect males more often than females. In women, it affects the joints away from the spine. This condition is more common in some Native American tribes. Currently, there is no treatment for Ankylosing Spondylitis, but early diagnosis and treatment of this condition help control pain and stiffness and also help to prevent or reduce significant deformity.

The exact causes of AS are unknown. This condition may develop due to the combination of genetic and environmental factors. Following are the few risk factors:

1. Sex:  Men are more likely to develop Ankylosing Spondylitis than women.
2. Age: Ankylosing Spondylitis usually begins in early adulthood. It can also affect children.
3. Heredity: Genetics plays an important role in disease. Most of the people who suffer from Ankylosing Spondylitis have a specific type of gene that produces genetic marker known as known as the HLA-B27. However, there are also many people who never develop AS despite having HLA-B27 gene.
4. Frequent gastrointestinal infections: Ankylosing Spondylitis is also associated with inflammatory bowel diseases.

Ankylosing Spondylitis: Pathological Changes and Complications

Ankylosing Spondylitis causes changes to occur in your body because of the inflammation it causes in the areas where skeletal bones are attached to tendons, ligaments, discs or joints. It typically affects the sacroiliac joints, where the lower back meets the pelvis, and begins with inflammation in this area (sacroiliitis).

In the spinal column, AS starts in the fibrous tissues of the discs between the vertebrae. Ankylosing Spondylitis causes inflammation that leads to the breakdown of the tissues and, over time, makes them thickened and rigid. This leads to stiffness of the spine, and pain due to compression of the nerve roots.

Eventually, the prolonged and recurrent inflammation of Ankylosing Spondylitis can result in a complete fusion, or cementing the bones of the spine together (vertebrae). This fusion is called Ankylosis. When the spine is fused, it loses its mobility.

Because it is a systemic inflammatory disease, Ankylosing Spondylitis can affect other areas of the body away from the spine, such as the kidneys, heart, lungs, and eyes.

Ankylosing Spondylitis complications varies greatly in everyone. Painful and debilitating as it is as it progresses. If the inflammation is left unchecked can contribute to other complications such as the following:

• Hunched posture – a curled forward, chin to chin stance can occur if the spine fuses together in a hunched forward thereby reducing spinal flexibility. Heart, Lungs and other surrounding organs may be affected.
• Uveitis –is a common and frequent complication of ankylosing spondylitis, uveitis can cause rapid-onset eye pain, photophobia, and blurred vision.
• Osteoporosis/ Osteopenia  – bones may lose mineral density resulting in brittleness and more prone to fracture.
• Caudaequina syndrome – this rare condition involves extreme pressure and swelling of the nerves at the end of the spinal cord. The condition can cause weakness, tingling, or numbness in the legs, and/or feet on one or both sides of the body. It also causes bowel bladder dysfunction. This condition is considered a medical emergency.
• Spondylodisctis – is when one or more intervertebral disc or disc spaces become infected by bacteria such as Staphylococcus aureus (common), Streptococcus viridans, Mycobacterium and Brucella.  About 8% of persons with ankylosing spondylitis have this condition.

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Symptoms and Diagnostic Procedures

Ankylosing Spondylitis Symptoms

Pain and stiffness, especially in the lower back and hips, are two common ankylosing spondylitis symptoms. These symptoms may be worse in the morning upon rising and after periods of prolonged inactivity. The symptoms may worsen over time, or they may gradually improve. In some cases, the pain and stiffness of ankylosing spondylitis stop completely.

Ankylosing spondylitis is a disease that affects the bones and joints of the skeleton. The most common areas to be affected are:

• The joint that connects your pelvis and the base of your spine
• The vertebrae located in your lower back
• The places where tendons and ligaments are attached to bones. Ankylosing spondylitis mainly affects the spine, but it also affects the tissues in the back of the heel.
• AS also affects the tissues (cartilage) between the ribs and the sternum (breastbone).
• The shoulder joints and hip joints may also be affected by ankylosing spondylitis

Diagnostic Procedures

There is no single specific test to confirm a diagnosis of ankylosing spondylitis. Your physician will most likely complete a thorough physical examination to rule out other causes for your Ankylosing Spondylitis symptoms. The major diagnostic tools used when AS is suspected are magnetic resonance imaging (MRI), X-rays of the spine, which will reveal specific changes in the spine, and blood tests to check for inflammation and for the presence of the characteristic genetic marker of ankylosing spondylitis.

X-Rays

An x-ray can reveal changes in the joints caused by AS, but many times these changes are not visible on a plain x-ray until ankylosing spondylitis has been progressing for 8-10 years.

Magnetic resonance imaging tests may lead to an earlier diagnosis, but the reliability of MRIs in diagnosing AS has not been firmly established.

Blood parameters

During an acute flare-up of the disease, some AS patients will have an increase of certain blood components (CRP and ESR). In patients who have an extreme amount of inflammation with ankylosing spondylitis, these levels do not increase. These blood tests alone are not an accurate diagnostic tool.

Genetic testing

People with the HLA-B27 gene are at greater risk of developing AS than the general population. A blood test for this genetic marker can help in the diagnosis of ankylosing spondylitis, but alone, it is not a diagnosis, as not everyone with this marker develops AS.

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Ankylosing Spondylitis: Treatment and Medications

Ankylosing Spondylitis Diagnosis and Treatment

The treatment for ankylosing spondylitis is most beneficial when it is started early; before the inflammation has caused joint damage that cannot be reversed.  That is why it is critically important to have ankylosing spondylitis diagnosis in time. The goals of treatment are aimed at:

• Relieving the stiffness and controlling pain
• Preventing or delaying complications caused by ankylosing spondylitis
• Preventing or delaying spinal deformities

Medications

The medications most commonly used to treat ankylosing spondylitis are nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen, ibuprofen, and aspirin. These medications help to reduce swelling and inflammation as well as help to the relieve the pain of ankylosing spondylitis. One of the side effects is gastrointestinal bleeding, so they must be taken with food.

If NSAIDs are not effective in controlling the pain and inflammation of AS, your doctor may prescribe tumor necrosis factor (TNF) blocker medications for ankylosing spondylitis. These drugs are sometimes used to treat rheumatoid arthritis. They work by reducing your body’s inflammatory response, therefore stiffness, pain, and swelling also decreased. TNFs are given by an injection under the skin, or into a vein (intravenously). Examples of these drugs your doctor may prescribe for ankylosing spondylitis include:

• Adalimumab (Humira)
• Etanercept (Enbrel)
• Golimumab (Simponi)
• Infliximab (Remicade)

People who are at risk for developing tuberculosis, have latent TB or who have decreased immunity should not take TNFs for ankylosing spondylitis because these drugs interfere with the body’s natural ability to fight infection.

Therapy

Physical therapy can provide many strategies for dealing with ankylosing spondylitis. Some of the benefits include:

• Posturing education: to help reduce pain and prevent complications
• Stretching exercises and Range of motion exercises: to help maintain joint flexibility and mobility
• Aerobic exercise: to increase or maintain endurance
• Pain management techniques
• Proper sleep positioning: Adequate rest is essential when coping with ankylosing spondylitis
• Use of adaptive equipment or assistive devices
• Safety instruction and energy conservation techniques to help deal with ankylosing spondylitis

Surgery

Most people with AS won’t need surgery. However, joint replacement surgery may be recommended to improve pain and movement in the affected joint if the joint has become severely damaged. For example, if the hip joints are affected, a hip replacement may be carried out. In rare cases, corrective surgery may be needed if the spine becomes badly bent.

Laser spine surgery is currently being considered as a good treatment for people with ankylosing spondylitis. It is often used alongside minimal invasive techniques making it more efficient and effective.

Patients with ankylosing spondylitis should be aware of their options and the risk involved in considering surgery.

Surgery is not recommended for most people with ankylosing spondylitis, but if your hip or other joints are severely damaged, your physician may recommend surgery. Surgery is also sometimes recommended for people who have severe pain caused by ankylosing spondylitis.