Ankylosing Spondylitis

Ankylosing Spondylitis is a variant of arthritis that affects the spinal column, pelvis and eyes. It’s symptoms include pain and stiffness from the neck down to the lower back up to the coccyx (tail bone). The spinal bones (vertebrae) may fuse together, resulting in a rigid inflexible spine. These changes could be mild or severe, and may lead to a bent stooped-over hunching posture gradually over time. Early diagnosis and supervised management helps control pain and stiffness and may decrease or prevent further revealing deformity.

Incidence of Ankylosing Spondylitis

Ankylosing spondylitis affects men more than women in about 0.1% to 0.6% of the adult population. Although it can occur at any age, spondylitis most often affects men in their adolescence and 20s. It is less common and has lesser symptoms in women.

Symptoms of Ankylosing Spondylitis

The most common and early symptoms include:

• Chronic pain and stiffness in the lower back, buttocks and hip areas that continue for more than two or more months esp. in the mornings. Spondylitis often starts around the sacro-iliac joints, where the sacrum joins the ilium bone of the pelvis. This extends to the upper spine, tendon and ligament attachments.
• Bony fusion. It can cause an ‘fusion’ of the bones, which may lead to abnormal joining of bones when attempted healing occurs with calcification of vertebral ligaments. Fusion affecting bones of the neck, back, or hips  areas may restrict a person’s ability to perform Activities of Daily Living (ADL). Fusion of the ribs to the spine and/or breastbone may limit chest expansion and affect breathing.
• Pain in ligaments and tendons. Spondylitis also may affect some of the ligaments and tendons. Achilles Tendonitis (inflamed tendon) may cause stiffness in the heel area. Other ligaments get involved gradually.
• Compression Fractures. Weak crumbling vertebral bones increases hunching of back.
• Late complications include Eye pain, photophobia and blurring (Uveitis). Heart dysfunction when aorta is involved in the inflammation.
• Fever fatigue and appetite loss could be associated.

Causes

The specific cause of ankylosing spondylitis is unknown, a strong genetic  factor or family link may be involved. Some people with spondylitis carry a gene called HLA-B27 and people carrying this gene are more likelier to develop spondylitis. Up to 10% of people with HLA-B27  have no signs and symptoms.

Test and Diagnosis

• Physical Examination: Range of spine flexibility (Serial checks)
• Measurements of the chest expansion (Serial checks)
• X-Rays of the back and pelvis (Oblique views of sacro-iliac joints)
• Lab tests to check the level of inflammation CRP and ESR with routine blood counts
• To rule out other arthritis in early stages including RA test and Anti CCP test
• Blood test for HLA-B27

Treatment and Medication

Ankylosing spondylitis is incurable, but there are treatments that can reduce alleviate pain and improve function being the goals of treatment. Recommended to maintain a good posture, prevent deformity, and preserve the ability to perform normal activities of daily living (ADL). A team approach to treat spondylitis is recommended including the patient, doctor, physical therapist, and occupational therapist. In patients with severe fixed deformities, osteotomy and fusion may be required.

A program of daily exercises helps reduce stiffness, strengthen the muscles around the joints and prevent or minimize the risk of disability and deformity.

Deep breathing exercises may help keep the rib cage flexible.

Swimming is highly recommended.

Certain drugs help provide relief from pain and stiffness, and allow patients to perform their exercises with minimal discomfort. In moderate to severe cases, other drugs may be added to the treatment regimen.

Level 2: DMA (Disease Modifying Agents) such as methotrexate can be used when routine drugs alone are not enough to reduce the pain, stiffness and inflammation. These drugs have more toxicity and serial blood checks are required along this line of treatment.

New Drugs called biologics : Certolizumab pegol (Cimzia), (Humira) Adalimumab, Etanercept (Enbrel), golimumab (Simponi), and Infliximab (Remicade) — have been FDA-approved. Steroid injections into the joint  may be helpful in some cases. Antidepressant can be prescribed.

Above listed TNF blockers can reactivate latent TB (tuberculosis) and neurological conditions.

Artificial joint replacement surgery may be a treatment option in some patients with advanced joint stiffness affecting knees and hips.

Management of each patient is tailor-made