Ankylosing Spondylitis is a type of negative spondyloarthritis. It is a chronic inflammatory Arthritis affecting most commonly sacral, iliac joints, and spine. It is distinctive from rheumatoid arthritis as it causes asymmetrical inflammatory joint disease and lower Limbs are most commonly involved than upper limbs.
It is a type of oligoarthritis that is the disease that causes damage to more than 4 joints at a time. It has no Association with Rheumatoid factor and causes inflammation in the areas where tendons and ligaments attached to the bone. Ankylosing Spondylitis symptoms of axial skeleton involvement are hazardous and cause chronic back pain.
Ankylosing Spondylitis Causes
- Age: it usually starts at the age of 22 to 30 years of age and Ankylosing Spondylitis is very rare after the age of 40
- Gender: males and females both are affected by the disease but it is three to four times more common in males as compared to females
- Genetic factors: genetic factors play an important role in causing Ankylosing Spondylitis. 90% of patients are positive for HLA-B27
- Environmental factors: environmental factors like cigarette smoking and infections are associated with causing the disease
- Inflammation triggering factors: various inflammatory markers like cytokines and chemokines Trigger the initial reaction and cause the manifestations of the disease.
Ankylosing Spondylitis Symptoms
- Lower back pain: the person suffering from Ankylosing Spondylitis complaints of lower back pain which is chronic in nature the patient is usually 20 to 30 years of age. The pain occurs more at night and the patient wakes from sleep due to severe disease.
- Morning stiffness: there is morning stiffness of fewer than 30 minutes. This is different from morning stiffness of rheumatoid arthritis which has morning stiffness of more than 1 hour and improves with activity over the day.
- Peripheral arthritis: peripheral Arthritis is present in 40% of patients with Ankylosing Spondylitis. It is usually asymmetrical and affects large joints. The Lower Limb is involved more as compared to upper limb
- Enthesitis: enthesitis means inflammation at the sites where tendons and ligaments insert to the bone and are usually seen at the elbow, Achilles tendon and fascia of the foot
- Pain improvement: the pain of ankylosing Spondylitis does not improve with rest where as it improves with exercise and hot bath
- Axial skeleton involvement: flattening of normal lumbar curvature the chest expansion is decreased as it involves axial skeleton
Extra Articular Features of Ankylosing Spondylitis:
- Eye diseases: a patient suffering from ankylosing Spondylitis suffer severe eye symptoms, anterior uveitis is the most common extra-articular feature which occurs in 25% of people. Conjunctivitis which is inflammation of conjunctiva also occurs which causes irritation of eyes and blurring of vision
- Heart involvement: heart involvement occurs in later stages of the disease and results in carditis, myocardial infarction, atrioventricular heart block, pericarditis and valvular heart diseases like aortic regurgitation and mitral Incompetence
- Lungs involvement: Lung involvement is common and disease commonly affects the upper lobe of the lung causing atypical pulmonary Fibrosis and pleural effusion leading to respiratory distress and obstructive respiratory diseases.
- Central nervous system involvement neurogenic complications like spinal cord fractures due to bone weakness and cauda equina syndrome
- Genital involvement: genital involvement in males is 3 times more as compared to females. There is inflammation of prostate gland in 80% of males the prostatitis is usually asymptomatic and patients exhibit no symptoms for genital diseases.
Tests for Ankylosing Spondylitis
- Ankylosing Spondylitis typically evolves slowly with fluctuating symptoms of inflammation and fibrosis. Bone erosions and ankylosis develops in patients over a period of many years. It may also cause osteoporosis of bones and vertebra leading to increased risk of bone fractures and vertebral collapse. The initial signs and symptoms of ankylosis are painful, tender joints, reduced mobility, lower back pain, and pain in buttocks. Pain occurs after waking up in the morning. The following tests for ankylosing spondylitis are required for proper diagnosis of the disease so treatment can begin.
- X-RAY of sacroiliac joints: As the disease causes bone erosions, the osteoclasts which are the bone-forming cells lay down new bone. Small Bony projections called osteophytes are formed which bridge the gap between normal bones and as a result the fusion of joints occurs which causes stiff and inflexible joints and causes the patient to maintain an erect posture. X-ray of sacroiliac joint shows irregular margins, widening of joint spaces, and subsequent joint space narrowing and fusion.
- X-ray of the spine inside view: side view or lateral spinal x-ray show anterior ‘squaring’ of vertebra due to division of anterior corners of the bone. Bridging bones which are also called bridging syndesmophytes may be seen. These are areas of calcification and fibrosis. In advanced diseases, the longitudinal ligaments of bone may fuse which may also be visible on X-Ray. The characteristic feature of ‘bamboo spine’ is seen
- MRI spine: is very sensitive for the detection of inflammatory changes in lumbar area osteoporosis is common and dislocation can arise which is the late feature but can be seen in MRI. MRI spine is very crucial for disease diagnosis and is considered best test for ankylosing spondylitis. When the changes on X-Ray is insignificant and are not able to reach the diagnosis. The changes in MRI become significant and is used before the disease becomes Apparent and the clinical symptoms of the disease are affecting the patient.
- DEXA scan: it is important as a part of the fracture assessment of bone. As the bone density is decreased in ankylosing Spondylitis. It is very important to assess bone density as the patient is prone to recurrent fractures which heals slowly as a result of a decrease in bone density. It may result in osteoporosis, which will destroy the bone. And DEXA scan is important to test the symptoms for ankylosing spondylitis of osteoporosis to prevent frequent bone fractures.
- Erythrocyte Sedimentation rate: buy Erythrocyte sedimentation rate, we mean that staggering of RBC is over one another. It is increased in Ankylosing Spondylitis as the charge of RBC is for each other is increased. Elevated levels of ESR confirms the disease.
- C reactive protein level: C reactive protein level is the marker of inflammation as Ankylosing Spondylitis is an inflammatory condition and the joint surfaces are inflamed, the level of C reactive protein is elevated. Initially, C – reactive protein is not used to test Ankylosing Spondylitis but as soon as the inflammatory process progress, we can check the level of C reactive protein to diagnose the disease.
- Autoantibody level: autoantibodies such as Rheumatoid factor (RF), ANA, ACPA are negative. These autoantibodies are increased in Rheumatoid arthritis and osteoarthritis, but they are not specific for diagnosing ankylosing spondylitis as their level is not increasing in this disease.
- HLA-B27 Levels: HLA-B27 is increased in patients who have a genetic tendency to develop this disease. One or more family members of the person will be affected in ankylosing Spondylitis. There is 1 and 10 chances of siblings being affected if they are HLA-B27 positive. It is not a confirmatory test for ankylosing spondylitis through cases that may be positive for it and they remain asymptomatic for the year.
- The exact cause of ankylosing Spondylitis development is not known. Most cases of Ankylosing Spondylitis idiopathic however b27 positive individuals are more prone to develop Ankylosing Spondylitis. But only a few of the people who have defect acquired disease most people do not acquire the signs and symptoms and test for ankylosing spondylitis become difficult.
What Complications Can Develop If Test For Ankylosing Spondylitis Is Not Done On Time?
- Uveitis (inflammation of the eye): the most common extra-articular complication is uveitis which causes inflammation of the eye and as a result blurring of vision occurs.
- Bone fractures: bone becomes weak as result osteoporosis occurs which causes the bone and vertebral fractures.
- Heart problems: cardiovascular diseases commonly involve the aortic valve in 20% of patients. In some patients, myocardial infarction and heart blocks may also occur.
- Lung problems: Ankylosing Spondylitis causes fibrosis in the upper zones of the lung. The fibrosis process is atypical in nature. This pulmonary Fibrosis is a very rare complication of the disease.
- Genital problems: genital problems occur most commonly in males. there is inflammation of prostate gland which is called prostatitis
- GIT complications: the patient may suffer alternate attacks of constipation and diarrhea which is called inflammatory bowel disease in up to 50% of patients.
How to Diagnose Ankylosing Spondylitis?
Your doctor will take your brief history and ask you simple questions like
- when did the disease starts?
- which joints were involved first?
- was at monoarticular or polyarticular?
- what is the duration of the disease?
- is a disease limiting your mobility?
- are there any extra-articular features?
after asking the brief history he will perform your general physical examination and later will examine your joints and may perform active or passive movements on the joints to assess the joint conditions and complications associated. The following investigations may be required
- Complete blood count: CBC
- ing inflammatory disease of the spine.
Ankylosing Spondylitis Treatment
- Nonsteroidal anti-inflammatory drugs: NSAIDs are the best initial drugs for the treatment of ankylosing Spondylitis as it relieves pain and inflammation.
- Anti-tumor necrosis factor: it is the best next therapy after NSAIDs. it is used in severe active inflammation and it causes Rapid decrease in symptoms of spinal and peripheral joints.
- Disease-modifying antirheumatic drugs: DMARDs like methotrexate, Hydroxychloroquine, and sulfasalazine can reduce peripheral Arthritis, uveitis, and extra-articular manifestations of Ankylosing Spondylitis. It has no effect on spinal disease hence not used for disease of the spinal cord.
- Biological agents: biological agents like anakinra, tocilizumab, rituximab reduce symptoms of the disease.
Conservative Management of Disease
- Exercise is the cornerstone of Management. Daily back extension exercises are taught to patients. Swimming is an ideal exercise
- Physiotherapy helps to relieve symptoms
- Avoiding poor posture
- Physical activity
- Maintaining ideal weight and BMI of less than 25
When to Seek Medical Help?
When the disease is causing severe Ankylosing Spondylitis symptoms like immobility with chronic back pain and morning stiffness of more than 1 hour you should seek medical help. your doctor after discussing with you the disease nature will tell you about treatment options and help you to get rid of the disease.