Ankylosing spondylitis affects the small bones of the spine, leading to their fusion and resulting in hunched-forward posture. This article discusses the causes, clinical features, diagnosis, and management of ankylosing spondylitis in detail.
Ankylosing spondylitis is a chronic inflammatory autoimmune disorder of the spine characterized by pain and stiffness with a variable course. It mainly affects the joints of the spine and sacroiliac joint in the pelvis. As the severity increases, the joints start to fuse with each other resulting in a rigid spine.
It is thought to be genetic. The disease is more common with HLA-B27 in their first relatives, such as their father or mother. HLA-B27 is also present in individuals without ankylosing spondylitis development. Therefore, it is thought that there must be some other associated triggering factor responsible for the disease. It is often associated with genitourinary or gastrointestinal infections.
Antigen-antibody reaction triggers the inflammatory process. Inflammation takes place at bone-ligament and bone-tendon junctions. Synovitis of synovial joints of the body, such as sacroiliac joint, hip joint, facet joint, etc., also occurs. The joint becomes swollen, and the movements of joints are limited. Destruction of articular cartilage occurs over time, followed by subchondral bone formation.
The costovertebral joints are frequently involved with the limitation of chest expansion. Inflammation of bone-ligament junctions affects the sacroiliac ligaments, intervertebral joints, symphysis pubis, and manubrium sterni. The inflammatory reaction is characterized by cellular infiltration, granulation tissue formation, and erosion of the adjacent bones. Granulation tissue is replaced by fibrous tissue, which gets ossified over time, leading to ankylosis of the joint.
The ossification of the longitudinal ligament results in syndesmophytes between two adjacent vertebral body bridges that limit the movement, and as a result, the spine becomes stiff like bamboo. And so we call it the bamboo spine.
Insidious onset of intermittent low back pain and morning stiffness occurs. In the beginning, there will not be any pain at rest. The pain will be present only with movements and activities. Pain radiates down the buttock. Gradually, when the disease progresses, one may experience continuous pain at rest or on movement, and the stiffness will get increased.
Involvement of the synovial joints is characterized by swelling, pain, and limitation of movements. Inflammation of bone-ligament or bone-tendon joint (enthesopathy) is characterized by localized pain, tenderness, and swelling.
It usually involves the insertion of the tendon Achilles at the ankle joint. In about 10% of cases, the disease starts from the peripheral joints, usually the hip joint.
Asymmetrical polyarthritis may develop. As the disease progresses, it involves the lumbar spine, the lordosis (concavity of lumbar spine) gets obliterated, and then kyphosis (convexity of the spine) may develop.
It may be associated with head forward posture and hip joint flexion deformity. The joint movement limitations further may give rise to disability.
Chest expansion will be limited with the involvement of costovertebral joints.
Peripheral joints such as shoulder, hip, and knee may be involved with effusion, loss of mobility, and movements. Pain and tenderness are also present.
Progressive spinal deformity gives rise to typical kyphotic posture and subluxation of the atlanto occipital or atlantoaxial joint.
Apart from the fusing of the bones, ankylosing spondylitis leads to eye inflammation, compression fractures, heart problems, inability to breathe deeply, etc.
Extra Musculoskeletal Manifestations:
Ocular inflammation in above one-third of the patients.
Aortic valve disease.
X-ray - The cardinal sign in the early stage is the erosion of the sacroiliac joint, and later periarticular sclerosis usually develops on the iliac side of the joint. Sclerosis will be present in the x-ray.
ESR - Erythrocyte sedimentation rate increases during the active stage.
Presence of HLA-B27 in 90% of cases.
1. In the absence of a specific cause, the disease is managed by anti-inflammatory and analgesics. Nonsteroidal anti-inflammatory drugs (NSAIDs) like Naproxen and Indomethacin are the medicines most commonly given by doctors to treat ankylosing spondylitis. It helps to relieve the pain, inflammation, and stiffness. But these medications may cause gastrointestinal bleeding. When these medicines are not helpful, the doctor will suggest a biologic medication, like an interleukin-17 (IL-17) inhibitor or a tumor necrosis factor (TNF) blocker.
Tumor necrosis factor blockers will target a cell protein that causes inflammation. Interleukin-17 acts as the body's defense against infection and inflammation. Tumor necrosis factor blockers help reduce stiffness, pain, tenderness, and swollen joints. These blockers are administered by injecting the medicine under the skin, or an intravenous (IV) line is preferred. The tumor necrosis factor blockers approved by the FDA (Food and Drug Administration) to treat ankylosing spondylitis are,
Interleukin-17 inhibitors approved by the FDA (Food and Drug Administration) to treat ankylosing spondylitis are,
The tumor necrosis factor blockers and interleukin-17 inhibitors can reactivate untreated tuberculosis and improve the infection. When you are not supposed to take tumor necrosis factor blockers or interleukins-17 inhibitors because of some other health conditions, the doctor recommends the Janus kinase inhibitor Tofacitinib. This is an approved drug for psoriatic arthritis and rheumatoid arthritis, and research is still going on for ankylosing spondylitis.
2. Physiotherapy is very important in maintaining joint’s range of motion, prevention of deformity, and prevention of muscle wasting.
3. Radiotherapy can also be done to improve the patient's well-being and functional activities.
4. There is a variable mode of onset and course of the disease. The patient must be educated properly regarding the onset, course of the disease, and prognosis.
5. Surgery - Most people with ankylosing spondylitis do not require surgery. But, the doctor might recommend surgery when there is joint damage or severe pain or if the hip joint is damaged and it needs to be replaced.
6. Postural awareness plays a very important role in preventing disability. Typically, there is a gradual onset followed by remission and then relapse. In some cases, the disease runs a chronic course without remission or relapse.
7. Stay healthy and fit with regular exercise and say goodbye to drugs.
Ankylosing spondylitis is an inflammatory joint disease of the spine and rarely other joints in the body. The definite cause of ankylosing spondylitis is unknown. It is an inherited autoimmune disorder, where the genes are likely transferred from the parents to children. The primary gene associated with the risk for ankylosing spondylitis is the HLA-B27.
A patient with ankylosing spondylitis usually will feel pain or stiffness in the lower back region. The symptoms will be typically more hurtful in the morning or after the periods of inactivity. The back pain usually begins in the sacroiliac joint and is transferred to the lower spine region. Ultimately, the disorder will affect the entire spine.
Foods to avoid in ankylosing spondylitis are:
- Highly processed foods.
- High in sugar and fat.
- High sodium content.
- Dairy products.
- Preserved or canned foods.
- Saturated fats.
- Trans fats (hydrogenated oils).
Ankylosing Spondylitis (AS) will affects the axial skeleton (bones of the head and trunk), including the ligaments and joints and other joints and organs in the body, such as the eyes, kidneys, heart, lungs, shoulders, knees, hips, and ankles.
Ankylosing spondylitis of the neck is also known as cervical ankylosing spondylitis. It is a potentially severe autoimmune disease that affects the spinal joints. Ankylosing spondylitis initially will cause pain and swelling in the lower back and hips. Postural changes due to the symptoms in these areas can also lead to neck pain before the condition spreads to the cervical spine.
Turmeric, by its anti-inflammatory and analgesic properties, serves to be a complementary therapy in ankylosing spondylitis. Dietary turmeric can be helpful in relieving pain and inflammation in ankylosing spondylitis and add to overall health improvement.
The natural methods to reverse ankylosing spondylitis are:
- Heat therapy.
- Cold therapy.
- Massage therapy.
- Alexander therapy (To improve long-term pain).
- TENS therapy (Transcutaneous electrical nerve stimulation).
- Quitting smoking.
Patients with ankylosing spondylitis can get bowel problems known as inflammatory bowel disease (IBD) or colitis. It is good to consult with the physician if there is diarrhea for more than two weeks or have a bloody or slimy bowel movement, and fatigue, which is severe tiredness that does not improve with sleep or rest.
Yes, you can live a regular life with ankylosing spondylitis if you follow the doctors' instructions and take the required precautions. A person equipped with willpower can lead a normal life by practicing certain precautions.
Ankylosing spondylitis has no cure, as it is a lifelong condition. But there are effective treatments to manage it. Treatment goals are to reduce pain, stiffness, and flares.
Work disabilities are a significant issue for patients with ankylosing spondylitis. People suffering for more than ten years of the onset of symptoms, up to 70 percent affected, become disabled.
Ankylosing spondylitis is a progressive disorder, meaning it worsens as you age. It can also limit progress in some people. There is an increased risk of acquiring cardiovascular disease as you become older with ankylosing spondylitis.
The best nutrition for ankylosing spondylitis are:
- Omega-3 fatty acid.
- Whole foods and grains, high in fiber.
- Dietary supplements with a diet rich in fruits, vegetables, nuts, lean meats, and legumes.
Ankylosing spondylitis sufferers will have an extremely dry mouth that disrupts healing, causes ulcers, and fungal infections like candidiasis. The enamel on the teeth will begin to decalcify, and the decay is prominent along the gingival margin. Dental professionals are usually the first person to notice the symptoms.
Last reviewed at:
07 Oct 2021 - 4 min read
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