Ankylosing spondylitis (AS) is a common type of spondyloarthropathy (Spondyloarthropathy refers to a group of rheumatic diseases that present common clinical and genetic features). Ankylosing spondylitis is a chronic inflammatory autoimmune disease that mainly affects spine joints and in advanced cases causes spine fusion too.
Ankylosing spondylitis is first described over 2 centuries ago, typically develops in Male around the age of 30-40 with the involvement of spine joints, sacroiliac joints, and their adjacent soft tissues such as tendons and ligaments and in advanced cases, inflammation can lead to fibrosis and calcification.
Ankylosing spondylitis is an autoimmune disease that develops through complex interactions between genetic background and environmental factors. The immune cells and innate cytokines are suggested to be crucial in the pathogenesis of ankylosing spondylitis, especially human leukocyte antigen (HLA)-B27 and interleukin-23/17 axis. Etiology is not clear, still, 90% of cases are found to be genetic.
AS typically exhibits either at least one of the following; 1. Alternating buttock pain, 2. Sacrolitis, 3. Heel pain (enthesitis, insertion of a muscle is inflamed with possible fibrosis and calcification), 4. Psoriasis, 5. Intestinal bowel disease, 6. urethritis/acute diarrhoea in preceding 4 weeks or at least 4 of the following 5 characteristics; 1. age of onset is less than 40, 2. Insidious onset, 3. Improvement with exercise, 4. Rest gives no improvement & 5. Pain increases at night.
The other symptoms are as follows:
- Back pain, tenderness, stiffness with alternating buttock pain which worsens at night or in the morning and is eased by physical activity and is present for more than 3 months.
- Muscle spasm
- Impaired spinal mobility
- Postural abnormalities like increase thoracic kyphosis and decrease lumbar lordosis.
- Progressive spinal rigidity
- Inflammation of hips, shoulders, peripheral joint and fingers/toes.
- Acute anterior uveitis (painful unilateral eye with photophobia, increased tear production, blurred vision).
- Increased risk of cardiovascular diseases
- Inflammatory bowel disease
- The ability to exercise every day diminishes, pain increases in the evening time and improves with physical movement.
- Cauda equina syndrome: a very rare complication of long-standing ankylosing spondylitis.
- Eye irritation
- Lungs: dynamic fibrosis of the upper bit of the lung
- Cardiovascular inclusion incorporates irritation of the aorta, aortic valve deficiency, or aggravation of the heart’s electrical conduction framework.
- Cardiovascular: a. Aorta involvement, b. Conduction abnormalities, c. Hypertension, d. Reduced physical activity and e. Smoking can be seen. 10-30% of cases are affected and younger are at more risk. This remains undiagnosed until the patient is symptomatic.
- Bone involvement: a. osteoporosis- diffuse osteoporosis is a well-known feature found during the complication of ankylosing spondylitis. 63% of cases of AS are either osteopenic or osteoporotic and are often found in the early stage.
- Eye: Uveitis is most common and found in 20-30% of cases.
- Lung: pathophysiology is not clear but apical fibrosis, chest wall restriction, and ventilatory abnormalities are found in a few cases among which apical fibrosis is seen in approximately 1.3-30% of cases depending upon the duration of the disease.
- Cachexia is an accelerated loss of skeletal muscle in the context of a chronic inflammatory response.
- Skin: psoriasis is found in 10-25% of cases of AS.
- Gastrointestinal: AS with Crohn’s disease in 5-10% cases and AS with Ulcerative colitis in 25-49% cases.
- Renal: 10-25% of cases of AS come with renal involvement; glomerulonephritis, deposition of renal amyloid, microscopic haematuria, microalbuminuria and decrease renal function.
- Neurological: Cauda equina syndrome is very rare.
- Lower back pain and solidness are present for more than 3 months which improves with exercise but do not diminish or decrease by rest. Fibrosis and ossification of the tendon, ligament, and capsule insertion at the area of intervertebral and sacroiliac discs are the main characteristics of ankylosing spondylitis.
- In 70% of cases in blood test; increased Erythrocyte sedimentation rate (ESR) & elevated C-reactive protein is seen.
- X-Ray or MRI is also done for the diagnosis and confirmation.
- A genetic test is done to determine the gene HLA-B27.
- Excellent prognosis by physical and medical management. There is no effective disease-modifying treatment due to unclear pathogenesis. Treatment aims to improve & maintain spinal flexibility, normal posture, relieve symptoms, decrease functional limitations, and reduce complications.
- Pharmacologically NSAIDs & TNF-alpha inhibitors are anti-inflammatory drugs. Local injection of glucocorticoids for immediate symptom relief.
- Physiotherapy is an important approach for the long-term management of the disease. Physiotherapy must be done under proper monitoring. The disease is either active or stable, physical therapy is a universal advice along with regular exercise and quitting smoking.
- Surgical treatment if there is a long-term severe deformity and which cannot be treated by any other intervention.
Alternative treatments are also done like:
- Climatotherapy is an alternative line of treatment, treatment of disease is done in an area with a favorable climate; results are very beneficial.
- Hydrotherapy is an alternative line of treatment in which water is been used. The warmth and buoyancy of the water allow for muscle relaxation and reduction in weight-bearing load on the trunk and lower extremities.
- Mud packs
- Tai chi is an ancient Chinese philosophy where physical exercise and relaxation techniques are merged.
Regular short breaks
Ankylosis spondylitis is the most common of all spondylitis and is usually found in the third decade of life. Due to unclear pathology, treatment is done symptomatically. Regular exercise and taking regular short breaks throughout the day help in reducing pain. Maintaining a habit of physical activity decreases the possibility of spondylitis. Even if a person is diagnosed with the same can be cured with medicine and physiotherapy.