Ankylosing Spondylitis (AS)

As mentioned in the introduction the word “itis” stands for inflammation. The word “spondy “signifies related to the spine hence “Spondylitis” effectively means inflammation in the spine. The word Ankylosing means to join together or fuse. In Toto the phrase “Ankylosing Spondylitis” effectively means “inflammation in the spine leading to joining or fusion of the spine”. This kind of Inflammatory arthritis is also categorized under the term spondyloarthropathy.

As mentioned above “Spondy” means spine and the word “arth” stands for joints. The phrase “pathy” means disease or illness hence “Spondyloarthropathy” means disease of the joints of the spine. The “Spondyloarthropathies” comprises of an umbrella of related diseases all causing inflammation in the spine and sometimes the other joints of the upper and lower limbs as well. As is the prototype of these diseases. This disease starts with inflammation in the joints of the spine (vertebral joints and the sacroiliac joints), effectively leading to fusion of the spine.
Sacroiliitis or inflammation in the Sacro-iliac joints is quite often the starting point of this disease. This is known as “Sacroiliitis”. The “Sacrum” is a triangular bone at the end of the spine and the “iliac” bones are the bones below the buttocks. Hence when inflammation begins at the sacroiliac joints patients complain of pain in the buttock and low back.

Finally, this illness is also known as “seronegative spondyloarthropathy”. The word seronegative only serves to underline the fact that these diseases are negative for the rheumatoid factor hence “seronegative”. Having explained the nomenclature let’s get on with understanding the disease a little more.

Ankylosing Spondylitis usually occurs in a younger subset of patients with a predilection towards males rather than females. This is one of the few rheumatic diseases that is predominant in males. Additionally, this is one of the few illnesses which could be classified as hereditary rather than just genetic. A first degree relative such as a parent or a sibling increases the risk of an individual developing AS.

The gene implicated in this disease is HLA B27 positive and hence if there are symptoms and signs of the illness and the individual tests positive for the presence of this gene then the chances of the patient having AS are close to 95%. However, there are a few caveats here and that is what patients and even many medical professionals do not understand.

1) If you are HLA B 27 positive then this does not mean that you will surely get the disease. HLA B 27 is present in one percent of the normal population and only 10 percent of these individuals go on to develop the disease, 90 % do not.

2) If you are HLA B 27 negative does not mean you will never get spondyloarthropathy. The triggering event for onset of this disease is sometimes an infection usually of the bowel or of the genitourinary tract. Sometimes a trauma resulting in an injury to the back can also be a precipitating factor in the onset of this disease.

The common symptoms of this Ankylosing Spondylitis(AS) comprise of the following:

  1. Onset of low back pain or buttock pain in young individuals between the ages of 18 to 30.
  2. Sometimes buttock pain alternates between left and right side.
  3. This pain is associated with stiffness which is much worse in the morning after rest called “early morning stiffness” (EMS) and may last 30 minutes sometimes even more.
  4. In some patients the stiffness increases in the middle of the night waking the patient from his sleep. The pain and stiffness reduce after a period of activity or exercise.
  5. Sitting in a single position for a prolonged period once again brings on the stiffness in the low back and the entire spine known as “Inactivity Stiffness”. Again this is again relieved only after a period of activity.
  6. Anti- inflammatory drugs (NSAIDS or non-steroidal anti-inflammatory drugs) provide significant relief in the pain.
  7. Hip joint involvement characterized by groin pain is quite common.
  8. Sometimes limb joints may also be involved namely the heels, ankles, knees, elbows etc. Usually the involvement of these joints is referred to as peripheral arthritis and is quite often asymmetric in nature, meaning one knee and opposite ankle of knee and ankle on one side while sparing the other leg completely. When Peripheral joints are involved the composite term used is AS with peripheral arthritis.
  9. Sometimes symptoms may be few and the pain minimal because of which the illness gradually progresses causing fusion of the spine.
  10. There may sometimes be associated constitutional symptoms such as fatigue, low grade fever or more often a feverish feeling but no actual fever.
  11. This illness can sometimes affect other organs such as the eyes characterized by pain and redness in the eye along with blurred vision. Often there is photophobia which means intolerance to light. Sometimes there is complete loss of vision as well. There may also be involvement of the intestinal walls giving rise to inflammation of the intestinal walls these diseases being called inflammatory Bowel diseases such as Crohn’s disease or Ulcerative Colitis to name a couple.
  12. Over time there is stiffness and loss of flexibility of the spine resulting from fusion of the vertebral joints (joints of the spinal bones called vertebrae).

Diagnosis of Ankylosing Spondylitis:

Diagnosing is based on a combination of the patient’s history and clinical examination followed by investigations which can range from X rays to an MRI or a radionuclide bone scan, depending on the case and the stage at which the patient presents.

Treatment of Ankylosing Spondylitis:

Treatment of AS is based on a combination of Medications and Exercises. This is one of the illnesses where exercise plays an as important role as medication in the management of this disease. The logic is simple. This disease results in fusion of the vertebral joints over time and exercises which promote flexibility of the spine will prevent the vertebrae from fusing with each other. Despite this simple logic and repeated hammering into the patients heads to exercise they still don’t. It is probably human nature that since exercises are free they do not have any value. Moreover, who wants to make so much of an effort? Sleeping in a prone position (upside down, sleeping on the stomach) helps in preventing stooped posture that occurs following fusion of the spine joints.

Medications for AS:

1) NSAIDS (non-steroidal anti-inflammatory drugs): Commonly called as painkillers by patients. Here is the interesting part this is probably the only disease where NSAIDS actually works as an anti-rheumatic drug and this has been proven in studies. However, as we all know that regular consumption of these drugs is associated with its own problems in terms of side effects. Such as stomach upset or

ulcers in the stomach and small intestine. Long term usage can also prove harmful to the kidneys hence these drugs should be taken only under supervision in prescribed doses and with regular blood tests etc.

2) DMARDS (disease modifying anti-rheumatic drugs): Commonly used DMARD in this illness is Sulfasalazine though it is known that this drug is likely to be effective mainly in peripheral joints rather than the spine. However, the drugs known to be really effective in this disease are biological drugs (which we will allude to shortly) which are extremely expensive and hence out of reach of the majority of patients as yet in this country. Thus given the current scenario it is worth trying for at least 6 months and seeing the effect on the disease. Some patients do respond. This drug should be used under the monitoring of a rheumatologist only as it can be associated with side effects (read on sulfasalazine in the drugs section).

3) Biological Drugs: Anti-tumour necrosis factor agents such as “Infliximab” and “Etanercept” have been proven to be highly effective agents in the treatment of this disease. However, these drugs are extremely expensive as mentioned above. These drugs are powerful and hence provide significant and in fact almost dramatic relief in the pain by rapidly controlling the inflammation. Having said that, please remember that they are also a powerful immunosuppressant and hence there is an increased chance of contracting infections from the community considering that our country is endemic for quite a few diseases.

Surgery: In advanced stages of the disease where spinal fusion and hip joint damage have already occurred resulting in restricted mobility: Surgery such as hip Joint replacement may go a long way in maintain the patient’s mobility and thus independence. In some patients where there is severe spinal deformity and stooping, or where dislocation of the vertebrae has occurred, Spine surgery may be the way forward to help the patient.

Prevention for Ankylosing Spondylitis(AS):

One cannot prevent AS however one can prevent complications of AS.

1) To prevent spinal fusion and stooping, regular exercise and sleeping on the stomach are helpful.

2) Avoiding or stopping smoking is mandatory: Smoking weakens the bones and also the lungs. In an already precarious position where the spine and ribs get fused over time smoking and worsening the situation can only be called stupid on the part of the patient.

3) Chronic alcohol consumption also weakens the bones. Moreover, the liver which already has the burden of digesting the various medications gets affected by alcohol creating further complications.

4) Avoid High Impact sports. Bones in AS are weak already and such activities may cause fractures.