ANKYLOSING SPONDYLITIS

Ankylosing Spondylitis (AS), a chronic inflammation type of progressive arthritis, leads to chronic inflammation of the spine, and sacroiliac (SI) joints.  AS can lead to pain and serious impairment of strength and ability to function.

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ANKYLOSING SPONDYLITIS (AS)

Southwest Scoliosis Institute’s board-certified, fellowship-trained orthopedic physicians Richard Hostin, MD,  Shyam Kishan, MDand Kathryn Wiesman, MD, have years of experience treating thousands of patients with complex spine conditions.  As an example, Ankylosing Spondylitis can be a very debilitating disease. In addition, patients who suffer from the pain associated with this condition, begin complaining of low back pain and pain in the buttocks.

Ankylosing Spondylitis (AS) primarily affects the axial skeleton (bones of the head and trunk), including the ligaments and joints. Furthermore, inflammation due to AS can also affect other joints and organs in the body, such as the eyes, lungs, kidneys, shoulders, knees, hips, heart, and ankles. Unfortunately, AS causes changes throughout the body.

One way to understand what Ankylosing Spondylitis does to the body is to look at the words “ankylosing” and “spondylitis.” So, Ankylosing means stiffening and the word comes from the Greek word “angkylos,” which means bent. Also, Spondylitis means inflammation of the spine and this word comes from the Greek word “spondylos,” which means spinal vertebrae. In essence, AS causes your spine to stiffen due to inflammation of the joints and may cause the vertebrae to fuse together. Moreover, it may also cause a kyphosis of the spine, which gives your spine a forward curve.

A Healthy Spine

A healthy spine moves in many directions, which enables the body to bend, turn, and twist. The spinal bones are joined together by flexible ligaments and are separated by cushiony discs, which allow a lot of movement. Movement can become impossible if the ligaments calcify and the bones fuse together. AS can be disabling in its advanced stages.

Learn about Ankylosing Spondylitis including:

  • what causes the condition
  • what are the symptoms associated with Ankylosing Spondylitis
  • how to diagnose AS 
  • what treatment options are available

Anatomy

In order to understand your symptoms and treatment options, it helps to begin with a basic understanding of spinal anatomy. Therefore, this includes becoming familiar with the various parts that make up the spine and how these parts work together.

Male runner with back pain stemming from Ankylosing Spondylitis

Ankylosing Spondylitis begins with low back pain and possibly
pain across the buttocks.

CT scan of human lumbar spine

CT of the lower spine. Sometimes physicians utilize a computerized tomography to see the inside anatomy to help with diagnosis and/or to help prepare a surgery plan.

Learn more about the anatomy of the spine

Often, the first sign of Ankylosing Spondylitis (AS) occurs with the inflammation of the sacroiliac (SI) joints. To be more specific, the SI joints are the two joints that connect the lower spine to the pelvis. Also, you can feel these joints about two inches to either side of the spine in the low back.

With this disease, inflammation eventually moves to the spine. As a result, long-term inflammation of the spinal joints (called spondylitis) leads to calcium deposits forming in the ligaments around the intervertebral discs (the cushions between your spinal vertebrae) and the ligaments that hold the vertebrae together. When these ligaments calcify, movement becomes restricted. Eventually, there can be a complete fusing together of the vertebrae (called ankylosis).

Causes

At this time, the origin of AS remains unknown. However, we know lots about how Ankylosing Spondylitis progresses and why it causes spinal stiffening, which may affect the movement of other parts of the body. When AS first appears, an inflammation of the bones (called osteitis) occurs around the edges of the joints. In these areas, the number of special cells (called inflammatory cells) begins to increase. Because inflammatory cells produce chemicals that damage the bone, bones begin to dissolve and weaken around the edge of each joint.

Once damage to the bone starts, the body continually tries to repair the damage with scar tissue and new bone tissue. As the process continues, the bone becomes weaker and weaker. When the inflammation finally “burns out” and begins to disappear, the body attempts to heal the bone by producing calcium deposits around the area of the damage. For some unclear reason, as the bone heals itself, the calcium deposits spread to the ligaments and discs between the vertebrae. Meanwhile, this leads to a fusion of the spine, sometimes referred to as bony ankylosis.

Those Affected

AS primarily affects younger adult males, in adolescence or early adulthood. Furthermore, AS occurs three times more in males than in females. Although AS can strike people of any age, race, or sex, the onset occurs more often in Caucasian men between the ages of 17 and 35. In women, the symptoms of AS often begin to appear during pregnancy.

Also, AS appears to be genetic. Research reveals a specific gene — the HLA-B27 gene — is present in 80 to 90 percent of people who have the disease. Fortunately, this does not mean that if you have the gene you will automatically get AS. About eight percent of Americans have this gene, but only about one percent of those will actually develop the disease.

Ankylosing Spondylitis Symptoms

Like other forms or types of arthritis, the symptoms of AS are from the effects of inflammation. Initially, the symptoms may come and go for weeks or months at a time.

  • The first sign of AS occurs with a patient diagnosed with sacroiliitis or inflammation of the sacroiliac joints. This condition causes pain in the low back and buttock areas.
  • People with Ankylosing Spondylitis usually complain of severe low back pain, along with buttock, hip, and thigh pain on one or both sides. It usually comes on gradually and gets worse with time.
  • Stiffness and low back pain commonly occur in the morning and ease with activity over the course of the day.
  • Prolonged rest worsens the symptoms of AS, which differs from some other forms of low back pain that are eased with rest.
  • AS reduces Spine flexibility, which can affect the ability to bend forward and backward.
  • In the mid-back, AS can affect the joints where the ribs connect to the vertebrae. These are called the costotransverse and costovertebral joints. Inflammation in these joints can cause pain in the chest wall and abdomen.
  • Symptoms in the neck include stiffness, pain, and limited neck motion.
  • Because AS attacks the joints of the body, synovitis can occur. Synovitis describes a term used to describe inflammation of the synovial membrane (lining of the joints). Symptoms of synovitis include pain, stiffness, and swelling in any joint in the body.

Other Organ Symptoms

  • Breathing can be affected as AS progresses. The disease can make the mid-back round forward, a deformity called kyphosis. When this occurs, it can compress the lungs and make it increasingly difficult to take a breath. Also, when the disease affects the joints between the ribs and spine, the chest loses its ability to expand enough to take a full breath. Inflammation of the lungs can also occur with AS, making it even harder to breathe.
  • The eyes can be affected by AS, causing eye inflammation. About 25 percent of AS patients develop iritis, a condition caused by inflammation of the iris.  There may be pain and redness in the eye, but usually, vision loss does not occur.
  • Eventually, the spine bones may grow together, fusing into one continuous column of bone. This occurs with the calcification of the ligaments and discs between each vertebra. If the vertebrae fuse together, the spine’s mobility decreases, leaving the vertebrae brittle and vulnerable to fractures. When the spine becomes completely fused together, the pain in the spinal area usually goes away. This does not signal a remission of the disease. However, patients are left with no spinal mobility and brittle bones that are more likely to fracture. If pain suddenly reappears in the back after a long period of no pain, there may be a fractured vertebra.

Ankylosing Spondylitis Diagnosis

In the early stages of AS, the disease makes it difficult to make a definite diagnosis. Therefore, doctors will request a history of your health and perform a physical exam. Other diagnostic tests include X-rays and lab tests. Then doctors will take the following into consideration to make a diagnosis of AS:

  • the onset of back pain before age 35-40
  • gradual onset not caused by a trauma
  • pain that has lasted more than three to six months
  • improvement with exercise and motion
  • spinal stiffness in the mornings
  • family history of AS

X-rays

As previously mentioned doctors may order X-rays of the spine and pelvis if indications of AS occur.  If examination of the X-rays reveal that the vertebral bodies are deformed and have a square shape, then AS is present. Doctors refer to this as a “bamboo spine” as the spine appears very symmetrical and segmented.

For early-onset AS, X-ray findings will confirm the disease around both sides of the SI joint. Specifically, these signs will include patchy osteoporosis (loss of bone mass), poorly defined joint margins, a widening of the SI joint space, and erosion of the joint. In advanced cases of AS, the X-rays will show many changes including calcium deposits in the ligaments and discs, complete spinal fusion, and sometimes old spinal fractures.

Lab Tests

If your doctor suspects that you have AS, a blood test can determine if the HLA-B27 gene is present.  As of this date, a specific blood test does not exist to determine if a person has AS. You may see AS referred to as a seronegative spondyloarthropathy. This refers to a patient who has all the symptoms of AS but does not have the positive blood test for the gene that usually indicates AS. (The negative test is called the rheumatoid factor.) In addition, this is simply a way for doctors to classify AS in relation to other forms of systemic arthritis. If you have the symptoms of AS and the HLA-B27 gene, AS is likely to be the correct diagnosis.

Additionally, the Erythrocyte Sedimentation Rate (ESR) blood test will show inflammation in the blood from any cause. Furthermore, a urinalysis might be used to test the kidneys for possible abnormalities for similar AS symptoms.

Treatment Options

Presently, a cure for AS does not exist, but effective treatments can help relieve pain and improve the condition. Doctors should start with a conservative treatment plan usually involving medication, physical therapy, and exercise. At some point, surgery may be necessary to treat problems caused by AS in the spine and other joints of the body.

Medication

As mentioned, doctors will suggest medications to reduce inflammation and pain. If they prove effective, NSAIDs, particularly indomethacin is the preferred medication. It is best to take these medications as prescribed by your doctor. Possible side effects of NSAIDs include nausea, stomach upset, diarrhea, and abdominal pain. To avoid side effects, patients should take these drugs after eating.  

If NSAIDs are not sufficient, a medication called sulfasalazine may also be suggested. Corticosteroids, such as prednisone, are also very effective at reducing inflammation, but their side effects can be serious if taken on a long-term basis.

If anti-inflammatory medications do not control the pain and inflammation sufficiently, there are medications available that block the immune system in order to reduce inflammation. These medications have many side effects, so patients who take them must be closely monitored.

Learn more about medications used to treat back problems

Physical Therapy

Your doctor may have you work with a physical therapist. In calming pain and inflammation, a well-rounded rehabilitation program assists by improving mobility and strength and may play a role in helping with daily activities with greater ease and ability.

Conducting safe movements can improve spine mobility and posture. In view of the fact that physical therapy assists in pain control and the prevention of deformities from AS. patients are advised against prolonged sitting and bed rest and encouraged to keep their spine straight, walk erect, and avoid stooping over for long periods. Therefore, doctors may schedule therapy sessions two to three times each week for up to six weeks.

The goals of physical therapy are to help you

  • Learn correct posture and body movements to counteract rounding of the upper back (kyphosis)
  • Use appropriate sleep positions upon a firm mattress and thin pillow
  • Maintain appropriate activity levels
  • Implement daily stretching and strengthening exercises
  • Learn ways to manage your condition

Learn more about spinal rehabilitation

Surgical Treatment

Surgical intervention does not usually occur with AS. If the disease has led to severe deformities, such as extreme kyphosis, that prevents standing up and looking forward, then a spinal osteotomy might be considered. This operation involves cutting through the spinal bones and realigning them into a position that allows better upright posture. The spinal cord is never cut, only the vertebrae.

Finally, surgery may take place if the hip joints have been affected by arthritis associated with AS. If the hips become severely damaged by arthritis, an artificial hip replacement may be required. Patients with AS commonly need this surgery. 

If you or a loved one suffers from spinal pain, you owe it to yourself to call Southwest Scoliosis Institute at 214-556-0555 to make an appointment.