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   Ankylosing Spondilitis

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                             Ankylosing Spondylosis
 

Ankylosing spondylitis is an seronegative arthritis in which the sacroiliac joints and axial spine undergo a progressive ossification. Ankylosing spondylitis attacks the insertions points of ligaments, tendons, fascia, and fibrous joint capsules, (in contrast to rheumatoid arthritis, which attacks synovial membranes) and yields fibrosis and ossification of the insertions. Ligamentous attachments are collectively referred to as "entheses", hence "ensethopathy" is a common feature of ankylosing spondilitis.

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The disease typically starts at the sacroiliac joint (SI joint is fused in the pelvic radiograph above), and spreads upwards, ossifying ligaments of the posterior facets of the spine and fusing vertebrae together, thus stiffening the spine and decreasing range of movement. Ossification within the anulus fibrosis (the fibro-cartilaginous ring that is wrapped around the outside of the intervertebral disk ) yields syndesmophytes , radio-dense lines that connect vertebrae. With enough syndesmophyte formation, the whole spine has an undulating contour called "Bamboo Spine". A characteristic combination of bone erosion and formation occurs in this disease, such that the vertebrate become less concave and more 'square'. This squaring of the vertebral bodies is typical of ankylosing spondilitis.    

 

   

 
 

Onset is typically in young people, usually in their late teens or twenties, and rarely after age of 35. Clinically, the disease is usually first noticed as a persistent backache which is not relieved by rest, and improves with exercise (unlike muscular back pain). It may also present as sciatica, peripheral joint pain, a painful sacroiliac joint or chest pain. Associated symptoms are anorexia, weight loss and a low grade fever. At its extreme, ankylosing spondylitis results in an ossification of the axial spine such that mobility is greatly reduced, and the spine becomes completely stiff and flexed, and the hips may be ankylosed as well, affecting gait. The spine is also at increased risk of fractures, further deforming the person's stance. However, only 20% of patients reach the extreme of a completely rigid spine.
Medical treatments include analgesia and an emphasis on posture and exercise to retain flexibility and range for as long as possible. Swimming is recommended.
Ankylosing spondylitis is associated with HLA-B27 in affected persons of European ancestry. However, only ca. 20% of people with HLA-B27 develop ankylosing spondylitis, so there are presumably other factors at work as well. Ethnic groups among whom HLA-B27 is rare also have a low incidence of ankylosing spondylitis

Ankylosing spondylitis (AS) is a HLA-B27 spondyloarthropathies which is characterized by bony ankylosis and syndesmophyte formation.


                                           

Distribution:
It primarily affects the axial skeleton and secondarily the appendicular skeleton to involve proximal large joints in a bilateral symmetrical distribution. The arthropathy begins in the SI joints and then progresses to the lumbar spine and ascends to involve the thoracic and cervical spine. Afterwards, arthritis progresses to involve the hips, shoulders, knees, hands, and feet in decreasing order of frequency. In early stages, bilateral symmetric erosions involving the SI joints are present which is followed by sclerosis which eventually results in bilateral ankylosis. The feet are affected in about 10% of patients in later stages of the disease. The IPs and MTPs are affected.
 

Erosion pattern:
Erosions are usually superficial, with productive response. Intra-articular ankylosis occurs in a short period of time.
 

3. Differential diagnosis:
The presence of bone proliferation and bony ankylosis, and the lack of osteoporosis are common finding of all seronegative arthritis and are useful in the differentiation of ankylosing spondylitis from rheumatoid arthritis. The distinction among seronegative arthritis is based on the distribution, ankylosing spondylitis
has a predilection for the axial skeleton with rare involvement of the small joints of the appendicular skeleton.

 

                Joint

 
    Frequency  
1st interphalangeal

+

 
2nd - 5th interphalangeal

_

 
1st Metatarsophalangeal

+

    
2nd-5th Metatarsophalangeal

+

Tarsometatarsal                +  
Chopart                _  



Introduction
Ankylosing spondylitis (AS) predominantly affects the spine and may lead to severe stiffness of the back.
 

What happens
Spondylitis means inflammation in the joints of the spine, and comes from the Greek word for vertebra (spondylos). As the inflammation goes and healing takes place, bone grows out from both sides of the vertebrae and may join the two together; the stiffening this causes is called ankylosis.
The cause is not yet known. Occasionally more than one member of a family may get it as there is a hereditary factor. AS is neither infectious nor contagious, nor can it be caused by athletic activity or injury.
However, symptoms sometimes follow unusual exertion or strain, which may be blamed at first. Typically, it attacks young men but it can occur in women as well.
 

The backbone
The backbone, or spine, is made up of 24 bones (vertebrae) and 110 joints. The three main sections, cervical, thoracic and lumbar, differ in their shape and curve. The cervical (neck) section is the most mobile. In the thoracic (chest) section each vertebra has a rib attached by joints on each side. Below the lumbar section is the sacrum which sits like a keystone in the ring of bone which forms the pelvis. AS usually starts at the sacroiliac joints which lie between the sacrum and the pelvis.
 

                    
 

The most common cause of backache is 'back strain', which can happen at any age. A 'slipped disc' is another example. In older patients degenerative or wear-and-tear problems often affect the back. Diagnosis is made by listening to your symptoms and examining you. Your doctor at A+ clinic may do certain blood tests and arrange for an x-ray
 

The effects (early signs)
At the start AS usually causes low backache and stiffness and may be misdiagnosed as common back pain. You may feel pain in the buttocks, possibly down the back of your thighs and in the lower part of your back. You may have first noticed these symptoms after some exertion or strain. Aches and pains in the neck, shoulders and hips, or in the thigh (like sciatica), may follow.
In a few cases, and especially in children, the first complaint may not be in the back at all, but in the hip or knee, or in the leg perhaps just a swollen knee.
In the beginning, in spite of these complaints, even careful examination by a doctor may reveal nothing.
Some people experience nothing more than a series of mild aches and pains coming and going over a period of months, never troubling them greatly. Others pass through a phase of active AS when symptoms are more troublesome; they become generally unwell, lose weight and tire easily. Gradually the ailment settles down and the worst pains disappear.
 


 

When AS has been present for several months the back may stiffen, usually lower down; and in some patients the disease then dies out, causing no further trouble. The stiff back is often painless and does not interfere with physical activity, because the upper part of the spine, the neck, hips and limbs can remain quite normal. If you feel stiff in the early morning this is a sign of inflammation and perhaps it may be an hour or so before you have properly limbered up it may indicate the need for anti-inflammatory drugs.
In its early stages AS causes considerable pain, but effective treatment is available to relieve this, even though the discomfort is not always banished. In some people the disease becomes much less active, or even ceases completely. In others the disease continues to be active, causing pain and stiffness. At first you will most probably be able to carry on with your work and lead a normal life. Later you may find it difficult to continue in the same job.
 

Limb joints
Sometimes, either earlier or later, AS may affect joints other than the spine. The hips, knees, ankles and shoulders may be involved. The smaller joints of the hands and feet can be attacked, but usually only in a few places. You may experience a period of aching in the joints in question, perhaps with some swelling. As a result some of them may not move fully, but with treatment and active exercises from the start the disability should remain slight. In particular, your hip must not be allowed to stiffen in a bent position as this can lead to damage in the knees, and cause more backache.
 

Other trouble spots
Tender places may sometimes develop in bones that are not part of the spine the heel bone for example. When this is affected it becomes uncomfortable to stand on a hard floor. The bone of your 'seat' (ischium) can be involved and make sitting on chairs uncomfortable.
Some patients experience chest pain. This does not come from the heart, but from the joints between the ribs and the breastbone. You may notice a strapped-in feeling as the ribs become less easy to move. However, your lungs are working well because the diaphragm is not affected. Breathing exercises will help you maintain ribcage mobility.
Iritis (inflammation of the iris which forms the pupil) occasionally occurs, so if you suddenly develop a red eye go to your doctor immediately.
Other rare complications, affecting less than 1 patient in 100, may occur. These include the heart, lung and nervous system, but treatment is available for all of them. Patients with AS are not any more at risk from getting heart attacks, strokes or cancer than the general population. Colitis, or inflammation of the bowel, is associated with AS in some people, as is a skin condition called psoriasis.
 

Tests
AS is often not diagnosed until a patient has had backache for 2 or 3 years or even longer. A blood test for inflammation may show an abnormal result in the early stages and so help your doctor to distinguish it from more common forms of backache. There are three commonly used blood tests for inflammation: the CRP (C-reactive protein), the ESR (erythrocyte sedimentation rate) and the PV (plasma viscosity). Your doctor may request one or more of these. X-rays may also confirm the diagnosis. However, in the early stages x-rays may be normal, even when the symptoms are severe.
A special test (HLA-B27 antigen) can be used. This is like testing for a blood group but concerns the white and not the red blood cells. If it is positive it shows that you have a tendency to AS, but does not prove the diagnosis.
 

Associated problems
It is now clear that AS is one of a group of diseases ('spondarthritides'). Other examples are psoriatic arthritis, colitic arthritis and reactive arthritis. Each of these can occur with AS or even before it. Some children can develop arthritis which later develops into AS. In some cases reactive arthritis, which may be associated with an infection of the bowel or the urethra (the tube from the urinary bladder), can develop into AS. The link between these and other diseases has revealed some of the genetic factors that are involved. Having certain genes will predispose you to AS, but without one of the 'triggers' the disease will not appear.

Treatment
Do your best to keep fit. Eat anything, especially protein such as meat and fish, but don't get overweight. Take plenty of exercise. The motto for treatment which all patients should remember is: it is the doctor's job to relieve pain, and the patient's job to keep exercising and maintain a good posture.
 

Rest
If the AS is very active and the stiffness very troublesome, a spell off work or in hospital may be necessary. This does not mean keeping still in bed, because this can hasten the stiffening of the spine. So even a spell of rest from work means that you will be encouraged to do exercises for your back, chest and limbs to keep them supple.
When you are in bed it is important that you should lie quite flat on your back. Some of the time you should practise lying on your front. 'Prone lying', as this is called, is best done for 20 minutes before rising in the mornings and 20 minutes before going to bed at night.
At first you may not be able to tolerate more than 5 minutes at a time, or may even need a pillow under your chest. But with practice, as the spine relaxes, it will become easier. If you make a habit of this it will help prevent your back and hips becoming bent. It may, of course, not be practical every day but it is better to devote some time to it than nothing at all.
 


Medical approach
There is no cure at present for AS. The doctor aims to relieve the symptoms, to improve spinal mobility where this has been lost, and to allow you to maintain a normal job and social life.
Although AS will tend to become less active as you get older, treatment must continue. In particular you must pay close attention to good posture, mobility and exercise.
Although the disease cannot be cured, much can be done to help. The doctor will prescribe tablets that relieve pain (analgesic) and inflammation. There are several drugs which will reduce or kill the pain, and give you a good night's sleep and sufficient freedom from pain to do exercises.
You will probably need tablets during bad patches and some people need a small maintenance dose of their drug over a longer period. Some tablets are manufactured to remain effective throughout a 24-hour period, thus helping relieve night pain and morning stiffness.
Some drugs are called 'disease-modifying': they never make an immediate impact on the disease but rather take some time to start working, but ultimately they may make a big difference to the disease. Sulfasalazine and methotrexate are two such drugs. Both these drugs, commonly used in other forms of arthritis, are more likely to benefit the arthritis in the limb joints rather than the arthritis in the spine.
Some of the newer drugs are given by injection. These fall broadly into two groups:
Bisphosphonates are given in short bursts over a period of a few weeks an example is the drug called pamidronate. You may feel pain relief in the spine soon after receiving this drug.
Biological therapies are drugs which are also given by injection either as an infusion over a few hours or as a twice-weekly injection.
Heat in its various forms will help to relieve pain and stiffness. A hot bath before going to bed, a hot-water bottle or electric blanket may be quite enough.
Surgery has only a small place in treatment. An operation is used to help restore movement to damaged hip joints (arthroplasty) and, rarely, to straighten the back or neck of someone who has become so bent they cannot look forward (and find it dangerous just to cross the road).
 

Posture
Since untreated AS causes increased bending of the spine (the person becomes progressively more stooped), you must keep as straight and erect as possible. Hardback, upright chairs or straight-back rocking chairs are far better for your back posture than low, soft, upholstered chairs.
Pay special attention to the position of your back when at work, so that you do not have to stoop. If you sit at a desk or bench, see that your seat is at the proper height and do not sit in one position for too long without moving your back .
 


 

A job which allows sitting, standing and walking is ideal. The most unsuitable type of work is that in which you have to stoop over a bench for hours at a time. If you have a heavy or tiring job do not tackle other activities at home or elsewhere until you have had a break. If necessary, rest flat for a time. It may also help if you can rest flat for 20 minutes at midday. At such times try to lie for part of the time face downwards.
Corsets and braces are hardly ever helpful, and indeed can make AS worse. It is better to develop your own muscles, and keep a straight back by natural means. Very occasionally some form of support may be necessary, for example after a back injury. However, this decision should only be taken by a doctor who is experienced in treating people with AS.
 

Sport and exercise
Exercise is good for AS, so you should keep active. Swimming is the best form of sport as it uses all muscles and joints without jarring them. And regular swimming is something the whole family can join in with.


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