ANKYLOSING SPONDYLITIS

Ankylosing Spondylitis is a form of arthritis that affects the spine, generally starting at a young age. Although the cause is unknown, there is a strong genetic or family link. Most, but not all, people with spondylitis are positive for HLA-B27 upon blood testing. Although people carrying this gene are more likely to develop spondylitis, it is also found in up to 10% of people who do not carry this gene and have no family history.

The vertebrae, and the ligaments surrounding it, fuse together and lead to a rigid spine. This is particularly a problem in the cervical spine, which leads to spine flexion preventing the patient from looking up without bending backwards. In the thoracic spine, it leads to compromise of lung expansion. In the lumbar spine, it leads to a bent-forward posture and contribute to back pain. These changes may be mild or severe.

Early diagnosis and treatment, particularly exercise and physiotherapy, helps control pain and stiffness and may reduce disability.

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SYMPTOMS

• Pain and stiffness – There is generally pain and stiffness in the area of the spine, which is involved, for example neck pain if the cervical spine is affected. This will result in pain on neck movement - making it difficult to sleep at night or to drive. In thoracic spine cases, as the lung function is compromised, breathing may be compromised on physical exertion or in cases of lung infection. In the lumbar spine, it can be a cause of chronic back pain and sacroiliac joint pain.

• Pain in ligaments and tendons – May affect some ligaments and tendons, such as the Achilles tendon (back of the ankle) making it difficult to walk when inflamed.

• Fever, fatigue and loss of appetite – may occur as Ankylosing spondylitis is a systemic disease. This means that it may not just affect the joints and ligaments.

• Eye inflammation – Pain and redness in the eye requires urgent ophthalmological review from an eye specialist.

• Rare cases – may involve the lung and heart.

 

 

INVESTIGATIONS

1. Blood Tests – including CBC, ESR, CRP, HLA-B27, RA Factor and Serum Uric Acid are all initial tests that are required.

2. X-Ray – of the symptomatic part of the spine (i.e, cervical, lumbar or thoracic AP and lateral views) and X-Ray of the pelvis AP view.

3. MRI (Magnetic Resonance Imaging) – is particularly useful following trauma as these patients may fracture their spine more easily.

4. CT scan – gives better bony definition, is helpful in planning treatment and defining the full extent of spine involvement.

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TREATMENT OPTIONS

Although there is no permanent cure for ankylosing spondylitis, treatment is aimed towards reducing pain, improving function and reducing stiffness. This will improve the quality of life and, in fact, many patients do indeed lead a normal life. A multidisciplinary team of doctors may be required – including the family physician, rheumatologist, spine surgeon, pain specialist, physiotherapist and occupational therapist.  

1. Rehabilitation: This includes physical and occupational therapy. This is given for relief of pain, reduced stiffness and improve function & mobility. The rehabilitation expert will also guide the patient on the exercises they will need to do at home.

2. Exercise at home: A program of daily exercise should be part of the daily routine. The physiotherapist can teach the patient exercises that are safe to perform. Breathing exercises are important to maintain lung function and improve chest expansion.

3. Medical Management: Relief from acute pain can be provided by drugs, such as Nonsteroidal anti-inflammatory drugs (NSAIDs) – e.g. ibuprofen. Asprin should be avoided in young patients. Newer disease-modifying drugs (anti-rheumatic drugs) may also be necessary in severe cases but should be used in consultation with the rheumatologist as they may have serious side-effects.

4. Surgical Management –

   • Spine Decompression and Stabilization or Spinal Fusion 

   • Spine surgery will be necessary to treat spinal injuries in these patients and should be performed by an experienced spine surgeon as this can be quite challenging, particularly the use of implants. Thickening of ligaments and soft tissue, and bony growth may cause compression of the nerves and spinal cord. It may present even without trauma as numbness and weakness of the limbs requiring surgery.

   • Osteotomy surgery is a type of surgery performed to reduce deformity and improve posture.

   • Joint replacement surgery may be necessary in cases of advanced disease affecting, particularly, the hip joint.