Ankylosing spondylitis...an autoimmune disease affecting the spine...
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Ankylosing spondylitis (AS) is an autoimmune-driven inflammatory form of arthritis that affects the spine as well as other joints.
Usually the sacroiliac joints (joints joining the pelvis to the sacrum of the spine) are involved first with progressive involvement of the rest of the spine following. AS falls into the category of diseases designated as the “spondyloarthropathies.” Other members of this group include psoriatic arthritis and reactive arthritis. The term spondyloarthropathy refers to the propensity for spinal involvement.
There is a strong genetic predilection with 90 per cent of Caucasian patients showing the presence of the HLA B27 genetic marker. Many AS patients will have a positive family history for the disease.
Spondyloarthropathies cause early erosion and damage. As the disease progresses, there is gradual destruction of joints with bony bridging leading to marked deformity and loss of function. Like the other spondyloarthropathies, AS is an enthesopathy causing inflammation at the site where the tendon inserts into bone.
AS occurs in about 0.5 per cent of the population. It is more common in men than women in a ratio of about 5:1. It should be mentioned that AS is probably under-diagnosed in women. When AS does affect women, it tends to happen a bit later, have less hip involvement, have more symphysis pubis involvement, and definitely more cervical spine (neck) involvement.
The peak age of onset is in the 15 to 30 age range.
Symptoms usually begin in young adulthood. Low back stiffness and pain are usually the first symptoms. Low back morning stiffness is relieved by activity and anti inflammatory medication. Symptoms of fever, weight loss, and loss of appetite may be seen. With progression, there is restricted ability to walk and a reduction in the ability to perform activities of daily living.
Physical examination shows restricted range of motion in the spine and muscle spasm as well. Chest expansion may be restricted.
Patients with AS also have inflammatory arthritis affecting peripheral joints in a non-symmetric fashion. The hip joints may be severely affected. Other possibly affected joints include the ankles, shoulders, elbows, wrists, hands, and feet.
AS is a systemic disease. Eye involvement is seen in up to 40 per cent of patients. It is particularly common in B27 positive patients. It is acute, unilateral (one side), accompanied by pain, and will lead to progressive visual loss.
Other systemic problems include inflammation of the aortic valve and conduction system in the heart and scarring in the lungs.
As AS progresses, there is increasing risk for spinal fracture. This is a danger in patients with severe neck involvement who require intubation for surgical procedures.
Laboratory tests will often show an elevated erythrocyte sedimentation rate or an elevated C-reactive protein. The presence of HLA B27, while not critical, is helpful.
X-rays are often normal in early disease. MRI is more sensitive. As sacroileitis progresses, evidence of erosion and even fusion may be seen. Late findings show complete fusion of all the vertebrae.
AS needs to be differentiated from other causes of low back pain. AS should be considered in patients who present at a young age, have a positive family history of back pain, have low back symptoms lasting longer than 3 months, have prolonged morning stiffness, have improvement with exercise/ activity, have limited spinal mobility, and have an elevated erythrocyte sedimentation rate or C-reactive protein.
Goals of treatment include reduction of pain and stiffness, maintenance of mobility and posture, and restoration of normal activities of daily living.
Patient education, joint protection, physical and occupational therapy, dietary and vocational counseling should be instituted.
Non-steroidal anti-inflammatory drugs are sometimes effective for symptom relief. They do not alter the course of illness.
Disease-modifying anti-rheumatic drugs (DMARDS)should be instituted as soon as possible. The drugs that have been most used include methotrexate and sulfasalazine.
In addition, rapid institution of biologic therapy (TNF-inhibitors) has been shown to induce remission and these drugs should be employed earlier rather than later.
More information on drug therapy will be found in the treatment section.
Patients with advanced disease may require surgical intervention.
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