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What is ankylosing spondylitis? Is it similar to common lumbar spondylitis?
Ankylosing Spondylitis is another autoimmune inflammatory disease characterised by inflammation of the sacroiliac joints of our body that often affects young males. The symptoms are low back pain that is characterised by excessive stiffness at early morning after waking up from the bed, alternate buttock pain, improvement of pain on movement and activity and development of stiffness after periods of prolonged rest. It has been noted that sleep is disturbed in the second half of the night due to flare of pain at that moment.
Actually the term Lumbar Spondylitis is a misnomer. It is actually called Lumbar Spondylosis. Lumbar spondylosis is a mechanical problem and the symptoms are almost the opposite of AnkylosingSpondyslitis. The pain is aggravated with movement, jerking, jolting and often coughing, Heavy weight lifting and forward bending also aggravates pain. Pain is felt better when the person is at rest. Exercise actually worsens pain and usually there is no early morning stiffness. It is actually a benign disorder of abnormal posture and overburdening of the lower lumbar vertebra with body weight or external weight bearing. It occurs in overweight individuals and incidence increases with age and has no major gender predilection.
Are the terms Spondylosis, Spondylitis and Spondylolysis same? Do they mean the same disorder?
Spondylitis is an inflammatory disorder of the vertebral column and almost always denote the disease ankylosing spondylitis unless mentioned otherwise.
Whereas, Spondylosis means a benign mechanical disorder of vertebral column and it may occur at any level. Although, it occurs frequently in Cervical ( Neck ) vertebra and Lumbar Vertebra ( Low Back ), thoracic ( Mid Back ) spondylosis is often unheard of.
Spondylolysis is actually a fracture of a particular part of a vertebra called pars interarticularis and is beyond the scope of simplification in this article. However, this problem may also present with mechanical pattern of low back pain often at either of the sides of the low back region.
There is another term of importance which is called spondylolisthesis. This is a condition when one of the lumbar vertebrae slips over the lower vertebra anteriorly thus producing a step like gap over the low back region which can be felt from the skin surface. Once again, it is a common cause of mechanical low back pain and can easily be diagnosed by an X ray.
What is HLA B27? What does a HLA B27 Positive mean?
HLA B27 is a protein located on the surfaces of White Blood Cells ( WBC ) in the blood. The purpose of this protein is to bind with external microbes and present them to the cells of the immune mechanism for destruction. It is normally found in less than 5% of individuals. However, in patients who are suffering from Ankylosing Spondylitis, HLA B27 is found in over 90% of them. Thus HLA B27 Positive status along with classical inflammatory low back pain is highly suggestive of Ankylosing Spondylitis.
What are the symptoms of ankylosing spondylitis?
The most common symptom is low back pain. Low back pain can be of three types.
• Inflammatory
• Mechanical
• Radicular
BACK PAIN: It is the inflammatory type of pain that occurs in Ankylosing Spondylitis. Inflammatory Low Back pain is characterised by pain and stiffness after prolonged period of rest and especially after waking up from sleep in early morning. There may be profound stiffness in the early morning that may last up to an hour. Activity andmovements cause pain alleviation.
Often there is alternate buttock pain and the second half of sleep is often disturbed due to this pain.
JOINT PAIN: Apart from a low backache, there may be involvement of other joints also. Most commonly one or two joints of the legs are affected usually the knees or ankles. However, big joints of arms are also not spared at times. Pain and swelling of small joints is not a very common symptom. The joints may be painful, swollen and often warm to touch.
RED EYE: Red eye is another important symptom of this disease. Red painful eyes are caused due to autoimmune inflammation of the uvea called Acute Anterior Uveitis. Often, this symptom may be present even in absence of any back pain and thus serves as a clue to the disease. Acute Anterior Uveitis occurs in approximately 40% of patients suffering from Ankylosing spondylitis. Almost 90% of them are positive for the HA B27 antigen in their blood. Symptoms may include redness, pain, blurred
vision, increased lacrimation and photophobia. The diagnosis is characteristically confirmed by slit-lamp examination, which is also usefulin monitoring response to treatment.
COLITIS: Although not very symptomatic, but almost 50%of the patients of ankylosing spondylitis suffer from inflammation of large intestine called colitis. Obvious colitis manifests as painful defecation and passage of blood and pus with stool. In severe disease patient may suffer from fever too. Diagnosis is confirmed by Colonoscopy.
HEART: In approximately 2 to 10% of patients of ankylosing spondylitis, a regurgitation of aortic valve is found. In another 1to 9% of patients, cardiac conduction block or first degree heart block is noted. Complete Heart Block requiring pacemaker insertion is rare. Both of them are benign disorders and hardly need any definite treatment. However, if the intensity of aortic regurgitation increases, symptomatic treatment for heart failure is necessary.
LUNG: Lung is often involved in ankylosing spondylitis and it may cause fibrosis of upper lobes of the lung and pleural involvement. Neither of them may be diagnosed by checking the Xray of the chest and needs High Resolution Computerised Tomography of the Lungs ( HRCT) for diagnosis. Further, since the vertebral column is involved in this disease, there may be limitation of expansile capacity of the lungs thus causing shortness of breath and restrictive lung disease. This in turn may increase the chances on infections.
OSTEOPOROSIS: Osteoporosis is on of the well recognisded complication of this disease. We have found men as young as 26 years to develop severe osteoporosis as ankylosing spondylitis is a state of accelerated osteoporosis. Osteoporosis is diagnosed by doing a Dual emission X Ray Absorptiometry ( DEXA Scan ) of the body. While managing this disease treatment for osteoporosis should be considered and periodic Bone Mineral Density should be checked by DEXA Scan.
NECK : The first vertebra of our body just below the skull is called atlas and the next one is called axis. Ankylosing spondylitis can cause damage to this joint and may cause movement of one vertebra over other all of a sudden and may result either into complete paralysis of both hands and legs or sudden respiratory arrest. This is one of the most feared complications of this disease.
What is Sacroilitis?
Our vertebral column ends at coccyx. The bone that lies just above the coccyx is called the sacrum. This boat shaped bone is attached with two butterfly shaped flat bones on either side called ileum via the joints called sacroiliac joints. In ankylosing spondylitis, these joints are affected first which may be either on one side or both. The inflammation of this sacroiliac joint is called sacroilitis.
Sacroilitis can be detected very early by doing a Magnetic Resonance Imgaing ( MRI Scan ) even when the patient is not having any symptoms. Sacroilitis is obvious on Xrays of Pelvis in a late stage. Thus, MRI is ideally the first scan of choice in confirming a diagnosis of Sacroilitis.
How do I know that my back pain is due to Ankylosing Spondylitis?
Ideally one should consult a rheumatologist for evaluation of a back pain. But, there are few clues that suggest that the back pain is due to ankylosing spondylitis. These clues are:
a. Low back pain in persons aged less than 40 years
b. The character of the pain is typically inflammatory pattern
c. Blood reports show that ESR and CRP values are high
d. Low back pain is associated with pain and swelling of one or two large joints of legs.
e. Somebody in family is already suffering from Ankylosing Spondylitis, Psoriasis or similar inflammatory back pain.
f. Low back pain with history of Red eye ( Acute Anterior Uveitis )
g. HLA B27 Tests come out to be positive
h. MRI or X Ray of Pelvis shows Sacroilitis.
Is ankylosing spondylitis a life threatening disease? What happens if it is not treated properly.
The basic problem in ankylosing spondylitis is inflammation of the sacroiliac joint. Due to this autoimmune inflammation, there is destruction of the sacroiliac joint and there is widening of the joint space. Human body has got an automatic tendency to repair any damage. Thus, new bone is formed at the site of the destroyed joint and this goes uncontrolled. Uncontrolled bony repair causes obliteration of the joint space and ultimately the sacrum and ileum gets fused to form a single bone. This causes severe immobility of the joint. This process of new bone formation and fusion of the adjacent bones continue upwards there by fusing each vertebra staring from the lumbar and proceeding upwards. This process of bony fusion may reach as high as up to the cervical vertebra i.e the vertebra at the level of the neck. Ultimately the entire spine becomes fixed and immobile and the person is unable to bend down, turn to a side or move his head. This situation is called Bamboo Spine and the spine indeed looks like a bamboo in Xray.
This advanced condition is beyond any scope of treatment and that what is left in the patient’s life is pain, immobility and poor quality of life. Treatment is directed to arrest the disease when it is in its early state thereby preventing such a complicated morbid condition.
Involvement of thoracic spine and the adjoining ribs cause severe restriction of lung expansion and collapse which occurs during respiration. This results in infections and pneumonia. Due to these added complications, patient may succumb to the disease.
I have been prescribed pain killers. How long can I take pain killers? I heard that they have bad side effects.
Non Steroidal anti Inflammatory Drugs (NSAIDs) aka Pain Killers are actually the mainstay of treatment for Ankylosing Spondylitis. The process of new bone formation and inflammatory destruction of the sacroiliac joint can only be reversed by these groups of drugs. Thus, we often prescribe NSAIDs for a long duration. NSAIDs must be frequently co-prescribed with antacids and they should preferably be avoided in persons suffering from Gastric Ulcer, Kidney and Liver Disease, Cardiac Problems and in elderly individuals. Kindly note that NSAIDs can exacerbate Asthmatic attack is susceptible individuals.
Do we have any other medicine that treats this disease?
Many doctors prescribe methotrexate and Sulfasalazine. In fact Sulfasalazine helps those who also suffer from a large joint pain and swelling apart from Low Back Pain. In persons with only Low Back Pain, sulfasalazine is of no help. Sulfasalazine can prevent recurrence of Uveitis (Red Eye) in patients who are suffering from such a problem and hence are recommended in patients suffering from Uveitis.
A controversy exists on use of methotrexate in treatment of this disease. Although, quite a good number of doctors prescribe this drug, but there are no evidences in favour of this drug in treating Ankylosing spondylitis. I use methotrexate when there is a large joint involvement and it does not respond well to sulfasalazine at least after 3 months of therapy.
Thalidomide is one of the obsolete drugs which is currengtly having only historical importance. However, researchers have rediscovered some benefits of this medicine in treatment of ankylosing spondylitis.
My doctor says that I have been diagnosed with peripheral seronegative spondyloarthropathy? What is all about such a complicated name?
Seronegative Spondyoarthropathy is a syndrome that encompasses 5 disease.
• Ankylosing Spondylitis
• Psoriatic Arthritis
• Reactive Arthritis
• Enteropathic Arthritis
• Undifferentiated arthritis
They are characterised by absence of Rheumatoid Factor in blood and presence of HLA B27 antigen is most of the cases (but not all). They have a tendency to affect the low back region and large joints of legs often asymmetrically. Even the treatment of these diseases overlap considerably.
Peripheral Seronegative Spondyloarthropathy means that you are suffering from arthritis of large joints of hands or legs or both along with or without Low Back Pain ( Joints which are placed in the midline of our body is called Axial, where as those distant from the midline are called peripheral ).
Similarly, ankylosing spondylitis is often interchangeably used with the term Axial Seronegative Spondyloarthropathy which means that only spine is involved and no other joints of hands or legs are involved.
There is a thin line of difference between the treatment strategies of them.
What exercises are necessary for ankylosing spondylitis?
The details of the excercises are given in the Physiotherapy section of this website but the main principle of physical therapy is to stay active. The activity has to be a vigorous one in form of playing soccer, swimming, contact games etc. Heavy activity keeps the sacroiliac joint in motion. Thus, a mobile joint does not develop destruction easily, hence the damage is delayed and pain is alleviated.
My doctor has asked me to take biologics. What are these? Why they are so costly?
Biologics are the most updated and advanced therapeutic options for the autoimmune diseases. They are very big molecules in comparison to normal medicines and the production is very complicated and highly regulated as almost all of them are injections. This process of development and some patent protection issues make these molecules very costly.
In a simplified version, biologic molecules when administered in our body, seeps into the blood and blocks the offending immune cells and chemicals that are causing autoimmune destruction of the joints. In a word, they suppress the immune mechanism of our body so that autoimmune inflammation is arrested.
Needless to state that, suppression of the human immune system can increase the chances of external infections and thus, this risk of external infections is the major adverse effect of use of biologics.
Does Biologics complete cure the disease? How long do I need to take the biologics?
Biologic injections do not cure the disease completely. Ideally Biologics are prescribed on a particular schedule. Such as Adalimumab is prescribed in a format of 40mg subcutaneous injections taken every 2 weeks for 6 injections. That does not mean that the patient will never require the injection any further after completion of the six injection course.
If necessary and depending on the patients symptoms and some blood reports, biologics are started again and may continue life long.
Why should I spend so much of money on an injection when the disease will not be cured?
First of all, the cost of the injections is beyond the control of rheumatologists. There has been no restriction on price from the Health and Family welfare Department, GOI. Thus, the cost is indeed going to bury a deep hole in common men’s pocket.
The rationale of using biologics is like this:
Early use of Biologics can arrest the progression of the disease. Since Ankylosing Spondylitis can cause severe debility and loss of quality of life, use of biologics in an early stage is advocated. The principal of treatment of these autoimmune diseases is to arrest the disease when it is young. Once new bone formation starts and the joints start getting fused, medicines including the biologics will not be of much help. Thus it is also important to note that patients suffering from advanced disease should not go for therapy with biologics as it will not be cost effective at all.
Where can I get cheap biologics?
There are two options:
1. You can talk to the doctor or research yourself and find the local distributor of the biologic injection. There is a huge difference in the distributor price and retailer price which may amount to a 5 digit figure in INR. Get the biologics from the distributors directly.
2. In some states the State government has made arrangements to these biologics injection free of cost from the government hospitals and medical colleges. Such as in West Bengal, they are freely available in the SSKM Hospital or IPGMER Hospital and Calcutta Medical College. One needs to contact the Department of Rheumatology and Immunology of the respective medical colleges for availing the benefit; it is not available over the counter. |
