Ankylosing Spondylitis

Overview

Ankylosing spondylitis (AS) is a chronic and progressive type of inflammatory rheumatism that primarily affects the spine and hip joints. This condition can cause the small bones in the spine (vertebrae) to fuse over time; this process may make the spine less flexible and can lead to a forward-hunched posture.

The disease usually begins in young adulthood with insidious low back pain and can be considered an autoimmune process where the body's defense system attacks its own tissues. Inflammation of the soft tissues between the vertebrae can trigger the body to produce new bone tissue to heal the area; this new bone formation can limit the joints' ability to move, leading to the structure known as "bamboo spine."

Professional rheumatological follow-up aims to provide comprehensive protection by monitoring the possibility of inflammation spreading to other parts of the body (such as the eyes, heart, or lungs).

The primary focus of treatment is to manage pain, maintain joint mobility, and help reduce the risk of developing permanent spinal deformities.

Symptoms of ankylosing spondylitis

Symptoms of ankylosing spondylitis usually develop slowly and may reach their most severe level in the morning or after long periods of inactivity. Unlike mechanical back pain, the nature of the pain may tend to improve with movement.

• Morning stiffness and back pain: A dull pain spreading to the buttocks that lasts for more than half an hour after waking may be felt; this can be severe enough to wake one from sleep and make it difficult to start the day.
• Pain decreasing with movement: Pains that increase during rest may ease as a result of joints warming up with light exercise or walking; this can reflect the inflammatory nature of the disease.
• Heel and joint pains: Inflammation can affect not only the spine but also the areas where ligaments attach to the bone; this may lead to sensitivities, especially in the heels or the rib cage, making breathing difficult.
• Postural changes: As the disease progresses, the loss of spinal flexibility may cause the person to unintentionally lean forward and restrict neck movements.
• Extreme fatigue: The body constantly fighting inflammation can cause a person to expend much more energy than normal during daily tasks and may cause a feeling of chronic exhaustion.

When to see a doctor

If you have back pain that lasts longer than three months, increases in the morning, and improves with movement, it may be recommended to consult a rheumatologist regarding the possibility of it being inflammatory rather than mechanical.

However, if you experience sudden vision loss, severe eye redness and pain (suspected uveitis), or stabbing pain and severe shortness of breath in the chest while breathing, you should apply to the emergency department immediately, as this could indicate that inflammation has affected other organs.

Causes of ankylosing spondylitis

While the exact cause of ankylosing spondylitis is not yet fully known, it is thought that a genetic predisposition combined with environmental factors may trigger this process. A misguided response of the immune system can be seen as the main source of joint damage.

• HLA-B27 gene: A large majority of patients may test positive for this genetic marker; the presence of this gene can make the person's immune system more susceptible to spinal inflammation.
• Immune system malfunctions: The body's defense cells may perceive healthy tissues in the joint areas as threats and attack them, potentially starting a chronic cycle of inflammation.
• Gut health and infections: Some research suggests that imbalances in gut flora or certain past infections might trigger the immune system in genetically predisposed individuals, initiating the disease.

Diagnosis of ankylosing spondylitis

The diagnosis process is based on combining the history of the patient's complaints with physical examination findings. Since X-ray findings may appear normal in early stages, advanced imaging methods may be required.

• Physical examination: Your doctor may measure the flexibility of your spine and check how much your rib cage expands when breathing to evaluate movement restriction.
• MRI (magnetic resonance imaging): This is the most sensitive method that can detect early-stage inflammation (sacroiliitis) that cannot be seen on X-ray; thus, the disease can be diagnosed before permanent damage occurs.
• Blood tests: Levels of inflammation markers (CRP, ESR) can be checked; additionally, the presence of the HLA-B27 gene may be examined to support the diagnosis.

Treatment of ankylosing spondylitis

In the treatment of ankylosing spondylitis, the aim is to relieve pain and preserve the freedom of movement by preventing the spine from fusing. The treatment process usually consists of a combination of medications and specific exercises.

• Non-steroidal anti-inflammatory drugs (NSAIDs): In addition to reducing pain, they may help slow the stiffening of the spine by suppressing inflammation.
• Biological drugs (TNF blockers): In cases that do not respond to conventional medications, they can stop the progression of the disease by targeting specific inflammatory proteins in the immune system.
• Physical therapy and exercise: Regular swimming, stretching movements, and upright posture exercises can form the most critical part of treatment to prevent joints from freezing.
• Surgical intervention: When joint damage is very advanced or the spine is severely curved, hip replacement or spinal surgery may rarely be needed to improve quality of life.

Risks of ankylosing spondylitis

In cases where the disease is not controlled, chronic inflammation may lead to complications that could negatively affect other systems of the body, not just the joints.

• Eye inflammation (Uveitis): This condition, characterized by eye pain, light sensitivity, and blurred vision, can pose a risk of permanent vision damage if not treated quickly.
• Spinal fractures: Bones may weaken over time (osteoporosis), and this situation may cause fractures in the spine even with a simple jolt.
• Heart and lung problems: In severe cases, the rib cage losing its flexibility can lower lung capacity; rarely, inflammation of the aorta, the main artery, may develop.

Prevention of ankylosing spondylitis

Since it is a genetically based disease, it may not be possible to prevent ankylosing spondylitis entirely; however, it may be possible to minimize its effects and eliminate the risk of disability with the right steps.

• Regular movement: Inactivity can be seen as the biggest enemy of this disease; staying active throughout the day may slow the rate at which inflammation freezes the joints.
• Smoking: Smoking can trigger lung problems in AS patients and may lead to faster progression of spinal damage, so quitting may be of vital importance.
• Early diagnosis: For people with a family history of this disease, taking simple back pain seriously and going for early check-ups may allow the disease to be stopped before it causes a permanent deformity.

Preparing for your appointment

If you have long-term back and hip pain, taking note of your symptoms before going to your doctor's appointment can speed up the diagnosis process. Being prepared can help your health team better analyze your situation.

What you can do:

• Make a list of symptoms: Note when the pain increases during the day, how long it lasts, and whether it goes away with movement.
• Prepare your medical history: Mention people in your family with similar pains, psoriasis, or inflammatory bowel disease.

Prepare your questions:

• Could this pain be caused by ankylosing spondylitis?
• What imaging tests do I need?
• Will exercising damage my joints or be beneficial?
• What are the long-term side effects of the medications?

What to expect from your doctor?

• How long does your morning stiffness last?
• Do you feel any relief in your pain when you exercise?
• Have you had eye redness or pain complaints before?
• What medications have you tried before for your back pain?