Spondylitis (also called ankylosing spondylitis) is a type of arthritis that affects the spine or backbone. Spondylitis may cause back pain and stiffness. The bones of the spine, called vertebrae, may grow or fuse together resulting in a rigid spine. These changes may be mild or severe. Severe disease may lead to poor posture and deformities. Early diagnosis and treatment helps control pain and stiffness, and may reduce or prevent significant deformity.
Who is affected by spondylitis?
Spondylitis affects about three hundred thousand Americans or 0.2% of the adult population. Although it can occur at any age, spondylitis most often affects men in their 20s and 30s. It is less common and generally milder in women. It is more common in Caucasians than in African Americans.
What are the signs and symptoms of spondylitis?
The most common early signs of spondylitis are constant pain and stiffness in the low back, buttocks and hips that continue for more than three months. Spondylitis often starts around the sacroiliac joints where the sacrum (the lowest major part of the spine) joins the ilium of the pelvic bone. Spondylitis can cause an overgrowth of the bones, which may lead to abnormal joining of parts that are normally separate. This is called bony "fusion."
Fusion affecting bones of the neck, back or hips may impair a person's ability to perform routine activities. Fusion of the ribs to the spine or breastbone may limit a person's ability to expand his or her chest when taking a deep breath.
Spondylitis may also affect some of the ligaments and tendons that attach to bones. Tendonitis (inflammation of the tendon) may cause pain and stiffness in the area behind or beneath the heel, such as the Achilles tendon at the back of the ankle.
Spondylitis is a systemic disease, which means symptoms may not be limited to the joints. Patients may also have a fever, fatigue and loss of appetite. Eye inflammation (redness) occurs in about one-fourth of patients with spondylitis. In rare cases, lung and heart problems may also develop.
What causes spondylitis?
Although the cause of spondylitis is unknown, there is a strong genetic or family link. Most, but not all, patients with spondylitis carry a gene called HLA-B27. Although people carrying this gene are at increased risk of developing spondylitis, the majority (over 75%) will never develop the disease.
How is spondylitis diagnosed?
The diagnosis of spondylitis is based on several factors, including:
- Presence of signs and symptoms as noted previously
- Findings on physical examination and X-rays
- How is spondylitis treated?
There is no cure for spondylitis, but discomfort can be reduced and function can often be improved. The goals of treatment are to:
- Reduce pain and stiffness
- Maintain a good posture
- Prevent deformity
- Preserve one's ability to perform normal activities
When properly treated, people with spondylitis may lead fairly normal lives. Under ideal circumstances, a team approach to treat spondylitis is desirable. Members of the treatment team typically include the patient, doctor, physical therapist and occupational therapist.
Physical and occupational therapy
Early intervention with physical and occupational therapy is important to maintain function and minimize deformity. The patient should try to maintain normal posture.
Patients with spondylitis are encouraged to sleep on a hard mattress with their back straight. Placing large pillows under the head is discouraged, since it may promote neck fusion in flexion. Similarly, propping the legs up on pillows should be avoided as it may lead to hip and/or knee fusion in a bent position. When sitting, chairs, tables and other work surfaces should be designed to avoid slumping or stooping. Armchairs are preferred over chairs without arms.
Since patients with spondylitis could easily hurt their rigid necks or backs, special care should be taken to avoid sudden impact, such as jumping, or falling.
Exercise
A program of daily exercise will help reduce stiffness, strengthen the muscles around the joints, and prevent or minimize the risk of disability. Deep breathing exercises may help keep the chest cage flexible. Swimming is an excellent form of exercise for patients with spondylitis.
Medications
While a cure for spondylitis is not available, certain drugs help provide relief from pain and stiffness and allow patients to perform their exercises with minimal discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used drugs for spondylitis treatment. NSAIDs are not related to cortisone (a steroid), although both work by reducing inflammation. A variety of NSAIDs are currently available, and the choice of a particular drug should be discussed with the treating doctor.
In severe cases, other medications may be added to the treatment regimen.
Other treatments
Patients experiencing eye inflammation (red eye) should be evaluated and treated by an ophthalmologist (eye doctor).
Patients are urged to not smoke or chew tobacco products because of the increased risk of lung problems and reduced chest cage expansion. Certainly, all of the other reasons why doctors discourage smoking also apply to spondylitis patients. Artificial joint replacement surgery may be a treatment option for certain patients with advanced joint disease affecting the hips or knees.
Patients are encouraged to discuss coping strategies, work-related issues, sexuality and other important concerns with their health care team.
Background Information
Spondylitis is an inflammation of a vertebra which is characterized by stiffness of the spine or neck and sometimes both, making movement painful, it can also affect hands and feet. Inflammation is either caused by some infection or medical diseases such as arthritis. There are various forms of spondylitis like ankylosing, rheumatoid, traumatic and few other. ankylosing spondylitis is the most common type of spondylitis, it is a type of arthritis that affects the spine or backbone.
The bones of the spine, called vertebrae, may grow or fuse together resulting in a rigid spine. These changes may be mild or severe. Severe disease may lead to poor posture and deformities. Early diagnosis and treatment helps control pain and stiffness, and may reduce or prevent significant deformity.
Some of the symptoms related to the disease are stiffness in the neck, fatigue, slight fever, limited expansion of the chest, stiffness and limited motion of low back, joint pain and swelling in shoulders, ankles and knees. Symptoms may come and go anytime, the course of the disease is unpredictable.
Specific cause of the disease is unknown but certain genes are known to play an important role in causing ankylosing spondylitis. Most frequently the disease begins between ages 20 and 40 but may begin before age 10 and rarely occurs after 40 years of age. It affects more men than women and is mostly genetic.
There is no direct test to diagnose AS. A clinical examination and X-ray studies of the spine, which show characteristic spinal changes and sacroiliitis, are the major diagnostic tools. Options for more accurate and much earlier diagnosis are tomography and magnetic resonance imaging of the sacroiliac joints. The Schober's test is a useful clinical measure of flexion of the lumbar spine performed during examination.
There exists no particular cure for AS, treatments and medications are available only to reduce symptoms and pain. Physical therapy and exercise, along with medication, are the most important part of therapy for ankylosing spondylitis. Physiotherapy and physical exercises are to be preceded by medical treatment in order to reduce the inflammation and pain.
Exercise will help in reducing pain and stiffness, care needs to be taken not to exercise in an active inflammatory state, this will make the pain worse. Maintaining good posture reduces the likelihood of a fused or curved spine which occurs in a significant percentage of diagnosed persons, as speculated by medical professionals and health experts .
Good posture techniques will also help alleviate some of the complications of AS. Most often, it is a rheumatologist who will outline a treatment plan, but other professional may also be able to help. Alternative treatments are massage, using a TNS unit or electrical stimulators, applying heat/cold all aide in pain relief. Maintaining a healthy body weight and balanced diet can also aide in treatment.
There are three major types of medications used to treat ankylosing spondylitis.
Anti inflammatory drugs include aspirin, ibuprofen, indomethacin, naproxen and COX-2 inhibitors, they reduce inflammation, and consequently pain. These drugs tend to respond to the pain and inflammation,
Opioid analgesics have also been proven to be very effective in alleviating chronic pain commonly experienced by those suffering from AS, especially in low dose time-release formulations. While NSAIDs should generally be tried first, the use of opioid analgesics either apart from or together with NSAIDs, these should not be dismissed for fear of addiction, as studies have shown that patients who properly take opioid analgesics for pain rarely suffer from addiction on using such opioid therapy for pain relief purposes.
DMARDs such as sulfasalazine, cyclosporin, methotrexate, and corticosteroids, are used to reduce the immune system response through immunosuppression.
The recent trend in the medical drug treatment of ankylosing spondylitis include:
- Pamidronate infusions once every month. This is a slow acting medicine and requires once monthly admission to the hospital where the medicine is given as intravenous infusions. The success rate is moderate.
- Anti-TNF agents (infliximab abd etanercept) – this is a very expensive but effective medicine. The permanent spinal structure damage cannot be reversed but at least can prevent active inflammation of the disease. These are also effective in controlling the eye inflammation associated with this disease. The main drawbacks are firstly, these medicines are so expensive that only a few can buy it in India. Secondly, there is a small chance that dormant tuberculosis may become active in some patients. Surgery is performed if pain or joint damage is severe.
The latest breakthrough in this disease has been the discovery of a technique known as genome-wide association scanning, researchers led by Professors Lon Cardon, Matthew Brown and Paul Wordsworth from the Wellcome Trust Centre for Human Genetics at the University of Oxford, and Dr Panos Deloukas from the Wellcome Trust Sanger Institute, Cambridge, have analysed DNA samples from 1000 patients with ankylosing spondylitis and a further 1500 people unaffected by the disease in search of genetic mutations which, if present, increase a person's risk of developing the disease. The researchers have identified two genes, ARTS1 and IL23R, which increase the risk of developing the disease.
The IL23R gene plays a role in the immune response to infection, providing instructions for making a receptor present on the surface of several types of immune system cells. The receptor is involved in triggering certain chemical signals inside the cell that promote inflammation and help coordinate the immune system's response to infection. It is already recognised as playing a role in a number of autoimmune diseases, such as Crohn's disease and psoriasis. Ankylosing spondylitis, Crohn's disease and psoriasis were known to often occur together, and this genetic finding goes a long way to explain why Professor Brown believes that the unexpected involvement of IL23R in ankylosing spondylitis provides a major step towards being able to treat the disease.
"We already know that IL23R is involved in Crohn’s disease, but no one had ever thought it was involved in ankylosing spondylitis," says Professor Brown. "A treatment for Crohn's disease that inhibits the activity of this gene is already undergoing human trials. This looks very promising as a potential treatment for ankylosing spondylitis."
The disease cannot be prevented whereas awareness about the disease may help in early detection, arresting further deterioration.
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