Ankylosing spondylitis (AS)?

AS is a persistent (chronic) arthritic (rheumatic) disease of unknown cause. It mainly affects the spine and the sacroiliac joints. Sometimes other joints and other parts of the body are affected. The word spondylitis means inflammation of the spine. The word ankylosing means bones that tend to join together (fuse) across a joint.
Understanding the lower back
The spine is made up of many bones called vertebrae. The vertebrae are roughly circular and between each vertebra is a disc. The discs are made of strong rubber-like tissue which allows the spine to be fairly flexible. Strong ligaments also attach between adjacent vertebrae to give extra support and strength to the spine. There are also various muscles that are attached to the spine which enable the spine to bend and move in various ways. There are also small facet joints that help to attach vertebrae to each other. The sacrum is formed from five fused vertebrae that are joined together. They form a triangular-shaped structure at the bottom of the spine. The two sacroiliac joints are the large long joints that join the sacrum to the main bone of the pelvis (the ilium).

The spinal cord, which contains the nerves that come from the brain, is protected by the spine. Nerves from the spinal cord come out from between the vertebrae to take and receive messages to various parts of the body.
The lower back is typically the main site of inflammation
In AS, the ligaments of the lower spine become inflamed at the points where they attach to the spinal bones (vertebrae). In time, this can stimulate the bone-making cells and cause some bone to grow and form within the ligaments. In time, these bony growths may become larger and form bony bridges between vertebrae that are next to each other. This may, over time, cause some of the vertebrae in the spine to fuse together with this new abnormal bone material.
The sacroiliac joints and their nearby ligaments also commonly become inflamed. This too may ultimately end in fusion between the sacrum and pelvis. The small facet joints of the spine are also commonly inflamed.
Other areas of the body may be affected
The disease is not always confined to the spine and sacroiliac joints. In some cases, inflammation occurs in other joints and in other parts of the body outside of the spine (detailed below).
Who gets ankylosing spondylitis (AS)?
AS most commonly begins between 20 and 30 years of age, but sometimes first develops in children and older adults. It is three times more common in men than in women. There may be a family history with two or more members of a family being affected.
What causes ankylosing spondylitis (AS)?
The cause is not known. However, there is a strong hereditary (genetic) tendency. For example, there is a strong association with a gene called HLA-B27. About 9 in 10 people with AS have this gene compared with less than 1 in 10 in the general population. However, having this gene does not mean that you will automatically get AS. Also, some people develop AS who do not have this gene. As yet, the trigger is not known and other genes and factors may also be involved in causing AS.
What are the symptoms of ankylosing spondylitis (AS)?
Back pain
The main symptom is back pain. The pain usually starts in the lower back. It may be just mild backache at first. It typically becomes gradually worse over several months. The pain may be over the buttocks, and down the back of the thighs. Coughing or straining may make pain worse. Rest does not make it better. In fact, the pain may wake one up from sleep. Exercise and movement usually ease the pain. (This is the opposite to most bouts of common mechanical backache which may alert a doctor to the diagnosis of AS.) The pain tends to be worse first thing in the morning. The pain tends to ease as the day goes on.
The middle (chest part) of the spine may become affected. If this occurs, the joints between the ribs and the spine may also become painful.
Stiffness in the lower spine
The stiffness can be quite severe first thing each morning. It usually improves with activity and exercise, and tends to ease as the day goes on.
Other joint symptoms apart from the spine
Other joints are affected at some stage in about 4 in 10 cases. The most common are the hips, knees, ankles, and shoulders.
Inflammation of tendons and ligaments
Tendons and ligaments in various parts of the body (in addition to those attached to the bones (vertebrae) of the lower spine) may become inflamed and painful where they attach to bones. Common examples are the Achilles tendon where it attaches to the heel, and where chest muscles attach to the ribs.
Inflammation of part of the eye (uveitis)
Uveitis affects about 1 in 3 people with AS from time to time.A doctor should be consulted urgently if an As patient develops a painful or red eye and treatment with eye drops should be started as soon as possible. Treatment of uveitis is usually successful. However, if not treated quickly there can be permanent loss of vision in the eye (partial or complete).
General symptoms
Some people with AS feel generally unwell with symptoms of tiredness or depression. Weight loss or anaemia sometimes occur.
How is ankylosing spondylitis (AS) diagnosed?
This condition is diagnosed from the person’s symptoms and X-ray or MRI pictures. Blood tests can be helpful, mainly to rule out other conditions.
As the disease progresses, typical changes develop on X-ray pictures of the sacroiliac joints and spine. The X-ray pictures show the bones (vertebrae) gradually fusing together. However, these changes may take several years to become bad enough to be seen on X-ray pictures.
More recently, an MRI scan of the sacroiliac joints has been used to confirm the diagnosis at an earlier stage. An MRI scan can give a much more detailed view of a joint than a traditional X-ray picture and can detect inflammation in the sacroiliac joints.
How does ankylosing spondylitis (AS) progress?
Symptoms can vary in severity and usually wax and wane. Flare-ups of inflammation which cause periods of worse pain and stiffness tend to occur from time to time. If joints outside the spine are affected, they tend to flare up at the same time as back symptoms. The number of flare-ups that occur, how severe they are, and how long they last, can vary greatly from person to person.
In time, the mobility and flexibility of the spine may be reduced. This occurs as the inflammation and bony growths that occur cause gradual joining together (fusion, or ankylosis) of some of the vertebrae. The number of vertebrae involved and the extent of any fusion varies from person to person. A bent-over (stooping) deformity may occur in severe cases.
What are the treatments for ankylosing spondylitis (AS)?
The aims of treatment are:
• To ease pain and stiffness.
• To keep the spine as mobile and flexible as possible.
• To limit the extent of any deformity.
Physiotherapy and exercise
It is vital to have a good posture and a regular exercise routine. This helps to keep a full range of spinal movement and may help to prevent the spine from stiffening up. The exercises may also ease back pain. A physiotherapist can advise on the exact exercises to do. Exercises should become a routine part of life. Ideally, they should be done daily.
Anti-inflammatory medicines
non-steroidal anti-inflammatory drugs (NSAIDs) reduce inflammation and ease pain. An important reason to take these medicines is to ease pain so that regular exercises can be done without much discomfort.
It is thought that anti-inflammatory medicines only ease symptoms but do not alter the course of the disease. Therefore, these medicines should be taken as and when the pain flares up. But then if symptoms ease, not to take them. (This is repetition I think. Possible just refer to the OA or RA section)
Ordinary painkillers
Painkillers such as paracetamol may be sufficient if symptoms are mild between flare-ups
Immunosuppressant medicines
Biological therapies have become available in recent years that suppress the immune system and have made a significant impact on the treatment of AS. Biological therapies are genetically engineered proteins such as special antibodies called monoclonal antibodies. They can target specific chemicals of the immune system involved in the inflammation process. In AS, a chemical called cytokine tumour necrosis factor alpha (TNF-alpha) is involved in the inflammation process. Certain medicines in a group called TNF-alpha antagonists (which are really manufactured antibodies) block the action of this chemical and therefore suppress the disease activity.
Treatment should be started and supervised by a specialist who is experienced in diagnosing and treating AS.
Other medication
Occasionally, other medicines are used:
• A steroid injected directly into a badly inflamed joint is sometimes used to ease symptoms.
• Medicines called bisphosphonates are used to treat osteoporosis that is associated with AS.
Other treatments
Other treatments sometimes used include the following:
• Transcutaneous electrical nerve stimulation (TENS) machines are sometimes used to ease pain. (These give tiny electrical currents into the affected area.)
• Heat – for example, a hot shower – may help to ease pain, particularly each morning.
• Some people find regular massage is soothing.
• About 1 in 20 people with AS need a hip replacement at some stage, as their hip sometimes becomes badly affected. Rarely, surgery is needed to correct a severe spinal deformity.
Ankylosing spondylitis (AS) and cardiovascular disease
Patients with AS have an increased risk of developing cardiovascular disease when they become older. It is not clear why the risk is increased in people with AS. It may be that the persistent (chronic) inflammatory nature of the condition is partially responsible. Therefore, steps should be taken to reduce the risk of cardiovascular disease by other means.
What is the outlook (prognosis)?
Although there is no cure for ankylosing spondylitis (AS), the outlook is quite good for most people with the disease. After an initial period of inflammation, in many people with AS the disease settles down to a low level of activity. Flare-ups of symptoms occur from time to time, but are often mild or moderate. In most people with AS, regular exercise and medication keep symptoms away, or much reduced. The lower spine tends to become more stiff and less flexible over the years. In some people, the stiffness is more severe than in others.
About 8 in 10 people with AS remain fully independent or minimally disabled in the long term. This is despite eventual severe restriction of spinal flexibility that occurs in about 4 in 10 people with AS. Most people with AS are able to work full-time for the whole of a normal working life. However, heavy manual work may become difficult. If spinal deformities do arise, they do so after at least 10 years.
About 1 in 10 people with AS have a severe form of the disease, and may become quite disabled over time. However, the recent introduction of treatment with TNF-alpha antagonists (described above) seems to have improved the outlook for people with more severe AS.
In most cases, episodes of arthritis outside the spine and/or eye inflammation do not occur, or only occur now and again. In a small number of cases, these problems outside the spine return (recur) frequently, or become severe. Eye inflammation (uveitis) may lead to blindness if not treated promptly.
People with established AS have an increased risk of fracturing the spine if they are involved in a high-impact accident such as a car crash. This is because the spine becomes more easy to fracture as it becomes more stiff and rigid.

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