Ankylosing Spondylitis

What is Ankylosing Spondylitis?

               Ankylosing spondylitis (AS) is one of the many types of arthritis.  "Ankylosing" means joining together or stiffening;
 "spondylitis" means inflammation of the vertebral bones of the spine.  Inflammation of the bones in AS can lead to degeneration,
 pain, and loss of joint motion. AS typically affects the spine but can been seen in other areas, especially the hips. Ankylosing 
spondylitis can range from a mild to more severe disease in patients.  Ankylosing spondylitis is approximately 
three times more common in males than females.  It is usually diagnosed in young adults, with a peak onset between 
20 and 30 years of age.  Children may also be affected by a form of AS termed “juvenile ankylosing spondylitis”, 
seen in children younger than 16 years of age.  There is evidence suggesting a strong genetic component in the development 
of the disease.   Those with a family history of AS involving a first degree relative (i.e. mother, father, siblings) will be 5 to 16 
times more likely to develop AS.  

HOW DO YOU KNOW IF YOU HAVE ANKYLOSING SPONDYLITIS?

               Seventy-five percent of patients with ankylosing spondylitis most commonly complain of lower back pain. 
 Although lower back pain is a common complaint overall and can be caused by many other factors, back pain associated
 with ankylosing spondylitis is unique in part because of the following features:

-       Disease starts in early adulthood, often before 40 years of age.

-       Gradual onset of symptoms rather than a history of sudden onset such as after an injury

-       Symptoms persist for three months or longer.

-       Pain is worse after rest or prolonged sitting, such as pain upon waking in the morning.

-       Pain improves with activity and exercise. 

-       Rib cage pain; especially while taking a deep breath or coughing.

-       Stiffness or decreased movement of the back and neck. Ordinary tasks such as putting on socks and shoes may
 become difficult and painful. 

   AS is an inflammatory process that involves other areas of the body in addition to bones, including the eyes and spinal
 cord: 

Eyes — Uveitis, or inflammation of part of the eye, occurs in 25-40% of patients with AS.  Symptoms of uveitis

 include sudden onset of severe eye pain, blurring of vision and difficulty tolerating bright light.  Uveitis requires
 immediate medical attention and treatment.

Spinal Cord — Vertebrae, or bones of the spine, serve as the structural support to protect the spinal cord and

 nerves, and they provide motion, and function to the skeleton.  Patients with AS often develop fused vertebral spines. 

 Fused vertebral bones increase the chance of damaging the bones and place increased stress on surrounding structures

 such as ligaments, tendons, and muscles.  A fused spine creates not only pain but loss of motion, and can become more 

brittle with mechanical stresses.  If vertebrae become fractured and dislodge, there is an increased risk of damage from

 impingement of surrounding spinal cord structures and nerves.  Damage to the spinal cord, roots and nerves cause 

symptoms such as changes in sensation, strength and movement below the level of injury.  For example, decreased leg 

strength with numbness and tingling in a patient complaining of back pain may be a sign of spinal nerve compromise.  If

 symptoms such as these occur, immediate medical attention should be sought.  Other symptoms that should prompt 

emergent medical attention include saddle area numbness and/or new changes in bowel and bladder habits 

(e.g. constipation, loss of continence).

How is Ankylosing Spondylitis diagnosed?

               Ankylosing spondylitis is mainly diagnosed by the history of symptoms you provide your physician.  When the diagnosis

 of AS is suspected, your doctor may investigate by obtaining blood work and imaging studies such as X-rays of the back and 
pelvis.  The presence of X-Ray specific changes of the joints between the pelvis and the sacrum, or sacroiliac joints and vertebral

 bodies are signs of AS.  Changes in the sacroiliac joint space may be detected earlier than changes in the spine by joint space

 narrowing, erosion and possibly fusion.  The majority of the patients with ankylosing spondylitis experience their low back pain

 from inflammatory changes in their sacroiliac joints.  Similar joint changes can also be seen in the area of the vertebral bones in the

 lower back.  On X-Ray, these changes resemble bamboo, so it is given the name, “bamboo spine”.  Bamboo Spine signifies the

 complete fusion of the vertebral bones in the lower back. 

               Other imaging studies that are more sensitive than X-Ray include magnetic resonance imaging (MRI) and computed

 tomography (CT scanning). MRI and CT can be used to detect early changes of the affected joints. Although there is no specific

 blood test that can make a definitive diagnosis of AS, a protein named HLA-B27 can be measured.  A positive HLA-B27 

supports the diagnosis of AS, while a negative test strongly suggests that one does not have the disease.  Blood can also be 

tested for its erythrocyte sedimentation rate (ESR) and C reactive protein levels, which are increased during nonspecific active

 inflammatory processes, such as ankylosing spondylitis.

HOW TO SCORE THE SEVERITY OF YOUR ANKYLOSING SPONDYLITIS

               The pain from AS can last for a brief period of time, or can be a constant pain.  Your doctor may ask you a series of

 questions to understand the severity of your symptoms of ankylosing spondylitis. Constant fatigue, joint tenderness, stiffness or 

pain of the lower back and joints are signs of an active disease process.  Physicians may use a scoring system based on your

 symptoms to determine the degree of disease.  This system is named the “Bath Ankylosing Spondylitis Disease Activity Index”

 (BASDAI).  Scores are assigned on a range from 0 to 10, where 0 represents no symptoms to a score of 10 reflects the most 

severe symptoms.  The scores are based on the evaluation of six categories:

-       Fatigue

-       Spinal pain

-       Joint pain / swelling

-       Localized tenderness, a sign of ligament and tendon inflammation

-       Morning stiffness duration

-       Morning stiffness severity 

               The title of “active disease” is given to patients with a BASDAI score greater than four.  Determining whether your 
disease is considered “active” plays an important role in guiding treatment for ankylosing spondylitis by your doctor.

TREATMENT OF ANKYLOSING SPONDYLITIS

               There are many different treatment approaches due to the varying severity of disease in each patient.  Unfortunately,

 there is no cure for AS.  But treatment has been shown to improve symptoms.  The various treatments approaches are:

-       Smoking cessation to optimize lung function.  Patients often lose mobility of the chest wall, limiting the quality

 of deep breaths.  The chemicals found in cigarettes can irritate the lining of the lungs, further exacerbating symptoms

 adding to the underlying inflammatory process.   Smoking cessation hopes to improve the quality of breathing and 

maintain chest expansion.

-       Exercise can improve range of motion of affected joints, especially the lower back.  Overall gains in joint motion 

and posture have been shown to relieve symptoms of AS.  A physical therapy program can help target more 

problematic areas to improve mobility and decrease pain.   Modalities such as ultrasound, electrical stimulation,
 heat and/or cold therapy can be beneficial as adjuvant to complement an on going physical therapy program.

-       An anti-inflammatory diet is a reasonable adjunctive treatment for AS, an inflammatory disease.

-       Medications:

o   Non Steroidal Anti-inflammatory Drugs (NSAIDs), such as Ibuprofen, can also help during episodes

 of pain; their use has shown to be effective when taken regularly for a two week period.  Long term use of 
NSAIDS is associated with side effects such as stomach ulcers, high blood pressure and kidney problems 

for certain individuals.  It is important that you inform your doctor if you are taking or planning on taking 
NSAIDs.

o   If painful symptoms affect more one areas of the body, a medication named sulfasalazine may be a good 

treatment option.  This medication attempts to slow the progression of AS.  Some side effects include nausea,

 dizziness, headache, rash and low blood counts.  In rare instances, liver damage and destruction of blood cells

 have been seen; therefore routine blood test monitoring may be requested by your physician. 

o  Entanercept is an injectable drug that targets at a chemical mediator in the body called Tumor Necrosis

 Factor alpha (TNF alpha), which is made during periods of inflammation.  TNF alpha is responsible for fever,

 pain, tenderness and swelling during the painful episodes of ankylosing spondylitis.  Due to the binding of 

entanercept to TNF alpha molecules, arthritic symptoms are decreased and can prevent further destruction of 

joints.  The most common side effect is associated with irritation at the site of injection; however, headache, 
dizziness, and throat irritation may also occur.      

               For patients with severe symptoms in which conservative treatment options offer minimal relief, discuss with your doctor

 whether surgery to replace specific symptomatic joints may beneficial.  Partner with your physician to accurately assess where

 you lie in the spectrum of AS to seek optimal treatment with the goal of getting back to enjoying the activities you most enjoy
 rather than suffering in pain.   

Authors:  Hala Sabry, B.A., New York College of Osteopathic Medicine, Old Westbury, NY

                Victoria Chan Harrison, M.D., New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, 
New York, NY