Ankylosing spondylitis

Ankylosing Spondylitis (AS) is a chronic, inflammatory autoimmune disease primarily affecting the spine and sacroiliac joints (where the spine meets the pelvis). It causes inflammation in the affected areas, leading to pain and stiffness. Over time, the inflammation can result in the fusion of the spine, which can severely restrict movement and flexibility.

Key Features of Ankylosing Spondylitis:

• Inflammatory Disease: AS is part of a group of diseases called spondyloarthropathies, which are characterized by inflammation in the joints and entheses (sites where tendons or ligaments attach to bone).
• Progressive Stiffness: AS typically leads to chronic back pain, stiffness, and, eventually, the fusion of spinal bones (vertebrae).
• Autoimmune Mechanism: It occurs when the immune system mistakenly attacks the body's own tissues, particularly those in the spine and large joints.

Causes and Risk Factors:

The exact cause of ankylosing spondylitis is unknown, but it is thought to be linked to genetic and environmental factors:

1. Genetics: The vast majority of people with AS carry a gene called HLA-B27. However, not everyone with this gene develops AS, and not everyone with AS has this gene.
2. Family History: Having a family member with AS increases the risk of developing the condition.
3. Environmental Triggers: Infections, particularly those in the gastrointestinal or urinary tract, may trigger the disease in genetically predisposed individuals.

Symptoms:

The symptoms of AS can vary, but they usually develop gradually and worsen over time. Common symptoms include:

• Chronic Low Back Pain: Often starting in the sacroiliac joints (lower back and pelvis area). The pain tends to worsen at night and improves with movement.
• Stiffness: Particularly in the lower back, especially after periods of inactivity, such as in the morning.
• Reduced Flexibility: Over time, AS can limit the ability to bend or twist the spine due to spinal fusion.
• Enthesitis: Inflammation where tendons and ligaments attach to bones, often seen in the heels, knees, and hips.
• Fatigue: A common symptom in people with AS due to chronic inflammation.
• Postural Changes: As the disease progresses, some people develop a forward-stooping posture (kyphosis).
• Peripheral Joint Involvement: Although AS primarily affects the spine, it can also involve other joints, particularly the hips, knees, and shoulders.
• Other Symptoms: These can include eye inflammation (iritis or uveitis), which causes redness and pain in the eyes, and may lead to vision problems if untreated.

Diagnosis:

Diagnosing ankylosing spondylitis involves:

1. Clinical Evaluation: A doctor will take a detailed medical history, assess symptoms (particularly chronic back pain), and conduct a physical exam.
2. Imaging Studies:
   • X-rays can show characteristic changes in the sacroiliac joints and spine, including joint fusion and bone erosion.
   • MRI (Magnetic Resonance Imaging) may reveal early signs of inflammation in the spine and sacroiliac joints, even before visible damage appears on X-rays.
3. Blood Tests:
   • Testing for the presence of HLA-B27 (a genetic marker commonly found in people with AS).
   • Elevated C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR), which are markers of inflammation, may also be detected in blood tests.
4. Physical Tests: Specific tests like the Schober test and flexion tests can help assess spinal flexibility and joint mobility.

Treatment:

Although there is no cure for ankylosing spondylitis, treatment can help manage symptoms, reduce inflammation, and slow the progression of the disease:

1. Medications:
   • Nonsteroidal Anti-inflammatory Drugs (NSAIDs): These are often the first line of treatment to reduce pain and inflammation (e.g., ibuprofen, naproxen).
   • Disease-Modifying Antirheumatic Drugs (DMARDs): For more severe cases, medications like sulfasalazine or methotrexate can help manage inflammation and disease progression, especially if peripheral joints are affected.
   • Biologic Agents: Tumor necrosis factor inhibitors (TNF inhibitors) such as etanercept, infliximab, or adalimumab, as well as interleukin-17 (IL-17) inhibitors (e.g., secukinumab), can be used to target specific molecules involved in the inflammatory process.
2. Physical Therapy and Exercise:
   • Stretching and strengthening exercises are vital for maintaining flexibility and posture. A physical therapist can design a program to help improve spinal mobility and prevent deformities.
   • Posture training to help manage the forward-stooping posture and reduce spinal stiffness.
3. Surgery: In rare cases, surgery may be necessary, especially if there is joint damage, severe deformity, or if the disease does not respond to other treatments. This could include joint replacement or spinal surgery.

Prognosis:

The progression of ankylosing spondylitis varies from person to person. Some people experience mild symptoms, while others may have more severe disease progression and significant disability. However, with early diagnosis and appropriate treatment, many individuals with AS can maintain an active life and prevent significant complications.

• Long-term Outlook: In the early stages, with treatment, individuals can manage symptoms and prevent or minimize spinal fusion. However, if untreated, the disease can lead to severe spinal stiffness and disability.
• Quality of Life: With proper treatment and lifestyle modifications (such as regular exercise and maintaining good posture), people with AS can lead productive and relatively pain-free lives.

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