This is an inflammatory condition which results in the destruction of bones. Itinvolvescertain organs such as heart and lungs. There is a genetic predisposition to the disease. People with the gene called HLA B 27 are more prone to inherit the disease. But mind you not all with the gene HLA B27develop ankylosing spondylitis. Men are more prone than women. Appearing in early adulthood, the disease progresses over time. There is no permanent cure for ankylosing spondylitis. Treatment can lessen the disease and slower the progression. Pain control is a challenge.
The commonest areas to get affected are the spine, sacro iliac joint, ribs, shoulders, hips and lungs. As it is an inflammatory condition, the eyes can get affected.
Pain is a distressing problem due to the disease hence my involvement as a pain specialist with patients who suffer with the disease. My duty as a pain physician is to control the pain and allow the patients to have a comfortable life.
Symptoms
Pain and stiffness in the back, neck,especially in the morning and after periods of inactivity. Fatigue is a common symptom.
The symptoms can worsen, stop at irregular intervals.
The vertebrae can fuse and make the spine less flexible. The sacroiliac joint can fuse and make the movements of the pelvis troublesome.
Common areas to get affected
Sacro Iliac joint – Sacroilitis(inflammation of the sacro iliac joint) is the first symptom to appear. It is symmetrical and bilateral.
Lower spine –Can give a bamboo spine appearance
Shoulders – Bone formation, narrowing of the shoulder joint with pain.
Hip joint – Symmetrical and bilateral. Joint space narrows.
Ribs and the cartilages in between can get affected which can give rise to breathing problems.
Lungs – Can cause fibrosis of the lungs
Heart – Enlargement of the heart (cardiomegaly)
Risk factors
Sex - Men more than women
Age – Adolescent
Genetic - HLA B27 gene more prone
Spine with Ankylosing Spondylitis
Complications
New bone formation can result as a response to the disease by one’s body’s effort to heal. This can bridge the gap between vertebrae, sacro iliac joint and cause the joints to fuse. Ribs can get affected which can cause breathing problems.
Eye symptoms - Uveitis can lead to blurred vision.
Fractures of the vertebrae can put pressure on the spinal cord
Can affect the Aorta which is the largest artery in the body taking blood from the heart to the peripheries.
Diagnosis
Physical Examination
Patients generally present with pain,especially in the spine and the joints.
Doctor should carry out a thorough physical examination of the spine and the joints. The doctor may be able to identify the painful sites.
A reasonable time should be spent examining the patient.
X-ray - Not an expensive test. X-ray changes are easily identified.
MRI scans - Expensive but can show early changes
Lab Tests - No specific blood tests to diagnose ankylosing spondylitis. But usual inflammatory markets, such as raised ESR, high CRP, HLA B 27 antigen in blood can give a clue but not specific.
Treatment
The main goal of treatment is to relieve patients’ pain and stiffness and make them mobile. This helps them to carry on with day-to-day life.
Physical Therapy - Physiotherapy, good exercise regime can help control the pain.
Medication - Pain killers, such asnon steroidalanti inflammatory drugs (NSAIDS) such as imdomethacin, Brufen, Diclofenac, COX 2 inhibitors can be helpful. But you must bare in mind that these drugs if given on a long term basis can cause gastric bleeding, renal failure. I am not keen in prescribing these drugs on a long term basis. I have seen patients in Sri Lanka on long term NSAIDS. Monitoring becomes difficult with these patients as there is no proper system to monitor them. There are over 20 types of NSAIDS in the market with different trade names.
Interventions - Facet joint injections, injections into the joints, sacroiliac joint injections, radio frequency lesioning can ease the pain. I also do sacro iliac joint radio frequency lesioning to the sacro iliac joint.
Surgery - in rare cases I have seen sacro iliac joint replacement done in my unit in England by orthopaedic surgeons. I don’t think it’s done in Sri Lanka.
Biological medications such as Tissue Necrosis Factor (TNF) and interleukins can be used intramuscularly. IeHumira. These are expensive and close monitoring is necessary.
The writer Dr Namal Senasinghe MBBS (SL) FFARCS, Dip in Pain Medicine, FFPMCA, CCST (U.K.) is a consultant in pain medicine with specialist registrations in the general medical council, United Kingdom and the Sri Lanka Medical Council. He is in charge of the London Pain Clinic, 31 Horton Place, Colombo 7 and available for consultations.