Ankylosing spondylitis and back pain
Last reviewed: 23.04.2024
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Ankylosing spondylitis, or Bechterew's disease, is a systemic disease characterized by inflammation of the axial skeleton and large peripheral joints, nocturnal back pain, stiffness of the back, increased kyphosis, constitutional symptoms and anterior uveitis. For diagnosis it is necessary to identify sakroileitis on radiographs. Treatment includes an NSAID or antagonist of tumor necrosis factor and physical support to preserve joint mobility.
Ankylosing spondylitis is three times more common in men than in women, most often debuting at the age of 20 to 40 years. It is 10-20 times more likely [occurs in relatives of the first line of kinship than in the general population. The risk of contracting ankylosing spondylitis in relatives of the first line with the carriage of the HLA-B27 allele is about 20%. An increase in the frequency of HLA-B27 in white or HLA-B7 in black indicates a genetic predisposition. However, the level of concordance in identical twins is about 50%, which indicates the role of external environmental factors. In the pathophysiology of the disease, immunosuppressed inflammation is assumed.
[How does ankylosing spondylitis manifest?
In the debut, the most common symptom is back pain, but the disease can begin with peripheral joints, especially in children and women, rarely with acute iridocyclitis (iritis or anterior uveitis). Other early signs and signs may be a decrease in the volume of chest movements due to generalized defeat of the rib-vertebra joints, subfebrile, fatigue, anorexia, weight loss and anemia.
Back pain often occurs at night and varies in intensity, with time becomes more permanent. Morning stiffness, usually decreasing with activity, and spasm of paravertebral muscles develop gradually. Bending the body or posture with a forward tilt facilitates pain and paraspinal muscular spasm. Thus, kyphosis is common in untreated patients. Severe arthritis of the hip joint may develop. In advanced stages, patients have increased kyphosis, disappearance of lumbar lordosis, a posture with a fixed forward inclination, which disrupts the ventilation capacity of the lungs and makes lying on the back impossible. Possible development of deforming arthrosis and tendonitis of the Achilles tendon.
Systemic manifestation of the disease occurs in 1/3 of patients. Recurrent acute anterior uveitis is common, but usually self-healing. Rarely, it has a prolonged course and causes a decrease in vision. Neurological signs are occasionally caused by compression radiculopathy or sciatica, vertebral fractures or subluxations, horse tail syndrome. Cardiovascular manifestation may include aortic insufficiency, aortic, pericarditis, cardiac conduction abnormalities that can be asymptomatic. Shortness of breath, coughing and hemoptysis may result from nontuberculous fibrosis and cavity formation in the upper lobes of the lungs, secondary infection (aspergillosis) may be associated with this. Rarely, ankylosing spondylitis causes secondary amyloidosis. Subcutaneous nodules do not occur.
Other spondyloarthropathies
Other spondyloarthropathies may develop associated with rstrointestinal diseases (sometimes called zheteropathic arthritis), such as inflammatory enteritis, the imposition of surgical anastomoses, and Whipple's disease. Juvenile spondyloarthropathy is asymmetric, most pronounced in the lower extremities, most often debuting at the age of 7 to 16 years. Spondyloarthropathy can develop in patients without the characteristic signs of other specific spondyloarthropathies (undifferentiated spondyloarthropathy). Treatment of arthritis in these spondyloarthropathies is the same as with reactive arthritis.
How to recognize ankylosing spondylitis?
Ankylosing spondylitis should be suspected in patients, in particular a young age, with nocturnal back pain and kyphosis, a decrease in chest excursion, Achilles tendinitis, or unspecified anterior uveitis. Relatives of the first line, persons suffering from ankylosing spondylitis, should cause the greatest alertness. The following studies should be performed: ESR, C-reactive protein, leukoformula Immunoglobulins M, rheumatoid factor, antinuclear antibodies are determined only when peripheral arthritis causes suspicion of having another disease. Specific laboratory tests are not available, but the results may increase the grounds for diagnosis or exclude it in favor of diseases that mimic ankylosing spondylitis. If, after studies, suspicion of the disease persists, the patient should conduct a roentgenography of the lumbosacral spine to establish sakroileitis and confirm the diagnosis.
Alternatively, ankylosing spondylitis can be diagnosed with modified New York criteria. According to these criteria, the patient must have radiographic confirmation of sacroileitis and one of the following:
- limitation of mobility of the lumbar spine and in the sagittal plane (side view) and in the frontal plane (examination from the back);
- restriction of the chest excursion in comparison with the age norm;
- anamnesis of inflammatory pain in the back. Anamnestic differences of inflammatory pain in the back from non-inflammatory following debut at the age of under 40, gradual increase, morning stiffness, improvement in physical activity, duration of more than 3 months before seeking medical help.
ESR and other acute phase reactions (for example, C-reactive rothein) are unstable in patients with active disease. The test for rheumatoid factor and antinuclear antibodies is negative. The HLA-27 marker has no diagnostic value.
Early radiographic abnormalities are represented by pseudo-expansion due to subchondral erosions, followed by sclerosis or later narrowing and even overgrowth of the sacroiliac joint. The changes are symmetrical. Early changes in the spine are represented by an emphasis on the boundaries of the vertebral bodies with sclerotization of corners, spotted calcification of ligaments and one or two developing syndesmophytes. Late changes lead to the formation of a "bamboo spine" as a result of prominence of syndesmophytes, diffuse paraspinal calcification of ligaments and osteoporosis; these changes are noted in some patients who have been ill for more than 10 years.
Changes typical for ankylosing spondylitis may not be detected on the pathogens for several years. CT or MRI detect changes earlier, but to date there is no consensus on their use in routine diagnosis.
A herniated disc can cause pain and radiculopathy reminiscent of ankylosing spondylitis, but pain is limited to the spine, usually has a more acute symptomatology and does not have concomitant systemic manifestations or abnormalities in laboratory tests. If necessary, CT or MRI can be used for differential diagnosis of disk hernia from Bekhterev's disease. The defeat of only the sacroiliac joint may resemble ankylosing spondylitis in infectious lesions. Tuberculous spondylitis can mimic ankylosing spondylitis.
Diffuse idiopathic skeletal hyperostosis (DISG) occurs mainly in men over 50 years old and may have a clinical and radiological similarity to Bekhterev's disease. The patient marks vertebral pain, stiffness, and latent restriction of movements. Radiographically, with DISG, massive ossification is seen in front of the anterior longitudinal ligament (calcification resembles the flow of the molten wax of the suppository in front and along the sides of the vertebrae), the appearance of bone bridges between the vertebrae, usually affecting the cervical and lower thoracic vertebrae. However, the anterior longitudinal ligament is intact and is often delayed, the sacroiliac and vertebral apophyseal joints do not have erosion. An additional differential criterion is stiffness, which is not accentuated in the morning and normal ESR.
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How to treat ankylosing spondylitis?
Ankylosing spondylitis is characterized by alternation of periods of moderate and severe inflammation with periods of mild inflammation or lack of it. Proper treatment in most patients leads to minimal disability or lack of it and a full life despite stiffness in the back. In some patients, the course of the disease is severe and progressive, leading to severe disabling deformities. The prognosis is poor in patients with refractory uveitis and secondary amyloidosis.
The goal of the treatment is to reduce pain, maintain the functional condition of the joints and prevent visceral complications.
NSAIDs reduce pain, suppress joint inflammation and muscle spasm, thus increasing the amplitude of movements, which facilitates curative gymnastics and prevents contractures. Many NSAIDs are effective in a disease such as ankylosing spondylitis, but tolerability and toxicity of drugs dictate the need for choice. The daily dose of NSAIDs should be minimal effective, but the maximum doses may be necessary with the activity of the disease. An attempt to discontinue drugs should be slow in a few months, provided there are no joint symptoms and disease activity.
Sulfasalazine can help in reducing peripheral articular symptoms and laboratory markers of inflammation. Peripheral articular symptoms can also be reduced by methotrexate. Systemic administration of corticosteroids, immunosuppressants and other modified antirevigmatic agents has no proven efficacy and should not generally be used. There is increasing evidence that biological agents (eg etanercept, infliximab, adalimumab) are effective in the treatment of inflammatory back pain.
For the correct performance of exercise therapy, exercises for pozhnyh muscles (for example, postural training, therapeutic gymnastics), maximum activation of muscles, counteracting potential deformations (for example, extensors are preferable to flexors) are necessary. Reading in the supine position with the support of the elbows or the pillow, thus unrolling the back, can help maintain the mobility of the back.
Intra-articular corticosteroid injection can be useful, especially when one or two peripheral joints have a more severe inflammation than others, thus allowing exercise and rehabilitation This can be effective when systemic use of drugs is ineffective. Injections of corticosteroids into the sacroiliac joint sometimes help reduce the severity of sacroiliitis.
For the treatment of acute uveitis, usually local corticosteroids and mydriatica are sufficient. With severe hip arthritis, total arthroplasty can dramatically improve motion.
More information of the treatment