Fact number 1 about ankylosing spondylitis disease: Ankylosing spondylitis is a chronic autoimmune disease. What is an autoimmune disease? An autoimmune disease is a disease of the immune system. The main function of the immune system in our body is to recognize microbes that try to enter the body and to attack them with antibodies and eliminate them from the body. In an autoimmune disease, a misrecognition problem happens at the level of the immune system; the immune system fails to recognize some cells or tissues that are part of the body. It fails to recognize them as self-cells and tissues. It starts to deal with them the same way it deals with microbes; it attacks them. When those cells and tissues are attacked, they get inflamed and the patient develops symptoms and signs of that inflammation. This is the general concept behind any autoimmune disease in the body. The difference between one autoimmune disease and the other is the type of tissue or organ that is misrecognized by the immune system and that is attacked by the immune system.
In ankylosing spondylitis, the immune system attack is directed, very specially, against the ligaments of the joints of the neck and back and the sacroiliac joints located at the bottom of the back (figure 1). Other joints affected can be the hips and heels. Other organs affected can be the eyes (uveitis), the colon (colitis and diarrhea) and the lungs (especially the top parts of the lungs). The most important symptoms of inflammation of the back and neck in ankylosing spondylitis are pain and stiffness of the back and neck with an associated limitation of motion.
Fact number 2 about ankylosing spondylitis disease:
Early symptoms of ankylosing spondylitis are mostly caused by inflammation of the ligaments between the vertebrae (Figure 2b) and are reversible with treatment of ankylosing spondylitis. The most important early symptoms of ankylosing spondylitis are pain and stiffness of the neck and back with limitation of motion of the spine in these areas. The stiffness is mostly in the morning (morning stiffness) and may last for more than two hours. There is also pain at night when the patient turns in bed while sleeping. One important fact you need to know here is that the limitation of motion of the neck and back that is found when the rheumatologist examines the patient with ankylosing spondylitis is mainly caused by the pain. And because in the early stages of ankylosing spondylitis, most of the symptoms are caused by inflammation and pain, removing the pain with treatment like an anti-inflammatory painkiller will decrease the pain and restore the range of motion of the neck and back to normal.
Later symptoms of ankylosing spondylitis, and in particular limitation of motion of the spine, are mostly caused by transformation of the previously inflamed ligaments of the joints between the vertebrae, over the years, into bone tissue (Figure 2c). Why this happens? Because of lack of treatment of those inflamed ligaments in their earlier stages (earlier years) of inflammation. One important fact you need to know here is that the limitation of motion of the neck and back that is found when the rheumatologist examines the patient with ankylosing spondylitis is mainly caused by the transformation of ligaments between vertebrae into bone. When the ligaments of the joint between any two vertebrae are turned into bone, what happens is that the vertebrae become connected together as one unit that does not allow any motion between them anymore. Because the limitation of motion of the spine in the later stages of inflammation are caused by bony transformation of the ligaments of the vertebrae, those symptoms are not reversible with treatment of ankylosing spondylitis. Using treatment will not restore that range of motion to normal. It will still be limited as the cause of the limitation this time is different. However, treatment of ankylosing spondylitis with medications is still needed here though and is important to prevent more ligaments (the ligaments that are still healthy and the ligaments that are inflamed but have not transformed into bone) from turning into bone (Figure 3).
It is important to know that not every patient with ankylosing spondylitis will go the whole way to have the ligaments of his spine turn into bone tissue making several vertebrae turn into a one rigid piece of bone. This might happen only to those patients with a more severe disease (Figure 3) and it happens to varying degrees depending on the level of severity. There are milder forms of ankylosing spondylitis where hardly any transformation takes place and there are more severe forms of ankylosing spondylitis where really progressive bony transformation happens (the medical term for bony transformation is bony ankylosis). There are several levels of disease severity in between.
Fact number 3 about ankylosing spondylitis disease: Doctors diagnose ankylosing spondylitis by symptoms and signs and lab and imaging tests that reflect inflammation of the neck and back especially in the earlier stage of inflammation or that reflect, later on, the bony transformation of the ligaments of the neck and back. Concerning patient symptoms (history), it is the most important tool for diagnosis of a patient. We rely on the details of the symptoms of the patient like pain for example, the timing of the pain, associated symptoms and so on. The second most important tool is signs which is physical examination of the patient where we check which movements are limited or painful in addition to systemic examination of the body. After that, in patients suspected of having ankylosing spondylitis, we will do investigations, mostly plain X-rays of the sacroiliac joints and the spine and these are the very basic radiology investigations. Figure 3 shows an X-ray of a patient in whom bony transformation of the ligaments between the vertebrae had occurred over the years. We might also order an MRI of the sacroiliac joints, if the plain X-ray films were normal which means, they were not sensitive enough to show the changes caused by the disease. We also do lab tests that assess the degree of inflammation going on in the body like the erythrocyte sedimentation rate (ESR) and the C-reactive protein test (CRP). Other famous tests that most patients have read about like HLA-B27 test might also be ordered. The positivity of the HLA-B27 test helps but, alone, does not make the diagnosis of ankylosing spondylitis. At the same time, the negativity of the HLA-B27 test will not stand in the way of making the diagnosis.
Fact number 4 about ankylosing spondylitis disease: Early diagnosis and proper assessment and categorization of ankylosing spondylitis disease as mild or aggressive is very important to select the patients who need more aggressive treatment to prevent the progression of the disease and to improve their overall disease outcome. In the milder forms of ankylosing spondylitis, the disease will cause only mild chronic back pain with little, if any, stiffness and it will not affect the daily life of the patient. Most of the time those are the patients that are diagnosed later when they are in their late 40s or even 50s which is not at all the typical timing for a patient with ankylosing spondylitis to present to the doctor and to be diagnosed. The typical timing of presentation with symptoms for patients with the regular forms and also the more severe forms of ankylosing spondylitis is in the early 20s. Without treatment, the disease, in the more severe forms, will progress over the years to cause the fusion of the bones of the spine that will result in a rigid forwardly flexed spine that cannot extend.
Fact number 5 about ankylosing spondylitis disease: The care of the patient with ankylosing spondylitis will involve a multi-disciplinary team headed and coordinated by the rheumatologist. This team can include the physiotherapist, ophthalmologist, gastroenterologist, chest physician, orthopedist, cardiologist, psychiatrist and social worker.
Conclusion: Ankylosing spondylitis is a chronic autoimmune disease. It mainly causes inflammation of the ligaments of the joints of the neck and back the sacroiliac joints at the bottom of the back. Inflammation in these areas causes pain and stiffness at earlier stages of the disease and, at later stages, if left untreated, might cause transformation of the ligaments of the joints into bone tissue the causes limitation of motion of the spine. Doctors diagnose ankylosing spondylitis based on symptoms and signs and investigations that suggest inflammation or symptoms and signs and investigations that show bony transformation of the joints and ligaments. Disease severity and impact varies greatly between patients.
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This post was prepared and published by Dr. Hatem Eleishi. Dr. Hatem Eleishi is a professor of rheumatology at Cairo university (Egypt) and is especially dedicated to supporting arthritis patients with online educational videos and articles about arthritis causes and treatment. He also runs a rheumatology clinic in Cairo and a center for online medical consultations that, in addition to providing online rheumatology consultations, also provides online medical consultations in several different medical specialties by expert consultants from Egypt, Canada and the United States.
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