ANKYLOSING SPONDYLITIS (AS)

Definition

• Ankylosing spondylitis is a chronic, inflammatory, autoimmune disease.
• It primarily affects the spine and sacroiliac joints.
• It leads to pain, stiffness, and progressive fusion of the spine.

Types of Ankylosing Spondylitis

1. Primary Ankylosing Spondylitis

• Idiopathic form.
• Commonly associated with HLA-B27.
• Mainly affects spine and sacroiliac joints.

2. Secondary Ankylosing Spondylitis

• Occurs in association with other diseases:
  • Psoriasis
  • Inflammatory bowel disease
  • Reactive arthritis

3. Based on Age of Onset

• Juvenile-onset AS: onset before 16 years.
• Adult-onset AS: onset after 25 years.

Etiology

• Genetic predisposition:
  • Strong association with HLA-B27 gene.
• Environmental factors:
  • Infections
  • Physical stress or trauma.
• Hormonal factors:
  • Onset commonly during adolescence or early adulthood.

Pathology

• Chronic inflammation of:
  • Sacroiliac joints
  • Vertebral joints
  • Ligaments and entheses.
• Enthesitis:
  • Inflammation at tendon and ligament insertion sites.
• New bone formation:
  • Syndesmophyte formation.
• Progressive fusion:
  • Vertebral fusion leading to rigid spine (bamboo spine).

Pathological Process

1. Inflammation of sacroiliac and spinal joints
2. Fibrosis of ligaments and joint capsules
3. New bone formation
4. Ankylosis and spinal rigidity

Clinical Features

Spinal Features

• Chronic low back pain.
• Morning stiffness lasting more than 30 minutes.
• Pain improves with activity, worsens with rest.
• Reduced spinal mobility.
• Loss of lumbar lordosis.
• Increased thoracic kyphosis.

Peripheral Joint Features

• Hip involvement (common).
• Knee and ankle pain.
• Shoulder involvement.

Extra-Articular Features

• Fatigue.
• Weight loss.
• Uveitis:
  • Painful red eye
  • Photophobia.
• Cardiovascular involvement:
  • Aortitis
  • Aortic regurgitation.
• Respiratory involvement:
  • Reduced chest expansion.

Investigations

Imaging

• X-ray:
  • Sacroiliitis
  • Syndesmophytes
  • Bamboo spine.
• MRI:
  • Early inflammatory changes.
  • Active sacroiliitis.

Laboratory Tests

• ESR: raised.
• CRP: raised.
• HLA-B27: positive in majority.
• Rheumatoid factor: negative.

Complications

• Spinal deformity.
• Fixed kyphosis.
• Osteoporosis.
• Vertebral fractures.
• Restrictive lung disease.
• Uveitis.
• Cardiovascular disease.
• Depression due to chronic pain.

Management

Medical Management

• NSAIDs: first-line treatment.
• DMARDs:
  • Sulfasalazine (for peripheral joints).
• Biologic agents:
  • Anti-TNF drugs.
  • IL-17 inhibitors.
• Analgesics for pain relief.

Physical Therapy

• Postural exercises.
• Spinal mobility exercises.
• Breathing exercises.
• Regular stretching.

Lifestyle Modification

• Regular physical activity.
• Good posture habits.
• Firm mattress.
• Smoking cessation.

Surgical Management

• Corrective spinal surgery in severe deformity.
• Hip replacement if hip joint involved.

Homoeopathic Therapeutics

• Rhus toxicodendron: stiffness better with movement.
• Bryonia alba: pain worse with movement.
• Arnica montana: pain and soreness.
• Ruta graveolens: ligament and joint pain.
• Calcarea carbonica: degenerative changes.
• Silica: chronic inflammation and fibrosis.
• Arsenicum album: chronic pain with weakness.

Important Points

• Disease usually starts in young males.
• HLA-B27 strongly associated.
• Early diagnosis prevents deformity.
• Exercise is the most important non-drug therapy.
• Condition is chronic and progressive.