Thirty-year-old James (not his real name), a young energetic man, started suffering from backache. Initially, it was in the lower back, he presumed it was due to continuous desk work for long hours. But as the pain shifted to the mid and upper back as well, he decided to see a bone specialist. After a clinical examination and some investigations, he was informed that he had ankylosing spondylitis. Ankylosing spondylitis (AS) is a chronic inflammatory disease that affects the spine and joints. It causes pain, stiffness, and inflammation of the spine and affected joints. Usually, there is backache, pain, and swelling in the joints of the back, fingers, toes, ribs, shoulders, knees, and or feet. One may also suffer from chest pain, tightness or breathlessness. Along with that, there is fatigue, inflammation and redness of eyes, and skin rashes. Occasionally, there may be abdominal pain and loose bowel movements. The disease progresses slowly, resulting in stiffness of the spine. The spine becomes rigid (bamboo spine) and loses its mobility. It is an autoimmune disease, which means that the immune system attacks the body parts, instead of protecting it. The exact cause is unknown, but it is supposed to be due to the interplay of genetic and environmental factors. Those having HLA-B27 antigen in their genes are more vulnerable to developing AS (ankylosing spondylitis). Young men suffer more than women. As the disease progresses, there is a fusion of vertebrae (small joints of the backbone), resulting in stiffness of the backbone. Sometimes, spinal nerves may be compressed due to inflammation, causing abnormal sensations in the limbs. Pain and stiffness increase over time, causing a hunched posture of the individual. Inflammation and damage can occur in other joints like hips, knees, shoulders, and feet. Inflammation occurs over where ligaments and tendons attach to the bones. It can be painful and affect mobility. Small joints, if affected, become swollen and painful. Eyes become red and pain occurs. Untreated, vision becomes impaired. People with AS are at an increased risk of spinal fractures, particularly if they have pre-existing osteoporosis. These people are at greater risk of cardiovascular disease. It may affect the ribs, and lungs as well, causing breathlessness, due to fibrosis. Inflammation of the gut results in diarrhoea and digestive disturbances. The prognosis of ankylosing spondylitis is highly variable. Some individuals experience worsening of the disease, disabling the individual, whereas in some, the progression of symptoms is slow and quality of life is maintained despite pain and stiffness. Some individuals experience periods of remission (when symptoms are mild or absent) and flares (when symptoms worsen). Persons who experience an earlier onset of ankylosing spondylitis or have hip involvement may have a comparatively poor prognosis. The diagnosis involves a combination of detailed medical history, clinical examination, imaging tests (like X-rays and MRI), and blood tests to check for inflammation markers and the HLA-B27 gene. There is no root cure for AS. The focus of treatment is to maintain quality of life and prevent further joint damage and progression of the disease, along with complications. Non-steroidal anti-inflammatory drugs (NSAIDs) are used to relieve pain and stiffness. However, repeated use can cause side effects like gastritis and kidney damage. If they are not effective, other drugs like corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs), tumour necrosis factors (TNF) are used. Physical exercise is planned to relieve stiffness, maintain flexibility of the spine and maintain posture. Exercises to strengthen the back and spine are useful. Swimming, preferably in a warm pool is also a very good exercise in this regard. Maintaining a normal body weight and avoiding obesity helps in controlling symptoms as less weight is imposed on the backbone. Surgery is used rarely to repair or replace a damaged joint. Treatment is useful when started early. Therefore, awareness about AS is useful. AS should also be considered a possible condition in any young person with backache. Early diagnosis and treatment can help check the progression of the disease. Dr Rachna Pande is a specialist in internal medicine. rachna212002@yahoo.co.uk
