Some adolescents often tell their families about lumbosacral pain, which is especially severe in the second half of the night or at dawn, and wakes up in the morning with a feeling of stiffness, which is relieved by lumbar activities, adults often do not pay attention to it, always thinking that the child may be too tired or damaged back, but in fact the child is likely to suffer from “ankylosing spondylitis (AS)” this kind of disease. The child is probably suffering from ankylosing spondylitis (AS). What is ankylosing spondylitis (AS), a rheumatic disease?
Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease that mainly affects the sacroiliac joints, spinal prominences, paraspinal soft tissues and peripheral joints, and can be accompanied by extra-articular manifestations, and in severe cases, spinal deformities and ankylosis can occur. The preliminary prevalence of ankylosing spondylitis in China is about 0.3%, mostly in adolescent men aged 15-30 years (11 times more men than women).
What are the causes of ankylosing spondylitis (AS)?
The true cause of ankylosing spondylitis is not well understood and may be related to genetic and environmental factors. Epidemiological investigations have revealed and confirmed that a gene named “human leukocyte antigen (HLA) I B27” is closely associated with the development of the disease, and there is a clear tendency for families to cluster together. The living environment is cloudy, cold, damp and humid to promote the onset of ankylosing spondylitis triggers.
What are the main clinical manifestations of ankylosing spondylitis (AS)?
Most patients present early with soreness, pain, stiffness, and drowsiness (tautness) in the back and lower back, and often wake up with pain in the second half of the night. The pain and morning stiffness in the lumbosacral region are obvious when waking up in the morning or when standing up after sitting for a long time, and are relieved after activity. Some patients often have dull pain in the back of the neck and pain in the buttocks and groin. The pain can be aggravated by coughing, sneezing and sudden twisting of the lumbar region. In the early stage of the disease, the pain in the hip is mostly intermittent or alternating on one side, and after a few months, the pain is mostly bilateral and persistent. In most patients, as the disease progresses from the lumbar spine to the thoracic and cervical spine, pain, restricted movement or spinal deformity occurs in the corresponding areas.
Some patients also have asymmetrical, arthritic manifestations of the large joints of the lower extremities, such as swelling, pain, limitation of motion, difficulty in flexion, and joint ankylosis in the hip, knee, and ankle joints. Younger patients and those with peripheral joint disease are more likely to develop hip arthropathy.
In some patients, red eyes and uveitis occur during the course of the disease, alternating unilaterally or bilaterally, and can be recurrent or even lead to visual impairment.
Some patients even have the onset of heel pain, hypothermia, malaise, fatigue, and emaciation, and more severe patients have cardiac aortic valve lesions and pulmonary fibrosis.
With the further development of the disease, the patient’s lumbar, thoracic and cervical spine lesions can gradually aggravate, some patients appear “duck walk”, hip back bulge, flat waist, and even hunchback, lumbar spine and hip joint movement restrictions and other states, resulting in the inability to take care of themselves, loss of labor force, the disability rate is more than 30%.
How is ankylosing spondylitis (AS) diagnosed early?
Early diagnosis of ankylosing spondylitis is important because the disease starts slowly and progresses slowly, starting with intermittent low back pain and mild systemic symptoms that develop persistently only after several months or years.
Since low back pain is an extremely common symptom in the general population, but most of them are mechanical non-inflammatory low back pain such as: lumbar muscle strain, lumbar disc herniation, sciatica, osteophytes and other diseases, manifested as low back pain that worsens after activity and improves at rest, and no significant stiffness in the back after getting up in the morning. In contrast, ankylosing spondylitis low back pain is inflammatory pain: the age of onset is often less than 40 years old, the performance is the opposite of the above, that is, low back pain is heavy at night when resting, especially in the second half of the night, there is a significant stiffness, get up after activity improved.
(1) Imaging examination: X-ray changes are of definite diagnostic significance. The earliest change of the disease occurs in the sacroiliac joint. x-ray film shows blurring of the subchondral bone margin of the sacroiliac joint, bone erosion, blurring of the joint space, increase of bone density and joint fusion. Radiographs of the spine show vertebral osteophytes and square changes, blurring of the vertebral tuberosities, calcification of the paravertebral ligaments, and bone bridge formation. Extensive and severe ossifying bridges in the late stage are called “bamboo-like spine”. In early or suspicious cases, CT or magnetic resonance imaging (MRI) may be used. CT or magnetic resonance imaging (MRI) is an option.
(2) Laboratory tests: In active patients, an increased erythrocyte sedimentation rate (ESR) and an increased C-reactive protein (CRP) are seen. Mild anemia and mild elevation of immunoglobulins. HLA-B27 positivity rate reaches about 90%, but HLA-B27-negative patients cannot be excluded from the disease as long as clinical manifestations and imaging examinations meet the diagnostic criteria.
How is the differential diagnosis of ankylosing spondylitis (AS) made?
Herniated disc: It is one of the common causes of low back pain. The disease is limited to the spine, without fatigue, wasting, fever and other systemic manifestations, mostly of acute onset, and mostly limited to lumbar pain. It is aggravated by activity and relieved by rest; there is often lateral flexion when standing. On palpation, there were l to 2 painful trigger points in the spinal bony prominence. All laboratory tests are normal. The main difference between it and AS can be confirmed by X-rays, CT, and MRI of the sacroiliac joint.
Iliac dense osteoarthritis: It is mostly seen in middle-aged and young women, especially those with a history of multiple pregnancies, childbirth or in long-term standing occupations. The main manifestation is chronic lumbosacral pain. It is aggravated by exertion and is self-limiting. Clinical examination is not abnormal except for muscle tension in the lumbar region. The diagnosis mainly relies on anteroposterior radiographs, which typically show an obvious osteosclerotic area in the iliac bone along the middle and lower 2/3 of the sacroiliac joint, triangular in shape with the tip upward, uniform in density, without invasion of the sacroiliac joint surface, without joint stenosis or erosion, with clear boundaries, and normal bone and joint space on the sacral side.
How to standardize the treatment of ankylosing spondylitis (AS)?
(1) Treatment goals.
① Relieve signs and symptoms: eliminate or minimize symptoms such as back pain, morning stiffness and fatigue to the greatest extent possible.
(2) Restoration of function: To restore the patient’s physical function to the greatest extent possible. such as spinal mobility, social mobility and work ability.
③Prevent joint damage: To prevent new bone formation, bone destruction, bony ankylosis and spinal deformation in patients with involvement of the hip, shoulder, mid-shaft and peripheral joints.
④Improve the quality of life of patients: including socioeconomic factors, work, medical retirement, and retirement.
⑤ Prevent complications of spinal diseases: prevent spinal fractures and flexion contractures, especially in the cervical spine.
(2) Treatment options and principles.
There is no radical cure for AS. However, patients with timely diagnosis and reasonable treatment can achieve symptom control and improve prognosis. Non-pharmacological, pharmacological and surgical treatments should be used to relieve pain and stiffness, control or reduce inflammation, maintain good posture, prevent deformation of the spine or joints, and correct deformed joints if necessary, in order to improve and enhance the quality of life of patients.
(3) Non-pharmacological treatment.
① Education of patients and their families about the disease is an indispensable part of the overall treatment plan, which helps patients to actively participate in treatment and cooperate with physicians. The long-term plan should also include the patient’s psychosocial and rehabilitation needs.
② Advise patients to be reasonably and consistently physically active to obtain and maintain the best position of the spinal joints, strengthen the paravertebral muscles and increase lung capacity; swimming is one of the good and effective adjuncts to treatment.
③Standing should try to maintain a posture with chest up, abdomen in and eyes flat in front. The sitting position should also keep the chest upright. One should sleep on a hard bed and take more supine positions to avoid positions that promote flexion deformity. Pillows should be short and should be discontinued once there is upper thoracic or cervical spine involvement.
④Give necessary physical therapy for painful or inflamed joints or soft tissues.
(⑤ Smokers are advised to quit smoking, as smoking is one of the risk factors for poor prognosis for restoration of function in patients with ankylosing spondylitis.
(4) Drug therapy.
Once ankylosing spondylitis is diagnosed, aggressive treatment should be given, which can reduce joint symptoms, protect joint function, and minimize the occurrence of deformities.
(1) Non-steroidal anti-inflammatory analgesics (NSAIDs): They can rapidly improve patients’ low back pain and morning stiffness, reduce joint swelling and pain and increase range of motion, and are preferred for the treatment of symptoms in patients with either early or late AS. There is a wide variety of them, and their efficacy in ankylosing spondylitis is roughly equivalent. Commonly used are: Diclofenac extended-release tablets: such as Intacrine 25mg once or twice a day, Fotarine 25-75mg once or twice a day, etc. Meloxicam tablets: 7.5mg once or twice a day, or Cilazapro 0.2 once or twice a day.
The above drugs can be used as long as one, if the pain at night can be added, anti-inflammatory pain suppositories 50mg stuffed anus, once a night.
②Lyuzosulfapyridine: It can improve joint pain, swelling and stiffness of AS, and reduce serum IgA level and other laboratory activity indicators, especially for improving peripheral arthritis of patients. Gradually increase the dose from a small dose (250mg for one tablet), which can be started with 250-500mg per oral dose 3 times a day, and then gradually increased to 750mg 3 times a day. If the efficacy is not obvious, the dose can be increased to 3g per day, and it usually takes 4-8 weeks to take effect.
③ Biological agents: anti-tumor necrosis factor (TNF)-a antagonists include: etanercept (Yicep, etanercept), infliximab (Enzyme, infliximab) and adalimumab (adalimumab), with a total efficiency of 50% to 75%. In addition, timely correction according to clinical. Etanercept is a domestic aka “Yicep” and infliximab is an imported material aka “Enzyme”. You can use one.
Thalidomide: Some male patients with refractory AS showed significant improvement in clinical symptoms, increased erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) after applying thalidomide (thalidomide). The initial dose is 25-50mg/night (one tablet is 25mg), and the dose is increased by 25-50mg/night in 10-14 days, and can be maintained if there are no uncomfortable symptoms.
(5) Surgical treatment: Joint space narrowing, ankylosis and deformity caused by hip joint involvement are the main causes of disability in this disease. Artificial total hip arthroplasty is the best choice. After the replacement, the majority of patients’ joint pain is controlled, some patients’ functions return to normal or near normal, and 90% of the life span of the replaced joint reaches more than lO years.
How to determine the activity of ankylosing spondylitis (AS) disease?
Patients often have the clinical manifestations described above: mainly lumbosacral pain, which is particularly severe in the second half of the night or at dawn and is accompanied by stiffness when waking up in the morning. The hip, knee and ankle joints are swollen, painful, restricted in movement, difficult in flexion and joint ankylosis. It is also accompanied by increased erythrocyte sedimentation rate (ESR), increased C-reactive protein (CRP), mild anemia and mildly elevated immunoglobulins.
What are the poor prognostic factors for patients with ankylosing spondylitis (AS)?
Hip osteoarthritis; especially with hip effusion, which can lead to “aseptic femoral necrosis of the hip”.
Sausage-like fingers or toes; i.e., red, swollen, sausage-like appearance of the fingers or toes.
Poorly treated with non-steroidal anti-inflammatory analgesics (NSAIDs).
Persistently elevated erythrocyte sedimentation rate (ESR) (>30 mm/1h).
Restricted lumbar spine mobility; i.e., difficulty with anterior, posterior, right and left, and lateral bending of the lumbar spine.
Oligoarthritis and age of onset <16 years; i.e., persistent swelling, pain, and limitation of motion in single joints of the lower extremities such as the knee and ankle.
Smokers, those with low education level, and those who do not adhere to long-term functional exercise.
Presence of other diseases associated with “Spondyloarthropathy (SpA)” (e.g. psoriasis, inflammatory bowel disease), history of uveitis.
Delayed diagnosis, untimely and unreasonable treatment.