Ankylosing crestitis (AS) is a chronic inflammatory disease that mainly affects the sacroiliac joint, crestal eminence, paracristal soft tissues and peripheral joints, and can be accompanied by extra-articular manifestations, and in severe cases, crestal deformity and ankylosis can occur. If ankylosing crestitis is not treated properly with reasonable functional exercise, many patients will develop crestal deformity or functional limitation in their youth, which will seriously affect their quality of life, therefore, early diagnosis and standardized treatment of ankylosing crestitis are crucial.
The disease starts insidiously, progresses slowly, and has mild systemic symptoms, and is common in young people aged 16 to 30 years, more common in men and less common after the age of 40 years, accounting for about 3.3% of cases. In the early stage, there is often lower back pain and morning stiffness, which is relieved after activity, and may be accompanied by low fever, fatigue, waking up in the middle of the night with pain, difficulty in turning over, and lumbar stiffness in the morning or when standing up after sitting for a long time, but it is relieved after activity. Some patients feel dull pain in the buttocks or severe pain in the sacroiliac region, occasionally radiating to the periphery. The pain can be aggravated by coughing, sneezing, or sudden twisting of the lumbar region. As the lesion progresses from the lumbar spine to the crestal spine of the thoracic and cervical regions, pain, limitation of movement or crestal deformity may occur in the corresponding areas. Symptoms such as loss of appetite and emaciation may occur. The pain is intermittent at the beginning and develops into persistent after several months and years. Later, the inflammatory pain disappears, the crest is partially or completely straightened from the bottom to the top, and a hunchback deformity appears. Peripheral joint invasion is more common in female patients, with slower progression and less severe crestal deformity.
Peripheral arthropathy occurs in 24-75% of AS patients at the beginning or during the course of the disease, mostly in the knee, hip, ankle and shoulder joints, with occasional involvement of the elbow and small joints of the hand and foot. Asymmetric, few-joint or single-joint arthritis and arthritis of the large joints of the lower extremities are the characteristics of peripheral arthritis in this disease. In our patients, arthritis or arthralgia of the knee and other joints, except the hip, is mostly transient and rarely or hardly causes joint destruction and disability. The hip joint is involved in 38%-66% of cases, with localized pain, limited motion, flexion-twisting and joint ankylosis, most of which are bilateral, and 94% of the hip symptoms start within the first 5 years after onset. The disease is more likely to occur at a younger age and in those with peripheral joint disease.
The systemic manifestations of the disease are mild, with a few severe cases having fever, fatigue, wasting, anemia, or other organ involvement. Plantar fasciitis, Achilles tendinitis, and tendon terminal inflammation at other sites are common in this disease. 1/4 of patients develop uveitis during the course of the disease, alternating unilaterally or bilaterally, which usually resolves spontaneously and can lead to visual impairment with repeated attacks. Neurological symptoms arise from compressive cremasteric neuritis or sciatica, vertebral fractures or incomplete dislocations, and cauda equina syndrome, the latter of which can cause impotence, nocturnal incontinence, bladder and rectal dullness, and loss of ankle reflexes. Very few patients develop fibrosis of the upper lobe of the lung. It is sometimes accompanied by cavity formation and is considered tuberculosis, and can also be exacerbated by concurrent mycobacterial infections. Aortic valve atresia and conduction disturbances are seen in 3.5-10% of patients, and AS can be complicated by IgA nephropathy and amyloidosis.
Laboratory tests
The white blood cell count is normal or elevated, with a slightly higher proportion of lymphocytes. A few patients may have mild anemia (orthocytic hypochromia), and the hematocrit may be increased, but there is little correlation with disease activity, whereas C-reactive protein is more significant. Serum albumin is decreased, alpha1 and gamma globulins are increased, serum immunoglobulins IgG, IgA and IgM may be increased, and serum complement C3 and C4 are often increased. Alkaline phosphatase is elevated in approximately 50% of patients, and serum creatine phosphokinase is often elevated. Serum rheumatoid factor is negative. Although more than 90% to 95% of patients with ankylosing crestitis are positive for HLA-B27, HLA-B27 is not generally relied upon for the diagnosis of ankylosing crestitis, so HLA-B27 is not used as a routine test.
X-ray examination is of great importance for the diagnosis of ankylosing crestitis. About 98% to 100% of patients have early X-ray changes of the sacroiliac joint, which is an important basis for the diagnosis of the disease. The early X-ray manifestation is sacroiliac arthritis, and the lesion usually starts in the lower and middle part of the sacroiliac joint and is bilateral. Initially, it mostly invades the iliac side, and then the sacral side. Subsequently, the entire joint may be invaded, with jagged edges, subchondral osteosclerosis, osteophytes, and narrowing of the joint space. Eventually the joint space disappears and bony ankylosis occurs.
Sacroiliac arthritis can be classified into 5 grades under X-ray according to the following criteria.
Grade 0: as normal sacroiliac joint.
Grade Ⅰ: for suspected sacroiliac joint inflammation on both sides.
Grade II: for a blurred sacroiliac joint margin, with slight sclerosis and microerosion lesions and mild narrowing of the joint cavity
Grade III: sclerosis on both sides of the sacroiliac joint, indistinct joint margins, erosive lesions with disappearance of the joint cavity.
Grade IV: complete fusion or ankylosis of the joint with or without residual sclerosis.
The early stage of the crestal lesion is a generalized osteoporosis, the small joints of the vertebral body and the vertebral trabeculae are blurred (decalcification), the vertebral body is “square vertebrae” due to destructive erosion of the upper and lower corners of the vertebrae incidental to the intervertebral disc fiber ring, and the normal anterior curvature of the lumbar vertebrae disappears and becomes straight, which may cause compression fractures of one or more vertebral bodies. As the lesion progresses to the thoracic and cervical intervertebral joints, calcification of the intervertebral disc space may occur, and calcification and ossification of the annulus fibrosus and anterior longitudinal ligament and formation of ligamentous redundancies may unite adjacent vertebrae to form intervertebral bony bridges, becoming the most characteristic “bamboo-like crest”. Primary ankylosing crestitis and crestitis secondary to inflammatory bowel disease, Reiter’s syndrome, and psoriatic arthritis have similar radiographic appearances, but the latter is asymmetrical ankylosis. Osteomalacia and osteochondritis may be seen at the attachment of ligaments, tendons, and bursae, most often in the heel bone, sciatic tuberosity, and iliac crest. Similar radiographic changes may occur in other peripheral joints.
Diagnostic criteria
① the duration of lower back pain lasts at least 3 months, and the pain improves with activity but does not decrease with rest.
②limited movement of the lumbar spine in the anterior-posterior and lateral flexion directions.
③ thoracic extension less than the normal value for the same age and sex.
④ iritis and its secondary conditions.
⑤ Bilateral sacroiliac arthritis grade II-IV, or unilateral sacroiliac arthritis grade III-IV.
The diagnosis of AS can be confirmed if the patient has ⑤ and any 1 of ①-④, respectively.
Since the cause is not yet fully understood, there is no cure for AS. The key lies in early diagnosis and early treatment, and patients can achieve symptom control and improve prognosis if they are diagnosed and treated reasonably in time. A combination of 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 crest or joints, and correct deformed joints if necessary, in order to improve and enhance the patient’s quality of life.
Drugs used to treat ankylosing crestitis can be divided into four categories.
1.Non-steroidal anti-inflammatory drugs
2.Sulfasalazine (SSZ)
3.Methotrexate (MTX)
4.Glucocorticoids
5.Raglan polysaccharide
6.Rheumatism capsule
7.Biological agents
Etanercept, a recombinant human soluble tumor necrosis factor receptor fusion protein, can reversibly bind to TNFα and competitively inhibit the binding of TNFα to the TNF receptor site. site binding, and has been used abroad for the treatment of active AS.
1. Sports therapy: Sports therapy is beneficial for various chronic diseases, and is even more important for ankylosing crestitis. It can maintain the physiological curvature of the crest to prevent deformity; maintain thoracic mobility to maintain normal whistling function; maintain bone density and strength to prevent osteoporosis and limb wasting muscle atrophy, etc. The following exercises can be done.
① deep whistling: every morning, work breaks and before bedtime should be routine deep whistling exercise. Deep inspiration can maintain the maximum mobility of the thorax, to maintain good whistling function.
② cervical exercise: head and neck can be forward, backward, to the left, to the right, as well as head rotation movement to maintain the normal mobility of the cervical spine.
③Lumbar exercise: daily lumbar exercise, forward bending, backward bending, lateral bending and left and right rotation of the torso, so that the lumbar crest to maintain normal mobility.
④Limb exercises: push-ups, diagonal bracing, lower limb forward bending and backward extension, chest expansion exercises and swimming, etc. Swimming is not only good for limb exercise, but also helps to increase lung function and maintain the physiological curvature of the crest, which is the most suitable whole-body exercise for ankylosing crestitis. Patients can take appropriate exercise and exercise volume according to their personal condition. Muscle and joint pain or discomfort may occur at the beginning of exercise, but they can recover after a short rest after exercise. If the new pain persists for more than 2h and cannot be recovered, it indicates that the exercise is excessive and the amount of exercise should be reduced or adjusted appropriately.
2.Physical therapy: Physical therapy is generally available as heat therapy, such as Chinese medicine sealing package, Chinese medicine directional transdermal medicine, shock wave therapy, and more hot baths, tub baths or showers, mineral spring spa baths in daily life to increase local blood circulation, relax muscles, reduce pain, facilitate joint activities, maintain normal function and prevent deformity.
3.Minimally invasive treatment: silver needle treatment, radiofrequency treatment.
4.Surgical treatment.
Precautions.
1, pay attention to maintain normal posture and mobility in daily life, such as walking, sitting and standing with chest up and abdomen in, sleeping without pillows or with thin pillows, sleeping on hard wooden beds, taking supine or prone position, lying prone for 0.5h in the morning and evening every day; do labor and sports activities within your ability; pay attention to posture when working to prevent crestal bending deformity, etc.
2, maintain optimism, eliminate tension, anxiety, depression and fear; quit smoking and alcohol; work and rest on time.
3, understand the role and side effects of drugs, learn to adjust the drug dose and deal with the side effects of drugs, in order to facilitate cooperation with treatment and achieve better results.