Ankylosing spondylitis (AS) is common in young people between the ages of 16 and 30, with a male prevalence and a rare first onset after the age of 40, accounting for about 3.3%. The disease starts insidiously, progresses slowly, and has mild systemic symptoms. In the early stage, there is often lower back pain and morning stiffness, which is relieved after activity, and can be accompanied by low fever, fatigue, loss of appetite, wasting and other symptoms.
The pain is intermittent at the beginning and develops into persistent after several months and years. Later, the inflammatory pain disappears and the spine is partially or completely straightened from bottom to top, with hunchback deformity. In female patients, peripheral joint invasion is more common and progresses more slowly, and the spinal deformity is less severe.
1.Joint lesion performance
Most of the patients with AS have arthropathy, and most of them first invade the sacroiliac joint, and later develop upward to the cervical spine. In a few patients, the cervical spine or several spinal segments are invaded at the same time, and the surrounding joints may also be invaded. In the early stage, there is inflammatory pain in the joints, accompanied by muscle spasm around the joints and a feeling of stiffness, which is obvious in the morning; it may also be manifested as night pain, which is relieved by activities or taking painkillers.
As the disease progresses, the joint pain decreases, while the movement of each spinal segment and joint is restricted and deformed, and in advanced stages the entire spine and lower limbs become strongly bowed and flexed forward.
(1) Sacroiliac arthritis: About 90% of AS patients first present with sacroiliac arthritis. Later, it develops upward to the cervical spine and manifests as recurrent lumbar pain, lumbosacral stiffness, intermittent or alternating lumbar pain and hip pain on both sides, which may radiate to the thighs, without positive signs and negative extension and leg lift test. However, direct pressure or extension of the sacroiliac joint can cause pain, so it is not like sciatica. Some patients have no symptoms of sacroiliac arthritis and only abnormal changes are found on X-ray. About 3% of AS have the earliest cervical spine involvement and later progress down to the lumbosacral region, and 7% of AS have several spinal segments involved at the same time.
(2) Lumbar spine lesions: When the lumbar spine is involved, most of them show restricted lower back anterior and lumbar activities. The lumbar anterior flexion, buckling base peculiar to the moisture scythe Liao Wei brake (11) cup guide hired to hire lies stand stirrups about ∪ ration imitation dangerous slow deceitful wake up∥ entertainment
(3) Thoracic spine lesions: when the thoracic spine is involved, it is manifested as back pain, anterior and lateral chest pain, and most often as hunchback deformity. If the rib cage joints, sternal stalk joints, sternoclavicular joints and intercostal cartilage joints are involved, there will be band-like chest pain, restricted thoracic expansion, and the chest pain will increase when inhaling and coughing or sneezing. In severe cases, the thorax remains in the state of exhalation, and the expansion of the thorax is reduced by more than 50% compared with normal people, so it can only be assisted by abdominal breathing. Due to the reduction of thoracic and abdominal cavity capacity, it causes cardiopulmonary and digestive dysfunction.
(4) Cervical spine lesions: A few patients first present with cervical spondylitis, with pain in the cervical spine first, radiating along the neck to the head and arms. The neck muscles start with spasm and later atrophy, and the lesion may progress to cervicothoracic retroflexion deformity. Head movement is significantly limited, often fixed in a forward-flexed position, unable to supinate, lateral bend or rotate. Severe cases can only see a small piece of ground in front of their toes, and cannot raise their heads to look flat.
(5) Peripheral arthropathy: About half of the patients with AS have transient acute peripheral arthritis, and about 25% have permanent peripheral joint damage. It usually occurs more often in large joints and more in the lower extremities than in the upper extremities. According to some statistics, the rate of peripheral joint involvement is 40% for the hip and shoulder, 15 or 5% for the knee, 10% for the ankle, 5% for the foot and wrist, and very rarely for the hand. In 80 cases of AS, the involvement rate of hip joint was reported (100%); limitation of movement (64%), flexion contracture (38%), muscle atrophy (25%), and joint ankylosis (37%) were the main causes of disability in AS patients; 94% of the hip symptoms appeared within 5 years after the onset of the disease, suggesting that if the hip joint is not involved in the first 5 years of AS, it is unlikely to be involved later.
When the shoulder joint is involved, the pain is more pronounced when the joint is restricted, and activities such as combing the hair and lifting the hand are restricted. When the knee joint is involved, the joint is compensated for bending, making daily life such as walking and sitting more difficult. It rarely affects the elbow, wrist and foot joints, and is even rarer when it affects some of the joints.
In addition, the pubic symphysis may be involved, and the upper pelvic rim, sciatic tuberosity, greater trochanter of the femur, and heel may have symptoms of osteoarthritis, with early manifestations of local soft tissue swelling and pain, and later bony enlargement. Generally peripheral arthritis can occur before or after spondylitis, and local symptoms are not easily distinguishable from rheumatoid arthritis, but there are fewer remaining deformities.
2.Extra-articular manifestations
The extra-articular lesions of AS mostly appear after spondylitis, and occasionally extra-articular symptoms occur months or years before skeletal muscle symptoms.
(1) Cardiac lesions: aortic valve lesions are more common, and according to autopsy, about 25% of AS cases have aortic root lesions, and cardiac involvement may be clinically asymptomatic or markedly manifested. About 1% of the cases have varying degrees of aortic valve incompetence; about 8% have heart block, which can coexist with aortic valve incompetence and occur alone, or in severe cases, complete atrioventricular block and A.I.S. syndrome.
Angina pectoris may occur when the lesion involves the coronary artery. Rarely, aortic aneurysms, pericarditis and myocarditis occur. Patients with AS with combined heart disease are generally older, have a longer medical history, more spondylitis and peripheral joint lesions, and more pronounced systemic symptoms. gould [24] et al. examined the cardiac function of 21 patients with AS and found that the cardiac function of AS patients was significantly lower than that of the control group.
(2) Ocular lesions: long-term with the room, 25% of AS patients have conjunctivitis, iritis, uveitis or uveitis, the latter occasionally complicated by spontaneous anterior chamber hemorrhage. Iriditis is prone to recurrence, and the incidence increases the longer the disease is present, but is not related to the severity of spondylitis, which is common in those with peripheral arthropathy and may occur in a few cases before spondylitis. Ocular disease is often self-limiting, sometimes requiring corticosteroid treatment, and some can lead to glaucoma or blindness without proper treatment.
(3) Ear lesions: Gamilleri et al. reported that chronic otitis media occurred in 1/2 of 42 patients (29%) with AS, which is 4 times more than normal controls, and that the number of patients with AS who developed chronic otitis media was significantly higher than that of AS patients without chronic otitis media.
(4) Pulmonary lesions: A small number of patients with AS may develop irregular fibrotic lesions in the upper lobe of the lungs, manifested by coughing, shortness of breath, or even hemoptysis, and may be accompanied by recurrent pneumonia or pleurisy. x-ray examination shows diffuse fibrosis in the upper lobe of the lungs bilaterally, and there may be cyst formation and parenchymal destruction, similar to tuberculosis, which needs to be differentiated.
(5) Neurological lesions: due to spinal ankylosis and osteoporosis, cervical dislocation and spinal fracture can easily occur, causing spinal cord compression; if intervertebral discitis occurs, it can cause severe pain; in the late stage of AS, it can invade the cauda equina and cauda equina syndrome can occur, resulting in neurogenic pain in the lower extremities or buttocks; loss of infection in the sacral nerve distribution area, weakened Achilles tendon reflex and motor dysfunction of the bladder and rectum, etc.
(6) Amyloidosis: It is a rare complication of AS. In 35 cases of AS, routine rectal mucosal biopsy revealed amyloid deposits in 3 cases, mostly without specific clinical manifestations.
(7) Renal and prostatic lesions: Compared with RA, AS rarely has renal impairment, but IgAD nephropathy has been reported. chronic prostatitis is higher in AS than in the control group, the significance of which is unknown.