There is a type of low back pain that affects young people, especially young men. It causes sleepless nights, stiffness and pain in the early hours of the morning, and over time, deformities such as hunchbacks. Since early symptoms are easily confused with other diseases, it is common to miss timely treatment due to long-term misdiagnosis. In order to facilitate the diagnosis and treatment of ankylosing spondylitis, Peking University People’s Hospital will open a special clinic for ankylosing spondylitis in mid-November, so that ankylosing patients can find the right door for medical treatment.
At the request of our patients, we have recorded three representative questions from our patients’ consultations, which are described below; at the same time, we have summarized the most frequently asked questions by our patients.
1, there is a 20-year-old boy, the diagnosis of ankylosing spondylitis has been 5 years, has been taking oral lutjan sulfadiazepine tablets, intermittent oral Loxone, but still lower back pain, morning stiffness is obvious. I would like to consult Prof. Li Zhanguo on the next step of treatment. Will there be joint deformity?
After carefully inquiring about the patient’s condition, Prof. Li firstly explained to the patient that the disease could be completely relieved after standardized treatment and would not affect daily life and work. However, the prerequisite is to follow the medical prescriptions, regular follow-up, adhere to the correct posture of sitting, lying and standing, and strengthen the functional exercise. Among them, drug therapy is an important measure to relieve pain and improve prognosis. Currently, commonly used medications for ankylosing spondylitis include.
(1) immunosuppressants: these drugs are slow-acting, also known as slow-acting drugs. These drugs have a good effect on the peripheral joints and also have a certain effect on the medial joints.
(2) Non-steroidal anti-inflammatory drugs: they have anti-inflammatory and pain-relieving effects, reduce stiffness and muscle spasm. At present, there is a lack of clinical trial data on this class of drugs to delay disease progression and prevent bone destruction in a large sample. These drugs should be used in the principle of minimum effective amount and short course of treatment.
(3) Biological agents These drugs have good efficacy on both the medial and peripheral joints, and can rapidly relieve pain, delay or improve bone destruction, and improve prognosis. Tumor necrosis factor (TNF-α) antagonists (such as infliximab, etanercept, adalimumab, etc.) are currently the best choice for the treatment of spinal joint diseases such as AS, but these drugs are expensive and must be used under the guidance of a physician in a standardized manner.
In combination with the patient’s age and personal factors such as quality of life requirements, this young man should start an individualized treatment plan as soon as possible, applying disease-controlling drugs and requiring regular follow-up. It is recommended that he be seen by a rheumatologist at his local hospital or at one of our upcoming specialised ankylosing spondylitis clinics to assess his condition and develop a treatment plan. In the treatment of ankylosing spondylitis, individualized treatment plans and standardized medication are the two magic weapons of treatment. Individualized plans are based on the patient’s own characteristics, and the most suitable plan with the best results and the least adverse reactions is developed, which is different for each patient and requires direct mutual cooperation between the patient and the doctor. In addition, patients regularly visit rheumatologists for follow-up visits, which is one of the keys to successful treatment. During the follow-up visits, rheumatologists will give patients targeted guidance based on changes in their symptoms and laboratory indicators, and adjust their treatment medications at any time to avoid deviations in treatment.
2, a 28-year-old female patient friend, due to lower back pain in the hospital in his hometown, performed sacroiliac joint CT suggests “sacroiliac arthritis”, HLA-B27 positive, considered ankylosing spondylitis. The patient was given oral NSAIDs and oral Raglan.
Factors and patterns of ankylosing spondylitis: The development of ankylosing spondylitis is associated with genetic factors. Studies have proven that HLA-B27*02, HLA-B27*04 and HLA-B27*05 are susceptibility genes for this disease. Among the environmental factors, infections are most closely associated with the development of ankylosing spondylitis, especially Escherichia coli, Salmonella, Klebsiella and Chlamydia infections of the intestinal and urinary tract.
The development of ankylosing spondylitis has been shown to be closely associated with HLA-B27 and there is a familial predisposition to develop it, but it is not a genetic disease. People who carry the HLA-B27 positive gene have an increased rate of ankylosing spondylitis compared to those who are HLA-B27 negative, and similarly, those who are HLA-B27 positive or have a family history of ankylosing spondylitis have a significantly increased likelihood and risk of developing ankylosing spondylitis. However, approximately 80% of HLA-B27-positive individuals do not develop ankylosing spondylitis, while approximately 10% of patients with ankylosing spondylitis are HLA-B27-negative. Therefore, it cannot be assumed that HLA-B27-positive individuals necessarily develop ankylosing spondylitis, whereas HLA-B27-negative individuals necessarily do not develop ankylosing spondylitis.
Recently, the role of microbial infection in the pathogenesis of ankylosing spondylitis has received increasing attention. Microorganisms or their components enter the joint through the blood circulation, where the microorganisms act as antigens to stimulate an immune response and form immune complexes with locally produced antibodies to the antigenic causative agent, which in turn produce an inflammatory response and tissue damage by activating the immune system. The increased detection of Klebsiella pneumoniae in the stool of patients with ankylosing spondylitis during the active phase of the disease, the increased level of serum anti-Klebsiella antibodies, and the discovery of molecular mimicry between HLA~B27 and Klebsiella suggest that Klebsiella resembles the bacteria that stimulate reactive arthritis. Therefore, prevention of infections in daily life, especially urinary and genital infections, in patients with ankylosing spondylitis and those at risk may have a role in preventing the onset or exacerbation of the disease.
The use of tretinoin in young women may lead to abnormal menstrual and reproductive functions in patients and should be used with great caution or temporarily, and patients are advised to visit a rheumatology specialist for adjustment of drug therapy.
3. A male patient with a 16-year history of ankylosing spondylitis, 42 years old, has some ankylosis of the spinal joints and usually has a slight hunchback, but no conscious symptoms such as low back pain and other joint swelling and pain.
Patients with ankylosing spondylitis may end up with ankylosing spinal joints with bamboo-like changes and pseudarthrosis may form around them. Biological agents are the most beneficial “heavy weapon” in the treatment of ankylosing spondylitis, and are very effective in relieving disease activity, slowing the progression of bone destruction, and are ideal for patients with high disease activity, especially when bone destruction occurs. However, even this good weapon was not effective in restoring the spinal deformity in this patient who had developed a hunchback. Because this patient’s spinal deformity has been present for 16 years and the bones have been permanently damaged, non-surgical treatment cannot relieve the patient’s humpback deformity, but aggressive medication can stop the progression of the condition so that the patient’s deformity does not develop further. This patient may not progress to hunchback deformity if he is clearly diagnosed and treated aggressively in the early stage of low back pain. Biologic agents are one of the most beneficial weapons to relieve the disease activity in the early stage of the disease.
4. In addition to this, we have summarized the other aspects that are more frequently consulted by patients as follows.
Question 1: Ankylosing spondylitis (AS) is a typical representative of seronegative spondyloarthropathies, so what are the common features of seronegative spondyloarthropathies?
Seronegative spondyloarthropathies (spondyloarthropathies) include a group of interrelated multisystemic inflammatory diseases that primarily involve the spinal joints, peripheral joints, and periarticular tissues and may be associated with a variety of characteristic extraarticular manifestations. Seronegative spondyloarthropathies include ankylosing spondylitis, reactive arthritis (Reiter syndrome), psoriatic arthritis, and inflammatory bowel disease arthritis.
The common features of spondyloarthropathies are: (1) negative serum rheumatoid factor in most patients; (2) absence of rheumatoid subcutaneous nodules; (3) spondylodynia or asymmetric, predominantly lower limb joint arthritis; (4) sacral arthritis on radiographs; (5) extra-articular manifestations of various spondyloarthropathies: psoriatic rash or nail changes, ophthalmia, oral, intestinal or genital ulcers, urethritis, prostatitis, erythema nodosum, necrotizing (6) The characteristic pathological changes occur mainly at the site where the tendon terminal ligaments attach to the bone, i.e. tendonitis, rather than inflammation of the synovial membrane; (7) There is a tendency for familial aggregation; (8) There is a correlation with HLA-B27, especially in ankylosing spondylitis and Reiter syndrome.
Question 2: What clinical manifestations can be suspected as ankylosing spondylitis?
In the past, ankylosing spondylitis was thought to be more prevalent in men, but recent studies suggest that the ratio of men to women is 2:1 to 3:1. However, women have a slow onset, atypical symptoms, and milder disease. The possibility of ankylosing spondylitis should be suspected when the following clinical manifestations occur: ① intermittent pain and/or stiffness in the lumbar back or sacroiliac region, with stiffness evident in the morning; as the disease progresses it is often accompanied by increased pain and difficulty turning over at night, which affects sleep and later develops into persistent. (2) Asymmetrical large arthritis or monoarthritis of the lower extremities, with the knee, hip, ankle and shoulder joints as common sites of onset. ③Tendon terminal inflammation is more common, such as plantar fasciitis and Achilles tendonitis, manifested as heel pain or plantar tingling pain. ④Pain in the hip or hip joint. ⑤ Conjunctivitis. (6) Positive pressure pain in sacroiliac joint and paravertebral muscles, and limited motion in all directions of the spine. (7) Reduction of thoracic extension and posterior cervical protrusion.
Question 3: What is the significance of functional exercise in ankylosing spondylitis?
Patients with ankylosing spondylitis should actively participate in various treatments. The significance of functional exercise in cooperation with physicians is to maintain the diseased spine and joints in the best functional position, to enhance the strength of the paravertebral tendons and to increase lung capacity, which is no less important than drug therapy.
Question 4: What are the factors that affect the prognosis of ankylosing spondylitis?
The survival of patients with mild ankylosing spondylitis is not different from that of the general population. However, severe complicating symptoms such as fractures, cardiovascular system involvement, and renal amyloidosis can shorten survival in some patients.
Factors affecting prognosis include: (1) lack of awareness of the disease, (2) lack of timely formal treatment, (3) combined uveitis and visceral involvement, (4) early spinal involvement, and (5) poor prognosis for hip involvement.