Ankylosing spondylitis (AS) is a disease characterized by inflammation of the sacroiliac joints and spinal attachment points. It is a chronic disease with the spine as the main lesion site. In order to provide patients with a more accurate understanding of the disease, this article answers some common questions about ankylosing spondylitis (AS).
1. What are the causes of ankylosing spondylitis? (What is ankylosing spondylitis? Why do you get ankylosing spondylitis?)
Many patients want to know why they have ankylosing spondylitis, but so far there is no clear answer, but a large number of studies have found that ankylosing spondylitis is mainly associated with the following factors.
(1) Genetics: Studies have observed that the likelihood of ankylosing spondylitis in children of patients with ankylosing spondylitis is 20-40 times higher than in the general population. In monozygotic twins, the likelihood of one person developing the disease is more than 50% for the other. In a family, 2 or more people often develop the disease.
(2) Infections: Patients with ankylosing spondylitis usually develop intestinal and urinary tract infections, especially Klebsiella pneumoniae infections. Patients with ankylosing spondylitis have a 79% positive stool culture for Klebsiella pneumoniae, compared to 30% in the normal population. It was also found that serum anti-Klebsiella pneumoniae antibody levels were significantly higher in patients with ankylosing spondylitis, with a positivity rate of 43.3% compared to 4.4% in normal subjects.
(3) Environment: Some studies have confirmed that environmental and other factors can also contribute to the development of the disease. There is no single theory that can elucidate the full etiology of ankylosing spondylitis, and it can only be assumed that the disease may develop on a genetic basis, combined with the influence of infection and the environment. What is ankylosing spondylitis
2. Who is prone to ankylosing spondylitis?
Ankylosing spondylitis is more common in men, with the incidence in men being about three to four times higher than in women. young men between the ages of 20 and 30 have a high incidence of the disease, but it is rare in those under 8 years of age and over 45. In young men with a family history of ankylosing spondylitis, the presence of low back pain, stiffness of the spine in the morning, which is relieved by activity, mostly suggests the occurrence of the disease.
3. How is ankylosing spondylitis diagnosed? What is ankylosing spondylitis?
Most of the diagnoses of ankylosing spondylitis are made using the New York criteria revised in 1984, or the European preliminary diagnostic criteria for spondyloarthropathies. More recently, in 2009, the International Spondyloarthritis Evaluation Association developed the Diagnostic Criteria for Medial Spondyloarthropathies, which help to confirm the diagnosis of early ankylosing spondylitis and determine the later treatment plan.
(1) New York criteria.
Low back pain of at least 3 months’ duration, with pain relieved by activity but not at rest.
Restriction of lumbar spine movement in anterior-posterior and lateral flexion and extension.
positive thoracic expansion test (as detailed in the physical examination for ankylosing spondylitis).
X-ray suggestive of bilateral sacroiliitis II-IV or unilateral III-IV (ankylosing spondylitis X-ray manifestations are described in detail).
Ankylosing spondylitis is diagnosed if the patient has ④ and meets any one of ①~③.
This criterion is more stringent and does not diagnose early ankylosing spondylitis. In order to confirm the diagnosis early, the patient’s family history, the presence or absence of positive HLA-B27, and the presence or absence of pain at the tendon end attachment site should also be analyzed clinically in a comprehensive manner.
(2) European criteria.
The patient’s diagnosis is confirmed by the presence of spinal pain, or asymmetric lower extremity joint-dominated synovitis, with any of the following additional criteria.
Positive family history.
Psoriasis.
Inflammatory bowel disease.
UTI, cervicitis, acute diarrhea within one month prior to arthritis.
alternating bilateral pain in the buttocks.
Terminal tendinopathy.
Sacroiliac arthritis.
(3) Diagnostic Criteria for Medial Spondyloarthritis.
The diagnosis is confirmed in patients with low back pain for ≥3 months and age of onset <45 years (with or without peripheral clinical manifestations) with any one of the following.
Imaging showing sacroiliac arthritis with ≥1 spondyloarthropathy feature.
HLA-B27 positivity with ≥2 spondyloarthropathy features.
Spondyloarthropathy features.
Inflammatory low back pain.
Arthritis.
Tendon adhesionitis (heel).
Uveitis.
Finger (toe) inflammation.
Psoriasis.
Crohn’s disease/ulcerative colitis.
Effective treatment with NSAIDs pain medication.
HLA-B27 positivity (diagnosis confirmed by meeting the combination of ①).
A family history of spondyloarthropathy.
Elevated C-reactive protein (CRP).
4. What physical examinations can be done to find out if you have ankylosing spondylitis? What is ankylosing spondylitis
(1) Lumbar spine mobility check: the patient stands upright, make a mark at the level of the iliac crest in the midline of the back for 0, and another mark 10 cm upward, then make the patient bend as far as possible (need to keep both knees upright), measure the distance between the two marks, if the increase is less than 5 cm, suggesting a decrease in lumbar spine mobility.
(2) Occipito-wall distance: the patient stands upright against the wall, both heels against the wall, legs straight, back against the wall, eyes level, if the occiput cannot be against the wall, it is abnormal.
(3) Thoracic expansion test: The patient stands upright, and the difference between the patient’s chest circumference during deep exhalation and deep inhalation is measured with a graduated soft ruler at the patient’s 4th rib space (the lower edge of the female breast), and less than 4.5 cm is diagnostic of ankylosing spondylitis.
(4) pelvic compression test: the patient lies on his side, and pressure on the pelvis from the other side can cause lumbosacral pain is positive.
5, what are the x-ray manifestations of ankylosing spondylitis? What is ankylosing spondylitis
(1) sacroiliac joint changes: is of great importance to the diagnosis of ankylosing spondylitis. 98% to 100% of cases have early X-ray changes of the sacroiliac joint, which is an important basis for the diagnosis of the disease.
The X-ray diagnostic criteria of sacroiliac arthritis are divided into 5 stages.
Stage 0 for normal sacroiliac joint.
Stage I for suspected sacroiliac arthritis.
Stage II for blurred sacroiliac joint margins and no change in the joint space.
Stage III for sclerosis of the joint area, narrowing/widening of the joint space and bone destruction.
Stage IV is complete fusion or ankylosis of the joint.
(2) “Bamboo-like” changes in the spine.
Spinal changes often occur after sacroiliac joint lesions and progress from the bottom to the top, eventually involving the cervical spine. The early manifestations of universal bone decalcification, the appearance of small joint blurring, accompanied by ligaments, joint capsule gradually calcification and joint fusion, the formation of intervertebral bone bridges, X-ray can be seen in the spine of the vertebral body into a section of the bamboo-like, so the medical term spine is “bamboo-like” changes.
6.What is the relationship between ankylosing spondylitis and HLA-B27?
First of all, it should be clear that a positive HLA-B27 does not confirm a diagnosis of ankylosing spondylitis. This is because only 20% of people who are HLA-B27 positive have ankylosing spondylitis. But more than 90% to 95% of people with ankylosing spondylitis are HLA-B27 positive. Therefore, there is a strong correlation between HLA-B27 and the development of ankylosing spondylitis, and a positive HLA-B27 is more helpful in confirming the diagnosis of ankylosing spondylitis.
The HLA-B27 is carried for life and will not change with treatment.
7.When I have ankylosing spondylitis, will there be any problems with other organs besides the spine?
(1) Cardiac lesions: Aortic valve lesions are more common. About 1% have varying degrees of clinical aortic valve insufficiency.
(2) Eye lesions: Patients with ankylosing spondylitis may have conjunctivitis, iritis, and uveitis, which manifest as photophobia, lacrimation, and eye redness.
(3) Ear lesions: predisposition to otitis media.
(4) Pulmonary lesions: pulmonary fibrosis, manifested as coughing, shortness of breath, and even respiratory dysfunction.
(5) Neurological lesions: Patients with ankylosing spondylitis are prone to spinal fractures, which can lead to spinal cord and nerve compression and, in severe cases, paraplegia.
8, ankylosing spondylitis (AS) is rheumatic disease (RA)?
The rheumatism commonly referred to by the people is rheumatoid arthritis (RA), which is two diseases with ankylosing spondylitis, with the following differences.
(1) The pathological basis of rheumatoid arthritis is synovitis, while ankylosing spondylitis is mainly tendon attachment pointitis.
(2) Ankylosing spondylitis is more prevalent in men, with a male to female ratio of about 3 to 4:1 and a peak age of onset in the 20s and 30s, whereas rheumatoid arthritis is more prevalent in women, with a male to female ratio of about 3 to 4:1 and a peak age of onset in the 40s and 50s.
(3) Ankylosing spondylitis has a clear racial, the highest incidence of Indians, followed by Caucasians; yellow than Caucasians; black incidence is the lowest. Rheumatoid arthritis is not racial, with similar prevalence in all races worldwide.
(4) Ankylosing spondylitis also has a familial tendency to run in families, and the genetic tendency for rheumatoid arthritis is much less pronounced than for ankylosing spondylitis.
(5) More than 90% to 95% of patients are HLA-B27 positive, while the rate of HLA-B27 positivity in patients with rheumatoid arthritis is the same as in the normal population, but is associated with HLA-DR4.
(6) Patients with ankylosing spondylitis are mostly negative for rheumatoid factor and patients with rheumatoid arthritis are mostly positive.
(7) The involvement of joints, rheumatoid arthritis is often symmetrical, mostly involving the small joints of the metacarpals and fingers, and the joints of the upper limbs are more common, while ankylosing spondylitis mainly invades the large joints of the lower limbs, and is often asymmetrical, that is, often involving one side of the large joints, the knee, hip, ankle and shoulder joints are more involved
(8) Ankylosing spondylitis mainly affects the sacroiliac joints and the spine, and is episodic, i.e., progresses upward from the lower part of the spine. The rheumatoid arthritis rarely involves the sacroiliac joints, and even if it affects the spine, it only affects the cervical joints.
9. Is ankylosing spondylitis prone to osteoporosis?
Statistics show that more than 50% of patients with ankylosing spondylitis have osteoporosis. Osteoporosis is manifested in the reduction of bone density in the spine and femur, which can lead to fractures of the spine and hip joints, resulting in paraplegia or even life-threatening.
In normal life ankylosing spondylitis patients should pay attention to a diet high in calcium, such as milk, bone broth, etc., and to have adequate sun exposure.
10.Why do patients with ankylosing spondylitis have a “hunchback” and a “rosette”?
Ankylosing spondylitis causes calcification of the spinal ligaments, stiffness and loss of elasticity. During the course of the disease, the paravertebral muscles become spastic, and because the flexor muscles are stronger than the extensor muscles, combined with gravity, the spine has a tendency to flex forward.
In addition, due to the pain in the low back, patients are often reluctant to lift the chest and straighten the back. If this posture is maintained for a long time, the spine will be flexed, making the thoracic spine more pronounced, so that the entire spine becomes a rigid rounded hunchback, forming what is commonly referred to as a “pot”.
11.What should patients with ankylosing spondylitis pay attention to? How to prevent the occurrence of hunchback deformity?
(1) When sleeping, it is better to sleep on a hard bed, preferably supine or prone, not side-lying, without pillows.
(2) Sitting with chest up and head up to prevent forward flexion of the spine and avoid sitting and standing for too long; if you have to sit for a long time, you should get up at least every hour for 10 minutes.
(3) Avoid heavy weight and heavy physical labor, avoid prolonged bending, squatting, and if necessary, wear a brace to avoid deformities.
(4) Do appropriate exercises, such as pull-ups, traction suspension, etc. These activities can prevent the occurrence of hunchback deformity by pulling the spine with its own weight.
(5) Massage therapy can improve local blood circulation and avoid or reduce the atrophy of paravertebral muscles, which is suitable for early mild deformity.
(6) When the back is stiff in the morning, hot bath can be taken to improve it. Hot compresses are also partially effective in relieving local pain.
(7) Do not smoke to avoid lung damage.
(8) Infections of the gastrointestinal tract and urinary tract often trigger spinal pain, so you should pay attention to dietary hygiene and avoid holding urine and constipation.
(9) Do appropriate sports, such as jogging, swimming (breaststroke is best).
11.What medications are available for ankylosing spondylitis?
(1) non-steroidal painkillers, eat when it hurts, do not eat if it does not hurt, mainly to relieve pain, commonly used drugs: etoricoxib, Xilabao, Loxone tablets, ibuprofen, and so on, these drugs are non-steroidal anti-inflammatory painkillers, just eat one of them, do not combine to eat, because the joint pain relief effect of these drugs will not be superimposed, but the side effects will be superimposed. These drugs can quickly relieve the patient’s low back pain and morning stiffness, reduce joint swelling and pain, and increase the patient’s range of motion. When taking these pain medications, it is important to weigh the risk of damage to one’s cardiovascular, gastrointestinal tract and kidneys, and one should seek prompt medical attention if one is unwell.
(2) Biologics, usually referred to as inhibitors of TNF-a, include etanercept, infliximab, adalimumab and Ixepro (recombinant human type II tumor necrosis factor receptor antibody fusion protein for injection). Tumor necrosis factor (TNF-α) is an important pathogenic mediator of ankylosing spondylitis, and these drugs are able to reduce the biological activity of TNF-α, which has good anti-inflammatory and retard TNF-a inhibitors are characterized by a rapid onset of action and a marked inhibition of bone destruction. TNF-a inhibitors are recommended to be continued if they are effective for 12 weeks, and patients who are not satisfied with the efficacy of one TNF-a inhibitor or who cannot tolerate it may choose another.
Biologics have the potential for injection site reactions or infusion reactions, with an increased risk of tuberculosis infection, hepatitis virus activation, and tumors. Etanercept does not cause lysis of immune cells expressing transmembrane TNF, making it less likely to induce tuberculosis infection and tumors. Screening for tuberculosis and hepatitis, excluding active infection and tumor, should be performed prior to drug administration. Blood tests and liver and kidney functions should be reviewed regularly during drug administration.
(3) Immunosuppressants, which are used to delay the development of the disease and need to be taken for a long time, such as salazosulfapyridine, methotrexate, and ralston. Among them, salazosulfapyridine is more commonly used, and it ke improve the pain, swelling and morning stiffness of peripheral joints of patients, and also reduce the level of serum IgA and other indicators of active laboratory. The recommended dose is 2 g/day, divided into 2-3 oral doses. The onset of action of salazosulfapyrimethamine is slow, and the maximum effect usually occurs in 4-6 weeks.
(4) Hormones, used when the above three drugs cannot be relieved, such as prednisolone, dexamethasone, hydrocortisone, etc., have greater side effects and are not easy to use for a long time.
12.What should be done if there is a hunchback deformity and I can’t see the sky or my feet?
When ankylosing spondylitis progresses to hunchback deformity, it will cause the patient to be unable to look up or even flat and see the sky; some patients can only look up and cannot see their feet. When the disease progresses to this point, spinal surgery is required and usually results in better outcomes.