Ankylosing spondylitis Symptoms Types and Effective Treatment

Ankylosing spondylitis is a chronic disease that primarily affects the spine and large joints in the body, causing severe pain and stiffness, particularly in the lower back and pelvis. Many people suffer from this condition without realizing its causes or how to manage it effectively. In this article from Dely Medical, we will explore the causes of ankylosing spondylitis, its common symptoms, and the main types of the condition. We will also discuss available treatment options to relieve symptoms and improve the quality of life. If you experience persistent pain or stiffness in your joints, this article may help you understand the nature of the disease and how to better manage it.

What is Ankylosing Spondylitis?

Ankylosing spondylitis is a chronic disease that primarily affects the spine and large joints such as the pelvis and hips. In this condition, inflammation causes the vertebrae to fuse together, leading to stiffness in the spine and difficulty moving over time. The disease typically begins in the lower back and can also affect other joints like the knees, shoulders, and feet.

What Causes Ankylosing Spondylitis?

The exact cause of ankylosing spondylitis is not fully understood, but it is believed that genetic factors play a significant role, particularly the presence of the HLA-B27 gene. Environmental factors, such as infections, may also contribute to the development of the disease in people with a genetic predisposition. Chronic inflammation is also thought to play a part in the appearance of symptoms.

Is Ankylosing Spondylitis Inherited?

Yes, ankylosing spondylitis has a strong genetic link. The presence of the HLA-B27 gene increases the likelihood of developing the disease. However, having this gene does not necessarily mean that a person will get the disease, but it is considered a contributing factor that increases the risk.

Can Ankylosing Spondylitis Be Cured?

There is no definitive cure for ankylosing spondylitis, but with proper treatment, symptoms can be managed effectively, and the progression of the disease can be slowed down. The goal of treatment is to reduce pain and inflammation and maintain flexibility in the spine and joints.

Does Ankylosing Spondylitis Affect Sexual Life?

Yes, ankylosing spondylitis can affect sexual life due to chronic pain or stiffness in the spine and joints. Some individuals may have difficulty performing daily activities, including sexual activity. It’s important to talk to a doctor about how to manage pain and discuss any issues related to sexual health.

Can Ankylosing Spondylitis Lead to Eye Problems?

Yes, some patients with ankylosing spondylitis may develop uveitis (inflammation of the front part of the eye). This inflammation causes eye pain, redness, light sensitivity, and blurred vision. Prompt treatment of eye inflammation is important to avoid permanent vision damage.

Can Ankylosing Spondylitis Affect the Heart?

In some cases, ankylosing spondylitis can lead to heart and vascular problems, such as inflammation of the heart valves or an increased risk of atherosclerosis. Regular monitoring of heart health is essential to manage these risks.

Types of Ankylosing Spondylitis

Standard Ankylosing Spondylitis (Classic Type):
- Description: The most common form, typically starting in the spine and large joints such as the pelvis and knees. This type is characterized by pain in the lower back and stiffness, especially in the morning, which gradually leads to vertebral fusion.
- Main Symptoms: Lower back or pelvic pain, stiffness in the spine, and pain in large joints.
- Characteristics: Usually begins in youth (20-30 years old) and affects men more than women. Often linked with the HLA-B27 gene.
Ankylosing Spondylitis with Tendonitis (Enthesitis):
- Description: This type focuses on inflammation of the tendons where they attach to bones, causing pain and swelling in areas like the feet, knees, shoulders, and ankles.
- Main Symptoms: Joint pain with swelling in tendons, lower back or pelvic pain, and stiffness after rest.
- Characteristics: Chronic inflammation can lead to mobility issues, commonly in weight-bearing joints like knees and feet.
Ankylosing Spondylitis with Uveitis:
- Description: This type is associated with inflammation of the uvea (front part of the eye), a common condition among patients with ankylosing spondylitis, leading to eye pain, redness, and light sensitivity.
- Main Symptoms: Eye pain, redness, light sensitivity, and blurry vision.
- Characteristics: Eye inflammation can occur suddenly and needs prompt treatment to prevent complications.
Ankylosing Spondylitis in Women:
- Description: This type affects women less frequently than men and typically begins at a later age (after 30). Symptoms may be less noticeable, often delaying diagnosis.
- Main Symptoms: Lower back or pelvic pain, stiffness upon waking up, and increased symptoms during menstruation.
- Characteristics: Symptoms can resemble rheumatoid arthritis, leading to delayed diagnosis.
Ankylosing Spondylitis Associated with Bowel Diseases:
- Description: Some individuals with ankylosing spondylitis also suffer from gut conditions such as ulcerative colitis or Crohn’s disease. In this type, the immune system attacks both joints and the intestines.
- Main Symptoms: Lower back pain, joint pain, and gastrointestinal symptoms like diarrhea or blood in the stool.
- Characteristics: Requires integrated treatment for both joints and gastrointestinal health.
Ankylosing Spondylitis with Severe Stiffening:
- Description: This type is characterized by severe stiffness in the joints, which leads to permanent movement impairment in some cases.
- Main Symptoms: Constant joint pain, severe spinal stiffness, difficulty walking or performing daily activities.
- Characteristics: Can result in permanent loss of mobility in extreme cases.
Ankylosing Spondylitis with Cardiovascular Impact:
- Description: Some patients may experience heart-related problems, including inflammation of heart valves or an increased risk of cardiovascular diseases like atherosclerosis.
- Main Symptoms: Chest pain, shortness of breath, and abnormal heart rhythms.
- Characteristics: Ankylosing spondylitis can increase the risk of heart diseases, so regular heart health monitoring is important.
Ankylosing Spondylitis and Environmental Factors:
- Description: In some cases, exposure to environmental factors like pollution or smoking can worsen symptoms or trigger the onset of the disease in individuals with a genetic predisposition.
- Main Symptoms: Increased pain and swelling in joints, rapid disease progression.
- Characteristics: People living in unhealthy environments may experience faster deterioration of disease symptoms.

Stages of Ankylosing Spondylitis

Stage 1: Early Stage

Description: In this stage, symptoms are mild and nonspecific, making it difficult to diagnose the disease accurately. It may take months or years before a proper diagnosis is made.

Main Symptoms of Ankylosing Spondylitis:

Lower Back Pain:
- Typically begins in the lower back or pelvis, worsening at night or after periods of rest. Some may mistake it for normal muscle strain or fatigue.
Stiffness in the Spine:
- A feeling of stiffness in the morning after waking up, making it difficult to move the spine.
Mild Joint Swelling:
- There may be mild swelling in joints such as the knees or hips, though the pain is not severe at this stage.
Early Diagnosis Challenge:
- Due to symptoms being similar to other conditions like rheumatoid arthritis, it may be difficult to diagnose the disease early on.

Stage 2: Progressive Stage (Gradual Development)

Description:
If left untreated, the disease gradually worsens, with increased pain and inflammation in the joints and other areas of the body. Symptoms become more evident.

Main Symptoms:

Increased Pain and Stiffness:
- Pain in the lower back increases and starts affecting large joints such as the knees or hips.
Joint Swelling:
- Swelling in joints like the pelvis, knees, shoulders, and feet may occur.
Chest Pain:
- Inflammation may begin affecting the joints between the ribs and spine, causing chest pain and difficulty taking deep breaths.
Fatigue:
- Extreme fatigue, especially in the morning or after long periods of rest.
Vertebral Fusion:
- At this stage, vertebrae may begin to fuse together due to chronic inflammation, leading to stiffness in the spine and loss of flexibility.

Stage 3: Advanced Stage

Description:
In this stage, ankylosing spondylitis reaches an advanced stage, where complete fusion of the vertebrae or permanent joint destruction occurs. The impact on movement and daily activities becomes more noticeable.

Main Symptoms:

Vertebral Fusion:
- Vertebrae become fused due to fibrosis and excessive bone growth, leading to total stiffness in the spine.
Spinal Curvature:
- The spine may begin to curve abnormally, causing posture and movement problems.
Joint Swelling and Stiffness:
- Joint destruction leads to mobility issues, possibly requiring surgical intervention.
Breathing Difficulty:
- Due to increasing stiffness in the rib cage and rib joints, the patient may experience difficulty breathing deeply.
Severe Chronic Pain:
- Pain becomes constant and severe, and patients require pain relievers and ongoing medical treatment to manage symptoms.

Stage 4: Degradation or Complications

Description:
At this stage, complications arising from the disease may become significant. Patients may experience additional health issues in organs such as the heart, eyes, or intestines.

Main Symptoms:

Eye Issues (Uveitis):
- Eye inflammation can cause pain, redness, light sensitivity, and blurred vision. If not treated promptly, it may lead to permanent vision problems.
Cardiac Complications:
- Patients may develop heart issues such as valve inflammation or atherosclerosis.
Bowel Inflammation:
- Some patients may also suffer from gastrointestinal problems like ulcerative colitis or Crohn’s disease, which complicates diagnosis and treatment.
Psychological Impact:
- As pain and mobility limitations increase, patients may experience depression and anxiety due to ongoing disability, which may require psychological treatment or support.

Potential Complications of Ankylosing Spondylitis:

If ankylosing spondylitis is not effectively treated, it can lead to a range of serious complications that significantly affect the patient’s quality of life. These complications include both physical and psychological effects, and in some cases, may lead to permanent disabilities.

Permanent Stiffness in the Spine:
- Vertebral Fusion: One of the most dangerous complications is vertebral fusion, where vertebrae fuse together due to chronic inflammation. This leads to total spinal stiffness and loss of movement, making it difficult to move the body normally.
- Spinal Deformities: With disease progression, abnormal curvatures may appear in the spine, such as a hunchback (kyphosis), causing difficulty maintaining a natural posture.
Breathing Issues:
- Impact on the Rib Cage: In severe cases, the joints between the ribs and spine may be affected, reducing the rib cage's ability to expand during breathing.
- Breathing Problems: Stiffness in the rib joints can lead to difficulty taking deep breaths, causing shortness of breath, especially in advanced stages.
Eye Inflammation:
- Uveitis: Some patients may develop eye inflammation, known as uveitis or anterior eye inflammation. This condition leads to the following symptoms:
  - Eye pain
  - Redness
  - Light sensitivity (photophobia)
  - Blurry vision or changes in vision
- Vision Damage: If uveitis is not treated promptly, it may lead to permanent eye damage and partial or complete vision loss. Regular eye health monitoring is crucial.
Joint Complications:
- Peripheral Joint Inflammation: Ankylosing spondylitis may also affect peripheral joints (such as the knees, shoulders, hips, and ankles), leading to swelling and pain in these joints.
- Permanent Joint Damage: Over time, persistent inflammation may lead to joint damage, causing mobility issues or deformities in the joints, which may require surgical intervention.
Cardiac Complications:
- Heart and Vascular Diseases: Ankylosing spondylitis can increase the risk of cardiovascular diseases, including:
  - Inflammation in the heart valves, increasing the risk of infective endocarditis.
  - Increased risk of coronary artery disease, leading to potential heart attacks or circulatory issues.
Tendon and Ligament Issues:
- Tendonitis: Ankylosing spondylitis can cause inflammation in the tendons, particularly where tendons attach to bones, such as in the feet, ankles, or knees.
- Pain and Weakness: This inflammation can cause pain and swelling in the tendons, weakening the affected joints and making movement difficult.
Anemia (Low Red Blood Cells):
- Effect on Red Blood Cell Levels: Chronic inflammation from ankylosing spondylitis can lead to anemia. Prolonged inflammation can lower red blood cell levels, causing fatigue and a lack of energy.
Disability:
- Mobility Disability: As ankylosing spondylitis progresses, spinal and joint stiffness can result in disability, making it difficult to perform simple daily activities such as walking, sitting, or bending.
- Psychological Effects: Chronic pain and limited movement may lead to depression and anxiety due to ongoing disability, adding to the challenges of daily life.
Psychological and Social Effects:
- Depression and Anxiety: Due to ongoing pain and movement limitations, patients may suffer from depression and anxiety, which can impact mental health and increase stress levels.
- Social Isolation: The disease can lead to a decline in social and professional relationships, as patients may struggle to participate in social activities or daily life tasks.

Treatment of Ankylosing Spondylitis with Medication:

Pain Relievers and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):
- Goal: To reduce pain and inflammation in the joints and spine.
- Medications Used:
  - Ibuprofen
  - Naproxen
  - Diclofenac
  - Meloxicam
- How They Work: These medications inhibit enzymes responsible for producing prostaglandins, chemicals that cause inflammation and pain. By reducing these chemicals, pain and swelling are alleviated.
- Side Effects: NSAIDs may cause gastrointestinal problems such as ulcers or stomach bleeding, and may affect the kidneys when used long-term.
Biologic Medications:
- Goal: Used for severe cases or when traditional medications are ineffective. They aim to reduce the immune response causing inflammation.
- Medications Used:
  - Tumor Necrosis Factor (TNF-alpha inhibitors):
    - Infliximab
    - Adalimumab
    - Certolizumab
  - Interleukin-17 (IL-17 inhibitors):
    - Secukinumab
    - Ixekizumab
- How They Work: These drugs block inflammatory proteins like TNF-alpha or IL-17, which play a major role in ankylosing spondylitis. By reducing the effects of these proteins, inflammation is reduced, and symptoms are alleviated.
- Side Effects: Biologic medications can increase the risk of infections, such as respiratory or skin infections, so patients need to be monitored closely during treatment.

3. Disease-Modifying Antirheumatic Drugs (DMARDs):

Goal:
Used in cases where symptoms do not respond adequately to pain relievers or biologic medications. They aim to slow the disease progression and prevent joint damage.

Medications Used:

Methotrexate: Works by reducing immune system activity.
Cyclosporine: An immunosuppressant.
Sulfasalazine: Has anti-inflammatory effects in the intestines and joints.

How They Work:
These medications modify the immune response and reduce chronic inflammation that causes joint damage.

Side Effects:
Includes nausea, vomiting, liver problems, and increased risk of infections due to immune suppression.

4. Medications for Eye Inflammation (Uveitis):

Goal:
To treat eye inflammation (uveitis) associated with ankylosing spondylitis.

Medications Used:

Steroid Eye Drops: Like Prednisolone to reduce inflammation in the eye.
Immunosuppressive Medications: Like Methotrexate or Azathioprine to treat chronic eye inflammation.

How They Work:
These medications help reduce inflammation inside the eye, alleviating symptoms and improving vision.

5. Corticosteroids:

Goal:
Corticosteroids are used in cases where other medications are ineffective or when there is acute inflammation. They are useful for quickly reducing inflammation in joints and the spine.

Medications Used:

Dexamethasone
Prednisone

How They Work:
Corticosteroids suppress the immune response and reduce inflammation rapidly.

Side Effects:
Long-term use can lead to weight gain, osteoporosis, increased blood sugar levels, and high blood pressure.

6. Pain Relievers (Analgesics):

Goal:
Pain relievers aim to reduce chronic pain caused by joint or spine inflammation.

Medications Used:

Simple Pain Relievers: Such as Paracetamol and Codeine.
Strong Pain Relievers: Opioid pain relievers may be used for severe pain under medical supervision.

How They Work:
These medications help alleviate chronic pain and improve the quality of life for patients.

Side Effects:
Opioid pain relievers may lead to addiction or strain on the digestive system (such as constipation).

Surgical Treatment of Ankylosing Spondylitis:

Joint Replacement Surgery (Knee or Hip):
Description:
When ankylosing spondylitis affects large joints like the knees or hips and causes joint wear or cartilage destruction, joint replacement surgery may be necessary. This surgery aims to alleviate pain and improve the function of the affected joint.

Goal:
To replace the damaged joint with an artificial joint, made from metal or plastic.

Characteristics:

Joint replacement in advanced cases of hip or knee involvement.
Effective at reducing pain and improving movement.

Side Effects:

Potential risk of infection at the surgical site.
Healing delays or issues with the artificial joint, which may require replacement.

Spinal Surgery: Spinal Fusion:
Description:
If vertebrae fuse due to fibrosis and swelling from ankylosing spondylitis, spinal fusion surgery may be needed. This surgery aims to fuse the affected vertebrae to stabilize the spine and reduce pain caused by friction between vertebrae.

Goal:
To reduce movement between the affected vertebrae and prevent slippage or fusion.

Characteristics:

Fusion of one or more vertebrae in the spine.
Metal supports or screws are used to stabilize the vertebrae in place.

Side Effects:

Risk of infection.
Nerve compression or chronic pain after surgery.
Long recovery time.

Osteotomy (Bone Removal):
Description:
In cases where ankylosing spondylitis causes spinal deformities like scoliosis or kyphosis, surgeons may perform an osteotomy to remove part of the bone causing the curvature, improving posture and relieving pressure on nerves.

Goal:
To remove or reshape bones to reduce pressure on nerves and improve posture.

Characteristics:

Removal of curved bone segments.
Helps straighten the spine in cases of scoliosis or severe curvature.

Side Effects:

Risk of infection.
Potential issues with bone healing, which may require additional surgery.

Costovertebral Joint Surgery (Rib-Spine Joint Surgery):
Description:
When the joint between the ribs and spine becomes severely inflamed and causes chronic pain, surgery may be an effective option. The surgery aims to free or repair the costovertebral joint.

Goal:
To remove damaged parts or implant a device to stabilize the rib joint with the spine, reducing pain and improving comfort.

Characteristics:

Removal or repair of the costovertebral joint.
Helps reduce pain caused by chronic inflammation in the chest area.

Side Effects:

Potential risk of infection or swelling at the surgical site.

Tendon Release Surgery:
Description:
In cases of tendon inflammation associated with ankylosing spondylitis, tendon release surgery may be necessary to remove or free the affected tendons from swollen joints.

Goal:
To release inflamed tendons from the joints, helping to reduce pain and improve mobility.

Characteristics:

Surgery may involve cutting or repairing tendons using advanced surgical techniques.

Side Effects:

Difficulty moving or pain in the area if the healing process is not properly managed or if recovery takes longer.

Surgical Treatment for Structural Deformities (Structural Deformity Surgery):
Description:
In severe cases where permanent structural changes occur in the spine (like severe kyphosis or scoliosis), surgery may be needed to correct the deformity caused by ankylosing spondylitis.

Goal:
To reshape the spine or correct structural deformities to restore normal posture and improve movement.

Characteristics: