Ankylosing Spondylitis

ANKYLOSING SPONDYLITIS Ankylosing spondylitis is a progressive, chronic, seronegative inflammatory disease involving the spine & the sacroiliac & peripheral joints. Ankylosing spondylitis is characterized by inflammation of Sacro-iliac joints and spine, which can progress to bony fusion of the spine.

Epideomology
The peak age of onset is second & third decades, with a male: female ratio of about 3:1. More than 90% of those affected are HLA B27 positive. The overall prevalence is less than 0.5% in most communities. Over 75% of patients are able to live a good quality of life. Even if severe ankylosis develops, functional limitation may not be marked as long as spine is fused in an erect posture.

Clinical features/ Signs and Symptoms:

Anlylosing spondylitis is a form of arthritis which affects the spine. Patient presents in following ways:

The onset is slow, with recurring episodes of low back pain and stiffness, usually patients start with lumbar symptoms.
Symptoms are most marked in early morning and after rest or inactivity and are relieved by movement.
Symptoms extend over many segments and axial and symmetrical.
Some patients present with mainly thoracic or neck symptoms.
The disease tends to ascend the spine slowly and after several years, whole spine may be affected.
As the disease progresses, neck movements can also be restricted due to involvement of cervical spine interfering with forward vision.
As the spine becomes progressively ankylosed, spinal rigidity and secondary osteoporosis predispose to spinal fracture. Spinal cord compression is rare.

Certain extra articular features are also seen in ankylosing spondylitis like Anterior uveitis & conjunctivitis, prostatitis, cardiac conduction defects, pulmonary fibrosis etc.

Signs:
Early signs:

Failure to bend forward (forward flexion) and failure.
Limitation of movement of spine in all directions, and possible pain on sacroiliac stressing.

Late stage signs:

Spinal fusion
Kyphosis
Fixed flexion contractures of hips or knees.
Costovertebral joint involvement in later stages can cause breathing difficulty as well as pleuritic chest pain.Plantar fasciitis, Achilles tendinitis and tenderness over bony prominences such as iliac crest and greater trochanter are common reflecting inflammation of sites of tendon insertion.

Extra articular features of AS

Anterior Uveitis (25%) and conjunctivitis (20%)
Prostatitis (80% men) usually asymptomatic
Cardiovascular disease
Aortic incompetence
Mitral incompetence
Pericarditis
cardiac conduction defects
amyloidosis
atypical upper lobe pulmonary fibrosis

Cause

It’s thought to result from exposure to a common environmental pathogen in genetically susceptible individuals, although no specific trigger has been identified. Increased Klebsiella aerogens occus in patients with established AS and may related to exacerbation of both joint and eye disease.

Investigation Findings

ESR & CRP : increased
HLA B-27 positive
RDW increased
X-RAY
MRI

X –Ray changes are characteristic but may take years to develop.
What do u see on X-ray:

Sacroilitis is often the first abnormality beginning in the lower synovial part of the joints with irregularity and loss of cortical margins, widening of the joint space and then sclerosis, narrowing and fusion.
Lateral thoracolumbar spine X-Ray : Squaring of vertebra due to erosion and sclerosis of anterior
MRI – more sensitive – early detection of Sacroilitis
Ossification of anterior longitudinal ligament and face joint fusion may be visible. Combination of these features may lead to Bamboo spine.
Erosive changes may be seen in symphysis pubis, the ischial tuberosities and peripheral joints.
Osteoporosis and atlanto-axial dislocation can occur as late features.

Management
The aim is to relieve pain, maintain mobility and prevent deformities & stiffness.

Spinal extension exercises and breathing exercises can help.
Swimming is a great exercise.
Poor posture should be avoided.
Avoidance of long hours of inactivity and taking breaks in between regularly.

Conventional treatment is with NSAIDs & analgesics. Also local corticosteroid injections are used. Surgery is done in cases of advanced deformity.

Homeopathy can be very helpful in case of Ankylosing Spondilitis as it can reduce inflammation of the joint as well as reduce to progression of disease to a great extent.

Auxially management of exercises is highly recommended along with homeopathic treatment. There is no specific medicine in homeopathy for A.S and treatment is based on totality presentation of case.

Few homeopathic remedies which can help in pain and inflammation are listed below but its strongly recommended to take medicine after seeing a Homeopathic practitioner in person.

OXALIC ACID: This remedy is suited when there is acute pain in the back & back is too weak to support the body. Pain worse from any kind of movement or exertion. Numbness is the characteristic.

CALCAREA FLUORICA: It has pain in the lower back, with fullness and burning pain. It is for backache simulating spinal irritation.

GNAPHALIUM: It is the remedy for chronic backache, with tired aching in the lumbar region.

RHUS TOXICODENDRON: Violent pain in the back, as if broken is the greatest characteristic. Suited for the chronic forms of backache where there is bruised & aching pains when attempting to rise or start any movement.

KALI CARBONICUM: Pains compel the patient to get up & move about mostly around 3 a.m. There are shooting pains down the buttocks. Pains in the back in the morning.