Ankylosing spondylitis is an inflammatory disease of the spine and sometimes joints, most often occurring in young men (up to 40 years old). The causes of its occurrence are unknown. However, 90 % of patients with ankylosing spondylitis have a genetic predisposition to the disease in the form of carrying the HLA B27 gene, it can be determined by a blood test. In healthy people, with the presence of the HLA B27 gene, there is an increased risk of developing Bechterew’s disease or other diseases from the group of spondyloarthritis (reactive arthritis, psoriatic arthritis, and others).
What are the manifestations of ankylosing spondylitis?
The main manifestation of Bekhterev’s disease is morning or night back pain, more often – in the lower back. At the same time, as a rule, they develop slowly over many months and even years, slowly becoming more intense. Usually, these morning pains are accompanied by stiffness or stiffness in the spine. An important distinguishing feature of inflammatory back pain that occurs with Bekhterev’s disease, from “ordinary” or “mechanical” back pain (what is popularly called “osteochondrosis”) is a reduction in pain (!!!) after physical exertion and increased pain at rest, while back pain, if you overexert it and there is a muscle spasm, on the contrary, will become even stronger from work and exertion! Let’s list once again all the main signs of”inflammatory back pain”.
- The age of the onset of pain – in persons younger than 40 years.
- The duration of pain is more than three months.
- Gradual onset of pain.
- Improvement of pain after exercise.
- No reduction of pain at rest.
- Morning stiffness (stiffness) in the spine for more than 30 minutes.
- Night or early morning pain.
Pain can be not only in the lumbar, but also in the cervical and thoracic spine, they worry from day to day for many months and years and significantly improve when taking NSAIDs (for example, diclofenac). Sometimes pain occurs in the upper part of the buttocks, which is caused by the defeat of a special area of the pelvic bones – the sacroiliac joints, which are almost always inflamed with Bekhterev’s disease, and, as a rule, from two sides: both on the left and on the right. This inflammation of the sacroiliac joints is called “sacroiliitis” – the calling card of Bekhterev’s disease. Over time, inflammation in the back leads to the appearance of “bone bridges” that tightly fasten the vertebrae to each other, and as a result, our mobile spine resembles a dry, sedentary bamboo stick. In some patients, tendons become inflamed (enteritis), sometimes eye inflammation develops according to the type of uveitis (damage to the vascular membrane of the eye): the eye turns red, watery and hurts.
How is ankylosing spondylitis diagnosed?
The diagnosis is based on the presence of inflammatory back pain, persistent deterioration of the mobility of the spine, changes in the sacroiliac joints according to X-rays. In the early stages of the disease, when there is still no fusion of the vertebrae and pronounced changes in the sacroiliac areas, MRI comes to the rescue. This method allows you to see the initial inflammatory changes in the spine and in the sacroiliac joints, that is, to diagnose spondylitis and sacroiliitis before an X-ray. When using radiography it is not possible to see structural changes in the sacroiliac joints, and the diagnosis is made only on the basis of MRI, doctors designate this form of the disease as axial X-ray negative spondyloarthritis, and not ankylosing spondylitis. Axial spondyloarthritis without radiological changes means either the initial stages of Bekhterev’s disease, when significant structural changes in the spine have not yet appeared, or the patient has a mild form of inflammation in the back, when structural changes may not occur.
Laboratory indicators of inflammation (ESR and C-reactive protein) are elevated only in 50-70 % of patients and are not reliable signs of ankylosing spondylitis.
As it was written above, the HLA B27 gene can be detected in 90% of patients with Bekhterev’s disease, but its absence does not exclude this disease!
It is also important to know that the HLA B27 gene is detected in approximately 5 % of people in the general population, and Bekhterev’s disease is diagnosed 10 times less often, that is, the detection of the HLA B27 gene in you does not automatically mean that you have a diagnosis of “ankylosing spondylitis”.
How is ankylosing spondylitis treated?
To begin with, if you smoke, you need to immediately break up this bad habit. For ankylosing spondylitis, numerous scientific studies demonstrate significant progress of the disease and loss of spinal mobility in smokers. Good news: you will not need to follow a special diet for Bekhterev’s disease.
As strange as it may sound, half of the success of treatment depends on the determination and will of the patient with Bekhterev’s disease. Yes, indeed, 50% of the forecast is determined by physical activity, and DAILY! It is recommended to perform breathing exercises that will not allow the chest to stiffen, slowly form a muscular corset on the back and develop its flexibility. All exercises, especially at the very beginning of training, should be done with minimal or no weight at all. Squats with a barbell or dumbbells, deadlift, back extension on an inclined bench and other traumatic exercises are contraindicated. Remember, the most important thing is daily muscle work without fanaticism and pain, but you can ignore minor back discomfort.
First-line medications, regardless of the stage and duration of the disease, are NSAIDs, and on a daily continuous basis. Bekhterev’s disease is the only disease that requires taking NSAIDs day after day for many months and even years! It is with daily intake of NSAIDs that they have not only an analgesic effect, but also reduce inflammation in the spine, and according to some reports, slow down the development of the disease. You can learn more about these drugs in the corresponding section of the book (see the chapter
“NSAIDs: myths and facts”). However, if you are treated with NSAIDs in full dosages for more than a month without significant effect, and the replacement of one anti-inflammatory drug with another does not give results, you need to discuss the transition to modern biological drugs (infliximab, etanercept, adalimumab, certolizumab pegol, golimumab, secukinumab, ixekizumab, netakimab). All these drugs are approximately the same in effectiveness, it is better to discuss the advantages and disadvantages of each of the biological drugs with the attending physician.
You can read more about them in the corresponding section (see the chapter “Biological preparations”).
It is important to remember that whatever treatment you are undergoing, we are talking about long-term therapy!
Sometimes the doctor may prescribe sulfasalazine in addition to NSAIDs – when it comes to the predominant inflammation of the peripheral joints, and not the back, for example, the knee and/or ankle.
It is important to know that for the treatment of inflammatory pain only in the back (without peripheral joints), sulfasalazine is recognized as ineffective and should not be prescribed.
In case of intolerance or ineffectiveness of sulfasalazine for the treatment of peripheral arthritis in Bekhterev’s disease, the doctor may prescribe methotrexate, but the scientific basis for its use in such situations is extremely small.
Perhaps the most pressing issue in the treatment of ankylosing spondylitis (Bekhterev’s disease) is the unjustified appointment of hormonal drugs (prednisone or methylprednisolone). All foreign and Russian leading experts on Bekhterev’s disease are unanimous in their opinion: hormonal drugs for the treatment of this disease SHOULD NOT be used either in tablets or in droppers (except in extremely rare situations)! Not only is there no long-term benefit from them, but a huge number of various drug complications also develop! The only exceptions are hormonal drugs for intra-articular injections (Diprospan or Kenalog), but remember that these drugs can not be injected into one joint more than 3-4 times a year.
Often, patients with a ruptured Achilles tendon come to me for an appointment due to frequent administration of a hormonal drug in the heel area. Why is this happening? Inflammation of the Achilles tendon at the place of its attachment to the calcaneus (scientifically called enthesitis) can be accompanied by severe pain, which significantly complicates walking. Therefore, an injection of the hormone, which has a quick and pronounced effect, is regarded as a salvation. The harm from such actions occurs if this” salvation ” is abused, because from the frequent administration of hormonal drugs, the tendon becomes thinner and can break even with daily physical exertion!
What does ankylosing spondylitis threaten me with?
The insidiousness of Bekhterev’s disease lies in the slow loss of mobility of the spine as a result of the formation of bone spines, which then form bridges or paper clips between the vertebrae, making it impossible to fully turn the neck, bend forward or sideways. That is why it is very important to engage in daily physical activity, increasing the flexibility of the spine and not allowing it to stiffen.
In some patients, the vascular membranes of the eye (scientifically called uveitis), the intestines (colitis), the aorta (aortitis), and the kidneys (IgA-nephritis) may become inflamed. As with rheumatoid arthritis, with Bekhterev’s disease with prolonged inflammation, a formidable complication can occur – amyloidosis, when the inflammatory protein amyloid is deposited in many organs and tissues, disrupting their structure and function. Like other inflammatory diseases of the joints, Bekhterev’s disease can increase the risk of cardiovascular complications!