Ankylosing spondylitis: An uncommon, but debilitating, cause of back pain

Back pain is one of the main symptoms of AS, while a bamboo neck is a common consequence of untreated AS. — Pixabay

At least 80% of us will experience back pain at least once in our lifetime.

Most times, it is self-limiting, i.e. it will go away by itself.

However, occasionally, it becomes chronic, i.e. lasting for more than three months, despite taking over-the-counter medication and rest.

There are two types of back pain: mechanical or degenerative, and inflammatory (see table below).

Ankylosing spondylitis (AS), also known as axial spondyloarthritis, is an inflammatory disease affecting the spine.

If inflammatory back pain is not treated, it results in new bone formation, causing the spine to fuse.

Over the years, an untreated patient will become more and more hunched, and develop deformities involving the spine, hips and knees.

Meanwhile, the cervical spine, which are the bones that form our neck, will fuse, making it look like a bamboo.

And it is indeed referred to as a bamboo spine.

Imaging procedures are necessary to make a diagnosis of AS.

However, in very early disease, the condition cannot usually be seen on X-rays, which tend to look normal.

Therefore, doctors rely on MRI (magnetic resonance imaging) to help diagnose early AS.

Treating this condition before there is damage visible on X-rays helps prevent progression of the disease that results in fusion of the spine.

AS can also involve other organs in the body (extra-articular manifestations), including the eyes (uveitis), the heart, other joints, the skin (psoriasis) and the intestines (Inflammatory bowel disease like ulcerative colitis and Crohn’s disease).

These extra-articular manifestations are usually associated with a positive marker for the HLA-B27 gene.

Delaying the disease

There is no cure for this disease, but its progression can be delayed and the patient kept in remission with medication.

Anti-inflammatory medications are usually the first line of treatment.

However, if and when they fail to control symptoms, drugs known as biologics are used to control the disease to prevent rapid progression that results in spinal fusion.

AS patients can indeed live a full and happy life.

Exercise also plays a big role in pain management and treatment.

Hydrotherapy, i.e. exercising in hot water, is very helpful in treating back pain as it relaxes the muscles and lets you strengthen your back muscles.

Tai chi, modified yoga and pilates help to stretch and build up strength too.

Acupuncture can also help in pain management.

Smokers should try to quit their habit as there is a high association of smoking with increased disease activity and difficult-to-treat disease.

However, there is often a delay from the beginning of the symptoms of back pain to the diagnosis of AS, which affects the outcome of treatment.

This delay ranges between 8.6 to 11 years worldwide.

Be aware

One of the main reasons for this delay is that AS is a complex disease and a relatively uncommon cause for a very common symptom.

AS is three times more common in men than women, and affects young adults more frequently than those above 40. — Los Angeles Times

This means that doctors will think of many other conditions that can cause back pain first, before arriving at AS.

There is also poor awareness among both the public and healthcare professionals regarding AS in general.

Patients often have difficulty reaching the right experts to get an early diagnosis, and most of the time, joint damage has already occurred by the time they see a rheumatologist (a doctor specialising in joint disease).

As mentioned earlier, X-rays of the spine and sacroiliac joint tend to look normal in the early stages of the disease, thus an MRI is needed.

This requires access to an MRI machine (not commonly available everywhere) and expert interpretation of the MRI scan by a musculoskeletal radiologist.

The disease usually starts in the younger age group, i.e teenagers and young adults, and is three times more common in men than in women.

At that age, patients are in the prime of their life; they want to travel the world, play sports, have a good education, get married and have successful careers.

If there is any delay in diagnosis, this will lead to irreversible damage.

When this happens, the patient’s world can come to a screeching halt.

They will develop deformities and have limited mobility.

They are sometimes bedbound due to the pain and have poor quality of life.

Some may not be able to work, have difficulty with normal daily activities, and have to be dependent on someone else to take care of them.

Early diagnosis and treatment prevents this, and lets an AS patient lead a normal life.

The earlier the diagnosis and treatment, the greater the response to treatment.

The key to early diagnosis is education and public awareness of the disease.

If you have back pain that persists for more than three months, ask yourself these questions:

• Are you younger than 40?
• Did your pain slowly become worse over time?
• Does your pain improve with exercise and movement?
• Does rest have no effect on the pain?
• Do you have pain at night?

If you have answered yes to at least four of the questions, please do seek treatment from a rheumatologist as soon as you can.

Dr Ramani Arumugam is a consultant rheumatologist and internal medicine physician. For more information, email [e-mail]. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.