What is Ankylosing Spondylitis? What Are Its Symptoms? How Is It Diagnosed and Treated?

Ankylosing spondylitis is a chronic rheumatic disease seen in 0.9% of the world's population, characterized particularly by lower back pain. It is generally seen 2-3 times more frequently in men than in women.

This disease is a condition that impairs the spinal structure by causing the bones that make up the spine to fuse over time as a result of inflammation of the spine and surrounding joints. It causes severe pain, especially in the pelvic, lower back, and upper back regions. You may also experience morning stiffness and significant stiffness that decreases with movement.

The most important risk factor in the development of ankylosing spondylitis is a genetic marker called HLA-B27. Approximately 90% of diagnosed individuals carry this gene. However, this rate is slightly lower in Turkey, where 80% of individuals diagnosed with ankylosing spondylitis carry the HLA-B27 gene.

In this article, you will find answers to questions about what ankylosing spondylitis is, what its symptoms are, how it is diagnosed, and how it is treated. You will also learn about the causes of the disease, who is more frequently affected, and how you can maintain your daily life.

What is Ankylosing Spondylitis?

Inflammatory rheumatism affecting the spine

Ankylosing spondylitis, also known as spinal rheumatism, is a chronic, progressive inflammatory rheumatic disease that affects the spine and large joints. It is a member of a group of diseases called spondyloarthritides. This disease causes inflammation in the spinal joints, the ligaments between the vertebrae, and the points where tendons attach to the bones as a result of your body's immune system functioning abnormally.

During the progression of the disease, new bone formations may occur in the spaces between the bones in the spine. Thus, the flexibility and natural curvature of the spine may be lost over time. As a result, limited movement and postural deformities may occur.

The sacroiliac joint, which is the area between the lower part of the spine and the pelvic bones, is the first area to be affected. In addition, it can affect other large joints such as the hips, shoulders, and knees, and rarely organs such as the eyes (uveitis), and occasionally the heart and lungs.

What does ankylosing spondylitis mean?

The word "ankylosing" means the fusing of bones, and "spondylitis" means inflammation of the spine. The combination of these two words expresses the fundamental characteristic of the disease: the fusing of bones as a result of inflammation in the spine.

Inflammation initially creates pain and stiffness in and around the spine. As the disease progresses over time, two inflamed bones may join to become a single bone. This situation can lead to the spine gradually becoming rigid and stiff.

In advanced stages, the spine bends forward and the bones forming the spine fuse together. Thus, the spine loses its mobility and a hunchback (kyphosis) develops. If the ribs are also affected, you may experience difficulty in breathing.

Who is it more common in?

Ankylosing spondylitis is a disease that usually begins at a young age. The first symptoms mostly appear between the ages of 15-30. In approximately 80% of patients, symptoms begin before the age of 30, and it is quite rare for the disease to start after the age of 40.

This disease, which is seen 2-3 times more frequently in men than in women, progresses faster and follows a more severe course in men. While it is seen in one out of every 200 men and 500 women in our country, it is generally encountered in 5-10 out of every 1000 people in the population. It is estimated that there are approximately 350,000 ankylosing spondylitis patients in Turkey.

Genetic factors play an important role in the development of the disease. The risk of the disease is higher, especially in individuals carrying a gene called HLA-B27. Additionally, the probability of it being seen increases in individuals with a family history of ankylosing spondylitis. However, this does not mean that if someone in the family has the disease, it will necessarily appear in other family members.

In conclusion, ankylosing spondylitis is a disease that begins at a very young age, has a chronic course, and can cause limitations in spinal movements over time. With early diagnosis and appropriate treatment, the progression of the disease can be slowed, and your quality of life can be preserved.

What Causes Ankylosing Spondylitis?

The exact cause of ankylosing spondylitis is not yet fully known. However, scientists believe that a complex interaction of genetic predisposition and environmental factors plays an important role in the development of the disease. Both the irregular functioning of the immune system and external triggers contribute to the emergence of this disease.

The role of the HLA-B27 gene

HLA-B27 is a protein found on the surface of white blood cells that plays a role in the proper functioning of the immune system. This protein helps the body distinguish healthy tissues from foreign substances. While the HLA-B27 gene tests positive in approximately 90% of patients diagnosed with ankylosing spondylitis, this rate is around 70-80% in patients in Turkey.

The presence of this gene alone is not diagnostic for the disease. However, it helps in diagnosis in the presence of symptoms and findings. The important point is this: the HLA-B27 gene accounts for only 20-30% of the genetic predisposition to the disease, and not everyone who carries this gene develops ankylosing spondylitis.

Family history is also among the risk factors. In individuals who are HLA-B27 positive and have first-degree relatives with ankylosing spondylitis, the risk of developing the disease can rise to 15-20%.

Immune system disorders

Ankylosing spondylitis is considered an autoimmune disease. In this disease, the immune system mistakenly attacks the body's own tissues, especially the spine and sacroiliac joints.

Normally, while the immune system protects our body against harmful microbes, in ankylosing spondylitis, this system does not work properly. As a result, inflammation occurs in the joints, and over time, abnormal growth and fusion occur in the spinal bones.

Environmental triggers

Environmental triggers that cause the disease to start in people with genetic predisposition may include:

• Recently passed infections (especially intestinal and urinary tract infections)
• Smoking
• Obesity and a sedentary lifestyle
• Certain intestinal bacteria such as Klebsiella pneumoniae
• Trauma or mechanical stress

These triggers can incorrectly stimulate the immune system and initiate inflammation or exacerbate existing inflammation. Situations where the disease appears or worsens, especially after physical trauma, can be observed.

Relationship with inflammatory bowel diseases

There is a strong relationship between ankylosing spondylitis and inflammatory bowel diseases (IBD). In a study conducted, it was determined that the frequency of inflammatory bowel diseases (IBD) in ankylosing spondylitis patients was 31.7%. This rate is higher than in the normal population.

The probability of seeing ankylosing spondylitis also increases in people with inflammatory bowel diseases such as Crohn's disease and ulcerative colitis. The reason for this is that inflammation in the intestines can also affect the joints through similar mechanisms.

An interesting point is that intestinal problems are seen more frequently in patients with high disease activity who are treated with biological agents. Furthermore, this association is more common in female patients and young patients under 50 years of age.

In summary, ankylosing spondylitis emerges as a result of the complex interaction of many factors such as genetic predisposition, immune system irregularities, environmental factors, and inflammatory bowel diseases. Understanding this disease, which can follow a different course in each patient, is important for developing effective treatment strategies.

What Are the Symptoms of Ankylosing Spondylitis?

Recognizing the symptoms of ankylosing spondylitis in the early period is very important to slow the progression of the disease. The symptoms of this disease can vary from person to person, but there are some typical complaints.

Lower back, upper back, and hip pain

The most fundamental symptom of ankylosing spondylitis is pain felt in the lower back, upper back, and hip region. This pain usually starts insidiously and intensifies over time. The point that should be paid particular attention to is that the pain increases after rest and decreases with movement.

In this disease, pain can often wake you from sleep after midnight. You may have difficulty turning in bed due to the pain. Also, hip pain that shifts between the right and left sides is a typical finding. The fact that the pain lasts longer than 3 months is an important sign regarding the disease.

Morning stiffness and limited movement

The feeling of stiffness that becomes prominent in the mornings or after remaining inactive for a long time is one of the most distinct features of ankylosing spondylitis. This stiffness usually lasts longer than 30 minutes and can affect your daily activities.

Due to the limitation in lower back movements, you may have difficulty even with simple movements such as putting on shoes or socks. When you lie on your back, you may not be able to put your neck on the pillow, there may be a gap, or your lower back may ache while bent forward.

Hunchback posture and difficulty breathing

As the disease progresses, as a result of the spine losing its flexibility, flattening in the lower back and a hunchback in the upper back may develop. You may experience difficulty moving your head, neck, and body.

Inflammation of the ligaments and joints that allow the ribs to attach to the rib cage can cause chest pain during deep breathing, coughing, and sneezing. Due to the rib cage being unable to expand, difficulty in breathing and a decrease in lung capacity may be observed.

Eye inflammation (uveitis)

Eye inflammation (uveitis) is seen in approximately 25-30% of ankylosing spondylitis patients. This condition is the most common extra-articular finding of the disease.

Symptoms of uveitis include redness in the eye, pain, sensitivity to light, and blurred vision. It usually starts in one eye, sometimes it can affect both eyes. If left untreated, it can lead to vision loss.

Fatigue and weight loss

A significant portion of ankylosing spondylitis patients may feel general fatigue and weakness. Also, complaints of weight loss or inability to gain weight are common. Patients state that with treatment, their energy levels increase and they begin to gain weight.

Besides these, mild fever, loss of appetite, and anemia are among the symptoms that can be encountered during the disease process. All these symptoms can become more prominent during the active periods of ankylosing spondylitis.

How Is Ankylosing Spondylitis Diagnosed?

Diagnosing ankylosing spondylitis can sometimes take many years because the symptoms may not be very prominent in the early period of the disease. The disease progresses insidiously, and patients usually apply to a doctor when morning stiffness develops and movement limitations emerge. Therefore, several different methods are evaluated together for early and accurate diagnosis.

Physical examination and patient history

The first and most important step in diagnosis is physical examination and patient history. The following information is very important for the diagnosis of the disease:

• Characteristics of the pain (especially lower back pain lasting longer than 3 months)
• Worsening of pain at night and in the mornings
• Pain that increases with rest and decreases with movement
• Morning stiffness lasting longer than 30 minutes
• Complaints starting before the age of 35
• History of ankylosing spondylitis or similar diseases in the family

During the physical examination, your doctor may ask you to bend in different directions to test the range of motion of your spine. They also check for pain upon pressure and movement in the spine, hips, and joints. Whether the rib cage expands while breathing is also evaluated.

HLA-B27 test

HLA-B27 is a protein found on the surface of white blood cells. While HLA-B27 tests positive in approximately 90% of ankylosing spondylitis patients, this rate is around 70-80% in patients in Turkey.

This test is not sufficient to make a diagnosis on its own. In 20-30% of patients diagnosed with ankylosing spondylitis, this test may be negative. However, in individuals who are HLA-B27 positive:

• Disease activity may be more intense
• Extra-articular problems such as eye inflammation (uveitis) may be seen more frequently
• The disease may be more progressive and recurrent

MRI and X-ray imaging

Radiological examinations are quite important in the diagnosis of ankylosing spondylitis. First, pelvis and spine X-rays are taken to evaluate the sacroiliac joints (the joints between the pelvic bone and the tailbone).

However, in the early stages of the disease, X-ray findings may be normal. In this case, Magnetic Resonance Imaging (MRI) comes into play. MRI helps in diagnosis by showing edema in the bone marrow and inflammation within the joint in the early period. Especially:

• In patients who cannot be clearly diagnosed with X-rays
• In the evaluation of disease activity
• MRI is preferred in determining treatment response

Blood tests (CRP, sedimentation)

Various blood tests are performed to evaluate the presence and severity of inflammation in the body. The most frequently used are:

• C-reactive protein (CRP): Inflammation marker
• Erythrocyte sedimentation rate (sedimentation): Increases in inflammatory conditions

These tests can show that there is inflammation in the body, but they are not specific to ankylosing spondylitis. In approximately half of the patients, these tests may be found to be normal. Therefore, they are not diagnostic on their own.

Ultimately, the diagnosis of ankylosing spondylitis is made by evaluating the information obtained from patient history, physical examination findings, laboratory tests, and radiological imaging together. Early diagnosis is of great importance in terms of stopping the progression of the disease and preserving your quality of life.

How Is Ankylosing Spondylitis Treated?

The main goal of treatment is to reduce pain and stiffness, and to prevent or slow the development of spinal deformity. There is currently no treatment method that completely eliminates ankylosing spondylitis. However, treatment started early ensures that the disease is controlled before it causes permanent damage to the joints.

Drug treatment: NSAIDs and biological agents

Non-steroidal anti-inflammatory drugs (NSAIDs) are primarily used in the treatment of ankylosing spondylitis. These drugs can alleviate inflammation, pain, and stiffness. Indomethacin and aceclofenac are among the most frequently preferred drugs.

In cases where NSAID drugs do not provide benefit, biological drugs can be switched to. These drugs are usually injected under the skin or given intravenously. Biological drugs are effective by targeting proteins that trigger inflammation in the body.

The important point is that every drug can have side effects and they must be used under doctor supervision. Especially during biological treatment, your risk of infection increases, and regular check-ups are mandatory.

Physical therapy and exercise

Physical therapy is one of the most important parts of ankylosing spondylitis treatment. Regular exercise preserves your spinal flexibility and can slow the progression of the disease.

Types of exercise include:

• Spinal flexibility and stretching exercises
• Posture and positioning exercises
• Movements that strengthen abdominal and back muscles
• Deep breathing and rib cage exercises

Swimming is very beneficial for ankylosing spondylitis patients because it works the whole body at the same time and reduces the load on the joints. Also, walking, pilates, and yoga are among the recommended activities.

Exercises performed under the supervision of a physiotherapist are more effective than those you do on your own. However, a regular home program is also an important part of the treatment.

When is surgical intervention necessary?

In most patients with ankylosing spondylitis, surgical intervention is not necessary. However, in some cases, your doctor may recommend surgery.

If there is uncontrollable pain and damage in the hip joint, a hip replacement may be considered. When severe spinal deformity and hunchback develop, and a curvature has formed to the level that prevents you from looking forward, spinal corrective surgery may come to the agenda.

Surgical interventions should be performed in experienced centers because such surgeries are quite complex.

Things to consider during flare-up periods

During ankylosing spondylitis flare-up periods, pain and stiffness increase. During this period:

• Lighten your exercises but do not stop them completely
• Use the painkillers recommended by your doctor
• Relax your muscles by taking a hot shower or bath
• Rest well and stay away from stress factors

Also, it is important to undergo a doctor's check-up in case of trauma. In patients with ankylosing spondylitis, especially in advanced stages, spinal fractures that may be overlooked can lead to serious consequences.

Frequently Asked Questions

We have compiled the questions that patients ask their doctors the most and their answers. This information can help answer questions that may be bothering you during the treatment process.

Ankylosing spondylitis is a chronic and progressive disease; it is currently not possible for it to heal completely. However, with early diagnosis and regular treatment, you can control the symptoms and slow the progression of the disease. With regular exercise and correct treatment approaches, you can comfortably maintain your daily life.

Yes, ankylosing spondylitis has a strong genetic aspect. In 80-90% of patients, a gene called HLA-B27 is found. If you have this disease in your family, the risk of it being seen in you increases. If you have this disease in your first-degree relatives (mother, father, sibling), the probability of it being seen in you is around 10-20%. This rate is approximately 10 times higher than in the normal population.

The most common extra-articular finding of ankylosing spondylitis is eye involvement. In approximately one-third of patients, eye inflammation called uveitis can occur. Redness in the white part of the eye lasting for a few days or longer, pain, sensitivity to light, and blurred vision are symptoms of uveitis. Sometimes one eye, sometimes both eyes can be affected. If not treated early, uveitis can lead to permanent vision loss.

There is no special diet that shows you can cure ankylosing spondylitis only with nutrition. However, proper nutrition can help in the control of the disease. Weight control is very important because excess weight increases the load on the joints. Mediterranean-style nutrition (dishes with olive oil, vegetables, fruits) can reduce inflammation. Fish containing Omega-3, and foods rich in calcium and Vitamin D are beneficial.

The most important difference between ankylosing spondylitis and a herniated disc is the characteristic of the pain:

• In ankylosing spondylitis, pain decreases as you move, and increases during rest and sleep
• In a herniated disc, rest usually reduces the pain
• In ankylosing spondylitis, morning stiffness lasts 20-30 minutes or more
• In ankylosing spondylitis, pain can wake you from sleep at night
• If you have lower back pain that lasts longer than 3 months and increases with rest, consult a doctor

In Summary: Ankylosing Spondylitis

As a result, although ankylosing spondylitis is a chronic condition, it is possible to preserve your quality of life with correct treatment approaches. Early diagnosis is the most important step in slowing the progression of the disease. Therefore, if your long-lasting lower back pain increases, especially during night and morning hours, definitely consult your doctor.

Physical therapy and regular exercise are indispensable parts of ankylosing spondylitis treatment. Movements that preserve your spinal flexibility, breathing exercises, and activities such as swimming make your daily life easier. Also, developing correct posture habits to prevent postural deformities is of great importance.

While drug treatments control pain and inflammation, regular physical therapy sessions preserve your mobility. However, the success of the treatment largely depends on your adherence to the regular exercise program.

Remember that most ankylosing spondylitis patients can lead an active and productive life. You can manage your disease by cooperating with your doctor, physiotherapist, and family. With regular check-ups, an appropriate treatment plan, and lifestyle changes, it is definitely possible to live in harmony with this disease.

What is ankylosing spondylitis, what are its symptoms, how is it diagnosed, and what are the treatment methods? You will find answers to all your questions in this comprehensive guide.

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