Ankylosing spondylitis (pronounced ank-kih-low-sing spon-dill-eye-tiss), or AS, is a form of arthritis that primarily affects the spine, although other joints can become involved. It causes inflammation of the spinal joints (vertebrae) that can lead to severe, chronic pain and discomfort.
In more advanced cases this inflammation can lead to ankylosis -- new bone formation in the spine -- causing sections of the spine to fuse in a fixed, immobile position.
AS can also cause inflammation, pain, and stiffness in other areas of the body such as the shoulders, hips, ribs, heels, and small joints of the hands and feet. Sometimes the eyes can become involved (known as iritis or uveitis), and -- rarely -- the lungs and heart can be affected.
The hallmark feature of ankylosing spondylitis is the involvement of the sacroiliac (SI) joints during the progression of the disease. The SI joints are located at the base of the spine, where the spine joins the pelvis.
It is important to note that the course of ankylosing spondylitis (AS) varies greatly from person to person. So too can the onset of symptoms. Although symptoms usually start to appear in late adolescence or early adulthood (ages 17 to 45), symptoms can occur in children or much later in life.
The most common early symptoms of AS are frequent pain and stiffness in the lower back and buttocks, which comes on gradually over the course of a few weeks or months. At first, discomfort may only be felt on one side, or alternate sides. The pain is usually dull and diffuse, rather than localized. This pain and stiffness is usually worse in the mornings and during the night, but may be improved by a warm shower or light exercise. Also, in the early stages of AS, there may be mild fever, loss of appetite, and general discomfort. It is important to note that back pain from AS is inflammatory in nature and not mechanical.
The pain typically becomes persistent (chronic) and is felt on both sides, usually lasting for at least three months. Over the course of months or years, the stiffness and pain can spread up the spine and into the neck. Pain and tenderness spreading to the ribs, shoulder blades, hips, thighs, and heels is possible as well.
Note that AS can present differently at onset in some people. This tends to be the case in women more than men. Quoting Dr. Elaine Adams, "Women often present in a little more atypical fashion so it's even harder to make the diagnosis in women." For example, we have heard anecdotally from some women with AS that their symptoms started in the neck rather than in the lower back.
Varying levels of fatigue may also result from the inflammation caused by AS. The body must expend energy to deal with the inflammation, thus causing fatigue. Also, mild to moderate anemia, which may also result from the inflammation, can contribute to an overall feeling of tiredness.
In a minority of individuals, pain does not start in the lower back, or even the neck, but in a peripheral joint such as the hip, ankle, elbow, knee, heel, or shoulder. This pain is commonly caused by enthesitis, inflammation of the site where a ligament or tendon attaches to bone. Inflammation and pain in peripheral joints is more common in juveniles with AS. This can be confusing since, without the immediate presence of back pain, AS may look like some other form of arthritis.
Many people with AS also experience bowel inflammation, which may be associated with Crohn's disease or ulcerative colitis.
AS is often accompanied by iritis or uveitis (inflammation of the eyes). About one-third of people with AS will experience inflammation of the eye at least once. Signs of iritis or uveitis are: Eye(s) becoming painful, watery, and red, blurred vision, and sensitivity to bright light.
HLA-B27 is a perfectly normal gene found in 8 percent of the Caucasian population. Generally speaking, no more than 2 percent of people born with this gene will eventually develop spondylitis.
Second, it is important to note that the HLA-B27 test is not a diagnostic test for ankylosing spondylitis. Also, the association between AS and HLA-B27 varies among different ethnic and racial groups. It can be a very strong indicator in that more than 95 percent of people in the Caucasian population who have AS test positive for HLA-B27. However, close to 80 percent of AS patients from Mediterranean countries and only 50 percent of African American patients with AS are HLA-B27 positive.
Since there is no single blood test for AS, laboratory work may, or may not, be of help. Elevated erythrocyte sedimentation rate (ESR), also known as SED rate, and C-reactive protein (CRP) are common indicators of inflammation. Elevated levels of these markers, however, are not present in all AS patients and, when they are, it can be from other causes such as anemia, infection, or cancer. For example, it is estimated that less than 70 percent of people with AS have a raised ESR level.
Finally, there is no association between AS and rheumatoid factor (associated with rheumatoid arthritis) and antinuclear antibodies (associated with lupus.)
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