Definition:

Ankylosing Spondylitis is one of many forms of chronic inflammatory and degenerative arthritis, affecting the spine,especially affects the joints between the vertebrae of the spine and the joints between the spine and the pelvis (sacro-iliac joints). It may also affect other joints of the body.

The joints are initially inflamed and this may be followed by progressive stiffness and inflexibility. It eventually leads to the fusion of the spine, giving permanent painful stiffness of the back. It is often called bamboo spine, as the spine tends get stiff like a bamboo. This condition is more common in males as compared to females and usually occurs in individuals between 16-40 years of age.

Ankylosing spondylitis can briefly be summaries as under:

1. Ankylosing spondylitis belongs to a group of arthritis conditions which tend to cause chronic inflammation of the spine as well as degeneration.

2. Ankylosing spondylitis is a cause of back pain in adolescents and young adults.

3. Tendency to develop Ankylosing spondylitis is genetically inherited.

4. The HLA-B27 gene can be detected in the blood of most patients.

5. Ankylosing spondylitis can also affect eyes, heart, lungs, and occasionally the kidneys.

6. The optimal treatment of Ankylosing spondylitis involves medications that reduce inflammation or suppress immunity, physical therapy and exercise.

7. Homeopathy offers encouraging results, significant disease control and pain relief.

Site of disease:

The sacroiliac joints are located in the low back where the sacrum (the bone directly above the tailbone) meets the iliac bones (bones on either side of the upper buttocks). Due to chronic inflammation in these areas there are symptoms like pain and stiffness of spine.

As this condition is chronic one with time this leads to fusion of the vertebrae i.e. complete cementing together of vertebrae.This process is known as Ankylosis.

Due to this condition there is loss of mobility if spine. The stiffness could eventually be very severe making the spine resembling a bamboo. Hence it is also called bamboo spine.

Ankylosing spondylitis can affect other tissues throughout the body. It can cause inflammation in or injury to other joints away from the spine, as well as other organs, such as the eyes, heart, lungs, and kidneys.

Prevalence:

Ankylosing spondylitis is two to three times more common in males than in females.
In women, joints away from the spine are more frequently affected than in men.
Ankylosing spondylitis affects all age groups, including children. The most common
age of onset of symptoms is in the second and third decades of life. One research study says that male to female ratio of this disease condition is 4:1.

Causes:

The exact cause of Ankylosing spondylitis is not understood. It has been considered to be an autoimmune disease (like many others such as Diabetes, Rheumatoid Arthritis, Alopecia Areata, Thyroiditis, etc.). Genetic factors are likely to be involved. The majority of people with Ankylosing spondylitis have a gene called HLA-B27. However, the presences of HLA-B27 (Human Leukocyte Antigen B27) is not absolutely diagnostic of Ankylosing spondylitis.

1. Genetic theory:

It has a strong genetic factor as a cause behind its development. About 90 % of patients with AS are born with HLA –B27 gene. There are blood tests to detect HLA-B27 gene marker. The HLA-B27 gene appears only to increase the tendency of developing Ankylosing spondylitis, while some additional factor(s), perhaps environmental, are necessary for the disease to appear or become expressed.
Interestingly, the presence of HLA-B27 alone does not make one prone to develop this disease. As per a study, about 7% of the United States populations have the HLA-B27 gene, only 1% of the population actually has the disease Ankylosing spondylitis.

Even among HLA-B27 positive individuals, the risk of developing Ankylosing spondylitis appears to be further related to heredity. In HLA-B27-positive individuals who have relatives with the disease, their risk of developing Ankylosing spondylitis is 12% (six times greater than for those whose relatives do not have Ankylosing spondylitis).

2. Autoimmune theory:

Autoimmunity is considered significantly involved in the development.Again, autoimmunity itself may be genetically oriented.

3. Prolonged stressful situation in one’s life could possibly trigger the unerlying genetic tendency.

4. Bacterial infection triggering Ankylosing spondylitis is one of the other theories.

Current research about Ankylosing Spondylitis:

Recently, two more genes have been identified that are associated with Ankylosing spondylitis. These genes are called ARTS1 and IL23R. These genes seem to play a role in influencing immune Function.

How inflammation occurs and persists in different organs and joints in Ankylosing spondylitis is a subject of active research. Each individual tends to have their own unique pattern of presentation and activity of the illness

The initial inflammation may be a result of an activation of body’s immune system by a bacterial infection or a combination of infectious microbes. Once activated, the body’s immune system becomes unable to turn itself off, even though the initial bacterial infection may have long subsided.

Chronic tissue inflammation resulting from the continued activation of the body’s own immune system in the absence of active infection is the hallmark of an inflammatory autoimmune disease.

Symptoms:

The most significant symptoms of AS are pain in lower back, painful stiffness and immobility of back.

The totality of symptom may be described as under:

1. Fatigue associated with active inflammation

2. Pain and stiffness in the low back, upper buttock area , neck and the remainder of the spine

3. Gradual onset of pain and it worsens progressively over months. Sometimes rapid and intense onset

4. Pain and stiffness relieved by motion, heat and warm shower in morning.

5. Pain and stiffness are often worse in morning and after prolonged periods of inactivity.

6. Patients with chronic condition can develop a complete bony fusion of spine. Once fused, the pain in the spine disappears, but the patient has a complete loss of spine mobility. These fused spines are particularly brittle and vulnerable to breakage (fracture) when involved in trauma, such as motor vehicle accidents.

7. Chronic spondylitis and ankylosis cause forward curvature of the upper torso (thoracic spine), limiting breathing capacity.

8. Spondylitis can also affect areas where ribs attach to the upper spine, further limiting lung capacity.

9. Ankylosing spondylitis can cause inflammation and scarring of the lungs, causing coughing and shortness of breath, especially with exercise and infections. Therefore, breathing difficulty can be a serious complication of Ankylosing spondylitis. This is not very common, though.

10. Patients with Ankylosing spondylitis can also have arthritis in joints other than the spine. Patients may notice pain, stiffness, heat, swelling, warmth, and/or redness in joints such as the hips, knees, and ankles.

11. Some patients with this disease develop Achilles tendonitis, causing pain and stiffness in the back of the heel, especially when pushing off with the foot while walking up stairs. Inflammation of the tissues of the bottom of the foot, plantar fascitis, occurs more frequently in people with Ankylosing spondylitis.

12. Patients with Ankylosing spondylitis can develop inflammation of the iris, called iritis.” Iritis is characterized by redness and pain in the eye, especially when looking at bright lights. Recurrent attacks of iritis can affect either eye.

13. In addition to the iris, the ciliary body and choroid of the eye can become inflamed and this is referred to as uveitis.

14. Advanced spondylitis can lead to deposits of protein material called amyloid into the kidneys and result in renal failure. Progressive renal disease can lead to chronic fatigue and nausea and may require dialysis.

15. Since Ankylosing spondylitis often affects patients in adolescence, the onset of low backache is sometimes incorrectly attributed to athletic injuries in younger patients.

Diagnosis:

Clinical evaluation, detailed case history, physical examination supported by laboratory investigations will help conclude the diagnosis.

The examination can demonstrate signs of inflammation and decreased range of motion of joints. This can be particularly apparent in the spine. Flexibility of the low back and/or neck can be decreased. There may be tenderness of the sacroiliac joints of the upper buttocks. The expansion of the chest with full breathing can be limited because of rigidity of the chest wall. Severely affected people can have a stooped posture.

Inflammation of eyes can be evaluated by the doctor with an ophthalmoscope. Further clues to the diagnosis are suggested by x-ray abnormalities of the spine and the presence of the blood test genetic marker, the HLA-B27 gene. Other blood tests may provide evidence of inflammation in the body. For example, a blood test called the sedimentation rate is a nonspecific marker for inflammation throughout the body and is often elevated in conditions such as Ankylosing spondylitis.

Urine Analysis is often done to look for accompanying abnormalities of the kidney as well as to exclude kidney conditions that may produce back pain that mimics Ankylosing spondylitis.

Investigations:

Most routine investigations are:

a. X-Ray of lumbosacral spine

b. HLA-B27 (blood test)

c. MRI spine

d. RA test (blood), ANA test (blood) to rule out Rheumatoid Arthritis

e. Routine blood test (CBE, ESR)

Other investigations may include, depending of on the case:

• Low-grade anemia of chronic disease may be present.

• Antinuclear antibody (ANA) and rheumatoid factor (RF) are within reference ranges.

• Erythrocyte sedimentation rate (ESR) is normal or mildly elevated; it is more likely to be elevated with active inflammation.

• C-reactive protein may be elevated with increased disease activity but is not a better indicator of inflammation than ESR.

• Serum alkaline phosphatase may be elevated when active bone remodeling is occurring.

• HLA-B27 antigen is positive 90-95% of the time but, notably, is not always present. Furthermore, its presence is not sufficient to make the diagnosis. The test is most helpful when diagnosis is not clear.

• Cerebrospinal fluid (CSF) protein may be elevated mildly during acute exacerbations.

Imaging Studies:

• Plain radiography of the pelvis shows sacroiliitis or fusion of sacroiliac joints.

• Lumbar spine radiography may show ossification of the anterior longitudinal
ligament and fusion of facet joints. The appearance gives rise to the term bamboo spine. With extensive fusion of the spine, a patient may have a poker spine.

• CT scan will show bony fusions and eroded laminae and spinous processes.

• MRI may be needed to document atlantoaxial subluxation. MRI may be indicated after trauma to evaluate the spinal cord and to rule out cauda equina syndrome or epidural hematoma.
o Cauda equina syndrome may be inflammatory or compressive.
o In inflammatory cauda equina syndrome, the spinal canal is normal to large with CSF diverticula that are best seen on MRI.

• Plain films or CT scan of the spine may be indicated after trauma to evaluate for bony injury.

Related conditions: 
1. Psoriatic Arthritis
2. Reactive Arthritis
3. Arthritis associated with Crohn’s disease and ulcerative colitis
4. Backache
5. Rheumatoid Arthritis
6. Multiple Myeloma

The Homeopathy Treatment:

Ankylosing spondylitis (AS) is a deep seated immunological disease, which requires treatment at a deeper level. The conventional treatment alone is not enough in most cases. Added homeopathic medication is strongly suggested for better control and long term management. It calls for internal, deep acting homeopathic treatment.

The individualized treatment is based on the study of patients patches, extent, cause, genetic pattern, emotional sphere, extent of tissue damage, and other factors which lead and maintain the disease

Major benefits of homeopathy could be summarized as under:

- It addresses altered immune system, treating the roots of this autoimmune disease.

- It helps in pain control without side effects.

- It aims at disease control .

- It is absolutely safe even if used for a long time.