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Thoracic Ankylosing Spondylitis

What does the word “Ankylosing Spondylitis” mean?

The word “Ankylosing Spondlitis”(AS) comes from two Greek words, “ankylos”, meaning “stiff” and ”spondylos”, meaning “vertebrae”. So, it means “stiff vertebrae”.

What is Ankylosing Spondylitis?

Ankylosing Spondylitis (AS) is a condition of the spine where spinal joints become inflamed, similar to Rheumatoid Arthritis. In both cases, the body sees these joints as foreign material and tells the immune system to attack it (autoimmune disease). In AS, all the spine joints including the sacroiliac joints can be affected. After long periods of severe inflammation of these joints, they eventually fuse (mend together) on their own, resulting in “stiff vertebrae”.

Are other organs also affected by Ankylosing Spondylitis?

Other organs such as the eyes, heart and kidneys can also be affected by this disease.

Who gets Ankylosing Spondylitis?

AS is a disease most commonly seen in males between 20-40 years of age, and is passed on through families (genetic link). 90% of patients with AS, have a specific gene (HLA-B27), which can be inherited.

What kind of symptoms do patients with Ankylosing Spondylitis get?

The initial symptoms of AS can be vague. This can make it difficult to diagnose the disease in its early stages.

On average, the first symptoms are present by the age of 23.

In more advanced stages, the following symptoms may be present:

  1. Stiffness in the back and other joints
  2. Pain in the spine, most often mid-back (thoracic spine)
  3. Pain in the buttock and thigh area (from sacroiliac joint pain)
  4. Loss of mobility of the spine

How do Spine Specialists diagnose Ankylosing Spondylitis?

Spine specialists use the information from the patient history, physical examination and specific tests to make this diagnosis:

  1. History

A history of slowly worsening stiffness and pain in the middle of the spine or over the hip bones may tip a doctor off to the diagnosis.

A family history of AS can be very suggestive when a patient has symptoms.

       2. Physical Examination

AS can be difficult to diagnose with a physical examination. Here are some examination techniques a doctor may use:

  • Looking at the spine (inspection)
  • Touch and pressure of the spine (palpation)
  • Mobility testing (Range of Motion)
  • Strength testing (motor exam) of the legs
  • Sensation testing (sensory exam) of the legs
  • Reflex testing of the legs
  • Sacroiliac joint testing:
    • Pelvic Rock test
    • Gaenslen’s test
    • FABERE’s test
    • Patrick’s test

 

      3. Tests

a. Imaging

    1. X-Rays

X-Rays of the spine can show signs of AS when the disease has progressed to involve the discs and joints of the spine. The discs can be seen getting thinner and eventually virtually disappear. However, it can take up to 10 years before X-Rays can show the diagnosis of AS.

X-Rays of the Sacroiliac joints can show joint degeneration and loss of joint space.

                  2. CT Scans

CT scans can show the bone anatomy of the spine and sacroiliac joints in detail. The loss of joint space from AS can be clearly seen in advanced cases.

                  3. MRI Scans

MRI scans can show degeneration and inflammation of the discs and joints of the spine. Specific bone details are better seen on a CT scan.

                 4. Blood tests

a. HLA-B27, the genetic marker for AS can be found on a blood test

b. Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP)

Elevated levels of inflammatory markers in the blood can point towards an inflammatory spine conditions such as AS.

How is Ankylosing Spondylitis treated?

There is no cure for AS, but here are some treatments which can help with the symptoms.

  1. Non-Surgical Care

A. Alternative Health Care

Alternative Health care options can often complement conventional medical care. Massage Therapy, Acupuncture, Meditation exercises and Herbal Remedies can all help with the pain. Massage Therapy techniques can help with the muscle components of AS.

B. Chiropractic Care

Spine manipulation for patients with Ankylosing Spondylitis has to be done with caution and is primarily done in the early stages of the disease only. Patients with the advanced stage of the disease are prone to spine fractures.

C. Spine Exercises

Spine exercises can help maintain mobility of the spine especially in the early stages of the disease. Generally, only mild to moderate intensity exercises are recommended. Pilates, Yoga and T’ai Chi can help maintain some of the spine’s flexibility.

D. Physical Therapy (PT)

Specific exercises to improve the spine’s mobility can lessen the symptoms. Aquatic therapy can be very beneficial.

E. Self Help Devices

Self Help Devices can help alleviate some of the discomfort for patients with this condition. Back Mattresses and Spine Pillows are some examples of these devices.

F. Medications

  1. Tumor Necrosis Factor-alpha (TFN-a) Blockers. They include Etanercept (Enbrel) and Infliximab (Remicade) amongst others.
  2. Sulfasalazine
  3. Non-steroidal Anti-inflammatory Drugs (NSAIDS)
  4. Steroids
  5. Muscle Relaxants
  6. Pain Killers

G. Injections

Injections can offer some help for AS patients with earlier stages of the disease. Here are some injections with may help:

  1. Trigger Point Injections
  2. Thoracic Muscle Blocks
  3. Thoracic Interlaminar Epidural Steroid Injections
  4. Thoracic Transforaminal Epidural Steroid Injections
  5. Thoracic Nerve Root Block
  6. Thoracic Facet Joint Injections
  7. Thoracic Medical Branch Blocks
  8. Thoracic Facet Joint Radiofrequency Rhizotomy

 

2. Surgical Care

Typically, surgery of the spine is not needed for AS. However, the following situations may require it:

  1. The spine is bent forward (flexed) into a position which causes a poor quality of life. The worst scenario is when the chin rests on or near the chest. This is called a severe Kyphosis, and often requires surgery to correct. The surgery to correct this is called a Thoracic Osteotomy and Fusion. Parts of the vertebrae are removed to make them wedge-shaped and be able to straighten the spine. The spine is then fused in a more upright position.
  2. The spine becomes unstable. This is usually the case when a fracture of a vertebra happens. A Thoracic Fusion with Instrumentation may be required.
  3. The neurological system such as the spinal cord or spinal nerve becomes compressed, causing numbness and weakness in the arms or legs. A surgery to remove the pressure on the nerve supply may have to be performed: Thoracic Laminectomy Decompression. This is often done in combination with a Thoracic Fusion with Instrumentation.