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Review Article
*Corresponding Author: Emanuele James
Citation: Emanuele James, Meres Zurta, An Ayurvedic Case Study of Spinal Cord Injury DOI: 10.31579/2642-1690/003
Copyright: © Domenico Elia 2018 et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 15 January 2018 | Accepted: 28 January 2018 | Published: 05 February 2018
Keywords: spondylitis; diagnosis; primary care
Abstract
Ankylosing spondylitis (AS) is generally easy to diagnose when the characteristic findings of the “bamboo” spine and fused sacroiliac joints are present on radiographs. Unfortunately, these changes are usually seen late in the disease after tremendous suffering has been incurred by the patient. Diagnostic delay averages seven to ten years. Historically, once the diagnosis was made, the treatment options were often inadequate or poorly tolerated in many individuals. This condition most often starts in early adulthood when people are typically in the earlier stages of their careers, resulting in diminished workforce participation and decreased quality of life. If an individual has a family physician, this might be the first encounter with a healthcare provider. Quite often, the initial practitioner is sought at a public walk-in clinic or chiropractic office.
In recent years, there have been two major developments in the management of AS that make earlier diagnosis possible and offer the hope of alleviating pain and preventing structural changes that result in loss of function. These developments include the use of magnetic resonance imaging (MRI) to visualize the inflammatory changes in the sacroiliac joint and the axial spine, and the demonstration that tumor necrosis factor (TNF) blocking agents are highly efficacious in reducing spinal inflammation and possibly in slowing radiographic progression.
Ankylosing spondylitis (AS) is the prototype disease within the spondyloarthropathies (SpA), a group of diseases presenting mainly with inflammation of the axial skeleton, peripheral arthritis and enthesitis (inflammation at insertion sites of bone to tendons, ligaments, and joint capsules). This disorder is in fact a systemic disease, causing numerous extraskeletal manifestations that have a significant influence on patient prognosis. Included among these accompanying features are inflammatory bowel disease, acute anterior uveitis (iritis), and psoriasis. In addition, there is a strong association with the HLA-B27 antigen and a familial aggregation.
It is estimated that AS affects about 0.5% of the population and male to female ratio is roughly 2:1.1–3 In comparison, rheumatoid arthritis is seen in about 1% of most populations.4 Ankylosing spondylitis most commonly has its onset while a patient is in their twenties, although late teenage years are also relatively common for initial symptoms.5 The disease onset is at a younger age and acute iritis is more common in B27 positive as compared to B27 negative patients.6 In a study of 1080 patients (90% HLA-B27 positive), the average age of onset in B27 positive patients was 24.8 years, whereas in those that were B27 negative it was 27.7 years.5 It is very unusual to have a patient present with this disorder beyond forty-five years old. A common diagnosis that is mistaken for AS in the more advanced aged groups would be diffuse idiopathic skeletal hyperostosis (DISH). In this condition, the sacroiliac joints are typically spared and there is usually a more flowing and bulky ossification of the anterior longitudinal ligament, rather than the syndesmophytes of AS that bridge between the vertebral body corners and include the annular fibers of the intervertebral discs.
The concept of enthesitis has emerged as an important contributor to the inflammatory process involved in AS. Inflammatory cell infiltrates invading the adjacent bone at the enthesis (bony sites of ligamentous attachments) have been well described.8 Bone marrow changes have also been observed in the vertebrae of some AS patient.9 Magnetic resonance imaging (MRI) using fat suppression techniques has confirmed that the extracapsular changes taking place in inflamed synovial joints of patients with AS commonly involve the entheses.
Extraarticular manifestations
Acute anterior uveitis (also referred to as iritis) is a well-recognized feature associated with AS and one or more attacks are seen in 20–40% of AS patients.11–12 The typical presentation is a sudden onset of eye pain, redness, visual blurriness, and photophobia. Some cases can be chronic and lead to permanent visual impairment. Psoriasis is seen in about 9% and inflammatory bowel disease (Crohn’s disease and ulcerative colitis) in up to 6% of those with AS.13–14 both of these co-morbidities seem to be associated with more severe AS disease activity and poorer functioning.15 There are also several associated cardiovascular features, such as aortic insufficiency, conduction abnormalities, and an increased risk of myocardial infarction.16–18
In addition to the obvious deleterious effects on quality of life, there is also a substantial economic burden associated with AS. When looked at in a large Canadian study, the mean annual overall costs associated with the disease was CDN$9,008, with indirect cost accounting for 38% of the total. Total costs increased with diminishing physical function as measured by the Bath Ankylosing Spondylitis Functional Index (BASFI). For example, a BASFI >7 resulted in mean annual costs of CDN$23,300.21 Longer disease duration, increased age, and smoking have been shown to be associated with decreased functioning.
Back pain is the predominant reason for a referral to a chiropractor. The prevalence of sacroiliac joint disease in lumbar spine and AP pelvis x-rays taken at the Canadian Memorial Chiropractic College has been studied.26 Findings showed that 23.2% of the cohort had degenerative changes in the sacroiliac joints compared to 3.8% having definite criteria for sacroiliitis consistent with AS. Another 4.1% had possible inflammatory changes (26
Making a diagnosis of AS can be challenging.27 It is quite common for the diagnosis of AS to be missed or markedly delayed,28 particularly in the primary care setting.29 On average, there is a 7–10 year delay in the diagnosis of this disease from the onset of symptoms.5 There are a number of factors that contribute to the delay in diagnosis. First, the majority of back pain sufferers do not seek care from healthcare providers. Young men tend to be the segment of the population that are the least likely to do so. When care is sought, the most common source is a general practitioner or chiropractor.30 Since AS has a predilection to affect young males, these findings would suggest that a substantial amount of sufferers do not even get assessed. Second, the existing criteria, namely the modified New York Criteria, requires advanced radiographic changes to be present in the sacroiliac joints.31 Unequivocal sacroiliitis of at least grade 2 bilaterally or grade 3 unilaterally plus clinical symptoms is required before a diagnosis of ankylosing spondylitis can be made. These changes usually lag several years after the onset of axial pain and stiffness, despite the presence of inflammation as detected by MRI. Thus, the established classification criteria for AS is more suited for picking up advanced disease.
Until recently treatment options for AS have been limited. Physical therapy techniques and non-steroidal anti-inflammatory drugs (NSAIDs) have been the mainstay of therapy in these patients. No real disease modifying anti-rheumatic treatment was previously available. There are multiple therapies such as methotrexate, sulfasalazine, and leflunomide that have proven efficacious in rheumatoid arthritis. However, all of these have failed to provide substantial benefit from the often disabling axial symptoms and signs of AS.39–41 Therefore, a previous delayed diagnosis did not have the same perceived adverse consequences because of the lack of highly effective therapeutic choices.
Some patients with milder forms of the disease can achieve success with exercise and physical therapy.42–45 There is consistent evidence in the form of randomized, placebo controlled trials to show that NSAIDs and cyclooxygenase-2 specific inhibitors (coxibs) are superior to placebo in improving spinal pain.46–51 In addition, NSAIDs may have a protective effect on structural damage when taken on a regular basis.52 Safety concerns, particularly with gastrointestinal (GI) bleeding and cardiovascular toxicity limit the use of these agents in many patients.53–55 These side effects appear to be dose-dependent.56 Despite traditional management approaches (education, exercise, physical therapy, and NSAIDs) remaining important, there are a sizeable proportion of patients that will continue to do poorly.
There is some data that suggests that AS patients with a short disease duration and younger age are more likely to respond to TNF-alpha blocking agents.78 Thus, underscoring that an early and reliable diagnosis of AS has now become an important and very relevant issue. In all of the larger studies, major side effects were low and minor side effects were mostly in the form of mild infections, although opportunistic infection such as the reactivation of tuberculosis can be more common.79 Infusion and injection site reactions can also occur but are generally quite manageable. Patients with a history of a solid organ malignancy or melanoma may not be appropriate candidates for TNF blockers because of a lack of information on experience with these subgroups.
Patient access to the anti-TNF therapies is somewhat restrictive, mostly because of the associated high costs of the medications. It is common practice to file applications with private health insurance plans or with provincial health ministries in Canada to obtain anti-TNF agents. This process usually requires the cooperation and know-how of a rheumatologist.
Now that there are medications that are highly effective in treating AS, it is more of a priority to diagnose this condition earlier. There are now proposed clinical pathways to make an earlier diagnosis prior to established radiographic changes becoming present.28 It is important to differentiate inflammatory from mechanical back pain symptoms. Moreover, consideration should be given to some of the extraskeletal manifestations, such as uveitis, inflammatory bowel disease, and psoriasis that when present can be helpful in determining the likelihood of a person having AS. MRI of the sacroiliac joints and spine also has a role in diagnosis in earlier stages of the disease when inflammation can be detected at a time when radiographs usually appear normal or equivocal.
The AS patient that fails conservative measures and NSAIDs, is the one that needs to be identified and considered for anti-TNF therapies as second-line treatments. The evidence shows that, unlike RA, the so-called “disease modifying” drugs like methotrexate, sulfasalazine, and leflunomide have proven to be ineffective in AS. The TNF blocking agents currently available, infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira), are approved for the treatment of AS in Canada. We are now in an era where not only symptoms can be targeted, but slowing down and possibly achieving clinical remission of a disease is possible. The implementation and follow up care should be undertaken by an experienced healthcare provider such as a rheumatologist specialized in their use, because of the specifics involved with drug access, tools to measure response to therapy, and the monitoring of potential side effects.
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