Ankylosing Spondylitis (AS) Treatment in Delhi, India

Ankylosing spondylitis (AS) is a progressive inflammatory condition that primarily targets the spine and large joints. Over time, the vertebrae may fuse, leading to stiffness, discomfort, and significant mobility limitations. This fusion can affect posture, often causing a forward hunch that impacts both physical function and quality of life. AS typically starts in early adulthood and is more prevalent in men. Although the condition primarily affects the spine, it can also involve other joints like the hips, shoulders, and areas such as the eyes or cardiovascular system.

Ankylosing spondylitis is classified based on how the disease presents itself and what areas of the body are involved:

Axial Spondyloarthritis (AxSpA)

This type mainly involves the spine and pelvis. Axial spondyloarthritis is further classified as:

• Radiographic Axial Spondyloarthritis: X-rays show damage to joints, indicating a more advanced stage of AS.
• Non-Radiographic Axial Spondyloarthritis : No damage to the joints seen on X-ray. 

Peripheral Spondyloarthritis

Affects the joints other than the spine, including the shoulders, hips, knees, and ankles. It can even impact areas where tendons and ligaments attach to bones — referred to as entheses, causing both pain and stiffness.

Juvenile Ankylosing Spondylitis

As the name suggests, this type is diagnosed in individuals under the age of 16, with symptoms typically affecting the knees and hips.

While the exact cause of ankylosing spondylitis is unclear, both genetic and environmental factors are believed to play a role. The HLA-B27 gene is a well-established genetic risk factor for AS, such that those who carry this gene are more likely to develop the disease. However, not all who possess the HLA-B27 gene develop AS.

There are risk factors that may make a person more likely to develop ankylosing spondylitis:

• The HLA-B27 gene: This gene is inherited, and a family history increases the likelihood of developing AS.
• Age: Signs and symptoms of AS usually develop in late adolescence or early adulthood — before the age 17 or after the age 45.
• Gender: AS is more common in men, but women can develop it as well, although they tend to have a milder presentation.

Signs of ankylosing spondylitis can vary from person to person, but commonly involve:

• Back Pain: Constant pain and stiffness in the lower back, especially first thing in the morning or after long periods of immobility.
• Joint Pain: Pain may also be experienced in other joints, such as the hips, shoulders, and knees.
• Loss of Flexibility: Limited range of motion due to the fusion of vertebrae in the spine.
• Fatigue: Chronic fatigue may occur depending on how the body responds to the disease. 
• Soreness in certain areas: Areas where tendons and ligaments attach to bones may feel tender and painful.

AS is characterised by flares (increased severity of symptoms) and remissions (reduced symptoms).

Diagnosis of ankylosing spondylitis includes physical exam, imaging tests, andlab tests. 

Physical Exam

During the physical examination, the doctor assesses the patient’s posture, flexibility, and range of motion for signs of pain,swelling, or stiffness in the affected area. Limitations in spinal or joint flexibility are often identified through basic movements such as bending and stretching. 

Imaging Tests

X-rays are typically the first imaging techniques performed, as they capture the structural changes in the spine over time. However, MRI scans are more sensitive and may detect early signs of inflammation that cannot be seen on an X-ray, especially in non-radiographic cases of AS.

Lab Tests

Blood tests can identify inflammatory proteins such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), which may be high in AS. Blood tests for HLA-B27 gene are also useful in supporting the diagnosis, but they are not conclusive, as not all AS patients carry this gene or are positive for it.

Management of ankylosing spondylitis focuses on alleviating symptoms, reducing joint pain and inflammation, and maintaining spinal mobility. At present, there is no cure for AS, but medications, physical therapy, and, in some cases, surgery can help individuals live a better quality of life.

Medications

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):  These drugs are often the first choice for treating ankylosing spondylitis. They help reduce inflammation, pain, and stiffness in affected areas, thereby improving spinal mobility and reducing discomfort.
• Biologic Medications: Biologic therapies are recommended for patients with moderate to severe AS. These treatments work by targeting specific parts of the immune system to control disease progression and reduce inflammation.

Physical Therapy

Physical therapy is a key component of AS treatment. Physical therapists guide patients through exercises that help with flexibility, posture, and strengthening specific muscles. Low-impact activities such as swimming or stretching also help minimise stiffness and promote spinal mobility.

Surgery

Surgery may be necessary in severe cases. Arthroplasty, typically of the hip or knee, is performed when these joints become irreversibly damaged, providing pain relief and restoring mobility. In some cases, surgery may also be performed to correct debilitating spinal deformities or abnormal curves.

Untreated ankylosing spondylitis can lead to various complications:

Spinal Fusion: In the later stages of the disease, the vertebrae may fuse completely, becoming fixed in a rigid position, which can severely impact mobility and posture.

Eye Inflammation: Also known as uveitis or iritis, this complication often occurs in AS patients and presents with signs such as eye pain, redness, and photophobia.

Heart Issues: AS can cause problems with the heart, such as inflammation of the aorta (aortitis), which may lead to valve dysfunction or heart rhythm issues.

Fractures: AS can cause bones of the spine to become fragile and prone to fracture, with the cervical spine being most vulnerable.

While ankylosing spondylitis cannot be prevented, steps can be taken to manage its impact and reduce the risk of complications:

Stay Physically Active: Regular, low-intensity activities help maintain joint mobility and flexibility, which helps prevent excess stiffness.

Maintain Good Posture: Focus on ergonomic habits and exercises to avoid aggravating any spinal conditions.

Quit Smoking: Smoking can worsen AS symptoms and increase the risk of associated complications.

Maintain a Healthy Diet: A balanced diet rich in anti-inflammatory foods is beneficial for overall health and may also help reduce inflammation.

Ankylosing spondylitis primarily targets the spine, but can it also affect other parts of the body?

Yes, AS can affect other joints in the body such as the hips, shoulders, and peripheral joints, as well as areas where tendons attach with bones. Furthermore, it can cause complications in the eyes (such as uveitis), heart, and lungs.

Can ankylosing spondylitis be inherited?

AS is not directly inherited, but certain genetic factors like the HLA-B27 gene, can increase the likelihood of developing the condition. A family history of AS or similar disorders may also increase the probability of developing the disease.

What lifestyle modifications can assist in the treatment of ankylosing spondylitis?

Regular exercise helps maintain flexibility, including stretching and low-impact activities like swimming. Other recommendations include maintaining correct posture at work, avoiding smoking, and adopting ergonomic practices in daily activities.

In what way does ankylosing spondylitis affect mental well-being?

AS can lead to stress, anxiety, and depression due to pain and restricted mobility daily. Patients should consult healthcare providers and mental health professionals, or join support groups to better manage mental health.

Is there any dietary advice that one should follow in case of ankylosing spondylitis?

Although there are no specific diets for AS, but an anti-inflammatory diet — one that is rich in fruits, vegetables, lean proteins, and omega-3 fatty acids — is beneficial. Avoiding foods that cause inflammation, such as processed foods, refined sugars, and trans fats, can prove to be beneficial for patients with AS.

Reviewed By Dr. Akshay Kumar Saxena, Senior Consultant, Orthopaedics & Joint Replacement, Spine Surgery on 10 January 2025.