Ankylosing spondylitis (Bechterew's disease)

Ankylosing spondylitis is a chronic form of arthritis primarily affecting the spine. It is characterized by pain and stiffness in the lower back, buttocks, thoracic back, neck and sometimes in the hips, feet, and chest. It may also manifest as swelling and limited mobility in other joints. This disease occurs more often in men than in women. To date, there is no way to completely cure this disease. The goal of treatment is to relieve symptoms and stop progression. Most patients retain their ability to work and be physically active. Complication of AS ( ankylosing spondylitis) there may be inflammation of the iris (iritis) and impaired respiratory function associated with kyphosis and deformation of the chest.

Symptoms

This disease can manifest itself as pain of varying intensity in the lower back and buttocks, especially in the morning. Some patients may have pain in the legs and feet. The pain tends to gradually decrease after some physical activity. AS usually occurs between the ages of 15 and 30 years. The disease, as it progresses, causes inflammation of the ligaments, tendons, and joints of the vertebrae, which leads to limited mobility in the lumbar and cervical spine (up to fusion of the vertebrae). As stiffness develops, the normal physiological curves in the neck and lower back change and kyphosis sharply increases. This leads to a pronounced forward tilt of the body and limitation of motor functions such as walking. Due to the fact that inflammation of the joints in the area of the articulation of the costal arches with the sternum is possible, difficulty breathing may occur. Other joints, eyes, sometimes lungs, heart valves, aorta, and intestines may be involved in the inflammatory process. A prolonged inflammatory process leads to tissue scarring and irreversible changes. In some cases, the disease progresses slowly and does not lead to significant complications; in others, rapid progression leads to disability and persistent symptoms. There is a certain dependence of the degree of progression of AS on the onset of the disease, age and area of localization of the pathological process. With early diagnosis and timely treatment, the likelihood of slow progression of the disease increases.

Recovery after surgery

The success of recovery after any intervention on the musculoskeletal system is determined by rehabilitation. We emphasize that the patient will need enormous patience and discipline, unquestioning adherence to the recovery regimen prescribed by the doctor. Otherwise, unsatisfactory results are expected. Postoperative recovery necessarily includes the following principles:

strict adherence to bed/physical rest, which is provided for by one or another type of intervention;
wearing a plaster cast, an orthopedic corset or an elastic tight bandage, using special devices for movement (crutches, canes, etc.) exactly as much as the doctor said;
antibiotic therapy to prevent the development of infection;
specific vascular therapy to prevent thrombus formation in the deep veins of the lower extremities and to prevent pulmonary embolism;
the use of painkillers, anti-inflammatory and decongestant drugs;
taking mineral and vitamin preparations, among which calcium preparations play a special role in the rapid recovery of the operated spine;
competent physical therapy under the supervision of a physician for the productive restoration of mobility and support stability, to prevent contractures and muscle atrophy;
physiotherapy to increase local immunity, blood circulation, cellular metabolism, to accelerate tissue regeneration processes in the operated area.

As a rule, the rehabilitation period after operations for ankylosing spondylitis lasts from 4 to 12 months. It is important to emphasize that surgery does not eliminate systemic pathology (it is incurable!). Therefore, unfortunately, it is impossible to completely exclude the possibility of the appearance of new articular lesions in any other area 100%. It must be taken into account that the disease can cause damage to the eyes, internal organs, heart, lungs, kidneys, etc. In this regard, it must be kept under constant and vigilant control.

The patient must throughout his life receive courses of basic physical and drug therapy aimed at suppressing the activity of the immune complex mechanism of inflammation.
Periodically (up to 2-3 times a year) you should take a set of laboratory tests and undergo control examinations of the spine and joints of the extremities without skipping.
You must be examined by a rheumatologist at least 3 times a year. It is also necessary to keep in touch with other key specialists: neurologist/orthopedist, ophthalmologist, cardiologist.

Doctors strongly recommend that all Bekhterev residents, not only those undergoing surgery, annually visit a sanatorium-resort medical institution that practices mud therapy, treatment with hydrogen sulfide and radon baths. The Czech Republic is an ideal medical resort in this regard.

Slowly progressive form

Typically, this form of AS is characterized by dull lower back pain and stiffness in the back. Exacerbations of the disease, manifested by increased pain and stiffness, last several weeks.

Pain and stiffness limiting mobility may appear in the lower back, middle back or neck. The pain intensifies slowly, over several weeks, and does not have a clear localization. Stiffness usually occurs in the morning (sometimes early in the morning at 3-6 am) and disappears within an hour of waking up. Physical activity helps reduce pain and stiffness.
Some patients report fatigue. This is due to the fact that part of the energy in the body is spent on the inflammatory process.
Inflammation of the iris. This inflammation (iritis) occurs in 20-30% of patients with AS. It manifests itself as redness, soreness in the eye and increased sensitivity to light.

Expected results

The prognosis for life with well-organized surgical and postoperative conservative care is optimistic. Thanks to current technologies in orthopedics, spinal neurosurgery, cardiac microsurgery and other know-how of modern surgery, including supportive treatment tactics after surgery, people with this diagnosis live to a ripe old age. Average life expectancy is 65-70 years. As for the results after operations, in 90% of cases it is possible to achieve significant progress in the fight against back deformities, in increasing physical performance, and eliminating neurological deficits.

Patients who have successfully undergone surgery, as they themselves note, can finally look at the world freely. They are pleased that after the operation they have regained the long-awaited ability to walk with a straight back and head up, to calmly perform everyday tasks, to attend their favorite job, without experiencing an aggravating block of obstacles, pain in the back and limbs.

Speaking about significant results, we note that this concept is purely individual for each individual patient, since surgeons work with completely different cases. Remember that the less the operation is delayed after it has been indicated, the greater the chances of a good restoration of the lost potential of mobility and the less risk of developing postoperative complications. Of course, much will be decided by the competence of the operating doctor, his reasonable approach in determining the volume and technique of intervention, and the quality of execution of each stage of the procedure.

Rapidly progressive form of AS

Processes of changes in connective tissue lead to irreversible processes and severe symptoms.

These processes in the spine lead to fusion of the vertebrae (ankylosis).
With ankylosis, the pain syndrome gradually decreases. But vertebral fusion increases the risk of fractures, especially in the cervical region.
Disorders in the spine lead to changes in mobility and balance of the body. With severe kyphosis, it becomes difficult to straighten the torso and keep the back straight. The process of standing and walking is especially disrupted when the hips are involved in the pathological process.
A pronounced forward tilt of the spine can cause breathing problems due to limited mobility of the chest. In addition, inflammatory changes can affect lung tissue, leading to pulmonary fibrosis and increased susceptibility to infection. The risk of lung infections is higher in smokers.
Scarring processes in the eyes can lead to poor vision and glaucoma.
In rare cases, damage to the myocardium and valve apparatus occurs, which leads to impaired contractile function and, as a consequence, to heart failure. Damage to the aorta and its expansion are also possible.
Sometimes there is a connection between intestinal inflammation and AS. Some patients develop Crohn's disease.
Possible kidney damage is largely associated with long-term use of medications prescribed for AS.
In some patients (with pronounced changes in the distal spine) cauda equina syndrome occurs. This syndrome is manifested by impaired sensitivity in the groin area and dysfunction of the pelvic organs.

Ankylosing spondylitis has much in common with a whole class of joint diseases called arthropathy. For example, this is psoriatic arthritis, reactive arthritis (Reiter's syndrome), enteropathic arthritis. But in these diseases, spinal lesions are not as pronounced as in AS.

Possible complications

Surgical procedures to eliminate the consequences of ASA are not without certain risks. Exceptionally, complications may develop in the form of:

deep and superficial infections, bleeding in the surgical area;
negative reactions to anesthesia - damage to the trachea and esophagus during the provision of anesthesia, a toxic effect on an incorrectly chosen drug, an incorrectly calculated dose of anesthetic;
thrombosis of leg veins;
pulmonary embolism;
injuries to the spinal membrane, spinal cord, nerve, vessel, which inevitably leads to the appearance or increase of neurological signs (surgeon errors);
violation of the integrity of the implant/metal structure, dislocation or migration of implanted components (often it is not so much the doctors who are to blame for this, but the patients themselves, who underestimated the importance of rehabilitation);
osteomyelitis, increased spinal canal stenosis;
delayed bone consolidation, formation of a false joint.

The likelihood of intra- and post-surgical complications, fortunately, is small, but only if the surgical technique and post-operative rehabilitation are adequate.

Diagnosis of ankylosing spondylitis

The first signs of AS are dull pain in the lower back or buttocks (a symptom that occurs in many diseases). What matters is a gradual increase in pain intensity. If AS is suspected, it is necessary to conduct an X-ray examination, genetic study or MRI of the iliosacral joints. Characteristic of AS are changes in the iliosacral joints visible on radiography, but they appear only after several years of the disease. Given the greater resolution of computed tomography and MRI, it is necessary to use these diagnostic methods more widely. Isolation of the HLA-B27 gene also helps in making a diagnosis. Therefore, early diagnosis of AS is a difficult task and often takes time to confirm the diagnosis.

Materials and methods

Recruitment of the cohort was carried out by the method of sequential inclusion of all those who came for a consultation appointment at the Federal State Budgetary Institution NIIR named after. V.A. Nasonova patients meeting the inclusion and refusal criteria for inclusion in the study. After inclusion, all patients were examined according to a specially developed protocol, including clinical, laboratory, radiological methods for assessing the condition of patients and MRI using a set of indicators characterizing individual manifestations of the disease over time during treatment (in accordance with ASAS recommendations).

Main inclusion criteria: residence in Moscow or the Moscow region; age from 18 to 45 years at the time of inclusion; the presence of inflammatory pain in the spine that meets the criteria of ASAS experts with a duration of ≥3 months and ≤5 years; voluntary desire to participate in the study.

Main criteria for non-inclusion: pregnancy; the presence of contraindications to MRI (pacemaker, hip replacement, metal structures on the spine, etc.); a clinically significant condition that, in the opinion of the investigator, may affect the data obtained during the study or the patient’s full participation in it (alcoholism, drug addiction, mental illness, severe organ pathology, etc.).

Each patient signed a voluntary informed consent to participate in the study.

The study was approved by the local ethics committee.

Currently, the CoRSaR cohort includes 132 patients with axSpA, of whom the preliminary analysis included 69 patients who were observed for at least 12 months. The average age of these 69 patients at the time of inclusion in the study was 28.1 ± 5.5 years, the average duration of the disease was 24.7 ± 15.8 months, 63 (91.3%) patients were positive for HLA-B27.

The patients were divided into 2 groups: the 1st group included 41 patients with reliable radiological SI, i.e., with a diagnosis of AS, and the 2nd group included 28 patients with nr-axSpA. The initial clinical characteristics of the patients are presented in Table. 1.

Table 1. Initial clinical characteristics of 69 patients with AS and nr-axSpA at the time of inclusion in the study Note. Here and in the table. 2: Data are presented as median (25th percentile; 75th percentile), mean ± standard error (range), or absolute number of patients (%). * — from the total number of patients with AS and nr-axSpA.

In the AS group, men predominated (58.5% versus 32.1% in the nr-axSpA group; p

=0.05), in contrast to the nr-axSpA group, in which there were more women (67.9%). Age at the time of inclusion in the study and duration of the disease did not differ, as did the frequency of detection of the B27 antigen, peripheral arthritis, and enthesitis. Disease activity, as measured by BASDAI, and performance status (BASFI) were comparable between the groups. Noteworthy is the slight predominance of elevated levels of CRP (Me 5.1 and 3.5 mg/l), ESR (Me 12 and 7 mm/h) and ASDAS CRP index ≥2.1 points (63.4 and 39.2%) in the group of patients with AS and the group of nr-axSpA, respectively, but these differences are not significant.

Methods used in research work.

The clinical activity of SpA and the functional status of patients were assessed according to generally accepted recommendations using ASAS indices. To determine disease activity, the indices BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) [13] and ASDAS CRP (Ankylosing Spondylitis Disease Activity Score) [13] were used. Functional status was assessed using the BASFI (Bath Ankylosing Spondylitis Functional Index) and BASMI (Bath Ankylosing Spondylitis Metrology Index) indices [13]. To assess back pain, morning stiffness, global assessment of the general well-being of patients, BASDAI and BASFI, a numerical rating scale with points from 0 to 10 was used. When calculating painful entheses, the MASES index (Maastricht Ankylosing Spondylitis Enthesitis Score) was used [13]. In addition to a clinical examination and standard laboratory tests (complete blood count, biochemical blood test, study of the level of highly sensitive CRP), the presence of HLA-B27 was determined in all patients, and a survey radiography of the pelvic bones and lumbar spine (LSP) was performed, including the last two thoracic vertebrae (in lateral projection). All patients underwent MRI of the SIJ and POP (using a low-field Signa Ovation 0.35 Tesla device, matrix 288×192). The POP was studied in sagittal projections, the SIJ - in semicoronal projections. Active inflammatory changes (AI) were determined in fat suppression mode (STIR) with slice thickness of 4 mm. Detection of obvious subchondral bone marrow edema (osteitis), visualized as a hyperintense signal in the STIR mode, was regarded as a sign of spondylitis and/or SI and/or coxitis. Availability of V.I. in the SIJ and spine were identified if signs of osteitis were detected on at least two sections or if more than two hyperintense foci of active inflammation were detected on one section. The modified New York criteria of 1984 were used to diagnose AS [1]. To diagnose axSpA, the ASAS criteria for SpA with predominant axial symptoms were used [8].

Statistical data processing was performed using the Statistica 6.0 application package (StatSoft, USA). The analysis included generally accepted descriptive statistics procedures and nonparametric comparison methods.

Treatment of AS

Treatment for ankylosing spondylitis mainly involves exercise and physical therapy. They help reduce stiffness and increase mobility. It is also possible to prescribe medication to relieve inflammation and reduce pain. With ankylosing spondylitis, there is a high risk of spinal injury, which requires the use of seat belts whenever driving a car. Regular eye examinations are necessary to check for inflammation of the iris. If necessary, you can use a cane to reduce the stress on your joints when walking. Surgical treatment methods are used extremely rarely for this disease (sometimes severely damaged joints are replaced with prostheses - hip and knee). Considering that today there are no pathogenetic treatment methods, the main task is to reduce symptoms and maintain motor activity.

Author: V.I. Dikul

Hospitals where operations are performed for ankylosing spondylitis

It is extremely important for surgical patients to seek such complex medical care from the most reputable medical institutions with an impeccable technological and qualification base. Moreover, operations for ankylosing spondylitis cost a lot of money. In Russia, prices for orthopedic care in connection with spinal curvatures, depending on the tactics, start from 90 thousand rubles. The estimated average maximum is 500 thousand rubles. Highly rated clinics within the Russian Federation are concentrated in Moscow and St. Petersburg, these are:

Burdenko Neurosurgery Center;
Clinic of Traumatology, Orthopedics and Joint Pathology of the First Moscow State University. Sechenov;
Central Research Institute of Traumatology and Orthopedics named after. Priorova;
Research Institute of Neurosurgery named after. Polenova;
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NI Children's Orthopedic Institute named after. Turner;
Russian Research Institute of Traumatology and Orthopedics named after. Harmful;
VM Academy named after. Kirov.

If we talk about foreign highly specialized centers, here, of course, there is no competition from medical institutions in the Czech Republic. Israel and Germany are countries with a diverse medical profile, but the Czech Republic is a state where the emphasis is specifically on orthopedics, traumatology, neurosurgery, endoprosthetics and postoperative rehabilitation of the musculoskeletal system. Czech orthopedists, spinal neurosurgeons and rehabilitation specialists are specialists of the highest level, practicing only safe high technologies that are relevant to our time using advanced intraoperative techniques. The rate of positive prognosis after surgery, according to verified medical sources of world statistics, in the Czech Republic is 95%. Another advantage in favor of Czech orthopedics is the prices: here they are 2 times lower than in Israel and Germany. For example, the maximum maximum cost for correcting the most complex spinal deformity in clinics in the Czech Republic is 18 thousand euros, for joint replacement – 12-14 thousand euros. This includes implants and full rehabilitation. In Israel and Germany, prices for similar procedures, but without taking into account the rehabilitation management of the patient, are at least 40% higher.

New drugs for therapy

Today, in the practice of modern rheumatology, immunosuppressive drugs are increasingly prescribed for AS. There is a wide range of drugs that suppress the immune system. These drugs are used in the treatment of inflammatory conditions, autoimmune diseases, and after organ transplantation to prevent transplant rejection.

Are there any prospects that modern methods already exist? If we talk specifically about the invention of new methods in the treatment of ankylosing spondylitis, then there are none yet. However, a cytostatic drug called Methotrexate is used. Its action is aimed at reducing the functional abilities of the immune system, which helps slow down the progression of the pathology.

Many patients are afraid of the fact that they will have to use oncological drugs. It is immediately worth noting that in this case the dosage will be significantly less than for a malignant tumor, so they will not have an extremely negative effect on the body.

What other news in the treatment of AS is there today? It is worth noting the drug Sufasalazine, which relatively recently began to be used in the treatment of rheumatic disorders. It is used for the same purpose as described above - to control the immune system and suppress the pathological process.

The discovery was made of biological drugs, which, according to experts, are much safer for humans and act directly on the source of inflammation. They can be used for quite a long time, but there will be no severe negative impact on tissues, organs and systems.