Neck pain and Back pain in Ankylosing spondylitis:

Ankylosing spondylitis belongs to a group of arthritis conditions that tend to cause chronic inflammation of the spine (spondyloarthropathies). It is one of the causes of back pain and neck pain in adolescents and young adults with a genetically inherited tendency where is the HLA-B27 gene can be detected in the blood of most patients. The optimal treatment involves medications that reduce inflammation or suppress immunity, physical therapy, and exercises. In this blog, we will explore the common questions related to Ankylosing Spondylitis

What is Ankylosing spondylitis?

Ankylosing Spondylitis is a disease process associated with chronic inflammation of the joints related to spine, particularly the sacroiliac joints. The sacroiliac joints are located at the base of the low back where the sacrum which is the bone above the tailbone meets the iliac bones which are bones on either side of the upper buttocks. Chronic inflammation in these spinal joints leads to pain and stiffness in and around the spine, including the neck, middle back, lower back, and buttocks. Over time, chronic inflammation of the spine can lead to a complete cementing together of the bones, a process referred to as ankylosis which leads to loss of mobility of spine presenting as stiffness. Ankylosing spondylitis is also a systemic disease and it can cause inflammation in and injury to other joints away from the spine manifest as arthritis, as well as to other organs, such as the eyes, heart, lungs, and kidneys. It is two to three times more common in men than in women. The most common age of onset of symptoms is in the second and third decades of life.

What causes Ankylosing Spondylitis?

Ankylosing spondylitis is believed to have a genetically inherited tendency with nearly 90% of such patients born with a gene known as the HLA-B27 gene, which can be detected by Blood tests. Even among individuals whose HLA-B27 blood test is positive, the risk of developing ankylosing spondylitis appears to be further related to heredity. 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 health research.

What are the symptoms and signs of Ankylosing Spondylitis?

Inflammation of the spine can lead to fatigue, pain and stiffness in the low back, upper buttock area, neck, and the remainder of the spine. The onset of pain and stiffness is usually gradual and progressively worsens with loss of range of motion noticeable over months. The symptoms of pain and stiffness are often worse in the morning or after prolonged periods of inactivity. Motion, heat, and a warm shower often reduces pain and stiffness in the morning. Those who have chronic, severe inflammation of the spine can develop a complete bony fusion of the spine (ankylosis). Once fused, the pain in the spine disappears, but the affected individual has a complete loss of spine mobility. A sudden onset of pain and mobility in the spinal area of these patients can indicate bone breakage.

Chronic spondylitis and ankylosis cause forward curvature of the upper torso (thoracic spine), which limits breathing capacity. People with ankylosing spondylitis can also have arthritis in joints other than the spine. This feature occurs more commonly in women. Patients may notice pain, stiffness, heat, swelling, warmth, and/or redness in joints such as the hips, knees, and ankles. Other areas of the body affected by ankylosing spondylitis include the eyes, heart, and kidneys.

Which health care professionals treat Ankylosing Spondylitis?

Rheumatologists are internal-medicine subspecialists with a particular interest in diagnosing and treating patients with ankylosing spondylitis. Orthopaedicians and primary care physicians can also aid in pain management. Spine surgeons are involved in the management of spinal deformities once fixed fusion or ankylosis affecting daily life as occurred due to the fusion of bones.
What are the tips for home management of Ankylosing Spondylitis?
Home management includes instructions and exercises to maintain proper posture. This includes deep breathing for lung expansion and stretching exercises to improve spine and joint mobility. Exercise programs need to be customized for each individual. Swimming and aerobic exercises are best suited for these individuals. Patients with advanced ankylosis need workplace adjustments to suit their limited motion in the spine.

What are the tests which aid in the diagnosis of Ankylosing Spondylitis?

The diagnosis of ankylosing spondylitis is based on evaluating the patient’s symptoms (as elaborated above), a physical examination, X-ray findings (radiographs), and blood tests. The examination can demonstrate signs of inflammation and a decrease in the range of motion of joint. The flexibility of the low back and/or neck can be decreased. There may be tenderness of the sacroiliac joints of the upper buttocks. Chest expansion with full breathing can be limited because of the rigidity of the chest wall. Severely affected people can have a stooped posture. Signs of ankylosis can be seen on X-rays. The presence of the genetic marker HLA-B27 can be identified by a blood test. Other blood tests including ESR, CRP, Blood counts provide evidence of inflammation in the body.

What are the management options for Ankylosing Spondylitis?

The treatment includes the use of medications to reduce inflammation and/or suppress immunity to stop the progression of the disease, physical therapy, and exercise. Medications, commonly used to decrease pain include aspirin and other nonsteroidal anti-inflammatory drugs. In some people with ankylosing spondylitis, inflammation of joints does not respond to the above and these individuals need the addition of disease-modifying antirheumatic drugs (DMARDs) that suppress the body’s immune system. These medications, such as Sulfasalazine (Azulfidine), may bring about the long-term reduction of inflammation. An alternative to sulfasalazine that is somewhat more effective is methotrexate, which can be administered orally or by injection. Newer, effective medications for spine disease attack a messenger protein of inflammation called tumor necrosis factor (TNF). These TNF-blocking medications include etanercept, infliximab, adalimumab, etc. Oral or injectable corticosteroids are potent anti-inflammatory agents and can effectively control spondylitis and other inflammations in the body. Surgery may be required in severe cases of ankylosis of hips or spine.

What is the role of Spine surgery in Ankylosing Spondylitis?

Signs which may suggest that surgery might me required in Ankylosing Spondylitis include: Inability to lift up the head and look forward due to abnormal fixed flexed position of spine, a fracture through the ankylosis wit compromised stability of spine leading to severe pain un responsive to medications, Presence of neurologic deficits, inability to carry out activities of daily living due to bony ankylosis and severe pain and also a combination of above scenarios. The type of spine surgery recommended is based on the type of presentation. Decompression surgery like laminectomy is required for neurological compression with deficits. Spinal instrumentation is required when stability is compromised due to fracture. Osteotomy which is breaking the bones, with screw fixation is required when the spine is fused in an abnormal position. Spine surgery has become safe with recent advances and availability of modern equipments.

Back pain and neck pain are not only extremely common but are also very debilitating. More than 90 percent of times these don’t need any intervention ( investigation or surgery). Enlisted below are some of the commonly asked questions about non-interventional options for relief of back pain and neck pain.In my practice as a spine surgeon in Bangalore at Bangalore spine specialist clinic as an orthopedic spine surgeon in Bangalore, I have come across that people in Bangalore are unaware about all the nonoperative modalities available for spinal treatment. Bangalore spine specialist Clinic, the best orthopedic spine clinic in Bangalore agrees with the above details relating to the nonoperative treatment of back pain and neck pain. Best spine surgeons in Bangalore can deal with back pain and neck pain. Top Spine Surgeons in Bangalore can provide proper evaluation and treatment for back pain in Bangalore.

 

I keep reading about Spine specialists prescribing Glucosamine for arthritis. Will this medication help my back pain?

Studies show that Glucosamine can help relieve the pain of knee osteoarthritis. However, these were short-term trials spanning a four to eight week period. Since osteoarthritis is a chronic problem, more studies will need to be done to investigate the long-term benefits of Glucosamine.

 

A second question is whether people with osteoarthritis of the spine will get the same benefits as those with knee osteoarthritis. At this time, no one knows for sure. Some Spine specialists feel there are enough benefits to encourage their patients to supplement with Glucosamine. Although you may find some relief, there are no studies yet that show with certainty that your back pain will be relieved by taking Glucosamine. As with all medications, be sure to discuss the use of Glucosamine with your Spine specialist before beginning to take this supplement.

 

Can I just use a brace to take my low back pain away?

Your Spine specialist may prescribe a supportive brace to help rest your spine, especially if you are feeling severe pain or have increased pain with movement. Using the brace for a short period of time may help you avoid extra movement and give your spine time to heal. You should remove the brace several times each day in order to do some gentle range of motion exercises. Long-term use of a brace can weaken your spine muscles and make your problem worse instead of better.

 

Which is better to use, heat or ice?

Ice is generally prescribed in the early stages of healing. This period begins at the time your pain or injury starts and lasts up to three days. The cold temperature makes your blood vessels in the sore area vasoconstrict (vase-oh-con-strict ) (become narrower), which helps with the initial stages of healing. Cold treatments can include cold packs or ice bags, which are usually put on the sore area for 10 to 15 minutes.

 

Heat is generally used after the early stages of healing are over. Heat makes your blood vessels vasodilate (vase-oh-dye-late) (get larger). This helps flush away chemicals that can cause pain. It also helps to bring in nutrients and oxygen, which help the area heal. True heat in the form of a moist hot pack, a heating pad, or warm shower or bath, is better than creams that give the feeling of heat. Hot packs are usually placed on the sore area for 15 to 20 minutes. When using heat, you must be careful to make sure your skin does not overheat and burn. It is also not a good idea to sleep with an electric heating pad at night. This can cause the “lobster effect” where your skin becomes red and actually burns from the prolonged heat.

 

As long as I have therapy I feel better. Can I keep coming once each week?

Some of the treatments your physical therapist (PT) uses are designed to give you relief from your symptoms. It is hoped that your treatments will give you a longer and longer period of relief between your scheduled visits. As you show steady signs of improvement in controlling symptoms and doing home exercises, your PT will schedule your visits further apart. The goal is to help you learn to manage your condition, even in the unfortunate event that your symptoms do not go away completely. Eventually, you may only need a visit every so often to refresh your exercises and to go over any new concerns you may have. Otherwise, people do not usually continue physical therapy on an ongoing basis.

 

Is there anything I can do now to help ease my pain?

Something you can do right away to relieve your pain is to use heat or ice. Cold treatments are usually used right after back pain or injury begins. The cold temperature makes the blood vessels in the sore area vasoconstrict (vase-oh-con-strict) (become narrower). This helps your body in the initial stages of healing. Cold treatments can include cold packs or ice bags, which are generally put on the sore area for 10 to 15 minutes.

 

Heat can be used after the early stages of healing are over—usually at least two or three days after the injury or pain began. Heat makes blood vessels vasodilate (vase-oh-dye-late) (get larger). This helps your body flush away chemicals that can cause pain. It also helps to bring in nutrients and oxygen, which help the area heal. True heat in the form of a moist hot pack, a heating pad, or warm shower or bath, is better than creams that give the feeling of heat. Hot packs are usually placed on the sore area for 15 to 20 minutes. Be careful that your skin does not overheat and burn. It is also not a good idea to sleep with an electric heating pad at night, which can lead to the “lobster effect” where your skin turns red and actually burns from the prolonged heat.

 

My friend told me about a TENS unit she uses for her back pain. What is a TENS unit, and will it work for me?

TENS is short for transcutaneous (trans-kew-tay-nee-us) (across the skin) electrical nerve stimulation. TENS uses a small, pocket-sized electrical stimulation unit. It can be used up to 24 hours a day if needed to help control pain. It is usually issued by a physical therapist (PT), but only if you have not found other ways to control your pain. Also, a prescription from your Spine specialist is required for you to use one of these units on your own.

 

TENS treatment stimulates your nerves by sending a small electrical current gently through your skin. Some people say it feels sort of like a massage on their skin. Electrical stimulation can ease pain by sending impulses that your brain feels instead of pain. Two respected scientists discovered a theory, called the Gate Theory. It says that when you feel a sensation other than pain, like rubbing, massage, or even a mild electrical impulse, your spinal column will actually “close the gate” and not let pain impulses pass to your brain.

 

In the case of electrical stimulation, the electrical impulses speed their way across your skin and onto your central nervous system much faster than pain. By getting there first, the electrical information “closes the gate” to pain, blocking its passage to the brain. Once the pain eases, muscles that are in spasm can begin to relax, letting you move and exercise with less discomfort. Other settings on the unit can be used to help your body release endorphins (en-dor-fins). Endorphins are natural chemicals produced by your body that can lower the sensation of pain for up to eight hours at a time.

 

Will I need to have therapy until my pain goes completely away?

Because back pain is unpredictable, it is not realistic to expect that you will be pain-free when you complete your therapy treatments. Every effort will be made to help take your pain away, but you should measure success by how well you can manage your spine condition—even if you still have pain.

 

The first goal of treatment is to find ways of controlling your pain and symptoms. This can include the use of treatment interventions like heat, ice, and manual therapy. By helping you understand how your spine works and which positions and movements can be used to protect your back and neck, you may find it easier to manage your pain and symptoms. As your symptoms begin to ease, you will be given specific exercises to improve your mobility and strength. An important part of helping you manage your spine condition is called functional training, which can include posture and alignment, safe body movements at home and at work, and safe lifting techniques.

 

Once your pain is controlled, your range of motion has improved, and your strength has started to return, you will be progressed to a final home therapy program. Your physical therapist will go over ways to take care of your soreness at home, and you will be given exercises to continue improving the range of motion, strength, and function of your spine.

 

Will my Spine specialist prescribe medications for my condition?

Mild pain medications can reduce inflammation and pain when taken properly. Medications you may be prescribed include:

 

Aspirin — over-the-counter pain relievers that can help relieve minor pain and back ache.

NSAIDs — non-steroidal anti-inflammatory drugs (NSAIDs) are very effective in relieving the pain associated with muscle strain and inflammation.

Non-narcotic analgesics — relieve pain at the point of injury.

Narcotic pain medications — help relieve severe pain by numbing the central nervous system.

Muscle relaxants — help a little in relieving pain from muscle spasm.

Antidepressants — help relieve the emotional stress that often compounds the symptoms of back pain.

General Caution: All medications can have side effects. Be sure to discuss these with your Spine specialist before beginning to take any of these medications.

 

My spine is really hurting but my Spine specialist recommends conservative treatment. What is conservative treatment? Will it help as much as surgery?

Back specialists use the term “conservative treatment” to describe any treatment that does not involve surgery. Sometimes, this can be as simple as reassuring you that it is not a serious problem, and recommending that you do nothing but watch and wait. Conservative treatment can also include medications to relieve your pain, physical therapy, and exercise. People with back and neck pain should also learn how to protect their spine by practicing good posture and doing strengthening exercises.

 

How much longer will I need physical therapy?

The goal of physical therapy is to help you control your pain and regain your best possible function. Once your pain is controlled, your range of motion is improved, and your strength is returning, you will be progressed to a final home program. Your therapist will give you some ways to take care of soreness at home and to keep working on your range of motion and strength too.

 

What is scoliosis?

Scoliosis is a disorder that causes an abnormal curve of the spine, or backbone with rotation of the spine along its axis. The spine has normal curves when looking from the side, but it should appear straight when looking from the front. People with scoliosis develop additional curves to either side of the body, and the bones of the spine twist on each other, forming a “C” or an “S” shape in the spine.

What are risk factors for scoliosis?

Scoliosis is about two times more common in girls than boys. Scoliosis affects about 2% of females and 0.5% of males Being a female increases the risk of scoliosis, and females have a higher risk of worsening spine curvature than males. Although many individuals who develop the problem do not have family members with scoliosis, a family history of scoliosis increases the risk of the disease.

What causes scoliosis?

In most cases, the cause of scoliosis is unknown (known as idiopathic). More than 80% of people with scoliosis have idiopathic scoliosis, and the majority of those are adolescent girls; the most common location for scoliosis is in the thoracic spine. This type of scoliosis is described based on the age when scoliosis develops, as are other some other types of scoliosis.
• If the person is less than 3 years old, it is called infantile idiopathic scoliosis.
• Scoliosis that develops between 3-10 years of age is called juvenile idiopathic scoliosis.
• People who are over 10 years old (10-18 years old) have adolescent idiopathic scoliosis.
• Recently all types of Scoliosis presenting before 8 years has been termed as Early Onset Scoliosis.

There are other types of scoliosis:

Congenital: If the curve is present at birth, it is called congenital. In this type of scoliosis, there is a problem when the bones of the spine are formed. Either the bones of the spine fail to form completely or they fail to separate from each other during fetal development. This type of congenital scoliosis develops in people with other disorders, including birth defects or Marfan syndrome (an inherited connective tissue disease)

Neuromuscular: In this type of scoliosis, there is a problem with the nervous system or the muscular system as in, muscular dystrophy, cerebral palsy etc. People with these conditions often develop a long C-shaped curve and have weak muscles that are unable to hold them up straight. If the curve is present at birth, it is called congenital. This type of scoliosis is often much more severe and needs more aggressive treatment than other forms of scoliosis.
Degenerative: Unlike the other forms of scoliosis that are found in children and teens, degenerative scoliosis occurs in older peoples. It is caused by changes in the spine due to age related arthritis. Weakening of the normal ligaments and other soft tissues of the spine combined with abnormal bone spurs can lead to an abnormal curvature of the spine in association with factors like osteoporosis, vertebral compression fractures, and disc degeneration.

Functional: In this type of scoliosis, the spine is normal, but an abnormal curve develops because of a problem somewhere else in the body. This could be caused by one leg being shorter than the other or by muscle spasms in the back.

Other potential causes of scoliosis include spine tumours such as osteoid osteoma. This is a benign tumour that can occur in the spine and cause pain. The pain causes people to lean to the opposite side to reduce the amount of pressure applied to the tumour. This can lead to a spinal deformity.

What are scoliosis symptoms and signs?

The most common symptom of scoliosis is detection of an abnormal curve of the spine or abnormal posture like uneven waist often noticed by a friend or a family member or physician doing routine screening of children for school or sports. Those affected may notice that their clothes do not fit as they did previously. It can also be found on a routine school screening examination for scoliosis. The change in the curve of the spine typically occurs very slowly so it is easy to miss until it becomes a more severe physical deformity. Scoliosis may cause the head to appear off centre, leaning to one side or notice one hip or shoulder to be higher than the opposite side. If the scoliosis is more severe, it can make it more difficult for the heart and lungs to work properly. This can cause shortness of breath and chest pain on activities like playing and swimming. In most cases, scoliosis is not painful, but there are certain types of scoliosis than can cause back pain, rib pain, neck pain, muscle spasms, and abdominal pain.

What clinical tests to do spine specialists use to diagnose scoliosis?

Spine specialist will ask questions related to scoliosis etiopathology, including if there is any family history of scoliosis, or if there has been any pain, weakness, or other medical problems.The spine specialist will look at the symmetry of the body to see if the hips and shoulders are at the same height, leaning to one side, or if there is sideways curvature. The physical examination involves looking at the curve of the spine from the sides, front, and back. The person will be asked to undress from the waist up to better see any abnormal curves, physical deformities, or uneven waist. The person will then bend over trying to touch their toes referred to as the Adams forward bending test. This position can make the curve more obvious. Any skin changes will also be identified that can suggest scoliosis due to a birth defect. A doctor may check your range of motion, muscle strength, and reflexes. The clues to the amount of growth remaining are examined including signs of puberty such as the presence of breasts or pubic hair and whether menstrual periods have begun in girls. The more growth that a person has remaining increases the chances of scoliosis getting worse. As a result, the doctor may measure the person’s height and weight for comparison with future visits. A note is also made of the height of father, mother and siblings of the chid for an assessment of the amount of growth potential.

What radiological and lab tests do spine specialists use to diagnose scoliosis?

If the doctor believes a patient has scoliosis X-rays are obtained, usually whole spine AP and lateral (at first visit, for further follow up visits usually AP is enough). The doctor can make measurements from them to determine how large a curve is present. This can help decide what treatment, if any, is necessary. Measurements from future visits can be compared to see if the curve is getting worse. It is important that the doctor knows how much further growth the patient has left. Additional X-rays of the hand, wrist, or pelvis can help determine how much more the patient will grow. If a doctor finds any changes in the function of the nerves, he or she may order other imaging tests of your spine, including an MRI or CT scan to look more closely at the bones and nerves of the spine.

What types of specialists treat scoliosis?

Usually a trained spine surgeon. In addition, a rehabilitation specialist, physical therapist, neurologist or an occupational therapist may be consulted as part of the treatment team.

What are the treatment options for scoliosis?

The treatment of Scoliosis cannot be generalised. The management is based on the type of scoliosis, the severity of the curve and the chances of the curve getting worse. There are three main categories of treatment: observation, bracing, and surgery.
Treatment of idiopathic scoliosis usually is based on the age when it develops.
In many cases, infantile idiopathic scoliosis will improve without any treatment. X-rays can be obtained and measurements compared on future visits to determine if the curve is getting worse. Bracing is not normally effective in these people, but casting has been tried.
Juvenile idiopathic scoliosis has the highest risk for getting worse of all the idiopathic types of scoliosis. Bracing can be tried early if the curve is not very severe. The goal is to prevent the curve from getting worse until the person stops growing. Since the curve starts early in these people, and they have a lot of time left to grow, there is a higher chance for needing more aggressive treatment or surgery.

Adolescent idiopathic scoliosis is the most common form of scoliosis. If the curve is small when first diagnosed, it can be observed and followed with routine X-rays and measurements. If the curve or Cobb angle stays below about 20-25 degrees (Cobb method or angle, is a measurement of the degree of curvature), no other treatment is needed. The patient may return to see the doctor every three to four months to check for any worsening of the curve. Additional X-rays may be repeated each year to obtain new measurements and check for progression of the curve. If the curve is between 25-40 degrees and the patient is still growing, a brace may be recommended. Bracing is not recommended for people who have finished growing. If the curve is greater than 40 degrees, then surgery may be recommended.

Functional scoliosis is caused by an abnormality elsewhere in the body. This type of scoliosis is treated by treating that abnormality, such as a difference in leg length. A small wedge can be placed in the shoe to help even out the leg length and prevent the spine from curving.
Neuromuscular scoliosis is caused by an abnormal development of the bones of the spine. These types of scoliosis have the greatest chance for getting worse. Observation and bracing do not normally work well for these people. Most of these people will eventually need surgery to stop the curve from getting worse.

SCOLIOSIS QUICK FACTS

• Scoliosis is an abnormal curve in the spine.
  There are several types of scoliosis based on the cause and age when the curve develops; most patients have no known cause termed as Idiopathic Scoliosis.
  The most common symptom of scoliosis is curvature of the spine.
  Scoliosis risk factors include age (9- to 15-year-olds), female sex, and family history.
  Diagnosis is done by the physical exam and by imaging techniques such as X-rays.
  Depending on the severity of the curve and the risk for it getting worse, scoliosis can be treated with observation, bracing, or surgery.
  Trained Spine surgeons are often consulted for treatment.
  Most scoliosis surgeons agree that children who have very severe curves (45-50° and higher) will need surgery to lessen the curve and prevent it from getting worse.
  The operation for scoliosis is a spinal fusion. The basic idea is to realign and fuse together the curved vertebrae so that they heal into a single, solid bone.
  The prognosis for an individual with scoliosis ranges from mainly good to fair, depending on how early the problem is diagnosed and treated. Screening is one of the key elements for early detection.

In my practice as a spine surgeon in Bangalore at Bangalore spine specialist clinic as an orthopaedic spine surgeon in Bangalore, I have come across that people in Bangalore are unaware about the condition of scoliosis.  Bangalore spine specialist Clinic, the best orthopaedic spine clinic in Bangalore agrees with the above details relating to the scoliosis. Best spine surgeon in Bangalore can deal with Scoliosis. Top Spine Surgeons in Bangalore can provide screening, bracing and surgery for scoliosis.