Ankylosing spondylitis (AS) is a form of arthritis that mainly affects the spine.
It tends to occur in young people, being more common in males. The explorer Christopher Columbus, cricketer Mike Atherton and golfer Ian Woosnam all suffered from AS.
Patients often present with back discomfort, stiffness and fatigue. Characteristically, the symptoms are worse in the morning, diminishing during the course of the day, or with exercise. Other places that can be affected include the lower back of the spine (the sacro-iliac joints) or the hips and/or knees. Other sites where inflammation occurs are where ligaments insert into bones (enthesitis), an example being the Achilles tendon.
For some people, progression of the arthritis is slow or even static, however, the course of the arthritis is not easily predictable.
Inflammation of the joint leads to pain and discomfort, swelling and limitation of movement. As healing takes place, damage may occur to the joint and fusion of the bones, giving rise to characteristic x-ray appearances of a ‘bamboo spine’ when the vertebrae are affected. This fusion limits the movement of the vertebra in all directions so the back becomes stiff and may alter the patient’s abilities to do normal day to day activities. Hence, a multi-disciplinary assessment may be needed to consider what the best treatment course is.
As mentioned, there are other sites that may be inflamed in AS, including the eye, the bowel and the skin.
The eye can be affected, becoming watery, painful and bloodshot - this is called an iritis. If there is visual disturbance, then the patient should go to an ophthalmic emergency department (an ‘eye casualty’) as there may be a permanent threat to vision.
The large bowel can be involved with a presentation of inflammatory colitis (blood and mucus with diarrhoea and abdominal pain are features that are seen in acute episodes of colitis).
Psoriasis is also associated with the arthritis, with around 3 in 20 patients being affected.
This type of arthritis is also a rheumatoid factor negative disease, i.e. it and AS are not part of the rheumatoid arthritis disease group. There is an inheritable link with the HLA- 27 gene.
As with any chronic illness, fatigue, tiredness and anaemia can occur.
The patient should be asked the following questions by the treating clinicians:
- Duration of pain, location and joints affected
- Is there any influence of the time of day or impact of exercise on the symptoms?
- How do you feel otherwise?
- Have you had any gastrointestinal, eye problems or skin rashes?
- Is there any family history of rheumatological/joint problems?
AS is managed by careful attention to pain relief, regulated exercise and physiotherapy to limit the extent of damage to joints. Medication, in addition to pain relief, such as tumour necrosis factor is used to reduce the amount of inflammation. Most people have little or no impairment but about 20% will have damage to hips or knees, reducing mobility. Other complications include osteoporosis (thinning of the veins) and fracture of the vertebra(e) from abnormal fusion between the bones of the spine. An assessment conducted by occupation health experts into how the arthritis affects every day living may be helpful too.
There may be considerable delay in the diagnosis as the early features may be non-specific and there can be a variable progression of the disease as mentioned. This means that the breach of duty must relate to the harm that arises from the failure to make an appropriate diagnosis, or alternatively, a failure to monitor and instigate the multi-disciplinary approach that is needed for optimal care. This requires proof that this harm could have been prevented – which will need expert advice.
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NB This article does not constitute legal advice and should not be relied on as such. No responsibility for the accuracy and/or correctness of the information and commentary set out in the article, or for any consequences of relying on it, is assumed or accepted by any member of Dutton Gregory LLP.