If you do suffer from a spinal injury/condition please seriously consider your options prior to allowing any type of spinal punctures. There are many alternatives to ESI's and they should really only be done as the last resort. ESI's are indeed linked to arachnoiditis. Nothing like trying to alleviate the sympotoms of one problem and you end up causing another one.
Ankylosing Spondylitis
What is ankylosing spondylitis?
Ankylosing spondylitis (pronounced ankle-low-zing spond-ill-eye-tiss) is arthritis involving the spine.
It causes pain and stiffness in the back, and also bent posture. This is a result of ongoing swelling and irritation of the spinal joints (vertebrae). This swelling and irritation is called inflammation.
The inflammation may eventually make the vertebrae fuse together.
Inflammation of the tendons and ligaments that connect and provide support to joints can lead to pain and tenderness in the ribs, shoulder blades, hips, thighs, shins, heels and along the bony points of the spine.
Ankylosing spondylitis (AS) is a chronic inflammatory form of arthritis that affects the spinal joints. The hallmark feature of AS is the involvement of the joints at the base of the spine where the spine joins the pelvis - the sacroiliac (SI) joints.
The disease course is highly variable, and while some individuals have episodes of transient back pain only, others have more chronic severe back pain that leads to differing degrees of spinal stiffness over time. In almost all cases the disease is characterized by acute painful episodes and remissions (periods where the problem settles).
Over the years AS has been known by many different names including poker back, rheumatoid spondylitis, and Marie-Strumpells spondylitis. Since the early 70s with increasing knowledge about the disease, there is almost universal use of the term ankylosing spondylitis (AS).
AS is a member of the family of diseases that attack the spine. These are named spondylarthropathies. In addition to AS, these diseases include Reiter’s syndrome, some cases of psoriatic arthritis and the arthritis of inflammatory bowel disease.
How Common is ankylosing spondylitis?
It affects between 150,000 and 300,000 Canadians (as many as 1 in 100)
Men develop ankylosing spondylitis three times more often than women.
It usually appears in people between the ages of 15 and 40.
AS is three times more common in men than in women. It typically affects young people, beginning between the ages of 15 and 30. It may affect younger people also, although in very young people it may take a slightly different form, causing pain around the heels, knees, and hips rather than beginning with the spine. Onset after age 40 is uncommon.
What are the warning signs of ankylosing spondylitis?
Frequent low back pain.
Back stiffness that lasts longer than 30 minutes first thing in the morning or after a long period of rest.
Pain and tenderness in the ribs, shoulder blades, hips, thighs, shins, heels and along the bony points of the spine.
In the early stages, there may be mild fever, loss of appetite and general discomfort.
The eyes can also be affected and symptoms can include eye pain, watery eyes, red eyes, blurred vision, and feeling sensitive to bright light.
The most universal symptom of AS is chronic low back pain that seems to just come on for no apparent reason. The pain is typically worse in the morning. On rising from bed, people with AS may feel stiff and sore and this may take anywhere from 30 minutes to several hours to pass off.
The back pain is usually dull and diffuse rather than sharp and localised. The most common site of pain is deep within the buttock, on one side, or on both sides. In addition to the buttock, there could be pain further up the back, perhaps between the shoulder blades or in the neck.
In a lesser number of individuals, pain does not begin in the spine but starts in a hip, knee or shoulder joint. This can be confusing when there is no back pain present and may initially look like some other form of arthritis.
The pain of AS results from inflammation of the joints. When inflammation is present, the involved area hurts. To avoid the pain there is a natural tendency to stoop forward as extending backwards is more uncomfortable. This reflex can lead to bad posture. Also in bed there is a tendency to curl up, as this may feel more comfortable.
If the inflammation associated with AS continues unchecked, it can produce changes within the spinal column. Small bony outgrowths extend from the edges of the vertebrae and can eventually bridge across from one vertebra to the next. Should this occur, over time it can result in stiffness and immobility between the vertebrae. While there are 24 different spinal vertebrae in the back, stiffness of any two can limit function. Stiffness of more can lead to progressive disability.
While spinal stiffness is to be avoided, even greater potential disability can occur if AS affects the hips, knees or shoulders. The hip joints are quite often involved and can progress to where the joint is damaged, becoming limited in mobility, and painful. The end stage of this hip damage is frequently total hip joint replacement.
Joints Affected
Most commonly the joints in the buttocks, called the sacroiliac joints, are affected. The low back is commonly involved, as is the mid-back (the thoracic spine) and the neck (the cervical spine).
Of the non-spinal joints, the hips are the most commonly involved and to a lesser extent the knees and shoulders. Involvement of the small joints of the hands and feet, wrists and ankles is unusual.
The joints between the ribs and the spine and between the ribs and the breast bone (sternum) can also become painful and stiff. Stiffness of these joints can result in decreased chest expansion.
Iritis (Inflammation of the Iris of the Eye)
Individuals with AS have a much greater likelihood of having episodes of iritis (inflammation of the iris of the eye). This results in the eye being painful and irritated. It is often described as a feeling of having had a handful of sand thrown in the eye. The individual may also be sensitive to bright light. This is usually treated with eye drops.
Aortitis
Although it is relatively uncommon, there is a possibility of inflammation involving the aorta near the heart. If you have AS, your physician may therefore listen to your heart from time to time.
What causes ankylosing spondylitis?
The exact cause is unknown.
Many people with ankylosing spondylitis have other family members with it.
AS tends to run in families. Just as we inherit our hair colour and blood type from our parents, we also inherit our tissue type. The tissue typing system is the Human Lymphocyte Antigen (HLA) system. One of the tissue types, HLA-B27, is found in only 6% of the broad population but occurs in approximately 93% of individuals with AS.
The HLA-B27 tissue type, while not causing AS, does predispose individuals with the B27 tissue type to developing AS. Thus we see AS tending to occur in families. Having the tissue type itself does not mean you will get AS, it simply increases the possibility. Identifying the activating agent that later triggers AS is the focus of much current research.
What can you do about ankylosing spondylitis?
If your doctor thinks you have ankylosing spondylitis, he or she will usually refer you to a rheumatologist (room-a-tol-o-jist). A rheumatologist is a doctor who has received special training in the diagnosis and treatment of problems with joints, muscles and bones.
If your eyes are affected too you could also be referred to an ophthalmologist (off-thal-mol-o-jist).
There is no cure for ankylosing spondylitis but there are things you can do to lessen your pain and maintain your movement and function.
Learn as much as you can about this disease. Speaking with people who are specialists in arthritis care can provide you with the information you need.
At this time, there is no cure for AS. Therefore, treatment is designed to minimize pain and to maintain mobility and function. Establishing the correct diagnosis early is important because the sooner appropriate treatment is started the better the chance of avoiding disability or deformity.
Diagnosis is made from several different features. The history of the onset of pain, the areas of involvement, and the times of the day when pain is worst, are key. In young people the presence of tender points at specific locations around the feet, heels, knees and hips can be indicative of AS. Since AS often affects young, active males, it is sometimes misdiagnosed as mechanical low back strain.
The most classic site of involvement is the sacroiliac (SI) joints on the right and/or left sides in the buttock area. Unfortunately, X-ray evidence of changes in the SI joints may take some time to occur, thus an X-ray taken in the early years of the problem may be negative. Over time the SI joints will usually show changes that can be seen on X-ray. In addition to the SI joint x-ray changes, changes at the edges of some vertebrae may be observed.
There is no blood test that diagnoses AS specifically, but blood tests may be done that could contribute to the picture. A test called an ESR is often done. This test shows whether or not inflammation is present in the body. This can help determine, for example, whether back pain may be inflammatory or a result of something else.
Often, precise measurements are made of the mobility of the spine and this can also contribute to the diagnosis. By the time spinal joints become markedly stiff, however, the disease has usually been present for some time.
A variety of treatments can help to lessen pain and stiffness and make movement easier. Your active involvement in developing your prescribed treatment plan is essential.
Medicine
The most common type of medicine used to treat ankylosing spondylitis is nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs help reduce the pain and swelling of the joints and decrease stiffness. However, they do not prevent further joint damage. Two common NSAIDS are Aspirin® and Advil®.
NSAIDs reduce pain when taken at a low dose, and relieve inflammation when taken at a higher dose. NSAIDs such as ASA (Aspirin, Anacin, etc.) and ibuprofen (Motrin IB, Advil, etc.) can be purchased without a prescription. Examples of other NSAIDs that require a prescription include Naprosyn, Relafen, Indocid, Voltaren, Feldene, and Clinoril. The various NSAIDs and Aspirin®, if taken in full doses, usually have the same levels of anti-inflammatory effect. However, different individuals may experience greater relief from one medication than another. Taking more than one NSAID at a time increases the possibility of side effects, particularly stomach problems such as heartburn, ulcers and bleeding. People taking these medications should consider taking something to protect the stomach, such as misoprostol (Cytotec).
For those with severe disease who have inflamed joints, a drug called sulfasalazine can help manage the symptoms, and better control the disease. Sulfasalazine is one type of a family of medicines called disease-modifying anti-rheumatic drugs (DMARDs). DMARDs try to stop AS from getting worse. DMARDS take about two to six months before they begin to make a difference in the pain and swelling.
Disease modifying anti-rheumatic drugs (DMARDs) may be prescribed when inflammation continues for more than 6 weeks or when AS strikes many joints at once. DMARDs target the processes causing the inflammation, but do not reverse permanent joint damage. The most common of them are gold salts, methotrexate, sulfasalazine, hydroxychloroquine, chloroquine and azathioprine. A DMARD is usually prescribed in addition to an NSAID or prednisone. Side effects may include mouth sores, diarrhea and nausea. More serious side effects, monitored through regular blood and urine tests, include liver damage, and excessive lowering of white blood cell count (increasing susceptibility to certain infections), and platelet count (affecting blood clotting).
Occasionally a cortisone injection into an affected joint or ligament brings short-term relief. Cortisone is a steroid that reduces inflammation and swelling.
For severe pain and inflammation, doctors can inject a corticosteroid directly into the affected joint. Cortisone is a steroid that reduces inflammation and swelling. It is a hormone naturally produced by the body. Corticosteroids are man-made drugs that closely resemble cortisone. An injection can provide almost immediate relief for a tender, swollen, and inflamed joint. However, this treatment can only be used rarely, since corticosteroids can weaken the cartilage and remove the minerals from (and therefore weaken) the bone, resulting in further joint weakness.
If your eyes are affected, cortisone eye drops may also be prescribed.
The medication that is working for you will be the one that best controls the inflammation and pain. Realize that in most instances it does not result in the pain going away totally. If taking the medication results in a 75% reduction of pain that may be a good result. Work with your rheumatologist to find something that helps most.
Exercise
Exercise is one of the most important activities in managing ankylosing spondylitis. Exercise helps keep joints moving and reduce pain.
A physical therapist can teach you exercises to do daily. Range of motion exercises reduce stiffness and help keep your joints moving. Strengthening exercises maintain or increase the strength of your back muscles and help you keep an upright posture.
Other activities such as swimming, walking and cross-country skiing also encourage good posture.
Because ankylosing spondylitis causes stiffness in the back you may be more at risk of fracturing your spine. You should be cautious of playing body contact sports, such as rugby or hockey, or doing activities that could involve falling, such as downhill skiing.
Exercise is one of the cornerstones to the successful long-term management of AS. It is done for three major reasons:
1) to maintain or restore spinal mobility,
2) to maintain or improve posture,
3) to maintain chest expansion.
A physical therapist can teach you a program of range of motion exercises for your neck, mid back and low back which should be done daily if you have AS. You won't necessarily do them all daily, but will do some exercise each day to maintain your mobility. You probably should focus with range of motion exercises on particular areas that are troublesome. For example, if your neck is painful and prone to stiffness you should be doing gentle mobility exercises to maintain movement of your neck.
As there is a tendency, because of AS, to stoop forward and to get stiff in this position, strengthening exercises should be done to increase the muscle power of those muscles that keep you upright and erect - the extensors or back muscles. This is contrary to the type of exercises often given to people with the more common back injury. Gentle stretching exercises are important to prevent stiffness and postural changes.
To maintain your chest expansion and rib mobility your physical therapist may also instruct you in breathing exercises.
Choose a time of the day for exercising that works for you. Most people with AS are stiff in the morning so this is probably not a good time to do your exercises. If you hurt take a warm bath prior to exercising.
Heat/Cold
Applying heat helps relax aching muscles, and reduces joint pain and soreness. For example, take a hot shower.
Applying cold helps to lessen the pain and swelling in a joint. For example, put an ice pack on the area that is sore.
Heat or cold application can provide temporary relief of pain. Heat helps to reduce pain and stiffness by relaxing aching muscles and increasing circulation to the area. There is some concern that heat may worsen the symptoms in an already inflamed joint. Cold helps numb the area by constricting the blood vessels and blocking nerve impulses in the joint. Applying ice or cold packs appears to decrease inflammation and therefore is the method of choice when joints are inflamed.
Protect Your Joints
Be kind to your body. After doing heavy work, or doing the same task over and over, stop. Slow down by doing an easy task, or by taking a rest.
Use your back, arms and legs in safe ways to avoid stress on joints. For example, carry a heavy load close to your body.
Sleep on a firm supportive mattress and support your neck with special neck supports or pillows.
Avoid the tendency to slump forward or slouch, even though this may feel more comfortable. Be aware of how you are standing or sitting and remind yourself to keep your back straight.
Protecting your joints means using them in ways that avoid excess mechanical stress from daily tasks. Benefits include less pain and greater ease in doing tasks. Three main techniques to protect your joints include:
Pacing, by alternating heavy or repeated tasks with easier tasks or breaks, reduces the stress on painful joints and allows weakened muscles to rest. Pacing and planning also provide you with ways to deal with fatigue.
Positioning joints wisely helps you use them in ways that avoid extra stress. Use larger, stronger joints to carry loads. For example, use a shoulder bag instead of a hand-held one. Also, avoid keeping the same position for a long period of time.
Using assistive devices, such as canes, raised chairs, grip and reaching aids, can help make daily tasks easier. Using grab bars and shower seats in the bathroom can help you to conserve energy and avoid falls.
If you have AS it is very important that you sleep on a firm supportive surface to maintain good spinal alignment for the one third of your day you spend in bed. A saggy mattress or waterbed can permit you to sleep in positions that, over time, might lead to posture that is stooped. Your neck should be supported in as good a position as can be achieved with special neck supports or pillows.
Also be aware of your posture during the day. Pay attention to how you are standing. Look at your habitual work postures. Do you sit upright? If you work at a computer is the monitor on your desk high enough so you are not looking downward? Modify your working positions to better maintain a good posture. Do your best to keep your back straight and avoid the tendency to slump forward, even if it does feel more comfortable. Deal with your pain with medication, exercise, rest and heat but maintain a good posture.
Relaxation
Relaxing the muscles around an inflamed joint reduces pain.
There are many ways to relax. Try deep breathing exercises. Listen to music or relaxation tapes. Meditate or pray. Another way to relax is to imagine, or visualize a pleasant activity such as lying on the beach, or sitting in front of a fireplace.
Developing good relaxation and coping skills can give you a greater feeling of control over your arthritis and a more positive outlook.
Surgery
You and your doctor may consider surgery, if one of your joints becomes badly damaged, or if the pain is too strong.
With ankylosing spondylitis the hip joints are quite often involved, and it can progress to where these joints are quite damaged. This can further limit movement and be painful. The end stage of this hip damage is often total hip joint replacement through surgery.
Outcomes
While the course of AS varies, most people do well and continue to live normal but sometime modified lives.
Those with very heavy jobs requiring a lot of bending and lifting may have to consider an alternative.
Additional Tips for Living Well
The Arthritis Society offers a variety of programs and services that can be helpful.
You can reach the Society at 1-800-321-1433 from anywhere in Canada.
You can also reach us through our Web site at www.arthritis.ca
Along with the physical symptoms of arthritis, many people experience feelings of helplessness and depression. Learning daily living strategies to manage your arthritis gives you a greater feeling of control and a more positive outlook. To get the best results, people affected by arthritis need to form close ties with their doctors and therapists, and become full partners in their treatment. From our perspective, it's all part of 'living well with arthritis.' There are several resources you can use in finding out how best to manage your own arthritis. Here are a few:
The Arthritis Self-Management Program (ASMP) is a unique self-help program offered by The Arthritis Society to help you better control and manage your arthritis.
The Open Forum within this Web site is an opportunity to discuss and share information with other visitors - people who, through their own experiences, may be able to offer some useful insights.
Of course, there are many other valuable resources for people with arthritis. If you're unclear about where to look for help, be sure to call The Arthritis Society at 1-800-321-1433
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