Ankylosing spondylitis and diagnostic errors: time to stop the disease

Ankylosing spondylitis and diagnostic errors: time to stop the disease pain is one of the most common complaints of patients referring to a neurologist. One of the most “popular” diagnoses, both among patients and among some doctors, is osteochondrosis. In fact, under the vague definition of this term there may be a rather dangerous disease that makes a person disabled – Bechterew’s disease. Finds out what it is and how not to turn into a “living mummy”. Ankylosing spondylitis and mummy: a diagnostic error the first description of patients with ankylosing spondylitis is found in the work “Anatomy”, written in 1559 by Realdo Colombo. A more detailed picture of an unusual disease was revealed after more than 100 years, in 1693, by Bernard Connor. He presented a description of the skeleton in which the thoracic, lumbar and hip sections of the spine constituted a single bone. And at the end of the 19th century, several researchers from different countries at once published the results of their research on ankylosing spondyloarthritis: 1892 – Russian neurologist and psychiatrist V.M. Bekhterev; 1897 – German doctor A.Struhumel ; 1898 – Frenchwoman and medic P. Marie. Their research and compiled a knowledge base of doctors about the disease, which eventually became known as Bechterew’s disease — Strumpel’s Marie. In the Russian-language literature, it was reduced to ankylosing spondylitis, and in English and French-speaking sources you can find the name “Strumpel ‘s disease — Marie”. In the descriptions of ankylosing spondylitis, it is often mentioned that this “disease of the pharaohs” – the characteristic signs of ankylosing spondyloarthritis were found in the mummies of three Egyptian reigning individuals: Amenhotep II, Ramses II and his son Merneptah . However, in 2014, this beautiful detail of Bekhterev’s medical history was overwhelmed by computed tomography of 13 Egyptian mummies. It turned out that those of the kings and princes, who were attributed to ankylosing spondylitis, really had a diseased spine. But the cause of the disease was a completely different disease. The four rulers of ancient Egypt showed symptoms of diffuse idiopathic skeletal hyperostosis (DISH), or Forestier’s disease. In ankylosing spondylitis, the destruction of intervertebral joints begins in the lower back and is inflammatory. At the same time, the sacroiliac joints merge first. And in “sick” mummies, spinal deformities were found in the upper back, which speaks of Forestier ‘s disease, which proceeds without inflammation. Other pathologies of mummy joints are explained by changes in the bone tissues that occur during the mummification process. So, the Egyptian kings suffered from spinal pathologies, but not Bechterew’s disease. What is ankylosing spondylitis? So, what is this disease with different names? In the medical term is a complete description of the disease. The term “ankylosis” implies the immobility of a joint, which arose due to the fusion between its individual parts. A “spondyloarthritis” indicates where and because of which this immobility originated: inflammation of the spine. And once spondyloarthritis ankylosing – it is a gradual process. Year after year, the flexible spine, which allows us to perform a lot of complex movements, feel free on land and in water, engage in various sports, etc., gradually turns into a “bamboo stick” —the head, body, and thighs are connected into a single whole, and the rest of the body and joints remain mobile, as before. The cause of ankylosing spondylitis has not yet been clarified. It is absolutely certain that among the predisposing factors are: Heredity (the significance of this factor is at least 20%). Postponed infectious disease of the intestine or genitourinary system. Increased activity of one type of bacteria, Klebsiella (Klebsiella pneumoniae) and some strains of Yersinia (Yersinia enterocolitica). Doctors have long known about the histocompatibility gene HLA-B27. Its presence increases the risk of developing the disease by 80 times. And in a study in 2011, several genes were identified that are involved in the development of ankylosing spondylitis by interacting with HLA-B27. For example, some variants of the ERAP1 gene increase a person’s susceptibility to the disease, while others, on the contrary, protect against it. It is also known that the tumor necrosis factor alpha (TNF-alpha) plays a key role in the development of the disease. This is a protein from the group of cytokines, which supports inflammatory processes in tissues, stimulates fibroblasts, collagen synthesis processes and increases the activity of the gene responsible for bone erosion. In general, the activity of TNF-alpha leads to the destruction of bone tissue and its formation in abnormal places and in abnormal quantities. Among other risk factors, according to research in recent years: restless legs disease – occurs in patients with Bechterew’s disease almost 3 times more often than in healthy people; birth weight less than 3 kg; hospitalization with infectious diseases at the age from 5 to 12 years. How does ankylosing spondylitis develop? Bechterew’s disease begins to develop usually at the age of 20-30 years, and the strong half of humanity suffers from it 5 times more often. The incidence of ankylosing spondyloarthritis varies depending on geography: in Norway, 1.4% of adults suffer from it, in France – 0.15%, in Russia – from 0.01 to 0.09%. Although in the latter case, there may be a non-detection of cases of the disease, and in fact our compatriots get sick much more often. In most cases, the disease develops with pain. First, the loin starts to hurt. Gradually, the pain spreads to the neighboring spine. Characteristic moment: the pain becomes stronger closer to the morning and generally at rest. After a hot shower and warming up gymnastics, it can fully pass. The pain is also well removed by taking NSAIDs, but as soon as their action ends, it returns. Over time, the spine begins to lose its mobility. In humans, the lumbar curve, lordosis, gradually disappears, this part of the spine becomes flat. Its ossification develops from the bottom up, therefore the limitations of mobility in the neck develop at rather late stages. Although not always. In the worst case, the disease quickly gets to the neck. When the cervical spine is already affected, the patient acquires the characteristic “bulging hunchback” – doctors call it the “petitioner’s posture”. When the thoracic vertebrae begin to stiffen, the ability to breathe deteriorates – and, as a result, chronic lung diseases develop. The spine is the center of our body, so its disease affects other joints. The shoulders and hips, lower jaw, chest, joints of the limbs may begin to hurt. Usually with arthritis, the joints are gradually destroyed. With ankylosing spondylitis, this does not happen, but their mobility decreases with each passing year. Every third patient with ankylosing spondyloarthritis develops eye lesions — uveitis (inflammation of the choroid) and iridocyclitis (inflammation of the iris and ciliary body) are detected in these patients. The second most common is heart damage, which is manifested in arrhythmias, disorders in the operation of valves, etc. Fibrosis of the lung tissue often develops, and the kidneys and nervous system are damaged. Treatment of ankylosing spondylitis Specific treatment of ankylosing spondylitis does not yet exist. Doctors prescribe drugs of the following groups: NSAIDs; hormonal medications (glucocorticosteroids); immunosuppressants; TNF alpha inhibitors and B cell activation inhibitors. To slow down the development of immobility of the thoracic spine and reduce the risk of lung diseases, the patient is prescribed physiotherapy, manual therapy and physiotherapy. Problems in the diagnosis of ankylosing spondyloarthritis Suspicion of ankylosing spondylitis should occur if at least one of the four New York criteria is present: Lower back pain that does not go away for 3 months, which can be reduced by gymnastics, but constant – at rest. Mobility impairment in the lumbar spine – when bending back and forth and right-left. Reducing the mobility of the ribs, exceeding the age and sex norms. Inflammation in the joints of the sacrum and ilium (sacroiliitis). But even if with the mummies, humanity has long been in error, it is not surprising that the problem of diagnosis exists for living people. Doctors and scientists have long pointed out that the disease is too often detected in the later stages. Recently, British researchers have pointed to the serious problem of timely diagnosis of ankylosing spondylitis. According to them, people too often use modern painkillers that smooth out the symptoms during the examination. Most often, it is non-steroidal anti-inflammatory drugs (NSAIDs), in most cases – ibuprofen. And ankylosing spondylitis is through an incurable disease, but can be treated with symptomatic drugs, you can even stop its development. He is well diagnosed with an MRI scan, but too often people come for an examination while taking NSAIDs. Ibuprofen and similar drugs hide the true scale of the “disaster”, and as a result, the correct diagnosis is made on average 8-11 years after the onset of the disease. The second large-scale problem, especially common in our country, is superficial diagnosis and, as a result, an erroneous diagnosis. We knowingly mentioned osteochondrosis at the beginning of the article. It is known that there are many cases when a patient turned to a neurologist and received this diagnosis due to complaints of back pain. To be precise, this is the most common diagnosis that people with Bechterew’s disease get in the early stages in Russia. At the same time, the patient develops eye disease, heart disease, and spinal health deteriorates despite attempts at treatment – and only after several years and after numerous attempts at treatment, do doctors still think about the need to send the patient for an extended examination – with MRI and blood tests.

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