Possible Complications of Spondylitis

Enthesitis

Inflammation of the enthesis, where the joint capsules, ligaments or tendons attach to the bone, is a hallmark of ankylosing spondylitis (AS). This can be felt in multiple areas of the body where your doctor can check for pain and tenderness. The sites are sometimes referred to as ‘hot-spots.’ They can lead to swelling and tenderness along the back, pelvic bones sacroiliac joints, the chest, and the heel. The heel can be significantly affected, in which case the pain and tenderness can have a serious impact on a person’s mobility. The two areas of the foot that can be affected are the Achilles tendon at the back of the heel, and the plantar fascia at the base of the heel.

Back & Spine

It is the process of healing and repair following inflammation of the enthesis that eventually can lead to scarring of the tissues, which subsequently can lead to extra bone formation. Thus in someone with very severe disease, the process of inflammation can lead, over many years, to a bony fusion of the ligaments in the spine and sometimes in other joints as well, which is called ankylosis. This can cause an increased risk of spinal fracture because of the restricted range of movement and the fact that the bone formed during fusion is inherently weak. Not everyone will go on to this stage of the spondylitis.

The fusion of the spine can sometimes lead to a forward curvature of the spine, kyphosis, causing a forward-stooped posture. Although this can happen in the most severe cases of AS, it is now far less common given the advances in treatment.

It is important to follow your doctor’s instructions and to take your medicine on schedule so that you can maintain a daily exercise schedule which over time, will make you feel better. It is also important to pay particular attention to your posture in order to avoid kyphosis. With the advent of the newer classes of medications, specifically the biologics (anti-tumor necrosis factor alpha agents) there is reason to believe that the natural course of spondylitis may be slowed or halted. More studies are needed to confirm this.

Hips and Shoulders

The hips and shoulders are affected in about one third of people with ankylosing spondylitis (AS). The hip involvement usually comes on gradually, and although the pain often is felt in the groin area, it can sometimes be felt in other areas of the body such as the knees or the front of the thigh. When this happens it is called ‘referred pain’ and it can be very misleading to both the doctor and affected person.

Hip involvement typically is more common in younger people when the symptoms first begin. It often carries with it a more severe prognosis (course of disease). Generally speaking, shoulder involvement is mild.

The Chest

Adults with spondylitis often have chest pain that mimics the heavy chest pain of cardiac angina or pleurisy the pain with deep breathing that occurs when the outer lining of the lung is inflamed). Anyone experiencing symptoms should seek medical attention to rule out a more serious condition. What often happens, over time, is that the joints between the ribs and spine, and where the ribs meet the breastbone in front of the chest, develop decreased chest expansion because of long-term inflammation and scarring of the tissues. If the pain is found to be spondylitis-related and you find yourself unable to practice the critical deep breathing exercises, which help maintain chest expansion, there are things that you can do to help yourself:

• Use ice packs on the affected areas for short periods
• Try gentle massage of the neck and shoulder area
• Try deep breathing exercises after a hot shower or warm bath

The Jaw

About 10% of people with spondylitis experienced inflammation of the jaw. This can be particularly debilitating causing difficulty in fully opening the mouth to eat.

Iritis or Anterior Uveitis

About one third to 40% of people with spondylitis will experience inflammation of the eye at least once. Iritis is a serious complication which requires immediate medical attention from an eye doctor.

Signs/Symptoms: Symptoms often occur in one eye at a time, and they may include redness, pain, sensitivity to light and skewed vision. An ophthalmologist (or optometrist) can use a special slit lamp microscope to distinguish iritis from other causes of eye redness or irritation.

Rare Complications

A small percentage of people with long-standing spondylitis may go on to develop rare, but serious complications. This is one of the reasons why it is important for everyone with spondylitis to be checked by a rheumatologist at least once a year. That way, any potentially threatening complications can be caught early and treated before permanent damage has occurred.

Cauda Equina Syndrome

Rarely, people with advanced (very long-term) ankylosing spondylitis (AS) may have problems resulting from the scarring of the bundle of nerves at the base of the spine. This condition can have a significant impact on a person’s quality of life, and can cause urinary retention and/or incontinence, loss of bowel control, sexual dysfunction and problems causing pain and weakness of the legs. If you have long-standing AS and are suffering with some of these symptoms, your rheumatologist will be able to refer you to neurologist for consultation.

The Kidneys – Amyloidosis

Some people develop problems with the kidneys due to long-term treatment with nonsteroidal anti-inflammatories or other medications. This complication has become very rare in North America.

The Heart

A small number of people with spondylitis will display signs of chronic inflammation in the base of the heart – around the aortic valve and origin of the aorta (i.e. that vessel which takes all blood from the heart to be distributed throughout the body). Years of chronic and silent inflammation at these sites can eventually lead to heart block and valve leakage, sometimes requiring surgical treatment. Although recognized, these cardiac lesions probably are seen in fewer than two percent of all patients with spondylitis, and nearly always in males. The lesions are readily detectable by the physician’s examination and when necessary, cardiac testing.

The Lungs

Poor chest wall movement may result in decreased vital capacity and a few patients develop scarring or fibrosis at the top of the lungs detected only by routine chest x-ray (recommended every five years unless there is a special need). Sometimes people have functional lung impairment which means that it can take longer for colds and other upper respiratory infections to heal. Smoking is absolutely contra-indicated in AS.