Ankylosing spondylitis

  • Definition
    • Ankylosing spondylitis (AS) is a chronic form of arthritis. It mostly affects the bones and joints at the base of the spine where it connects with the pelvis. These joints can become swollen and inflamed. Over time, the affected spinal bones may join together.

  • Alternative Names
    • Spondylitis; Spondyloarthritis

  • Causes
    • AS is the main member of a family of similar forms of arthritis called spondyloarthritis. Other members include psoriatic arthritis, arthritis of inflammatory bowel disease and reactive arthritis. The family of arthritis appears to be quite common and affects up to 1 in 100 people.

      The cause of AS is unknown. Genes seem to play a role. Most people with AS have positive HLA-B27.

      The disease often begins between ages 20 and 40, but it may begin before age 10. It affects more males than females.

  • Symptoms
    • AS starts with low back pain that comes and goes. Low back pain becomes present most of the time as the condition progresses.

      • Pain and stiffness are worse at night, in the morning, or when you are less active. The discomfort may wake you from sleep.
      • The pain often gets better with activity or exercise.
      • Back pain may begin in the between the pelvis and spine (sacroiliac joints). Over time, it may involve all or part of the spine.
      • Your lower spine may become less flexible. Over time, you may stand in a hunched forward position.

      Other parts of your body that may be stiff and painful include:

      • Swelling and pain in the joints of the shoulders, knees and ankles
      • The joints between your ribs and breastbone, so that you cannot expand your chest fully
      • Swelling and redness of the eye

      Fatigue is also a common symptom.

      Skeletal spine

      Less common symptoms include:

      • Slight fever

      Ankylosing spondylitis may occur with other conditions, such as:

  • Exams and Tests
    • Tests may include:

      • CBC
      • ESR (a measure of inflammation)
      • HLA-B27 antigen (which detects the gene linked to ankylosing spondylitis)
      • Rheumatoid factor (which should be negative)
      • X-rays of the spine and pelvis
      • MRI of the spine and pelvis
  • Treatment
    • Your health care provider may prescribe drugs such as NSAIDs to reduce swelling and pain.

      • Some NSAIDs can be bought over-the-counter (OTC). These include aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn).
      • Other NSAIDs are prescribed by your provider.
      • Talk to your provider or pharmacist before using any over-the-counter NSAID.

      You may also need stronger medicines to control pain and swelling, such as:

      • Corticosteroid therapy (such as prednisone) used for short periods of time
      • Sulfasalazine
      • A TNF-inhibitor (such as etanercept, adalimumab, infliximab, certolizumab or golimumab)

      Surgery may be done if pain or joint damage is severe.

      Exercises can help improve posture and breathing. Lying flat on your back at night can help you keep a normal posture.

  • Outlook (Prognosis)
    • The course of the disease is hard to predict. Over time, signs and symptoms of AS flareup (relapse ) and quiet down (remission.) Most people are able to function well unless they have a lot of damage to the hips. Joining a support group of others with the same problem may often help.

      Treatment with NSAIDS often reduces the pain and swelling. Treatment with TNF inhibitors appears to slow progression of the spine arthritis.

      Rarely, people with ankylosing spondylitis may have problems with:

      • Psoriasis, a chronic skin disorder
      • Inflammation in the eye (iritis)
      • Inflammation in the intestine (colitis)
      • Abnormal heart rhythm
      • Scarring or thickening of the lung tissue
      • Scarring or thickening of the aortic heart valve
  • When to Contact a Medical Professional
    • Call your health care provider if:

      • You have symptoms of ankylosing spondylitis
      • You have ankylosing spondylitis and develop new symptoms during treatment
  • References
    • Callhoff J, Sieper J, Weiß A, Zink A, Listing J. Efficacy of TNFa blockers in patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: a meta-analysis. Ann Rheum Dis. 2014;74(6):1241-1248. PMID: 24718959 Accessed February 11, 2016.

      Ferri FF. Ankylosing spondylitis. In: Ferri FF ed. Ferri's Clinical Advisor 2016. Philadelphia, PA: Elsevier; 2016:121-122.

      Hu SS, Ananthakrishnan D. Ankylosing spondylitis. In: Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, et al, eds. Rothman-Simeone The Spine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 35.

      Reveille, JD. Epidemiology of spondyloarthritis in North America. Am J Med Sci. 2011;341(4): 284-286 PMID: 21430444

      van der Linden SM, Baeten D, Maksymowych WP. Ankylosing spondylitis. In: Firestein GS, Budd RC, Gabriel SE, Mclnnes IB, O'Dell JR, eds. Kelley's Textbook of Rheumatology. 9th ed. Philadelphia, PA: Elsevier Saunders; 2013:chap 75.

      Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network. 2015 recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Rheumatol. 2016;68(2):282-298. PMID: 26401991 Accessed February 11, 2016.

      Werner BC, Feuchtbaum E, Shen FH, Samartzis D. Ankylosing spondylitis of the cervical spine. In: Shen FH, Samartzis D, Fessler RG, eds. Textbook of the Cervical Spine. Philadelphia, PA: Elsevier Saunders; 2015:chap 28.