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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 are positive for the HLA-B27 gene.

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 ankles, hips, shoulders, and knees
  • Tendonitis of the Achilles tendon, the plantar fascia of the foot, the shoulder, and the breastbone 
  • 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.

Less common symptoms include:

  • Slight fever

AS 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 daily long-term use of 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)
  • Secukinumab, an IL-17 inhibitor, which has recently been approved for treating AS

Surgery, such as hip replacement, 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 provider if:

  • You have symptoms of ankylosing spondylitis
  • You have ankylosing spondylitis and develop new symptoms during treatment

References

Ananthakrishnan D, Hu SS. Ankylosing spondylitis. In: Garfin SR, Eismont FJ, Bell GR, Fischgrund JS, Bono CM, eds. Rothman-Simeone and Herkowitz's The Spine. 7th ed. Philadelphia, PA: Elsevier; 2018:chap 85.

Baeten D, Sieper J, Braun J, et al. Secukinumab, an Interleukin-17A Inhibitor, in Ankylosing Spondylitis. N Engl J Med. 2015;373(26):2534-2548. PMID: 26699169 www.ncbi.nlm.nih.gov/pubmed/26699169.

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. 2015;74(6):1241-1248. PMID: 24718959 www.ncbi.nlm.nih.gov/pubmed/24718959.

van der Linden S, Brown M, Kenna T, Maksymowych W, Robinson P. Ankylosing spondylitis. In: Firestein GS, Budd RC, Gabriel SE, McInnes IB, O'Dell JR, eds. Kelley and Firestein's Textbook of Rheumatology. 10th ed. Philadelphia, PA: Elsevier; 2017: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 www.ncbi.nlm.nih.gov/pubmed/26401991.

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. St Louis, MO: Elsevier Saunders; 2015:chap 28.


Review Date: 10/1/2017
Reviewed By: Gordon A. Starkebaum, MD, Professor of Medicine, Division of Rheumatology, University of Washington School of Medicine, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
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