Ankylosing Spondylitis
Management of inflammatory arthritis affecting the spine and related joints
What is ankylosing spondylitis?
Ankylosing spondylitis is an inflammatory disease of the spine and of the joints where the base of the spine meets the pelvis. The immune system attacks the entheses, the points where ligaments and tendons anchor into bone. Inflammation there is painful, and as each episode settles the body lays down new bone at the site. Over years that new bone can bridge between the vertebrae and stiffen the spine.
It typically begins between the late teens and the mid thirties and is more common in men, though it is substantially underdiagnosed in women. There is a strong association with a gene called HLA-B27, which is inherited and which most carriers never develop any disease from.
The back pain has a characteristic pattern that separates it from ordinary mechanical back pain. It comes on gradually before the age of forty, has lasted more than three months, is worse with rest and in the second half of the night, wakes you and drives you out of bed to move around, improves with exercise, and is accompanied by morning stiffness lasting more than half an hour. It is not confined to the spine: the hips, shoulders, heels and chest wall can be involved, and so can the eyes, the bowel and the skin.
What you might notice
- Back stiffness worst in the second half of the night
- Stiff joints for an hour or more each morning
How it is diagnosed
The pattern of the pain carries more weight than any single test, so expect detailed questions about when it started, how long it has lasted, what time of night it wakes you, how long you are stiff in the morning, whether exercise makes it better or worse and whether anti-inflammatory tablets settle it dramatically. A strong response to those tablets is itself part of the picture.
Your doctor measures how far your spine moves in each direction and how much your chest expands between a full breath out and a full breath in, and records the numbers so that change can be tracked. They press over the joints at the base of the spine, examine the heels and the chest wall where tendons anchor, and check the peripheral joints. They will also ask about episodes of a painful red eye, about bowel symptoms and about psoriasis in you or your family.
An MRI shows active inflammation at these joints years before an X-ray shows any change, which is the reason the diagnosis is now made far earlier than it used to be. HLA-B27 and blood markers of inflammation support the picture and do not decide it on their own.
Recovery
This is a long-term condition managed over decades, so think in terms of control. Daily exercise is the foundation and is not optional: a specific programme of spinal extension, rotation and chest expansion from a physiotherapist, done every day, preserves the movement you have. Expect three to six months before you can judge the effect, and expect the movement to be lost again within months if the programme stops.
Anti-inflammatory tablets often work within days and are the first medication used, taken regularly during active phases under your doctor's supervision.
Where the disease stays active despite that, medicines that damp down the specific immune signals involved are considered. These are judged at around twelve weeks against your symptoms and your spinal measurements, and they require screening for tuberculosis and hepatitis before they are started and regular blood tests afterwards. Screening for tuberculosis matters particularly in India. Your rheumatologist will review you every three to six months once you are stable, and will repeat the spinal measurements at each visit.
If it is left untreated
The consequence that gives the condition its name is fusion. Repeated cycles of inflammation and new bone formation can join the vertebrae into a single rigid column, and where that happens the posture sets in a fixed stoop with the head carried forward. A fused spine cannot be unfused, and posture lost over years of untreated disease is not recovered by treating it later.
A stiffened chest wall reduces how much the ribs can expand, so breathing becomes more dependent on the diaphragm and exercise tolerance falls. Fused bone is also osteoporotic and brittle, and a rigid spine fractures from surprisingly minor injuries, sometimes with damage to the spinal cord, so any new neck or back pain after a fall in someone with a long-standing fused spine is treated as a fracture until imaging says otherwise.
Hip involvement that is left can destroy the joint. Inflammation inside the eye, which causes a painful red eye with light sensitivity and blurring, comes on over hours and needs treatment that day to protect the sight. The reason for treating early is straightforward: the inflammation responds to treatment and the new bone does not.
Questions about ankylosing spondylitis
I am in my twenties with back pain. How would I know it is this and not a disc?
The pattern separates them, and it is worth knowing because the two are managed in opposite directions. Inflammatory back pain starts gradually before the age of forty, has lasted more than three months, is worse with rest and better with movement, wakes you in the second half of the night and drives you out of bed, and comes with morning stiffness lasting more than thirty minutes. Mechanical back pain is worse with activity, better with rest, and is not usually a night problem. Anti-inflammatory tablets settle inflammatory pain strikingly well. If most of those apply to you, ask for a rheumatology opinion instead of waiting.
Will my spine fuse solid?
Not in most people diagnosed and treated today. Fusion is the end result of years of untreated inflammation, and the picture of a completely rigid, stooped spine comes from an era before the disease could be identified early on MRI and before effective treatment existed. What you do influences this substantially. Daily spinal exercises are the foundation and preserve the movement you have, and treatment that controls the inflammation reduces the new bone formation that causes fusion. Your rheumatologist will measure your spinal movement and chest expansion at each visit and track the numbers, and those measurements give the early warning before you feel any change yourself.
My HLA-B27 came back positive. Does that mean I have it?
No. HLA-B27 is a normal gene variant carried by a meaningful proportion of the population, and the great majority of carriers never develop any inflammatory disease at all. A positive result raises the probability where the symptoms already fit the inflammatory pattern, and it means very little in someone with ordinary mechanical back pain. It is a supporting piece of evidence and never the diagnosis on its own. The diagnosis rests on the pattern of your symptoms, the examination of your spine and an MRI showing active inflammation. Equally, a negative result does not exclude the condition, since a proportion of people who have it are negative.
Other rheumatology treatments
Long-term treatment to control autoimmune inflammation affecting the joints and other organs
Day CareManagement of joint pain and stiffness caused by cartilage wear and degenerative joint changes
Day CareTalk to a care coordinator about ankylosing spondylitis
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one