Topic Overview

The spinal column

What is ankylosing spondylitis?

Ankylosing
spondylitis (say “ang-kill-LOH-sing spawn-duh-LY-tus”) is a long-term form of
arthritis that most often occurs in the
spine. It can cause pain and stiffness in the low
back, middle back, buttocks, and neck, and sometimes in other areas such as the
hips, chest wall, or heels. It can also cause swelling and limited motion in
these areas. This disease is more common in men than in women.

There is no cure, but treatment can control symptoms and prevent the
disease from getting worse in most cases. Most people are able to do their
normal daily activities and can still work.

This disease can cause
several other problems. You may have redness and pain in the colored part of
your eye (iritis). You also may have trouble breathing as your
upper body begins to curve and your chest wall begins to stiffen.

What causes ankylosing spondylitis?

The cause is
unknown, but it may run in families. Most people with ankylosing spondylitis
are born with a certain
gene, HLA-B27. But having this gene does not mean that
you will get the disease.

Research suggests that bacterial
infections and your environment may have roles in causing this disease.

What are the symptoms?

This disease causes mild to
severe pain in the low back and buttocks that is often worse in early morning.
Some people have more pain in other areas, such as the hips or heels. The pain
usually gets better slowly as you move around and are active. Ankylosing
spondylitis most often begins anywhere from the teenage years through the 30s.

It gets worse slowly over time as swelling of the ligaments,
tendons, and joints of the spine causes the bones of the spine to
join, or fuse, together. This leads to less range of movement in the neck and low
back.

As the spine fuses and stiffens, the neck and low back lose
their normal curve. The middle back curves outward. This can keep you in a
bent-forward position and may make it hard for you to
walk.

As the small joints that connect the ribs and collarbone to
the breastbone get inflamed, you may find that it’s harder for you to breathe.
Other parts of the body, such as your eyes and your other joints, may also
swell. Sometimes the disease affects the lungs, the heart valves, the digestive
tract, and the major blood vessel called the aorta.

How is ankylosing spondylitis diagnosed?

The early
signs of this disease-dull pain in the low back and buttocks-are common. Your
doctor will ask about your symptoms and if they have become worse over time.
Your doctor will also ask if you have a family history of this joint disease or
others like it.

Your doctor may do several tests if he or she
thinks that you have ankylosing spondylitis. You may have an X-ray, a test for
the HLA-B27 gene, or an
MRI of the
sacroiliac joints.

The clearest sign of
the disease is a change in the sacroiliac joints at the base of the low back.
This change can take up to a few years to show up on an X-ray.

How is it treated?

Treatment includes exercise and
physical therapy. These will help reduce stiffness so that you can stand up
straighter and move around better. Your doctor will also give you medicine for
pain and swelling.

Because people with ankylosing spondylitis may be at a higher risk for spinal cord injury, it’s important that you wear a seat
belt every time you drive or ride in a car.

You will need to get
regular eye exams to check for inflammation in your eye, called iritis. You may
use a device such as a cane to help you walk and to help reduce stress on your
joints.

Surgery for the spine is rarely needed. You may want to
think about hip or knee replacements if you have severe arthritis in those
joints.

There is no cure for this disease. But early diagnosis and
treatment can help relieve pain and stiffness and allow you to keep doing your
daily activities for as long as possible.

Frequently Asked Questions

Learning about ankylosing spondylitis:

Being diagnosed:

Getting treatment:

Ongoing concerns:

Living with ankylosing spondylitis:

Symptoms

Ankylosing spondylitis is inflammation
primarily of the joints of the spine. But it can also involve inflammation of
the eye, other joints-especially those in the hips, chest wall, and around the
heels-and, on occasion, the shoulders, wrists, hands, knees, ankles, and feet.
Although it is unusual, ankylosing spondylitis can also cause changes such as
thickening of the major artery (aorta) and the valve in the heart
called the
aortic valve.

If the inflammation
continues over time, it will lead to scarring and permanent damage. In some
people the disease is mild and progresses slowly, and symptoms may never become
severe. Other people may have a more aggressive disease process.

Whether ankylosing spondylitis gets worse depends on a number of things
such as how old you were when the disease began, how early it was diagnosed,
and what joints are involved. It’s too early to tell yet, but experts hope
that early treatment with newer medicines will slow or minimize the
inflammation, prevent scarring, and limit the progression of the disease.

Mild or early ankylosing spondylitis

Ankylosing
spondylitis usually starts with dull pain in the low back and back stiffness.
Some people with ankylosing spondylitis have “flares” of increased pain and
stiffness that may last for several weeks before decreasing again.

  • Affected bones of the low back, middle back,
    hips, or neck may become painful, stiff, and limited in motion. Pain tends to
    increase slowly over a period of weeks or months, and it is often hard to point
    to exactly where the pain is. Stiffness is usually worse in the morning and
    usually lasts for more than one hour. Pain is often noticeable in the early
    morning hours of sleep, such as between 3 a.m. and 6 a.m. Physical activity
    often helps decrease pain and stiffness.
  • Some people feel tired as
    the disease progresses. This tiredness comes from the body fighting the
    inflammatory process that is part of ankylosing spondylitis and also from
    ongoing stiffness and pain.
  • The colored part of the eye (iris) may become inflamed. Symptoms of iritis include
    redness and pain in the eye and sensitivity to light.

Severe or advanced ankylosing spondylitis

If, over
time, the inflammation continues, it will lead to scarring and permanent
damage.

  • Scarring in the
    spine causes the joints of the spine to grow together
    (fuse, or “ankylose”).

    • As the
      bones fuse, back pain will gradually go away, but the spine will remain very
      stiff and unable to bend. The fused spine is more likely to break (fracture) if
      injured, especially the neck (cervical spine).
    • Changes in the spine can cause problems with balance, safety, and mobility. The upper spine can curve forward until eventually the person has a hard time looking
      straight ahead. Also, as the spine loses its natural curves, it becomes hard to
      balance while standing and walking, especially if the hips are also
      affected.
  • Breathing can become difficult as the upper
    body curves forward and the chest wall stiffens. Severe ankylosing spondylitis
    can also cause scarring of the lungs (pulmonary fibrosis) and an increased risk of lung infection. This can cause even
    greater problems in smokers, because their lungs are already more prone to lung
    infection and scarring.
  • Scarring in the eye from uncontrolled iritis can lead to permanent
    visual impairment and glaucoma.
  • In rare cases, the heart muscle
    can become scarred and the heart valves may become
    inflamed. The heart may be unable to pump properly
    (heart failure). The main artery leading from the heart
    (aorta) can also be affected by becoming inflamed and
    enlarged near where it leaves the heart.
  • Bowel inflammation is
    sometimes linked with ankylosing spondylitis.
  • The kidneys can be
    affected by taking
    medicines over a long period of time.
  • Some people who have
    ankylosing spondylitis for many years develop
    cauda equina syndrome from scarring around the nerves
    at the end of the spinal cord. This condition can cause loss of feeling in the
    saddle area of the groin and legs. It can also cause problems with bowel and
    bladder control and sexual activity. Talk to your doctor if you start having
    problems controlling your bowels or bladder.

The stiffening of the chest can feel like the discomfort
or “heaviness” of a heart attack. Ankylosing spondylitis can also cause the
heart to work less efficiently.

If you have any symptoms of heart
or lung problems-including heaviness of the chest or pain with deep
breathing-talk to a doctor right away to make sure you don’t have any serious
heart or lung problems. For more information on heart and lung problems, see
the topics
Heart Attack and Unstable Angina and
Pleurisy.

Ankylosing spondylitis is one disease in a group of joint diseases called the
spondyloarthropathies (say
“spon-dill-o-ar-THROP-a-thees”). These include
psoriatic arthritis, reactive arthritis, and enteropathic arthritis (joint
problems linked with
inflammatory bowel disease). Although inflammation of
the spine also occurs in these other conditions, it is less common and less
severe than the inflammation that occurs in ankylosing spondylitis.

Exams and Tests

Your doctor will use a medical history,
physical exam, and X-ray to diagnose
ankylosing spondylitis.

By asking
questions about your medical history, your doctor can evaluate your symptoms.
Most people with ankylosing spondylitis have back pain with four or five of the
following characteristics:

  • Begins before the age of about
    35
  • Starts and gets worse gradually
  • Persists for at
    least 3 months
  • Is linked with morning stiffness that usually
    lasts for more than one hour
  • Improves with exercise

Your doctor will want to know whether you have any family
members who have ankylosing spondylitis or a related joint disease. Many people
with ankylosing spondylitis have a family member with the same condition. He or
she may also ask whether you have had ongoing diarrhea, abdominal (belly) pain,
multiple infections of the
cervix (in women) or
urethra (more common in men),
psoriasis, or inflammation of the eye chamber (uveitis). These could be clues to having a condition
other than ankylosing spondylitis.

You will have a physical exam
to see how stiff your back is and whether you can expand your chest normally.
Your doctor will also look for tender areas, especially over the points of the
spine, the pelvis, the areas where your ribs join your breastbone, and your
heels. You may experience chest pain and stiffness with ankylosing
spondylitis.

Tests related to ankylosing spondylitis
include:

  • X-rays of the
    spine and pelvis to check for bone changes (bony erosions, fusion, or
    calcification of the spine and
    sacroiliac joints). Certain changes in the sacroiliac
    joint confirm the diagnosis of ankylosing spondylitis. But those changes can
    take several years to develop enough to show on X-ray.
    MRI and
    CT scan are more sensitive than X-ray. If no changes
    to the sacroiliac joints show on the X-ray but your doctor still suspects
    ankylosing spondylitis, an MRI or CT scan may allow an earlier diagnosis.
    Ultrasound is being studied as a way to diagnose
    ankylosing spondylitis earlier.
  • Blood tests. These may include:
    • C-reactive protein (CRP) or sedimentation rate (sed rate) to look for inflammation.
    • Rheumatoid factor or antinuclear antibody test (ANA) to look for other types of arthritis or illness.
    • A
      genetic test, which may be done
      to determine the presence of a
      gene (HLA-B27) that is often linked with
      ankylosing spondylitis. Many people who have the HLA-B27 gene will not develop
      ankylosing spondylitis, so having this test will not confirm whether you have
      the condition. But the test results can be helpful if your symptoms and
      physical exam have not clearly pointed to a diagnosis.

Treatment Overview

Treatment for
ankylosing spondylitis focuses on relieving pain and
stiffness, reducing
inflammation, keeping the condition from getting
worse, and enabling you to continue daily activities. Early diagnosis and
treatment may reduce pain, stiffness, inflammation, and deformity.

Talk with your doctor about the best treatment approach for your
condition. A consultation with a
rheumatologist is often recommended, especially to
confirm the diagnosis and lay out a treatment plan. Your
family medicine physician or
internist can treat mild cases. Or you may be referred
to a rheumatologist,
orthopedist, or
physiatrist.

Initial treatment

Initial treatment for
ankylosing spondylitis may include:

  • Education, so you know what you can expect as
    ankylosing spondylitis progresses and how you can minimize problems that can be
    caused by your condition.
  • Flexibility and strengthening exercises, to maintain mobility and control pain. People who exercise
    regularly find they have less pain and stiffness than those who are less
    active.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), to relieve
    pain and stiffness, reduce inflammation, and help with physical therapy. Some
    people seem to get more benefit from daily NSAIDs than from taking NSAIDs just
    when they notice symptoms. Talk to your doctor about using NSAIDs for
    ankylosing spondylitis, including how much to take and how often to take it.
  • Physical therapy, to help you keep proper posture, and deep
    breathing exercises, to enhance your lung capacity. A physical therapist can also
    help you learn to use heat and cold to help control your pain and stiffness.
    Heat can help with relaxation and pain relief, and cold can help reduce
    inflammation.
  • Assistive devices such as canes or
    walkers, which allow you to be physically active while reducing stress on
    joints.
  • Alternative therapies such as
    yoga or
    acupuncture, which may help relieve pain and improve
    quality of life.

Talking with your doctor about your job. A job that is physically demanding-such as a job that requires lots of heavy lifting-could increase your symptoms.

Ongoing treatment

If initial treatment does not
sufficiently reduce the pain and inflammation linked with
ankylosing spondylitis, and as your condition
progresses, ongoing treatment may include:

  • Flexibility and strengthening exercises, to maintain mobility and control pain. People who exercise
    regularly find they have less pain and stiffness than those who are less
    active. In addition to general flexibility and strengthening, walking and
    swimming are good activities for people who have ankylosing spondylitis. Some
    people continue to participate in sports also. Talk to your doctor or physical
    therapist about activities that will help you and that you will
    enjoy.
  • Medicine. Doctors usually will first recommend
    nonsteroidal anti-inflammatory drugs (NSAIDs) to
    reduce pain and inflammation. But you may need other, stronger medicines.
    Be safe with medicines. Read and follow all instructions on the label.

    • Corticosteroids, which are similar to natural hormones
      produced in the body, help reduce inflammation. Corticosteroids are sometimes used for joints such as the hips, not for the joints of the spine.
    • Disease-modifying antirheumatic drugs (DMARDs).
      Non-biologic DMARDs, such as methotrexate or sulfasalazine, may help relieve pain in joints other than the spine and pelvis. Biologic DMARDS, such as etanercept or infliximab, reduce inflammation by blocking harmful responses from the body’s immune system that lead to the symptoms of ankylosing spondylitis.
  • Physical therapy, to help you keep
    good posture, and deep breathing exercises, to enhance your lung capacity. A
    physical therapist can also help you learn to use heat and cold to help control
    your pain and stiffness. Heat can help with relaxation and pain relief, and
    cold can help reduce inflammation.
  • Assistive devices
    such as canes or walkers, which allow you to maintain physical activity while
    reducing stress on joints.
  • Alternative therapies such as
    yoga or
    acupuncture, which may help relieve pain and improve
    quality of life.

Your doctor will treat complications of ankylosing
spondylitis as they occur. For example,
iritis may be treated with medicines that can help
reduce inflammation of the eye, such as
corticosteroids and
mydriatic eyedrops.

Treatment if the condition gets worse

In rare
cases, you may need surgery to replace joints that are severely damaged by the
inflammation of
ankylosing spondylitis. The most common surgery done
is
hip replacement surgery. Spine surgery is done in a
very small number of people who have ankylosing spondylitis. If there is
loosening of the top two vertebrae in the neck and there are signs of pressure
on the spinal cord such as numbness or clumsiness in the hands or arms, a
surgeon may permanently join (fuse) the two vertebrae together. In very rare
cases, spinal surgery may be done to straighten a part of the spine that has
become severely curved, but the surgery is risky and cannot restore motion.

Because ankylosing spondylitis is a lifelong condition, other
treatment may include
complementary therapies,
which can reduce symptoms, help manage pain, and improve quality of life. These therapies may include
yoga and
acupuncture.

Even if your symptoms are
under control, you should see your doctor (often a
rheumatologist) every year to watch for and treat any
complications. People with hip symptoms and perhaps those whose disease started
in their teens may be at risk for a more severe progression of ankylosing
spondylitis.

Home Treatment

If you have been diagnosed with
ankylosing spondylitis, there are steps that you can
take at home to help reduce pain and stiffness and allow you to continue daily
activities. These steps include:

  • Educating yourself. Learn all you can about
    your condition and know what complications to watch for. This will help you
    control your symptoms and stay more active.
  • Taking pain relievers
    such as
    nonsteroidal anti-inflammatory drugs (NSAIDs) to
    reduce pain. If NSAIDs do not relieve your pain, try acetaminophen. Heat, such
    as warm showers or baths or sleeping under a warm electric blanket, may also
    reduce pain and stiffness.
  • Exercising regularly. This reduces pain
    and stiffness and helps maintain fitness and mobility of the spine, chest, and
    joints. Your doctor may recommend
    physical therapy to get you started on an exercise
    program.

    • Deep breathing exercises can improve or
      help you keep your lung capacity.
    • Swimming as part of your exercise program
      helps to maintain chest expansion and movement of the spine without jarring the
      spine. Breaststroke is especially good for chest expansion.
    • You
      should avoid contact sports, because joint fusion may make your spine more
      likely to fracture as the disease progresses. Your doctor may approve of other
      activities such as golf and tennis. Check with your doctor before you add any
      new activity.
  • Maintaining proper posture and chest expansion.
    Good posture is important because it can help prevent
    abnormal bending of the spine. Maintaining chest expansion may help prevent
    problems such as lung infection (pneumonia). It’s a good idea to lie on your
    stomach a few times each day to keep your spine and hips extended. For
    sleeping, choose a firm mattress and a small pillow that supports your neck.
    Try to lie flat on your back to sleep. If it’s comfortable for you, you can
    also sleep part of the night on your stomach.
  • Using
    assistive devices such as canes or walkers. Your local
    chapter of the Arthritis Foundation, your physical therapist, or a medical
    supply company may be able to help you find assistive devices in your area.
  • Taking steps to protect yourself in the car, such as always using
    a seat belt. Joints that are inflamed or damaged can easily be injured in an
    accident. If your neck is becoming stiff, your doctor may advise you to wear a
    soft neck brace when you ride in the car, to prevent injury in case of an
    accident.
  • Avoiding smoking, to prevent serious breathing
    problems and lung scarring. Lung damage from smoking, combined with
    decreased chest expansion and the lung infections that sometimes go with
    ankylosing spondylitis, can seriously limit your ability to breathe freely.
  • Seeing your doctor (often a
    rheumatologist) at least once each year, to check on
    your condition and watch for any complications. Catching complications early
    and treating them can prevent further problems.
  • Having regular eye
    exams by an
    ophthalmologist, to check for inflammation of the
    colored part of the eye (iritis).
  • Talking with your doctor about your job. A job that is physically demanding-such as a job that requires lots of heavy lifting-could increase your symptoms.
  • Joining a support group. Ask your doctor about the types of support that are available where you live. Meeting other people with the same problems can help you know that you’re not alone.

Other Places To Get Help

Organizations

National Institute of Arthritis and Musculoskeletal and Skin Diseases (U.S.)
www.niams.nih.gov

Spondylitis Association of America
www.spondylitis.org

References

Other Works Consulted

  • Deimel GW IV, Braverman SE (2015). Ankylosing spondylitis. In WR Frontera et al., eds., Essentials of Physical Medicine and Rehabilitation, 3rd ed., pp. 609-613. Philadelphia: Saunders.
  • Inman RD (2016). The spondyloarthropathies. In L Goldman, A Shafer, eds., Goldman-Cecil Medicine, 24th ed., vol. 2, pp. 1762-1769. Philadelphia: Saunders.
  • Van der Heijde D, et al. (2016). 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Annals of the Rheumatic Diseases, published online January 13, 2017. DOI:10.1136/annrheumdis-2016-210770. Accessed January 24, 2017.
  • Van der Linden SM, et al. (2013). Ankylosing spondylitis. In GS Firestein et al., eds., Kelley’s Textbook of Rheumatology, 9th ed., vol. 2, pp. 1202-1220. Philadelphia: Saunders.
  • Ward MM, et al. (2016). 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 and Rheumatology, 68(2): 282-298. DOI: 10.1002/art.39298. Accessed April 29, 2016.

Credits

ByHealthwise Staff
Primary Medical Reviewer E. Gregory Thompson, MD – Internal Medicine
Adam Husney, MD – Family Medicine
Martin J. Gabica, MD – Family Medicine
Kathleen Romito, MD – Family Medicine
Specialist Medical Reviewer Richa Dhawan, MD – Rheumatology

Current as ofOctober 10, 2017