Ankylosing Spondylitis

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What is ankylosing spondylitis?

Ankylosing spondylitis is a chronic, long-term inflammation of the joints between the vertebrae and between the spine and pelvis. It is an autoimmune disorder, meaning affected individuals express a unique protein (HLA-B27) that mistakenly triggers the immune system to attack healthy joint tissues. Over time, the affected joints can become fused together. The disease is thought to have a genetic component. It generally develops between 20 and 40 years of age and is three times more common in males (Source: PubMed). Ankylosing spondylitis usually begins with pain and stiffness in the lower back and pelvis and worsens with inactivity, particularly during sleep or in the morning. The disease can improve with exercise. Over time it may spread to involve other sections of the spine and may begin to limit your mobility, particularly in the lower spine and sometimes in the rib cage.

The course of ankylosing spondylitis is unpredictable. You may experience periods of remission and unless your hips are severely involved, you have a good chance of retaining fairly good spinal function. Unrelated infections and stress can provoke new attacks.There is no known prevention of the disorder, but in many cases medications and exercise can improve both pain and functionality. Surgery is used only in rare cases of severe pain.

Ankylosing spondylitis is a life-long disorder and can restrict your mobility, but it is not life threatening on its own. In rare cases, it can contribute to aortic heart valve and heart rhythm problems, pulmonary fibrosis, or restrictive lung disease. A more common complication is fracture or injury due to the spinal damage.

Seek immediate medical care (call 911) for serious symptoms of back injury, such as severe pain, numbness, weakness of the extremities, or urinary and fecal incontinence.

What are the symptoms of ankylosing spondylitis?

Symptoms of ankylosing spondylitis commonly start with intermittent bouts of pain in your lower back, with both pain and stiffness worsening at night, on arising, or during periods of inactivity. Conversely, symptoms frequently improve with exercise. Although pain is initially concentrated in the sacroiliac joints, which lie between the pelvis and spine, over time pain may spread to other areas of the spine as well as to other areas of the body. For example, TMJ (temperomandibular joint) involvement is common with ankylosing spondylitis.

Common symptoms of ankylosing spondylitis

You may experience ankylosing spondylitis symptoms daily or sporadically. At times any of these symptoms can be severe:

  • Eventual loss of spinal flexibility
  • Eventual reduced mobility (range of motion in the joint)
  • Fatigue
  • Hip and buttock pain
  • Lower back or sacroiliac pain
  • Neck and shoulder pain
  • Stiffness in the spine
  • Worsening pain and stiffness with inactivity

Other symptoms of ankylosing spondylitis

You may experience some of these less common symptoms as well, particularly if your disease progresses:

Serious symptoms that might indicate a life-threatening condition

While ankylosing spondylitis is not life threatening on its own, the damage to the joints can predispose to fracture or injury to the spine. Seek immediate medical care (call 911) if you, or someone you are with, have any of these life-threatening symptoms including:

What causes ankylosing spondylitis?

The cause of ankylosing spondylitis is not known, but the disease is thought to have a genetic component and appears to happen most prominently in young adults between the ages of 20 and 40, with some cases beginning as young as 10. Ankylosing spondylitis also occurs more frequently in males.

In ankylosing spondylitis, long-term inflammation of the joints between the vertebrae and between the spine and pelvis lead to progressive pain and stiffness, and eventually the affected joints become fused together.

What are the risk factors for ankylosing spondylitis?

A number of factors seem to increase the risk of developing ankylosing spondylitis. Not all people with risk factors will get ankylosing spondylitis. Risk factors for ankylosing spondylitis include:

  • Demonstration of HLA-B27 gene
  • Family history
  • Male gender (three times greater risk than females)
  • Young adults (typically between ages 20 and 40)

How is ankylosing spondylitis treated?

The most common treatment for the pain and inflammation associated with ankylosing spondylitis is nonsteroidal anti-inflammatory drugs (NSAIDs). In more challenging cases, some health care professionals prescribe corticosteroid therapy or drugs for their immune-suppressing properties. Other drugs, tumor-necrosis-factor alpha (TNF-a) blockers, help block a certain inflammatory protein known as TNF-alpha to improve symptoms. If you should not take corticosteroids, your doctor may recommend a cytotoxic drug to block cell growth.

In addition to medical treatment, physical therapy can be helpful. Surgery may be a last resort in cases of severe pain or joint damage. Following your entire treatment plan and making an effort to remain physically active or exercise on a daily basis can help minimize both pain and stiffness, keeping you as mobile as possible even if your disease progresses.

Common NSAIDs for pain and inflammation

The most common treatment for the pain of and inflammation associated with ankylosing spondylitis is nonsteroidal anti-inflammatory drugs (NSAIDs). Nearly half of all patients respond to NSAID therapy alone. These include:

  • Celecoxib (Celebrex)
  • Diclofenac (Voltaren)
  • Ibuprofen (Advil, Motrin)
  • Indomethacin (Indocin, Indocin SR)
  • Meloxicam (Mobic)
  • Naproxen (Aleve, Naprosyn)
  • Oxaprozin (Daypro)
  • Sulindac (Clinoril)

Corticosteroid injection for other joints

Oral steroids are almost never effective for ankylosing spondylitis, and corticosteroid injection is rarely used in the spine. However, if your medical practitioner finds evidence that a corticosteroid injection may help temporarily with pain that has spread to other joints, you will most likely be given cortisone (Celestone, Kenalog).

Cytotoxic drugs for blocking cell growth

Drugs that block cell growth can be useful if you either respond poorly to corticosteroid therapy or are already highly dependent on corticosteroids. Cytotoxic drugs include:

  • Azathioprine (Imuran)
  • Cyclophosphamide (Cytoxan)
  • Methotrexate (Amethopterin, Rheumatrex)

Disease-modifying antirheumatic drugs

Disease-modifying antirheumatic drugs (DMARDs) control the disease process of ankylosing spondylitis. The most common DMARD used for this disease is sulfasalazine (Azulfidine).

TNF-inhibitors for protein block

Tumor-necrosis-factor alpha (TNF-a) blockers (also called TNF-inhibitors) block an inflammatory protein that can exacerbate symptoms in people who have ankylosing spondylitis and include:

  • Adalimumab (Humira)
  • Etanercept (Enbrel)
  • Golimumab (Simponi)
  • Infliximab (Remicade)

What you can do to improve your ankylosing spondylitis

In addition to using medications that help reduce your symptoms of ankylosing spondylitis, you can also maximize your mobility and minimize stiffness by:

  • Exercising and remaining physically active
  • Practicing exercises to improve breathing and posture
  • Sleeping flat on your back

Complementary treatments

Some complementary treatments may help some people to better deal with ankylosing spondylitis and its treatments. These treatments, sometimes referred to as alternative therapies, are used in conjunction with traditional medical treatments. Complementary treatments are not meant to substitute for traditional medical care. Be sure to notify your doctor if you are consuming nutritional supplements or homeopathic (nonprescription) remedies as they may interact with the prescribed medical therapy.

Complementary treatments may include:

  • Acupuncture
  • Massage therapy
  • Nutritional dietary supplements, herbal remedies, tea beverages, and similar products
  • Yoga

What are the potential complications of ankylosing spondylitis?

In rare cases, complications of untreated ankylosing spondylitis can be serious. You can help minimize your risk of serious complications by following the treatment plan you and your health care professional design specifically for you. Complications of ankylosing spondylitis include:

  • Aortic insufficiency
  • Difficulty breathing
  • Heart arrhythmias
  • Pulmonary fibrosis
  • Restrictive lung disease
  • Spine fracture or injury
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Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2020 Nov 24
THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.
  1. Ankylosing spondylitis. PubMed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001457/
  2. Ankylosing spondylitis (AS). Arthritis Foundation. http://www.arthritis.org/conditions-treatments/disease-center/ankylosing-spondylitis-as/
  3. Bope ET, Kellerman RD (Eds.) Conn’s Current Therapy. Philadelphia: Saunders, 2012