Axial Spondyloarthritis (Ankylosing Spondylitis)

Spondyloarthritis (SpA) is an arthritic condition that affects the joints of the spine, causing inflammation, severe pain and stiffness in the back. SpA can also affect the joints, digits and tendons in the upper and lower limbs as well, and may occasionally cause inflammation of the eye (uveitis), skin (psoriasis) and intestines (eg. Crohn’s disease, ulcerative colitis).

Axial spondyloarthritis concentrates on the axial skeleton - chest, spine, and pelvis. Some of the conditions included under SpA are ankylosing spondylitis (AS), psoriatic arthritis (PsA), anterior uveitis and inflammatory bowel disease. AS is the prototype for SpA with mainly spinal involvement, thus the following information shall focus on purely on AS. 

The first signs of AS are pain and stiffness in the lower back. This is especially bad in the morning on getting up. This is quite different from back strain which is better with rest. Occasionally, this may be associated with pain in the hips and knees. 

As the condition progresses, the pain and stiffness can affect the entire spine and last the whole day. This causes difficulty in walking, getting out of bed, bending forward and other activities of daily living. Patients with active AS often experience fatigue, poor appetite and weight loss. Occasionally, the eyes can also be affected in AS and the symptoms include redness of the eyes, increased sensitivity to light and blurred vision.

Other risk factors include history of skin psoriasis, uveitis, inflammatory bowel diseases, and reactive arthritis in the patient or his family members. Having the HLA-B27 does not mean that you will develop AS. Only 1-5% of HLA-B27-positive individuals in the general population develop AS.

Your doctor will review your family medical history and conduct a physical examination especially of your spine and your limbs. If your doctor suspects that you may have this condition, you may be required to perform blood

investigations and X-rays of your spine. X-ray changes of the sacroiliac joints, known as sacroiliitis, is a key sign of spondyloarthritis. If X-rays do not show enough changes, but the symptoms are highly suspicious, your doctor may perform magnetic resonance imaging (MRI) on you, which are able to show these joints better and can pick up early involvement.

Specialised and dedicated AS clinics may result in better outcome. Treatment of AS is focused on alleviating symptoms and managing the progression of the condition, to regain and maintain the mobility of the spine and reduce of inflammation in the joints, digits and tendons of the upper and lower limbs.

Although most medications prescribed treat only the symptoms of AS, there is evidence that NSAIDs (non-steroidal anti-inflammatory drugs) may reduce the rate of disease progression in the spine NSAIDs are also important to reduce inflammation, pain and stiffness of the digits, joints and tendons in your upper and lower limbs. Other

pain relieving drugs may also be used.

Depending on the joints involved and the severity of the condition, steroids and DMARDs (disease-modifying

anti-rheumatic drugs) may be prescribed to reduce the inflammation of your joints. In patients who respond poorly to NSAIDs and DMARDs, you may be considered for biologic therapy.

The current approved biologic therapy for AS includes the TNF alpha blockers. They are very effective in treating both the spinal and peripheral joint symptoms of SpA. These drugs are injected subcutaneously (under the skin) or may require infusion in the hospital at regular intervals.

However, anti-TNF treatment is expensive and not without side effects, including an increased risk for serious infections, eg development of active tuberculosis in patients with latent TB. 

Your doctor will discuss the cost and weigh the benefits and risks with you when considering treatment with biologic therapies.

Exercise, including stretching, helps reduce stiffness of the spine and limbs.

Generally, swimming is recommended for all forms of arthritis. Other physical therapies must be recommended and approved by a rheumatologist in consultation with a physiotherapist. In order to be effective, all exercises need to be done regularly and on a long term basis.

Ankylosing Spondylitis has a variable course. In some patients the disease is mild and limited to the lower back or spine. In others the whole of the spine can be involved including many of the larger joints like the hips and knees.

In the advanced stage the following complications can develop: