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Ankylosing Spondylitis

By Editorial Team (2)
January 31, 2022

Ankylosing Spondylitis is a type of arthritis which causes recurring inflammation of the spinal bones and other joints such as sacroiliac joints. It is a chronic disorder which is also known as Marie-Strümpell disease or Bechterew’s syndrome. The symptoms of this condition include pain and stiffness from the neck down to the lower back. Chronic inflammation of these leads to ankylosis (new bone formation in the spine) and spinal bones fuse together completely, resulting in a condition known as “bamboo spine”, in which the spinal column becomes completely rigid. The changes can vary from mild to severe and may cause significant deformities. For doctors, it is already not clear enough what causes Ankylosing Spondylitis.

Ankylosing Spondylitis is a systemic disease, which means that the symptoms of this condition are not just limited to the joints, It can also affect other areas of the body, such as the shoulders, ribs, pelvic bones, heels, and small joints of the upper and lower extremities. It can also affect eyes and cause inflammation (redness and pain) of the eyes, and rarely, heart and lung problems may also develop. People with the condition can also suffer from fever, fatigue, and loss of appetite.

What Causes Ankylosing Spondylitis?

There is no known reason as to what causes Ankylosing Spondylitis, but there is a lot of information available about what effects it has on the body, and why it causes the vertebrae to become stiff and rigid.

People who have the particular HLA-B27 gene have a significantly greater risk of developing AS, but there are many people who have this gene that never develops AS. Infectious agents may be involved in the development of the disease.

Ankylosing Spondylitis: Classification

There are four different types of Ankylosing Spondylitis:

  • Slowly progressive
  • Slowly progressive with periods of exacerbations
  • Quick progressive
  • Septic

Ankylosing Spondylitis: Prevalence and Risk Factors

Ankylosing Spondylitis is more prevalent in Northern European countries and Afro-Caribbean populations. The overall prevalence of this disease is < 0.3% of the general population. Ankylosing Spondylitis is diagnosed twice as often in males as in females, but many doctors believe the number of females with the disease is underestimated because females tend to have milder symptoms. Typically, signs and symptoms of Ankylosing Spondylitis usually first appear between the ages of 15 and 25.

Ankylosing Spondylitis affects the 0.1%- 0.5% of the population. This condition usually begins in early adulthood. It can also affect children and this is known as Juvenile Ankylosing Spondylitis. It is most likely to affect males more often than females. In women, it affects the joints away from the spine. This condition is more common in some Native American tribes. Currently, there is no treatment for Ankylosing Spondylitis, but early diagnosis and treatment of this condition help control pain and stiffness and also help to prevent or reduce significant deformity.

The exact causes of AS are unknown. This condition may develop due to the combination of genetic and environmental factors. Following are the few risk factors:

  1. Sex:  Men are more likely to develop Ankylosing Spondylitis than women.
  2. Age: Ankylosing Spondylitis usually begins in early adulthood. It can also affect children.
  3. Heredity: Genetics plays an important role in disease. Most of the people who suffer from Ankylosing Spondylitis have a specific type of gene that produces genetic marker known as known as the HLA-B27. However, there are also many people who never develop AS despite having HLA-B27 gene.
  4. Frequent gastrointestinal infections: Ankylosing Spondylitis is also associated with inflammatory bowel diseases.

Ankylosing Spondylitis: Pathological Changes and Complications

Ankylosing Spondylitis causes changes to occur in your body because of the inflammation it causes in the areas where skeletal bones are attached to tendons, ligaments, discs or joints. It typically affects the sacroiliac joints, where the lower back meets the pelvis, and begins with inflammation in this area (sacroiliitis).

In the spinal column, AS starts in the fibrous tissues of the discs between the vertebrae. Ankylosing Spondylitis causes inflammation that leads to the breakdown of the tissues and, over time, makes them thickened and rigid. This leads to stiffness of the spine, and pain due to compression of the nerve roots.

Eventually, the prolonged and recurrent inflammation of Ankylosing Spondylitis can result in a complete fusion, or cementing the bones of the spine together (vertebrae). This fusion is called Ankylosis. When the spine is fused, it loses its mobility.

Because it is a systemic inflammatory disease, Ankylosing Spondylitis can affect other areas of the body away from the spine, such as the kidneys, heart, lungs, and eyes.

Ankylosing Spondylitis complications varies greatly in everyone. Painful and debilitating as it is as it progresses. If the inflammation is left unchecked can contribute to other complications such as the following:

  • Hunched posture – a curled forward, chin to chin stance can occur if the spine fuses together in a hunched forward thereby reducing spinal flexibility. Heart, Lungs and other surrounding organs may be affected.
  • Uveitis –is a common and frequent complication of ankylosing spondylitis, uveitis can cause rapid-onset eye pain, photophobia, and blurred vision.
  • Osteoporosis/ Osteopenia  – bones may lose mineral density resulting in brittleness and more prone to fracture.
  • Caudaequina syndrome – this rare condition involves extreme pressure and swelling of the nerves at the end of the spinal cord. The condition can cause weakness, tingling, or numbness in the legs, and/or feet on one or both sides of the body. It also causes bowel bladder dysfunction. This condition is considered a medical emergency.
  • Spondylodisctis – is when one or more intervertebral disc or disc spaces become infected by bacteria such as Staphylococcus aureus (common), Streptococcus viridans, Mycobacterium and Brucella.  About 8% of persons with ankylosing spondylitis have this condition.

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Symptoms and Diagnostic Procedures

Ankylosing Spondylitis Symptoms

Pain and stiffness, especially in the lower back and hips, are two common ankylosing spondylitis symptoms. These symptoms may be worse in the morning upon rising and after periods of prolonged inactivity. The symptoms may worsen over time, or they may gradually improve. In some cases, the pain and stiffness of ankylosing spondylitis stop completely.

Ankylosing spondylitis is a disease that affects the bones and joints of the skeleton. The most common areas to be affected are:

  • The joint that connects your pelvis and the base of your spine
  • The vertebrae located in your lower back
  • The places where tendons and ligaments are attached to bones. Ankylosing spondylitis mainly affects the spine, but it also affects the tissues in the back of the heel.
  • AS also affects the tissues (cartilage) between the ribs and the sternum (breastbone).
  • The shoulder joints and hip joints may also be affected by ankylosing spondylitis
Ankylosing spondylitis (AS) symptoms can develop slowly over a few months to several years. Its symptoms can vary from one person to another. Over many years, the symptoms of ankylosing spondylitis may come briefly or repeatedly and can either improve or worsen with the passing of time.
Ankylosing spondylitis usually first starts to develop during the later teenage years or early adulthood.
The main Ankylosing Spondylitis symptoms can be found below, although the patient may not develop all of these symptoms if diagnosed with AS.

Back pain

  • Back pain and stiffness are the main symptoms of AS
  • intermittent pain and stiffness in the lower back and buttocks, which comes on gradually over the course of a few weeks or months
  • discomfort may only be felt on one side, or alternate sides
  • pain is usually dull and diffuse, rather than localized
  • pain and stiffness is usually worse during the mornings and at night


Ankylosing spondylitis can also cause inflammation of the joints (arthritis) in other parts of your body, such as your hips and knees.
The main symptoms associated with arthritis are:
  • pain on moving the affected joint
  • tenderness when the affected joint is examined
  • swelling and warmth in the affected area
  • It is important to note that back pain from AS is inflammatory in nature and not mechanical


Enthesitis painful inflammation where the bone and tendon are connected (a tough sinew of connective tissue that connects muscles to bones) or a ligament (a fibrous tissue that connects bones to bones).
Common sites for enthesitis are:
  • at the top of the shin bone
  • behind the heel (Achilles tendon)
  • under the heel
  • where the ribs join the breastbone
If your ribs are affected, you may experience chest pain and find it difficult to expand your chest when breathing deeply.


Fatigue is a common symptom of untreated ankylosing spondylitis. Caused by inflammatory markers called cytokines that are circulating in the body.It can make you feel tired and lack energy due to the constant struggle with the pain. The body must spend energy to deal with the inflammation, thus causing fatigue.  Cases of mild to moderate anemia, which may also result from inflammation, can contribute to an overall feeling of tiredness.

Complication in Other Areas

People with ankylosing spondylitis may develop issues related to the scarring of the nerves found at the bottom of the spine resulting in conditions involving different internal organs. These may include urinary and bowel control problems, pain or weakness in your legs, and sexual dysfunction. It may also develop complications affecting the kidneys, lungs, or heart.

Diagnostic Procedures

There is no single specific test to confirm a diagnosis of ankylosing spondylitis. Your physician will most likely complete a thorough physical examination to rule out other causes for your Ankylosing Spondylitis symptoms. The major diagnostic tools used when AS is suspected are magnetic resonance imaging (MRI), X-rays of the spine, which will reveal specific changes in the spine, and blood tests to check for inflammation and for the presence of the characteristic genetic marker of ankylosing spondylitis.


An x-ray can reveal changes in the joints caused by AS, but many times these changes are not visible on a plain x-ray until ankylosing spondylitis has been progressing for 8-10 years.

Magnetic resonance imaging tests may lead to an earlier diagnosis, but the reliability of MRIs in diagnosing AS has not been firmly established.

Blood parameters

During an acute flare-up of the disease, some AS patients will have an increase of certain blood components (CRP and ESR). In patients who have an extreme amount of inflammation with ankylosing spondylitis, these levels do not increase. These blood tests alone are not an accurate diagnostic tool.

Genetic testing

People with the HLA-B27 gene are at greater risk of developing AS than the general population. A blood test for this genetic marker can help in the diagnosis of ankylosing spondylitis, but alone, it is not a diagnosis, as not everyone with this marker develops AS.

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Ankylosing Spondylitis: Treatment and Medications

Ankylosing Spondylitis Diagnosis and Treatment

At present, there is no cure for ankylosing spondylitis (AS), but treatment is available to help alleviate the pain and inflammation.
Treatment can also help delay or prevent the process of the spinal ankylosis and stiffening. In most cases treatment involves a combination of:
  • exercise
  • physiotherapy
  • medication
Timely ankylosing spondylitis diagnosis, keeping active and having a healthy lifestyle can improve patients posture and range of spinal movement, along with preventing the spine becoming rigid and painful. Living an active lifestyle along with physiotherapy is a key part of treating AS. A physiotherapist can help advise about the most effective exercises and draw up an exercise program that suits the patient.
Types of physiotherapy recommended for AS include:
  • a group exercise program – where the patient is advised to  exercise with others
  • an individual exercise program –  solo exercises
  • massage – muscles and other soft tissues are decongested to relieve pain and improve movement; the bones of the spine should never be worked on as this can cause injury in people with AS
  • hydrotherapy – the exercise in water, usually a warm, shallow swimming pool or a special hydrotherapy bath; the buoyancy of the water helps make movement easier by supporting the patient and the warmth can relax muscles
Daily stretching and exercise are also important to cope up with the pain.

The treatment for ankylosing spondylitis is most beneficial when it is started early; before the inflammation has caused joint damage that cannot be reversed.  That is why it is critically important to have ankylosing spondylitis diagnosis in time. The goals of treatment are aimed at:

  • Relieving the stiffness and controlling pain
  • Preventing or delaying complications caused by ankylosing spondylitis
  • Preventing or delaying spinal deformities


The medications most commonly used to treat ankylosing spondylitis are nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen, ibuprofen, and aspirin. These medications help to reduce swelling and inflammation as well as help to the relieve the pain of ankylosing spondylitis. One of the side effects is gastrointestinal bleeding, so they must be taken with food.

If NSAIDs are not effective in controlling the pain and inflammation of AS, your doctor may prescribe tumor necrosis factor (TNF) blocker medications for ankylosing spondylitis. These drugs are sometimes used to treat rheumatoid arthritis. They work by reducing your body’s inflammatory response, therefore stiffness, pain, and swelling also decreased. TNFs are given by an injection under the skin, or into a vein (intravenously). Examples of these drugs your doctor may prescribe for ankylosing spondylitis include:

  • Adalimumab (Humira)
  • Etanercept (Enbrel)
  • Golimumab (Simponi)
  • Infliximab (Remicade)
The first type of painkiller usually prescribed is a non-steroidal anti-inflammatory drug ( NSAIDs). Aside from helping to alleviate pain, NSAIDs can help relieve swelling (inflammation) in your joints.
Examples of NSAIDs include:
  • Ibuprofen
  • Naproxen
  • Diclofenac
  • Etoricoxib
If NSAIDs are inapt for patients, an alternative painkiller, such as paracetamol, may be recommended.
Paracetamol rarely causes side effects and can be used in women who are pregnant or breastfeeding. Paracetamol may not be suitable for people with liver problems or alcohol dependent.
Codeine is an opioid pain medication. An opioid is sometimes called a narcotic. It is used to treat mild to moderately severe pain.
Codeine can cause side effects, including:
  • feeling sick
  • vomiting
  • constipation
  • drowsiness
Anti-tumor necrosis factor (TNF) medication may also be recommended. TNF is a chemical produced by cells when tissue is inflamed.
Anti-TNF drugs are administered via injection and repress the effects of TNF, as well as it decreases the inflammation in the joints caused by ankylosing spondylitis.
Examples of anti-TNF medication include:
  • Adalimumab
  • Etanercept
  • Golimumab
  • Certolizumab
The following are to an extent new treatments for AS and their long-term effects are unknown. However, they have been used for longer in people with rheumatoid arthritis and this is providing clearer information about their long-term safety.

People who are at risk for developing tuberculosis, have latent TB or who have decreased immunity should not take TNFs for ankylosing spondylitis because these drugs interfere with the body’s natural ability to fight infection.


Physical therapy can provide many strategies for dealing with ankylosing spondylitis. Some of the benefits include:

  • Posturing education: to help reduce pain and prevent complications
  • Stretching exercises and Range of motion exercises: to help maintain joint flexibility and mobility
  • Aerobic exercise: to increase or maintain endurance
  • Pain management techniques
  • Proper sleep positioning: Adequate rest is essential when coping with ankylosing spondylitis
  • Use of adaptive equipment or assistive devices
  • Safety instruction and energy conservation techniques to help deal with ankylosing spondylitis


Most people with AS won’t need surgery. However, joint replacement surgery may be recommended to improve pain and movement in the affected joint if the joint has become severely damaged. For example, if the hip joints are affected, a hip replacement may be carried out. In rare cases, corrective surgery may be needed if the spine becomes badly bent.

Laser spine surgery is currently being considered as a good treatment for people with ankylosing spondylitis. It is often used alongside minimal invasive techniques making it more efficient and effective.

Patients with ankylosing spondylitis should be aware of their options and the risk involved in considering surgery.

Surgery is not recommended for most people with ankylosing spondylitis, but if your hip or other joints are severely damaged, your physician may recommend surgery. Surgery is also sometimes recommended for people who have severe pain caused by ankylosing spondylitis.

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