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Patient information: Ankylosing spondylitis and other spondyloarthritis (Beyond the Basics)

Author Section Editor Deputy Editor

David T Yu, MD Joachim Sieper, MD Jerry M Greene, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2014. | This topic last updated: Jun 10, 2013.

ANKYLOSING SPONDYLITIS OVERVIEW Ankylosing spondylitis (AS) is a chronic inflammatory disease

that causes pain in the back, the neck, and, sometimes, the hips. The back is composed of multiple separate
bones known as vertebrae. Ankylosing means joining together and refers to an inflexibility between the
vertebrae. Spondylitis means inflammation of the vertebrae. Spondyloarthritis refers to a group of diseases
that share a tendency to cause spondylitis, some of which also cause inflammation of other joints besides
those of the spine.

This topic discusses the symptoms, diagnostic tests, possible complications, and treatment of one of the
family of spondyloarthritis diseases, ankylosing spondylitis. It also discusses some of the diseases that are
classified as subtypes of spondyloarthritis. Separate topic reviews are available that discuss some of the
medications used to treat ankylosing spondylitis and exercises that can help people with ankylosing spondylitis
with stretching and strengthening. (See "Patient information: Disease-modifying antirheumatic drugs
(DMARDs) (Beyond the Basics)" and "Patient information: Arthritis and exercise (Beyond the Basics)".)

SPONDYLOARTHRITIS FAMILY OF ARTHRITIS Spondyloarthritis is a family of arthritis, of which

ankylosing spondylitis is the most common member. The other members are:

n Undifferentiated spondyloarthritis
n Non-radiographic axial spondyloarthritis
n Reactive arthritis
n Arthritis associated with psoriasis (psoriatic arthritis)
n Arthritis associated with inflammatory bowel diseases (ulcerative colitis or Crohns disease)

Spondyloarthritis has also been classified into axial and peripheral spondyloarthritis according to whether
the involvement is mainly in the spine or in the extremities. Ankylosing spondylitis belongs to the axial class
of spondyloarthritis. Many patients diagnosed as having an axial form of undifferentiated spondyloarthritis
may subsequently develop ankylosing spondylitis. Separate topic reviews discuss reactive arthritis, psoriatic
arthritis, and inflammatory bowel diseases. (See "Patient information: Reactive arthritis (formerly Reiter
syndrome) (Beyond the Basics)" and "Patient information: Psoriatic arthritis (Beyond the Basics)" and "Patient
information: Ulcerative colitis (Beyond the Basics)" and "Patient information: Crohn disease (Beyond the
Basics)".)

ANKYLOSING SPONDYLITIS SYMPTOMS The most common symptom of ankylosing spondylitis is pain
in the lower back. Pain, stiffness, and limited mobility in other joints also occur in some patients. More
detailed information is available separately. (See "Clinical manifestations of ankylosing spondylitis in adults".)

Spinal pain Spinal pain, almost always in the lower back, is usually the first and most common symptom
of ankylosing spondylitis. Back pain that occurs with ankylosing spondylitis generally has some of the following
characteristics:

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n Begins in early adulthood (before 45 years of age)

n Has gradual onset (rather than sudden onset after an acute injury)
n Lasts longer than three months
n Is worse after rest (for example, in the morning)
n Improves with activity
n Wakes you up in the second half of the night
n Can cause morning stiffness lasting more than 30 minutes
n Can cause buttock pain that alternates between the left and right side

Limited spinal mobility The flexibility of the back may be reduced. Putting on shoes and stockings may
become difficult due to a limited ability to bend forward.

Other symptoms

n Hip pain Arthritis of the hips is relatively common in ankylosing spondylitis, causing pain in the groin
or buttocks or difficulty walking.
n Shoulder pain Inflammation of the tendon and bone may cause shoulder pain and limited mobility of
the affected shoulder(s).
n Arthritis in other joints Pain, stiffness, and swelling of other joints may occur. A single joint
(monoarthritis) or a few joints (oligoarthritis) may be affected.
n Enthesitis An enthesis is a region in which a tendon or a ligament attaches to bone. Enthesitis
(inflammation of an enthesis) is a symptom of spondyloarthritis. In addition to the spine, a major area
of symptomatic enthesitis is at the heel.
n Constitutional features As with any chronic inflammatory disease, people with ankylosing spondylitis
may be tired and may feel unwell. Difficulty sleeping, caused by back or joint pain at night, may
contribute to fatigue. Low-grade fevers and weight loss occur in some patients.
n Other affected systems Body systems other than the joints can be affected. (See 'Ankylosing
spondylitis complications' below.)

ANKYLOSING SPONDYLITIS RISK FACTORS Ankylosing spondylitis is three times more common in
males than in females. It is usually diagnosed in young adults between the ages of 20 and 30 years.

The disease can be more common in certain families. For example, a person's risk of developing ankylosing
spondylitis increases if a first-degree relative (parent, sibling, or child) has ankylosing spondylitis. The
presence of a gene called HLA-B27 may also increase the risk of developing ankylosing spondylitis.

ANKYLOSING SPONDYLITIS DIAGNOSIS The diagnosis of ankylosing spondylitis is based upon a

combination of a patient's symptoms, physical examination, and imaging tests. (See "Diagnosis and
differential diagnosis of ankylosing spondylitis in adults".)

Imaging tests People with ankylosing spondylitis develop characteristic changes in the sacroiliac joints
(the joint that connects the base of the spine [sacrum] and large pelvic bone [ilium]). These changes can be
seen on x-ray images, although x-ray changes take time to develop and may not be apparent until years after
the onset of ankylosing spondylitis.

Imaging tests such as magnetic resonance imaging (MRI) are more sensitive than plain x-rays and may be
used if ankylosing spondylitis is suspected but is not clearly seen on x-ray.

Other tests There is no blood test that, by itself, is capable of definitively diagnosing or excluding
ankylosing spondylitis. However, testing for a particular type of gene, HLA-B27, can be helpful in selected
groups of patients. Ankylosing spondylitis is unlikely in a patient with a negative test for HLA-B27 who is white
and of European descent. Ankylosing spondylitis is even less likely if x-rays and MRI are normal or show no
changes to suggest ankylosis of the sacroiliac joint or inflammation in that area.

ANKYLOSING SPONDYLITIS COMPLICATIONS Complications of ankylosing spondylitis are uncommon,

with the exception of anterior uveitis.

Anterior uveitis Uveitis, or inflammation of part of the eye, is the most common ankylosing spondylitis-
related problem that does not involve joints. Uveitis causes pain in the eye, blurring of vision, and light

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sensitivity. Uveitis requires immediate medical attention and treatment with eye medications but often
resolves within several months.

Spinal fractures and spinal cord injuries Spinal fractures and spinal cord injuries are 4 and 11 times
more common in patients with ankylosing spondylitis than in the general population. Most of the acute
fractures occur in the neck. The preceding injuries might be trivial and of low impact. Patients with spinal cord
injuries may have only minor initial neurological symptoms. Any neck or spine injury requires immobilization,
consultation with a doctor, and evaluation in an emergency facility. More than half of neck fractures in
patients with ankylosing spondylitis are undetectable by plain x-ray. Computed tomography and MRI are more
sensitive imaging techniques.

Neurologic problems Cauda equina syndrome is a rare complication that occurs in people with
longstanding disease who have severe stiffening of the spine. The symptoms result from damage to many
nerves in the lower back and include abnormal sensation, weakness, and difficulty with bladder and bowel
control. Men may experience erectile dysfunction or impotence.

Cardiovascular disease The most serious problem is a leaking aortic valve (aortic regurgitation) which
can cause symptoms of heart failure, including leg or ankle swelling (edema) and shortness of breath during
exercise or exertion. (See "Patient information: Heart failure (Beyond the Basics)".)

Pulmonary disease Many people with ankylosing spondylitis are unable to expand the chest normally
during breathing because of stiffness between the ribs and the spine. In some cases, changes in the lungs can
result. This may or may not cause breathing problems.

Ulcerations in the bowel Some people with ankylosing spondylitis will develop ulcerations in the lining of
the bowels, although these ulcerations do not usually cause any symptoms.

EFFECTS OF ANKYLOSING SPONDYLITIS ON DAILY LIFE Ankylosing spondylitis can affect daily life in
various ways. Dressing, reaching, rising from a chair, getting up from the floor, standing, climbing steps,
looking to the side or over the shoulder, exercising, and doing household or work-related tasks can become
more difficult as a result of the limited joint and spinal motion in ankylosing spondylitis. These limitations can
affect you and your family, and many people with ankylosing spondylitis will require assistance from family
and friends.

ANKYLOSING SPONDYLITIS TREATMENT Ankylosing spondylitis treatment is tailored for each

individual, based on the characteristics and severity of the disease. Treatment may include any of the
following (see "Assessment and treatment of ankylosing spondylitis in adults"):

Exercise Exercise should be part of the treatment program for everyone with ankylosing spondylitis. It can
include home exercises, individual or group exercise with a physical therapist, or physical therapy (PT)
treatments. Optimally, each patient should be evaluated and given instructions by a physical therapist. The
exercise should consist of posture training, deep breathing, back extension, and other stretching movements.
(See "Patient information: Arthritis and exercise (Beyond the Basics)".)

Information about exercises designed for people with ankylosing spondylitis is available on the following
website: www.nass.co.uk/exercise/.

Safety issues Because of the increased risk of serious spinal injury from slips and falls, people with
ankylosing spondylitis should take care to avoid such mishaps. Some simple measures include limiting the use
of alcohol. Pain relieving drugs (such as codeine and other narcotics) and sedatives (sleeping pills) should also
be used cautiously, if at all, since these also increase the risk of falling. Contact sports and other high-impact
activities should be avoided.

Shower or tub grab-bars and night-lights decrease the chance of a fall. Loose rugs increase the risk of tripping
and should be removed or carefully attached to the floor with removable adhesive strips or pads. Seat belts
reduce the risk of injury in a car crash and should be worn while driving or riding in a vehicle. A wrap-around
rear view mirror can improve visibility for drivers who cannot turn their head and neck.

To avoid developing deformities of the neck, a thin, rather than a thick, pillow is recommended for sleeping.

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Medications

Nonsteroidal antiinflammatory drugs (NSAID) An NSAID is commonly used to control pain and
stiffness. NSAIDs need to be taken on a regular basis for several weeks before their maximum effect can be
judged. (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)

Sulfasalazine Sulfasalazine is a disease modifying antirheumatic drug, or DMARD, that may be given to
slow or stop the progression of ankylosing spondylitis. It may be given along with NSAIDs. This drug provides
some relief of arthritis symptoms but is not helpful if ankylosing spondylitis only affects the spine. (See
"Patient information: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)" and "Patient
information: Sulfasalazine and the 5-aminosalicylates (Beyond the Basics)".)

Anti-tumor necrosis factor therapy A group of medicines known as anti-tumor necrosis factor agents
(anti-TNF) or TNF inhibitors is often effective in the treatment of ankylosing spondylitis. Examples of anti-TNF
medications include infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab. People who do
not respond to one anti-TNF treatment may respond to another. Improvement in symptoms is common and
may occur within a few weeks of starting the drugs. However, these drugs may not be very effective in
stopping the progression of the disease.

n Who should use anti-TNF therapy? Not every patient with ankylosing spondylitis needs anti-TNF
therapy. In general, people with active disease in the spine who have not responded fully to NSAIDs
may be candidates. The decision to use anti-TNF therapy depends upon several factors that should be
discussed with your clinician.

Some clinicians may also recommend a glucocorticoid injection into particularly painful or swollen joints,
especially if there is only one or a two that are causing the most pain. (See 'Glucocorticoids (steroids)' below.)

Glucocorticoids (steroids) In some cases, a glucocorticoid injection into the sacroiliac joint may help
provide relief in patients who have sacroiliac pain that has not responded to other therapies.

In contrast, taking glucocorticoids by mouth is rarely necessary in ankylosing spondylitis treatment.

Surgery Hip or spine surgery may be beneficial in selected patients with ankylosing spondylitis. Surgical
procedures may include one or more of the following:

Total hip replacement Insertion of an artificial hip may be recommended in patients with ankylosing
spondylitis who have severe, persistent hip pain or severely limited mobility due to hip joint arthritis. (See
"Patient information: Total hip replacement (arthroplasty) (Beyond the Basics)".)

Spinal surgery Fusion of the bones in the cervical spine may be recommended for a small number of
patients who develop dislocation of these bones. Such surgery may help prevent spinal cord damage.

Wedge osteotomy Wedge osteotomy involves the removal of a wedge-shaped piece of bone from a
vertebra, followed by realignment of the spine. The spine is then braced and is allowed to heal in a better
position. This type of procedure may be recommended for people who develop severe deformities of the neck.

PREVENTING ANKYLOSING SPONDYLITIS COMPLICATIONS Because the severity and outcome of

ankylosing spondylitis vary considerably among patients, treatment must be tailored to each particular
patient. However, all patients can benefit from the following:

n Stop smoking cigarettes. People who smoke and have ankylosing spondylitis can have problems with
their breathing. Ankylosing spondylitis can limit the movement of the chest and can reduce the amount
of air the lungs can hold. (See "Patient information: Quitting smoking (Beyond the Basics)".)
n Maintain correct posture, and participate in an exercise program. (See "Patient information: Arthritis
and exercise (Beyond the Basics)".)
n Consume an adequate amount of calcium and vitamin D in order to reduce the risk of bone loss
(osteoporosis). Products that contain calcium and vitamin D include dairy products like milk, cheese,
and yogurt or non-prescription calcium and vitamin D supplements. (See "Patient information: Calcium

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and vitamin D for bone health (Beyond the Basics)".)

Medications that treat bone loss may be recommended if you have already lost bone strength. (See "Patient
information: Bone density testing (Beyond the Basics)" and "Patient information: Osteoporosis prevention and
treatment (Beyond the Basics)".)

UNDIFFERENTIATED SPONDYLOARTHRITIS Someone who has spondyloarthritis but who does not have
sufficient features to be diagnosed as having ankylosing spondylitis, reactive arthritis, arthritis associated with
psoriasis, ulcerative colitis, or Crohns disease may be diagnosed as having undifferentiated spondyloarthritis.
The major involvement might be the spine, the extremities, or both. The approach by the doctors toward
diagnosis and treatment are similar to those of ankylosing spondylitis listed above. (See 'Ankylosing
spondylitis treatment' above.) If the symptoms are mostly in the spine, the clinician may diagnose it as non-
radiographic spondyloarthritis instead of undifferentiated spondyloarthritis.

If a diagnosis of undifferentiated spondyloarthritis or non-radiographic spondyloarthritis is made, additional

medical visits are necessary, because, with time, one of the more specific types of spondyloarthritis may be
diagnosed. However, some patients continue to have undifferentiated spondyloarthritis or non-radiographic
spondyloarthritis, and some go into remission and can stop taking medications for pain and stiffness.

AXIAL AND PERIPHERAL SPONDYLOARTHRITIS Spondyloarthritis is also classified into axial and
peripheral types. In patients with axial spondyloarthritis, the symptoms are mainly, but not exclusively,
related to the spine. In patients with peripheral spondyloarthritis, the symptoms are mainly, but not
exclusively, experienced in the extremities.

NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS Patients with non-radiographic axial

spondyloarthritis are very similar to those with ankylosing spondylitis except that the sacroiliac joints of the
pelvis are normal by x-ray. Some patients with non-radiographic axial spondyloarthritis do have MRI changes
of the sacroiliac joints.

WHERE TO GET MORE INFORMATION Your healthcare provider is the best source of information for
questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for
patients, as well as selected articles written for healthcare professionals, are also available. Some of the most
relevant are listed below.

Patient level information UpToDate offers two types of patient education materials.

The Basics The Basics patient education pieces answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials.

Patient information: Ankylosing spondylitis (The Basics)

Patient information: Arthritis and exercise (The Basics)
Patient information: Reactive arthritis (Reiter syndrome) (The Basics)

Beyond the Basics Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are best for patients who want in-depth information and are comfortable with some
medical jargon.

Patient information: Disease-modifying antirheumatic drugs (DMARDs) (Beyond the Basics)

Patient information: Arthritis and exercise (Beyond the Basics)
Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient information: Sulfasalazine and the 5-aminosalicylates (Beyond the Basics)
Patient information: Total hip replacement (arthroplasty) (Beyond the Basics)
Patient information: Quitting smoking (Beyond the Basics)
Patient information: Calcium and vitamin D for bone health (Beyond the Basics)
Patient information: Bone density testing (Beyond the Basics)
Patient information: Osteoporosis prevention and treatment (Beyond the Basics)

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Professional level information Professional level articles are designed to keep doctors and other health
professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and
they contain multiple references to the research on which they are based. Professional level articles are best
for people who are comfortable with a lot of medical terminology and who want to read the same materials
their doctors are reading.

Clinical manifestations of ankylosing spondylitis in adults

Diagnosis and differential diagnosis of ankylosing spondylitis in adults
Diseases of the chest wall
General guidelines for use of anti-tumor necrosis factor alpha agents in ankylosing spondylitis and in
peripheral and non-radiographic axial spondyloarthritis
Pathogenesis of spondyloarthritis
Assessment and treatment of ankylosing spondylitis in adults
Non-radiographic axial spondyloarthritis, undifferentiated spondyloarthritis, and peripheral spondyloarthritis

The following organizations also provide reliable health information.

n National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
n Spondylitis Association of America
(www.spondylitis.org)
n Spondyloarthritis Research and Treatment Network
(www.spartangroup.org)
n National Institute of Arthritis and Musculoskeletal and Skin Diseases
(301) 496-8188
(http://www.niams.nih.gov/)
n American College of Rheumatology/Association of Rheumatology
(404) 633-3777
(www.rheumatology.org)
n The Arthritis Foundation
(800) 283-7800
(www.arthritis.org)

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REFERENCES

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radiological progression. J Rheumatol 2002; 29:1236.
Maugars Y, Mathis C, Berthelot JM, et al. Assessment of the efficacy of sacroiliac corticosteroid injections in
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spondylarthropathies: a double-blind study. Br J Rheumatol 1996; 35:767.
Braun J, Pham T, Sieper J, et al. International ASAS consensus statement for the use of anti-tumour
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necrosis factor agents in patients with ankylosing spondylitis. Ann Rheum Dis 2003; 62:817.
Mau W, Zeidler H, Mau R, et al. Clinical features and prognosis of patients with possible ankylosing
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spondylitis. Results of a 10-year followup. J Rheumatol 1988; 15:1109.
Rudwaleit M, van der Heijde D, Landew R, et al. The development of Assessment of SpondyloArthritis
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Ann Rheum Dis 2009; 68:777.
Rudwaleit M, van der Heijde D, Landew R, et al. The Assessment of SpondyloArthritis International Society
7 classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis
2011; 70:25.
Sampaio-Barros PD, Bortoluzzo AB, Conde RA, et al. Undifferentiated spondyloarthritis: a longterm
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