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Ankylosing Spondylitis: Causes, Symptoms & Treatment

Ankylosing spondylitis is a chronic inflammatory disease affecting the spine and sacroiliac joints, causing pain and progressive stiffness. Learn about causes, symptoms, and treatment.

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Things worth knowing about "Ankylosing Spondylitis"

Ankylosing spondylitis is a chronic inflammatory disease affecting the spine and sacroiliac joints, causing pain and progressive stiffness. Learn about causes, symptoms, and treatment.

What is Ankylosing Spondylitis?

Ankylosing spondylitis (also known as Morbus Bechterew or Bechterew disease) is a chronic inflammatory rheumatic disease that primarily affects the spine and the sacroiliac joints -- the joints connecting the lower spine to the pelvis. Over time, the disease can lead to progressive stiffening of the spine. It belongs to the group of spondyloarthritides and is classified as an autoimmune condition, in which the immune system mistakenly attacks the body's own tissues.

Causes

The exact cause of ankylosing spondylitis is not yet fully understood, but several key risk factors have been identified:

Genetic predisposition: More than 90% of people with ankylosing spondylitis carry the HLA-B27 gene marker, a protein found on immune cells. However, not everyone with HLA-B27 will develop the condition.
Environmental triggers: Certain bacterial infections, particularly in the gut, may trigger or worsen the disease in genetically susceptible individuals.
Immune system dysfunction: An abnormal immune response leads to chronic inflammation in the joints and spine.

Symptoms

Symptoms typically begin in early adulthood, most often between the ages of 20 and 40. Common signs and symptoms include:

Chronic lower back and buttock pain, often worse at night or in the early morning
Morning stiffness of the spine that improves with movement and exercise
Progressive loss of spinal mobility
Pain and swelling in other joints (e.g., hips, knees, shoulders)
Enthesitis: inflammation at the points where tendons or ligaments attach to bone, commonly at the heel
Eye inflammation (uveitis), a frequent associated condition
General fatigue and tiredness

Diagnosis

Diagnosis of ankylosing spondylitis is based on a combination of clinical evaluation and investigations:

Medical history and physical examination: Assessment of spinal mobility and pain characteristics
Blood tests: Testing for the HLA-B27 marker and inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
Imaging: X-rays of the spine and sacroiliac joints; MRI (magnetic resonance imaging) is particularly useful for detecting early inflammation before structural changes become visible

Diagnosis can be delayed by several years because the disease often progresses gradually and initial symptoms can be nonspecific.

Treatment

There is currently no cure for ankylosing spondylitis. The goals of treatment are to relieve pain, reduce inflammation, and preserve spinal mobility for as long as possible.

Medication

NSAIDs (Non-steroidal anti-inflammatory drugs): The first-line treatment for pain relief and reducing inflammation (e.g., ibuprofen, diclofenac, naproxen)
Biologics: When NSAIDs are insufficient, TNF-alpha inhibitors (e.g., adalimumab, etanercept) or IL-17 inhibitors (e.g., secukinumab) are used to target specific immune pathways
JAK inhibitors: Newer oral medications that block inflammatory signalling pathways
Corticosteroids: Used for acute flares, often as local injections into affected joints

Physiotherapy and Exercise

Regular physiotherapy and targeted exercises are a cornerstone of treatment. They help maintain spinal flexibility and relieve muscle tension. Recommended activities include:

Daily stretching and mobilisation exercises
Swimming and water-based exercise
Low-impact endurance activities such as cycling or Nordic walking

Additional Measures

Occupational therapy to support daily activities
Psychological support for managing chronic pain
Smoking cessation, as smoking is known to worsen disease progression
Regular eye check-ups due to the risk of uveitis

Prognosis and Outlook

The course of ankylosing spondylitis varies considerably between individuals. In some people the disease remains mild, while in others it can lead to significant spinal stiffening and disability. With early diagnosis and consistent treatment, quality of life can be substantially improved and the progression of the disease slowed.

References

Braun J, Sieper J. Ankylosing spondylitis. The Lancet. 2007;369(9570):1379-1390.
van der Heijde D et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Annals of the Rheumatic Diseases. 2017;76(6):978-991.
National Institute for Health and Care Excellence (NICE): Spondyloarthritis in over 16s: diagnosis and management. NICE Guideline NG65, 2017.

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