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Ankylosing spondylitis (AS)


 Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease that mainly affects the axial skeleton, especially the sacroiliac joints and spine. Over time, persistent inflammation can lead to new bone formation, spinal stiffness, and eventual fusion of vertebrae.

What happens in ankylosing spondylitis

  • Inflammation starts at entheses (sites where ligaments and tendons attach to bone)

  • Recurrent inflammation causes pain and stiffness

  • Healing occurs with abnormal bone formation, leading to ankylosis (fusion)

Key clinical features

  • Inflammatory low back pain

    • Onset before 40 years

    • Insidious onset

    • Morning stiffness lasting more than 30 minutes

    • Improves with exercise, not with rest

  • Reduced spinal mobility

  • Chest expansion reduced

  • Peripheral arthritis (hips, shoulders)

  • Extra-articular features:

    • Acute anterior uveitis

    • Aortitis and aortic regurgitation (rare)

    • Apical lung fibrosis (late)

Etiology and risk factors

  • Strong genetic association with HLA-B27

  • More common in young males

  • Family history increases risk

Pathology (brief)

  • Sacroiliitis is the earliest lesion

  • Inflammation → erosion → sclerosis → ankylosis

  • Formation of syndesmophytes leads to a bamboo spine

Investigations

  • X-ray pelvis: bilateral sacroiliitis (late finding)

  • MRI: detects early inflammatory changes

  • Raised ESR and CRP

  • HLA-B27 positive in many patients (not diagnostic alone)

Management (overview)

  • Patient education and regular exercise

  • NSAIDs are first-line drugs

  • Biologic agents (TNF-α inhibitors, IL-17 inhibitors) in resistant cases

  • Posture training and physiotherapy are essential

Why it is important

Untreated ankylosing spondylitis can lead to severe spinal deformity, functional limitation, and reduced quality of life. Early diagnosis and treatment significantly improve outcomes.


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