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Ankylosing Spondylitis



Ankylosing Spondylitis

Definition

Ankylosing spondylitis is a chronic inflammatory seronegative spondyloarthropathy that primarily affects the sacroiliac joints and axial skeleton, leading to progressive spinal stiffness and ankylosis.

Etiology and genetics

  • Strong association with HLA-B27 (present in >90% cases)

  • Autoimmune mechanism triggered by environmental factors

  • More common in young males

Age and sex

  • Onset: 15–30 years

  • Male predominance

Pathogenesis (high-yield)

  • Inflammation starts at entheses (sites of tendon and ligament attachment)

  • Leads to:

    • Erosion

    • New bone formation

    • Ankylosis of spine

Clinical features

Back pain

  • Inflammatory low back pain

  • Insidious onset

  • Morning stiffness > 1 hour

  • Improves with exercise, not relieved by rest

  • Night pain common

Spinal features

  • Loss of lumbar lordosis

  • Increased thoracic kyphosis

  • Reduced chest expansion (< 2.5 cm)

Peripheral joints

  • Hip and shoulder commonly involved

  • Asymmetrical large joint arthritis

Extra-articular features

  • Anterior uveitis (most common)

  • Aortic regurgitation

  • Apical lung fibrosis

  • Fatigue

Investigations

Laboratory

  • Raised ESR and CRP

  • HLA-B27 positive

  • Rheumatoid factor negative (seronegative)

Radiology

  • Sacroiliitis (earliest change)

  • Squaring of vertebrae

  • Syndesmophytes

  • Bamboo spine on X-ray (late stage)

Diagnostic criteria

  • Modified New York criteria

    • Clinical features + radiological sacroiliitis

Management

Non-pharmacological

  • Regular posture-correcting exercises

  • Physiotherapy

  • Avoid prolonged bed rest

Pharmacological

  • NSAIDs (first line)

  • TNF-α inhibitors (etanercept, infliximab) if NSAIDs fail

  • IL-17 inhibitors (secukinumab)

Key exam points

  • Young male with inflammatory back pain

  • HLA-B27 positive

  • Sacroiliitis is the earliest radiological sign

  • Bamboo spine is a late feature

One-line exam memory aid

Ankylosing spondylitis starts at sacroiliac joints and ascends the spine.


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