Ankylosing Spondylitis: Rigid Spine Due To Inflammation

Category: Inflammatory Spondyarthropathy Published on Wednesday, 25 June 2008 Written by Yong Tsai, MD

Do you have pain or stiffness in your lower back?  Are your symptoms worse when you are resting?  If you are a man between the ages of sixteen and thirty, you might have ankylosing spondylitis (AS) like Mr. Leclair.

Mr. Leclair is a 30-year-old computer programmer.  During the past few years, he has gradually experienced aching in his lower back and tailbone area.  His pain, which is worse at night, wakes him up frequently. And when he wakes up in the morning, he always has a very stiff back, which usually improves as the day progresses.  Mr. Leclair finds that, like his father who has similar symptoms, exercise and NSAIDs (non-steroidal anti-inflammatory drugs) really help. 


Our spine consists of a series of vertebrae that are stacked one on top of another and cushioned by discs of cartilage that act as shock absorbers.  Ligaments and tendons attach muscles to bones and keep bones and joints in place.  At the base of the spine is the pelvis, which is made up of four bones: two sacroiliac bones (hip bones), the sacrum (lower back bone) and the coccyx (tailbone). 


Ankylosing (rigidity) spondyl (spine) itis (inflammation), is a chronic inflammatory disease that primarily affects the spine and sacroiliac joints.  When spinal ligaments and tendons become inflamed, not only do they cause pain, but also they ossify (turn into bone) and form bone spurs on our vertebrae.  In severe cases, the joints and bones may grow and fuse together, transforming our flexible spine into a rigid column and making movement difficult. 


The actual cause of AS is unknown. However, even though AS can strike any age, gender or race, Caucasian males between the ages of sixteen and thirty seem to be at greatest risk.  Women have milder symptoms and are less susceptible.  Genes and heredity seem to play an important role in developing AS, particularly the HLA-B27 gene. Ninety percent of people with AS possess the HLA-B27 gene.  However, having it alone does not necessarily mean you’ll have AS.  Approximately eight percent of healthy Caucasian Americans and three percent of healthy African Americans carry this gene.  Having the HLA-B 27 gene without a family history only increases your risk by two percent.  However, having both a family history and the HLA-B27 gene increases your risk by twenty percent.  In addition to HLA-B27, there are additional unknown factors associated with AS. 


The main symptom of AS is back pain, which develops slowly and insidiously.  However, AS can also affect the knees, hips, shoulders, heels, and other small joints.  Twenty percent of patients with AS also show involvement in their hips and shoulders.

Interestingly, inflammation of the hip seems to occur only in teenagers, within the first 10 years of the disease, and not usually in patients over thirty.

“Rest pain” brought on by AS defines pain when you are sleeping or resting.  Symptoms are worse when moving after being still for a period of time and improve with activity.

If you have AS, you may experience pain in the soles of your feet due to inflammation of connective tissue (plantar fasciitis) or of the heel tendon (achilles tendinitis) or due to heel spurs.  Some people with AS have problems with their ligaments and tendons, while others have mostly inflamed peripheral joints and tend to have very little spinal involvement.  Other symptoms can include fever, loss of appetite and fatigue.

Because AS is a systemic disease, meaning it can affect other organs, such as the eyes, heart and lungs, it can also be connected with ulcerative colitis (inflammation of the large intestine) Crohn’s disease (inflammation of the small intestine), psoriasis (skin disorder) and iritis (inflammation of the iris).


The most important clue in diagnosing AS is a complaint of increased back pain at night followed by severe morning stiffness that improves as the day goes on.  Because x-rays may not show abnormalities for up to 10 years after symptoms begin, a CT scan of the sacroiliac joint is the best tool.  Unfortunately, there is no specific diagnostic test for AS, but different laboratory tests can help your physician exclude other diseases. 


NSAIDs (non-steroidal anti-inflammatory drugs) such as Naprosyn, Celebrex or Vioxx usually are quite helpful, but adequate doses must be used. DMARDs (disease modifying anti-rheumatic drugs) such as Methotrexate and Sulfasalzaine have not been proven as effective in the treatment of AS as in that of rheumatoid arthritis. However, they do seem to help some patients.  Biologic agent such as Enbrel and Remicade are under being studied for their effectiveness in treating AS.

Physical therapy, which includes therapeutic exercises and proper posture to prevent deformity, is a key element in treating AS.  Particular emphasis should be placed on range of motion and flexibility exercises along with strengthening of the back and hip muscles.  Deep breathing with full rib cage expansion and gentle static stretching, maintaining a good posture, and regular low-impact exercise such as swimming should be included in your daily exercise program.  Patient education on the progression of this disease and its impact on spinal mobility and posture is also extremely important.

For most patients, AS’s long-term outlook is very good. More than ninety percent of patients are able to cope with the demands of normal day living very well and can expect to have a normal life span.

In a nutshell, with the benefits of NSAIDs, good posture, regular exercise and the help of your physician, living a normal life is not just a dream, but also a reality.

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