Characteristics of Ankylosing Spondylitis

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In this opening segment, John D. Reveille, MD, Linda and Ronny Finger Foundation Distinguished Chair in Neuroimmunologic Disorders, Division Director, Professor, Vice-Chair - Rheumatology and Clinical Immunogenetics at McGovern Medical School, University of Texas, discusses the characteristics of ankylosing spondylitis.

Ankylosing spondylitis is part of the larger family of inflammatory spinal diseases called axial spondyloarthritis. Its hallmark is inflammatory back pain. It is back pain that is present every day for at least 3 months that improves with activity or exercise, associated with morning stiffness and does not get better with rest, and can move from side-to-side in the buttocks.

It starts out most of the time in the sacroiliac joints. Some people mistake that as hip pain. It characteristically starts out in the teens or the 20s, and then can move to other parts of the spine. After the sacroiliac joints, we tend to see the area at the lower part of the ribs in the spine affected; also the area where the neck joins the trunk. Those tend to be the next areas that are affected, and then as time goes on, it can spread to involve the entire spine.

Patients with ankylosing spondylitis, again, tend to present early on in life in the teens, 20s, and 30s with inflammatory back pain, usually beginning in the sacroiliac joints. The patient will note this pain being there every day, that it gets better with exercise, and that it is getting worse, or, at least, that it does not improve with rest. It tends to respond very well to full anti-inflammatory doses of nonsteroidal anti-inflammatory agents such as ibuprofen, naproxen, or meloxicam, or celecoxib. It can sometimes present with some of the other features of the disease that we see outside of the spine, such as, it can present, for example, in some patients initially with inflammatory eye disease or they can present with colitis initially. But, characteristically, the back pain starts first.

Spondyloarthritis has a number of unique clinical features that do differentiate it from other kinds of arthritis and help in the diagnosis; one being, of course, the presence of inflammatory back pain, the involvement of the sacroiliac joints. We do not see that in rheumatoid arthritis.

About 30% of patients with ankylosing spondylitis will have inflammatory eye disease called uveitis. That can be very painful. It’s usually diagnosed by an ophthalmologist. We do not see uveitis or iritis in patients with rheumatoid arthritis or most other kinds of arthritis. It can, in about 40% of the patients, affect the hip joints, and this is less commonly seen in rheumatoid arthritis, although it can be seen there.

It can affect the heart in about 6% of patients, causing damage to the aortic valve or even damages to the cardiac conduction system—called heart block—and it can also affect the skin, usually in the form of psoriasis. It can be associated with inflammatory bowel disease, such as ulcerative colitis or Crohn’s disease, and even in about 10%, it can affect the small joints of the hands and feet.