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Ankylosing Spondylosis


Ankylosing spondylitis is an seronegative arthritis in which the sacroiliac joints and axial spine undergo a progressive ossification. Ankylosing spondylitis attacks the insertions points of ligaments, tendons, fascia, and fibrous joint capsules, and yields fibrosis and ossification of the insertions. Ligamentous attachments are collectively referred to as “entheses”, hence “ensethopathy” is a common feature of ankylosing spondilitis.


The disease typically starts at the sacroiliac joint (SI joint is fused in the pelvic radiograph above), and spreads upwards, ossifying ligaments of the posterior facets of the spine and fusing vertebrae together, thus stiffening the spine and decreasing range of movement. Ossification within the anulus fibrosis (the fibro-cartilaginous ring that is wrapped around the outside of the intervertebral disk ) yields syndesmophytes , radio-dense lines that connect vertebrae. With enough syndesmophyte formation, the whole spine has an undulating contour called “Bamboo Spine”. A characteristic combination of bone erosion and formation occurs in this disease, such that the vertebrate become less concave and more ‘square’. This squaring of the vertebral bodies is typical of ankylosing spondilitis.


Onset is typically in young people, usually in their late teens or twenties, and rarely after age of 35. Clinically, the disease is usually first noticed as a persistent backache which is not relieved by rest, and improves with exercise (unlike muscular back pain). It may also present as sciatica, peripheral joint pain, a painful sacroiliac joint or chest pain. Associated symptoms are anorexia, weight loss and a low grade fever. At its extreme, ankylosing spondylitis results in an ossification of the axial spine such that mobility is greatly reduced, and the spine becomes completely stiff and flexed, and the hips may be ankylosed as well, affecting gait. The spine is also at increased risk of fractures, further deforming the person’s stance. However, only 20% of patients reach the extreme of a completely rigid spine.


Medical treatments include analgesia and an emphasis on posture and exercise to retain flexibility and range for as long as possible. Swimming is recommended.


When AS has been present for several months the back may stiffen, usually lower down; and in some patients the disease then dies out, causing no further trouble. The stiff back is often painless and does not interfere with physical activity, because the upper part of the spine, the neck, hips and limbs can remain quite normal. If you feel stiff in the early morning this is a sign of inflammation and perhaps it may be an hour or so before you have properly limbered up – it may indicate the need for anti-inflammatory drugs.


In its early stages AS causes considerable pain, but effective treatment is available to relieve this, even though the discomfort is not always banished. In some people the disease becomes much less active, or even ceases completely. In others the disease continues to be active, causing pain and stiffness. At first you will most probably be able to carry on with your work and lead a normal life. Later you may find it difficult to continue in the same job.

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Do your best to keep fit. Eat anything, especially protein such as meat and fish, but don’t get overweight. Exercise regularly . The motto for treatment which all patients should remember is: it is the doctor’s job to relieve pain, and the patient’s job to keep exercising and maintain a good posture.




If the AS is very active and the stiffness very troublesome, a spell off work or in hospital may be necessary. This does not mean keeping still in bed, because this can hasten the stiffening of the spine. So even a spell of rest from work means that you will be encouraged to do exercises for your back, chest and limbs to keep them supple.


When you are in bed it is important that you should lie quite flat on your back. Some of the time you should practise lying on your front. ‘Prone lying’, as this is called, is best done for 20 minutes before rising in the mornings and 20 minutes before going to bed at night.


At first you may not be able to tolerate more than 5 minutes at a time, or may even need a pillow under your chest. But with practice, as the spine relaxes, it will become easier. If you make a habit of this it will help prevent your back and hips becoming bent. It may, of course, not be practical every day but it is better to devote some time to it than nothing at all.




Since untreated AS causes increased bending of the spine (the person becomes progressively more stooped), you must keep as straight and erect as possible. Hardback, upright chairs or straight-back rocking chairs are far better for your back posture than low, soft, upholstered chairs.


A job which allows sitting, standing and walking is ideal. The most unsuitable type of work is that in which you have to stoop over a bench for hours at a time. If you have a heavy or tiring job do not tackle other activities at home or elsewhere until you have had a break. If necessary, rest flat for a time. It may also help if you can rest flat for 20 minutes at midday. At such times try to lie for part of the time face downwards.


Corsets and braces are hardly ever helpful, and indeed can make AS worse. It is better to develop your own muscles, and keep a straight back by natural means. Very occasionally some form of support may be necessary, for example after a back injury. However, this decision should only be taken by a doctor who is experienced in treating people with AS.


Sport and exercise


Exercise is good for AS, so you should keep active. Swimming is the best form of sport as it uses all muscles and joints without jarring them.

Medical Approach


There is no cure at present for AS. The doctor aims to relieve the symptoms, to improve spinal mobility where this has been lost, and to allow you to maintain a normal job and social life.


Although AS will tend to become less active as you get older, treatment must continue. In particular you must pay close attention to good posture, mobility and exercise.


Although the disease cannot be cured, much can be done to help. The doctor will prescribe tablets that relieve pain (analgesic) and inflammation. There are several drugs which will reduce or kill the pain, and give you a good night’s sleep and sufficient freedom from pain to do exercises.


You will probably need tablets during bad patches and some people need a small maintenance dose of their drug over a longer period. Some tablets are manufactured to remain effective throughout a 24-hour period, thus helping relieve night pain and morning stiffness.


Some drugs are called ‘disease-modifying’: they never make an immediate impact on the disease but rather take some time to start working, but ultimately they may make a big difference to the disease. Sulfasalazine and methotrexate are two such drugs. Both these drugs, commonly used in other forms of arthritis, are more likely to benefit the arthritis in the limb joints rather than the arthritis in the spine.


Some of the newer drugs are given by injection. These fall broadly into two groups:


  • Bisphosphonates are given in short bursts over a period of a few weeks – an example is the drug called pamidronate. You may feel pain relief in the spine soon after receiving this drug.
  • Biological therapies are drugs which are also given by injection – either as an infusion over a few hours or as a twice-weekly injection.


Heat in its various forms will help to relieve pain and stiffness. A hot bath before going to bed, a hot-water bottle or electric blanket may be quite enough.


Surgery has only a small place in treatment. An operation is used to help restore movement to damaged hip joints (arthroplasty) and, rarely, to straighten the back or neck of someone who has become so bent they cannot look forward (and find it dangerous just to cross the road).