Skip to main content
NCBI home page
Canadian Family Physician logoLink to Canadian Family Physician
. 2004 Feb;50:257–262.

Ankylosing spondylitis. Not just another pain in the back.

Walter P Maksymowych 1
PMCID: PMC2214553  PMID: 15000337

Abstract

OBJECTIVE: To review recent developments in diagnosis and treatment of ankylosing spondylitis (AS). QUALITY OF EVIDENCE: Level I evidence from three randomized placebo-controlled trials shows that AS is highly responsive to anti-tumour necrosis factor-alpha (anti-TNFalpha) therapies when the standard approach of nonsteroidal anti-inflammatory drugs (NSAIDs) and physical modalities fails. MAIN MESSAGE: Ankylosing spondylitis is associated with disability comparable to that of rheumatoid arthritis. Diagnosis should first focus on eliciting a history of nocturnal back pain, diurnal variation in symptoms with prolonged morning stiffness, and a good response to NSAID therapy. Physical examination is often unrevealing. Pelvic x-ray results are often normal in early disease. Magnetic resonance imaging is the most sensitive imaging technique for detecting early inflammatory lesions and should be considered when history supports the diagnosis but results of plain radiography are normal. When patients have failed at least two courses of NSAID therapy, anti-TNF(alpha)therapies are of proven benefit. CONCLUSION: New magnetic resonance imaging techniques and highly effective therapies make AS more readily detectable and managable.

Full Text

The Full Text of this article is available as a PDF (191.6 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Amor B., Dougados M., Listrat V., Menkes C. J., Dubost J. J., Roux H., Benhamou C., Blotman F., Pattin S., Paolaggi J. B. Evaluation des critères des spondylarthropathies d'Amor et de l'European Spondylarthropathy Study Group (ESSG). Une étude transversale de 2,228 patients. Ann Med Interne (Paris) 1991;142(2):85–89. [PubMed] [Google Scholar]
  2. Battafarano D. F., West S. G., Rak K. M., Fortenbery E. J., Chantelois A. E. Comparison of bone scan, computed tomography, and magnetic resonance imaging in the diagnosis of active sacroiliitis. Semin Arthritis Rheum. 1993 Dec;23(3):161–176. doi: 10.1016/s0049-0172(05)80037-x. [DOI] [PubMed] [Google Scholar]
  3. Braun J., Bollow M., Remlinger G., Eggens U., Rudwaleit M., Distler A., Sieper J. Prevalence of spondylarthropathies in HLA-B27 positive and negative blood donors. Arthritis Rheum. 1998 Jan;41(1):58–67. doi: 10.1002/1529-0131(199801)41:1<58::AID-ART8>3.0.CO;2-G. [DOI] [PubMed] [Google Scholar]
  4. Braun J., Brandt J., Listing J., Zink A., Alten R., Golder W., Gromnica-Ihle E., Kellner H., Krause A., Schneider M. Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial. Lancet. 2002 Apr 6;359(9313):1187–1193. doi: 10.1016/s0140-6736(02)08215-6. [DOI] [PubMed] [Google Scholar]
  5. Calin A., Porta J., Fries J. F., Schurman D. J. Clinical history as a screening test for ankylosing spondylitis. JAMA. 1977 Jun 13;237(24):2613–2614. [PubMed] [Google Scholar]
  6. Clegg D. O., Reda D. J., Weisman M. H., Blackburn W. D., Cush J. J., Cannon G. W., Mahowald M. L., Schumacher H. R., Jr, Taylor T., Budiman-Mak E. Comparison of sulfasalazine and placebo in the treatment of ankylosing spondylitis. A Department of Veterans Affairs Cooperative Study. Arthritis Rheum. 1996 Dec;39(12):2004–2012. doi: 10.1002/art.1780391209. [DOI] [PubMed] [Google Scholar]
  7. Dougados M., Béhier J. M., Jolchine I., Calin A., van der Heijde D., Olivieri I., Zeidler H., Herman H. Efficacy of celecoxib, a cyclooxygenase 2-specific inhibitor, in the treatment of ankylosing spondylitis: a six-week controlled study with comparison against placebo and against a conventional nonsteroidal antiinflammatory drug. Arthritis Rheum. 2001 Jan;44(1):180–185. doi: 10.1002/1529-0131(200101)44:1<180::AID-ANR24>3.0.CO;2-K. [DOI] [PubMed] [Google Scholar]
  8. Dougados M., vam der Linden S., Leirisalo-Repo M., Huitfeldt B., Juhlin R., Veys E., Zeidler H., Kvien T. K., Olivieri I., Dijkmans B. Sulfasalazine in the treatment of spondylarthropathy. A randomized, multicenter, double-blind, placebo-controlled study. Arthritis Rheum. 1995 May;38(5):618–627. doi: 10.1002/art.1780380507. [DOI] [PubMed] [Google Scholar]
  9. Dougados M., van der Linden S., Juhlin R., Huitfeldt B., Amor B., Calin A., Cats A., Dijkmans B., Olivieri I., Pasero G. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum. 1991 Oct;34(10):1218–1227. doi: 10.1002/art.1780341003. [DOI] [PubMed] [Google Scholar]
  10. Feldtkeller E., Bruckel J., Khan M. A. Scientific contributions of ankylosing spondylitis patient advocacy groups. Curr Opin Rheumatol. 2000 Jul;12(4):239–247. doi: 10.1097/00002281-200007000-00002. [DOI] [PubMed] [Google Scholar]
  11. Gorman Jennifer D., Sack Kenneth E., Davis John C., Jr Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor alpha. N Engl J Med. 2002 May 2;346(18):1349–1356. doi: 10.1056/NEJMoa012664. [DOI] [PubMed] [Google Scholar]
  12. Gran J. T., Husby G. The epidemiology of ankylosing spondylitis. Semin Arthritis Rheum. 1993 Apr;22(5):319–334. doi: 10.1016/s0049-0172(05)80011-3. [DOI] [PubMed] [Google Scholar]
  13. Maksymowych Walter P., Inman Robert D., Gladman Dafna, Thomson Glen, Stone Millicent, Karsh Jacob, Russell Anthony S., Spondyloarthritis Research Consortium of Canada (SPARCC) Canadian Rheumatology Association Consensus on the use of anti-tumor necrosis factor-alpha directed therapies in the treatment of spondyloarthritis. J Rheumatol. 2003 Jun;30(6):1356–1363. [PubMed] [Google Scholar]
  14. Maksymowych Walter P. Novel therapies in the treatment of spondyloarthritis. Expert Opin Investig Drugs. 2002 Jul;11(7):937–946. doi: 10.1517/13543784.11.7.937. [DOI] [PubMed] [Google Scholar]
  15. Mau W., Zeidler H., Mau R., Majewski A., Freyschmidt J., Stangel W., Deicher H. Clinical features and prognosis of patients with possible ankylosing spondylitis. Results of a 10-year followup. J Rheumatol. 1988 Jul;15(7):1109–1114. [PubMed] [Google Scholar]
  16. Russel A. S., Maksymowych W., LeClercq S. Clinical examination of the sacroiliac joints: a prospective study. Arthritis Rheum. 1981 Dec;24(12):1575–1577. doi: 10.1002/art.1780241219. [DOI] [PubMed] [Google Scholar]
  17. Underwood M. R., Dawes P. Inflammatory back pain in primary care. Br J Rheumatol. 1995 Nov;34(11):1074–1077. doi: 10.1093/rheumatology/34.11.1074. [DOI] [PubMed] [Google Scholar]
  18. Van Den Bosch Filip, Kruithof Elli, Baeten Dominique, Herssens Annemie, de Keyser Filip, Mielants Herman, Veys Eric M. Randomized double-blind comparison of chimeric monoclonal antibody to tumor necrosis factor alpha (infliximab) versus placebo in active spondylarthropathy. Arthritis Rheum. 2002 Mar;46(3):755–765. doi: 10.1002/art.511. [DOI] [PubMed] [Google Scholar]
  19. Ward Michael M. Functional disability predicts total costs in patients with ankylosing spondylitis. Arthritis Rheum. 2002 Jan;46(1):223–231. doi: 10.1002/1529-0131(200201)46:1<223::AID-ART498>3.0.CO;2-#. [DOI] [PubMed] [Google Scholar]
  20. Zink A., Braun J., Listing J., Wollenhaupt J. Disability and handicap in rheumatoid arthritis and ankylosing spondylitis--results from the German rheumatological database. German Collaborative Arthritis Centers. J Rheumatol. 2000 Mar;27(3):613–622. [PubMed] [Google Scholar]
  21. van der Linden S., Valkenburg H. A., Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984 Apr;27(4):361–368. doi: 10.1002/art.1780270401. [DOI] [PubMed] [Google Scholar]

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada

RESOURCES