Pain

A healthy spine is able to move in many directions, which is why you can bend, turn, and twist. The spinal bones are joined together by flexible ligaments and are separated by cushiony discs, which allow a lot of movement. Movement can become impossible if the ligaments calcify and the bones fuse together. This is why AS can be disabling in its advanced stages.

Often the first sign of AS is inflammation of the sacroiliac (SI) joints. The SI joints are the two joints that connect the lower spine to the pelvis. You can feel these joints about two inches to either side of the spine in the low back. It is the inflammation which causes the symtom of pain. Inflammation eventually moves to the spine. Long-term inflammation of the spinal joints starts a process of damage to the bone where the body continually tries to repair the damage with scar tissue and new bone tissue. As the process continues, the bone becomes weaker and weaker. When the inflammation finally "burns out" and begins to disappear, the body attempts to heal the bone by producing calcium deposits around the area of the damage. For some unclear reason, as the bone heals itself, the calcium deposits spread to the ligaments and discs between the vertebrae. This leads to a fusion of the spine, sometimes referred to as bony ankylosis.

Symptoms

Like other forms of arthritis, the symptoms of AS are from the effects of inflammation. Initially the symptoms may come and go for weeks or months at a time.

The first sign of AS is usually sacroiliitis (inflammation in the SI joints). This condition causes pain in the low back and buttock areas. There is often severe low back pain, along with buttock, hip, and thigh pain on one or both sides. It usually comes on gradually and gets worse with time. Stiffness and low back pain commonly occur in the morning and ease with activity over the course of the day. Prolonged rest, such as lying down or sitting for any length of time, worsens the symptoms of AS, which is different from some other forms of low back pain that are eased with rest.

Spine flexibility is reduced with AS, which can affect your ability to bend forward and backward. In the mid back, AS can affect the joints where the ribs connect to the vertebrae. These are called the costotransverse and costovertebral joints. Inflammation in these joints can cause pain in the chest wall and into the abdomen. Symptoms in the neck include stiffness, pain, and limited neck motion. Because AS attacks the joints of the body, synovitis can occur. Synovitis is a term used to describe inflammation of the synovial membrane (lining of the joints). Symptoms of synovitis include pain, stiffness, and swelling in any joint in the body.

Breathing can be affected as AS progresses. The disease can make the mid back round forward, a deformity called kyphosis. When this occurs, it can compress the lungs and make it increasingly difficult to take a breath. Also, when the disease affects the joints between the ribs and spine, the chest loses its ability to expand enough to take a full breath. Inflammation of the lungs can also occur with AS, making it even harder to breathe.

The eyes can be affected by AS. About 25 percent of AS patients develop iritis, a condition that is caused by inflammation of the iris. The iris is the colored part of your eye around the pupil. There may be pain and redness in the eye, but usually vision is not impaired.

The spine bones may eventually grow together, fusing into one continuous column of bone. This is due to calcification of the ligaments and discs between each vertebra. If the vertebrae fuse together, the spine is robbed of mobility, leaving the vertebrae brittle and vulnerable to fractures. When the spine becomes completely fused together, the pain in the spinal area usually goes away. This does not signal a remission of the disease. However, patients are left with no spinal mobility and brittle bones that are more likely to fracture. If pain suddenly reappears in the back after a long period of no pain, there may be a fractured vertebra.

TreatmentThe goal of treatment is to relieve pain and stiffness, and prevent or delay complications and spinal deformity. Treatment of ankylosing spondylitis is most successful early, before it causes irreversible damage to your joints, such as fusion, especially in positions that limit your function.

Medications
Your doctor may recommend that you take one or more of the following medications:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs — such as naproxen (Naprosyn) and indomethacin (Indocin) — are the medications doctors most commonly use to treat ankylosing spondylitis. They can relieve your inflammation, pain and stiffness.
• Disease-modifying antirheumatic drugs (DMARDs). Your doctor may prescribe a DMARD, such as sulfasalazine (Azulfidine) or methotrexate (Rheumatrex), to treat inflamed joints and other tissues.
• Corticosteroids. These medications, such as prednisone, may suppress inflammation and slow joint damage in severe cases of ankylosing spondylitis. You usually take them orally, ideally for a limited period of time because of their side effects. Occasionally, corticosteroids are injected directly into a painful joint.
• Tumor necrosis factor (TNF) blockers. Doctors originally used TNF blockers to treat rheumatoid arthritis. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers target or block this protein and can help reduce pain, stiffness, and tender or swollen joints. These medications, such as etanercept (Enbrel) and infliximab (Remicade), may decrease inflammation and improve pain and stiffness for people with ankylosing spondylitis.

Physical therapy
Physical therapy can provide a number of benefits, from pain relief to improved physical strength and flexibility. Safe movement can improve spine mobility and posture. Physical therapy assists in pain control and prevention of deformities from AS. Patients are advised against prolonged sitting and best rest and encouraged to keep their spine straight, walk erect, and avoid stooping over for long periods.

The goals of physical therapy are to help you:

• Learn correct posture and body movements to counteract rounding of the upper back (kyphosis)
• Use appropriate sleep positions upon a firm mattress and thin pillow
• Maintain appropriate activity levels
• Implement daily stretching and strengthening exercises
• Learn ways to manage your condition

As your condition worsens, your upper body may begin to stoop forward. Proper sleep and walking positions and abdominal and back exercises can help maintain your upright posture. Though you may develop spine stiffness despite your treatment, proper posture can help to ensure that your spine is fused in a fixed upright position.

Surgery
Most people with ankylosing spondylitis don't need surgery. Surgery may help if you have severe pain or joint damage. You may need surgery if a nonspinal joint needs to be replaced. However, doctors don't usually recommend back surgery.