Overview

Spondylitis refers to inflammation of the vertebrae, the bones that make up the spine. This chronic condition primarily affects the axial skeleton, including the spine, sacroiliac joints, and sometimes peripheral joints. The inflammation can lead to new bone formation, potentially causing segments of the spine to fuse together in a fixed, immobile position. This fusion, called ankylosis, can result in a rigid spine and significantly reduced flexibility.

The term spondylitis encompasses several related conditions, with ankylosing spondylitis (AS) being the most common and well-studied form. Other types include enteropathic arthritis (associated with inflammatory bowel disease), psoriatic spondylitis (associated with psoriasis), reactive arthritis, and undifferentiated spondyloarthritis. These conditions share similar features but may have different triggers, associated symptoms, and progression patterns.

Spondylitis typically begins in early adulthood, with most people experiencing their first symptoms before age 40. The condition affects approximately 0.1% to 1.4% of the population, with significant variation based on geographic location and genetic factors. While spondylitis can affect anyone, it shows a strong genetic component and tends to run in families. Early diagnosis and treatment are crucial for managing symptoms and preventing severe spinal deformity.

Symptoms

Spondylitis symptoms typically develop gradually over months or years, with periods of improvement alternating with flare-ups. The hallmark symptom is inflammatory back pain, which differs from mechanical back pain in several key ways. Understanding these symptoms is crucial for early diagnosis and appropriate treatment.

Primary Symptoms

  • Low back pain - Chronic pain in the lower back, often worse in the morning or after periods of inactivity
  • Back pain - Pain that may extend throughout the spine, typically improving with exercise
  • Stiffness all over - Morning stiffness lasting more than 30 minutes, particularly affecting the spine
  • Neck pain - Pain and stiffness in the cervical spine, especially in advanced cases
  • Hip pain - Deep pain in the hips or buttocks, often alternating sides
  • Side pain - Pain along the sides of the torso, especially with deep breathing

Additional Symptoms

  • Leg pain - Radiating pain down the legs, similar to sciatica
  • Lower body pain - Generalized pain affecting the pelvis and lower extremities
  • Back mass or lump - Swelling or prominence along the spine due to inflammation
  • Fatigue and general malaise
  • Loss of appetite and weight loss
  • Low-grade fever during flare-ups

Characteristic Pain Patterns

Inflammatory back pain associated with spondylitis has distinct characteristics:

  • Insidious onset: Develops gradually over weeks to months
  • Duration: Persists for more than 3 months
  • Morning stiffness: Worse upon waking, improves with activity
  • Night pain: Often awakens patients in the second half of the night
  • Exercise response: Improves with physical activity, worsens with rest

Extra-spinal Manifestations

Spondylitis can affect other body systems:

  • Eye inflammation (uveitis): Occurs in 20-30% of patients
  • Enthesitis: Inflammation where tendons attach to bones
  • Peripheral arthritis: Joint pain in knees, ankles, or shoulders
  • Cardiovascular involvement: Rare but serious complications

Causes

The exact cause of spondylitis remains unknown, but research indicates it results from a complex interaction between genetic predisposition, environmental factors, and immune system dysfunction. The condition appears to be triggered when the immune system mistakenly attacks healthy tissue in the spine and joints, leading to chronic inflammation.

Genetic Factors

  • HLA-B27 gene: Present in 90-95% of people with ankylosing spondylitis, though only 5-6% of HLA-B27 carriers develop the condition
  • Other genetic markers: ERAP1, IL23R, and other genes contribute to disease susceptibility
  • Family history: First-degree relatives have a 10-20 times higher risk
  • Ethnic variations: HLA-B27 prevalence varies by population, affecting disease distribution

Environmental Triggers

  • Bacterial infections: Certain gastrointestinal or genitourinary infections may trigger reactive arthritis
  • Gut microbiome: Alterations in intestinal bacteria may play a role in disease development
  • Mechanical stress: Physical trauma or repetitive stress on the spine
  • Smoking: Associated with more severe disease and poorer treatment response

Immune System Dysfunction

The pathophysiology involves:

  • Activation of inflammatory pathways, particularly IL-17 and IL-23
  • T-cell mediated inflammation targeting spinal structures
  • Abnormal bone formation following inflammation
  • Disruption of the balance between bone resorption and formation

Associated Conditions

Spondylitis may develop in association with:

Risk Factors

Several factors increase the likelihood of developing spondylitis. While some risk factors cannot be modified, understanding them helps identify at-risk individuals for early screening and intervention.

Non-Modifiable Risk Factors

  • Genetics: HLA-B27 positivity increases risk 50-fold
  • Family history: Having a first-degree relative with spondylitis
  • Age: Onset typically between ages 20-40, rarely after 45
  • Gender: Males are 2-3 times more likely to develop ankylosing spondylitis
  • Ethnicity: Higher prevalence in Northern European and Native American populations

Modifiable Risk Factors

  • Smoking: Associated with increased disease activity and radiographic progression
  • Obesity: May worsen symptoms and reduce treatment effectiveness
  • Sedentary lifestyle: Lack of exercise can accelerate stiffness and fusion
  • Poor posture: Can exacerbate spinal deformity

Associated Medical Conditions

  • Inflammatory bowel disease - 5-10% of IBD patients develop spondylitis
  • Psoriasis - Up to 30% may develop psoriatic arthritis
  • Uveitis - History of eye inflammation
  • Recent bacterial infections (for reactive arthritis)

Environmental Factors

  • Occupational factors involving repetitive spinal stress
  • Geographic location (higher rates in temperate climates)
  • Dietary factors (under investigation)

Diagnosis

Diagnosing spondylitis can be challenging, especially in early stages when symptoms may be subtle or attributed to common back pain. The average delay between symptom onset and diagnosis is 5-7 years. A comprehensive evaluation combining clinical assessment, imaging studies, and laboratory tests is essential for accurate diagnosis.

Clinical Evaluation

The diagnostic process begins with:

  • Medical history: Detailed assessment of pain characteristics, morning stiffness, family history
  • Physical examination: Testing spinal mobility, chest expansion, and joint involvement
  • BASMI score: Bath Ankylosing Spondylitis Metrology Index to assess spinal mobility
  • Schober's test: Measures lumbar spine flexion

Imaging Studies

X-rays (Radiography)

  • Shows structural changes in sacroiliac joints and spine
  • May be normal in early disease
  • Reveals erosions, sclerosis, and fusion in advanced cases

MRI (Magnetic Resonance Imaging)

  • Detects early inflammatory changes before X-ray abnormalities
  • Shows bone marrow edema and enthesitis
  • Essential for diagnosing non-radiographic axial spondyloarthritis

CT Scan

  • Better visualization of bony changes
  • Used when MRI is contraindicated

Laboratory Tests

  • HLA-B27: Positive in 90% of AS patients but not diagnostic alone
  • Inflammatory markers: ESR and CRP may be elevated but can be normal
  • Complete blood count: May show mild anemia
  • Autoimmune markers: Usually negative (RF, ANA)

Diagnostic Criteria

The Assessment of SpondyloArthritis International Society (ASAS) criteria include:

  • Back pain ≥3 months in patients <45 years old
  • Sacroiliitis on imaging plus ≥1 SpA feature, OR
  • HLA-B27 positive plus ≥2 other SpA features

Differential Diagnosis

Conditions to rule out include:

Treatment Options

Treatment for spondylitis aims to reduce inflammation, manage pain, maintain spinal flexibility, and prevent complications. A multidisciplinary approach combining medications, physical therapy, and lifestyle modifications provides the best outcomes. Early, aggressive treatment can significantly alter disease progression.

Non-Pharmacological Treatment

Physical Therapy and Exercise

  • Daily stretching: Maintains spinal flexibility and posture
  • Strengthening exercises: Core and back muscle strengthening
  • Swimming: Excellent low-impact whole-body exercise
  • Yoga or Pilates: Improves flexibility and breathing
  • Posture training: Prevents spinal deformity

Lifestyle Modifications

  • Smoking cessation (critical for treatment success)
  • Ergonomic workplace adjustments
  • Proper sleep positioning with appropriate mattress
  • Weight management to reduce joint stress
  • Stress reduction techniques

Medications

First-Line Treatments

  • NSAIDs: Reduce inflammation and pain; may slow radiographic progression
  • COX-2 inhibitors: Alternative for patients with GI risk
  • Analgesics: For additional pain control

Biologic Therapies

  • TNF inhibitors: Adalimumab, etanercept, infliximab, golimumab, certolizumab
  • IL-17 inhibitors: Secukinumab, ixekizumab
  • JAK inhibitors: Tofacitinib, upadacitinib for peripheral involvement

Other Medications

  • Sulfasalazine: For peripheral arthritis
  • Methotrexate: Limited efficacy for axial disease
  • Corticosteroids: Local injections for enthesitis or arthritis
  • Muscle relaxants: For severe muscle spasms

Surgical Interventions

  • Spinal osteotomy: For severe kyphotic deformity
  • Hip replacement: For advanced hip arthritis
  • Spinal fracture stabilization: For osteoporotic fractures

Complementary Therapies

  • Acupuncture for pain management
  • Massage therapy for muscle tension
  • Heat/cold therapy for symptom relief
  • Hydrotherapy and spa treatments

Treatment Monitoring

Regular assessments include:

  • Disease activity scores (BASDAI, ASDAS)
  • Functional assessments (BASFI)
  • Imaging to monitor progression
  • Side effect monitoring for medications

Prevention

While spondylitis cannot be completely prevented due to its strong genetic component, certain measures can reduce risk in susceptible individuals and prevent disease progression in those already diagnosed. Early intervention and lifestyle modifications play crucial roles in managing the condition.

Primary Prevention

For those at risk but not yet diagnosed:

  • Genetic counseling: For families with strong history of spondylitis
  • Early screening: Monitor HLA-B27 positive individuals with suggestive symptoms
  • Infection prevention: Proper hygiene to avoid triggering infections
  • Maintain healthy weight: Reduces mechanical stress on spine
  • Regular exercise: Strengthens supporting musculature

Secondary Prevention

For diagnosed patients to prevent progression:

  • Medication adherence: Consistent use of prescribed anti-inflammatories
  • Daily exercise routine: Essential for maintaining flexibility
  • Posture awareness: Regular posture checks and corrections
  • Smoking cessation: Critical for slowing disease progression
  • Regular monitoring: Early detection of complications

Preventing Complications

  • Osteoporosis prevention: Calcium, vitamin D, and weight-bearing exercise
  • Cardiovascular health: Regular screening and risk factor management
  • Eye care: Annual ophthalmology exams to detect uveitis
  • Fall prevention: Home safety modifications for those with limited mobility
  • Respiratory function: Breathing exercises to maintain chest expansion

Lifestyle Recommendations

  • Sleep on a firm mattress without thick pillows
  • Take frequent breaks during prolonged sitting
  • Use ergonomic furniture and tools
  • Practice stress management techniques
  • Maintain good dental hygiene (linked to inflammation)

When to See a Doctor

Early diagnosis and treatment of spondylitis can significantly improve outcomes and quality of life. Recognizing when to seek medical attention is crucial for proper management.

Seek Immediate Medical Care For:

  • Sudden, severe back pain with neurological symptoms
  • Loss of bowel or bladder control
  • Severe eye pain, redness, or vision changes
  • Chest pain or difficulty breathing
  • Signs of spinal fracture after minor trauma
  • Fever with severe joint pain and swelling

Schedule an Appointment If You Experience:

  • Chronic back pain lasting more than 3 months
  • Back pain that improves with exercise but worsens with rest
  • Morning stiffness lasting more than 30 minutes
  • Alternating buttock pain
  • Family history of spondylitis with new symptoms
  • Heel pain or other enthesitis symptoms
  • Recurrent eye inflammation

Regular Monitoring for Diagnosed Patients

  • Routine rheumatology appointments every 3-6 months
  • Annual eye examinations
  • Cardiovascular risk assessments
  • Bone density testing as recommended
  • Medication monitoring and adjustments

Warning Signs of Progression

  • Increasing difficulty with daily activities
  • Progressive loss of spinal mobility
  • New or worsening peripheral joint involvement
  • Development of extra-articular manifestations
  • Poor response to current treatments

Frequently Asked Questions

Is spondylitis the same as ankylosing spondylitis?

Ankylosing spondylitis (AS) is one type of spondylitis, specifically the most common form of axial spondyloarthritis. Spondylitis is a broader term that includes AS and other inflammatory spine conditions. All patients with AS have spondylitis, but not all spondylitis patients have AS.

Can spondylitis be cured?

Currently, there is no cure for spondylitis. However, with early diagnosis and appropriate treatment, most people can effectively manage their symptoms, maintain mobility, and lead active lives. Modern biologic medications have dramatically improved outcomes for many patients.

Will I end up in a wheelchair?

The vast majority of people with spondylitis do not require wheelchairs. With current treatments and regular exercise, most patients maintain mobility throughout their lives. Severe disability is much less common now than in the past, thanks to earlier diagnosis and better treatments.

Can women get spondylitis?

Yes, women can develop spondylitis, though it's historically been underdiagnosed in females. While men are 2-3 times more likely to develop ankylosing spondylitis, women often present with different symptoms, such as more peripheral joint involvement and less obvious spinal changes on X-rays.

Is exercise safe with spondylitis?

Exercise is not only safe but essential for managing spondylitis. Regular physical activity helps maintain flexibility, reduce pain, and prevent spinal fusion. Low-impact activities like swimming, walking, and yoga are particularly beneficial. Always consult with your healthcare provider before starting a new exercise program.

Should I be tested for HLA-B27?

HLA-B27 testing may be helpful if you have symptoms suggestive of spondylitis, especially with a family history. However, a positive test alone doesn't diagnose spondylitis, as only 5-6% of HLA-B27 positive individuals develop the condition. The test should be interpreted alongside clinical findings and imaging.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of spondylitis or any medical condition.

References

  1. Ward MM, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019.
  2. van der Heijde D, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017.
  3. Sieper J, Poddubnyy D. Axial spondyloarthritis. Lancet. 2017.
  4. Taurog JD, et al. Ankylosing Spondylitis and Axial Spondyloarthritis. N Engl J Med. 2016.
  5. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Ankylosing Spondylitis. NIAMS. 2023.