Citation, DOI, disclosures and article data
At the time the article was created Frank Gaillard had no recorded disclosures.View Frank Gaillard's current disclosures
At the time the article was last revised Akinola Ayodeji Odedeyi had no financial relationships to ineligible companies to disclose.View Akinola Ayodeji Odedeyi's current disclosures
Ankylosing spondylitis (less commonly known as Bechterew disease or Marie Strümpell disease) is a seronegative spondyloarthropathy, which results in fusion (ankylosis) of the spine and sacroiliac (SI) joints, although involvement is also seen in large and small joints.
Traditionally it was thought there was a male predilection of 3:1 or more, however, the gender predilection of the disease is a matter of recent debate and research (females may be under-diagnosed). According to some research, men tend toward more severe disease 28. The disease usually manifests in young adults, with the first symptoms becoming evident in the third decade, although up to 18% of cases manifest in the second decade.
anterior uveitis (25-40%)
apical/upper lobe predominant interstitial lung disease with small cystic spaces (in ~1% of patients) 4
aortic valve disease / aortitis
secondary amyloidosis (rare)
cauda equina syndrome (rare)
Patients are rheumatoid factor (RF) negative, hence seronegative. HLA B27 is the gene with the strongest association. Other possibly contributing genes include ERAP-1, IL23R and TNF-associated genes 22. Although approximately 90% of Caucasian individuals with ankylosing spondylitis have the HLA-B27 gene, it is important to note this gene is present in 8-9% of people of Northern European ancestry 5. Overall, ~5% of people positive for HLA-B27 develop ankylosing spondylitis.
The axial skeleton is predominantly affected, although in ~20% of cases the peripheral joints are also involved.
sacroiliitis is usually the first manifestation 5 and is symmetrical and bilateral
the sacroiliac joints first widen before they narrow
subchondral erosions, sclerosis, and proliferation on the iliac side of the SI joints
at end-stage, the SI joint may be seen as a thin line or not visible
diffuse syndesmophytic ankylosis can give a "bamboo spine" appearance
syndesmophytes are classically described as paravertebral ossification running parallel to the spine
linear ossification along the central spine; representing interspinous ligament ossification can give a "dagger spine" appearance on frontal radiographs;
ossification of spinal ligaments, joints and discs (with fatty marrow within the ossified disc, best seen on MRI)
apophyseal and costovertebral arthritis and ankylosis
pseudoarthroses may form at fracture sites
Hip involvement is generally bilateral and symmetric, with uniform joint space narrowing, axial migration of the femoral head sometimes reaching a state of protrusio acetabuli, and a collar of osteophytes at the femoral head-neck junction.
Whiskering of the pelvic bones primarily affects the ischial tuberosities, resulting from ossification of the ligamentous origins.
There can be bridging or fusion of the pubic symphysis.
Knees demonstrate uniform joint space narrowing with bony proliferation.
Hands are generally involved asymmetrically, with smaller, shallower erosions and marginal periostitis.
Radiographs of the lungs may demonstrate progressive fibrosis and bullous changes at the apices. These lesions may resemble tuberculosis infection and bullae may become infected.
Plain radiograph may be normal, or may reveal cardiomegaly.
may be useful in selected patients with normal or equivocal findings on sacroiliac joint radiographs
chronic structural changes such as joint erosions, subchondral sclerosis, and bony ankylosis are better visualized on CT than on MRI or radiographs 15-17
some normal variants of the SI joints may mimic features of sacroiliitis
supplements scintigraphy in evaluating areas of increased uptake
superior to radiographs and MRI in demonstrating injuries
imaging modality of choice in patients with advanced ankylosing spondylitis in whom there is suspicion of cervical spine fracture
sagittal reformats should be obtained as axial images poorly assess the transverse fracture plane
may have a role in early diagnosis of sacroiliitis; MRI is more sensitive than CT or plain radiography in detecting inflammatory changes (which precede structural changes) such as bone marrow edema (best demonstrated on STIR sequences), synovitis and capsulitis (on gadolinium enhanced T1 weighted sequences) 16,18
synovial enhancement on MR correlates with disease activity measured by inflammatory mediators
enhancement of the interspinous ligaments is indicative of enthesitis
increased T2 signal correlates with edema or vascularized fibrous tissue
superior to CT in the detection of cartilage inflammation and destruction
useful in following treatment results in patients with active ankylosing spondylitis
maybe helpful in selected patients with normal or equivocal findings on sacroiliac joint radiographs
qualitative assessment of accumulation of radionuclide in the SI joints may be difficult due to normal uptake in this location; thus, quantitative analysis may be more useful
ratios of SI joint to sacral uptake of 1.3:1 or higher is abnormal
Treatment and prognosis
First-line therapy is primarily focussed on NSAIDs and non-pharmacological measures including education, exercise, physiotherapy and group therapy. Together, these treatments can lead to substantial clinical improvement in 70-80% of patients. Local steroid injection and DMARDs (sulfasalazine and methotrexate) can also help with peripheral manifestations. Second-line therapy includes TNF-alpha blockers (etanercept, infliximab, adalimumab, certolizumab, golimumab) and IL17 inhibitors (secukinumab) 24. Whether TNF-alpha blockers can inhibit radiographic disease progression has been the subject of some debate and continues to be investigated 23.
patients with ankylosing spondylitis have a 4x higher chance than the general population of spinal fracture; the overall risk of fracture is 5-15% 30
diffuse paraspinal ossification and inflammatory osteitis creates a fused, brittle spine, susceptible to fracture, even with minor trauma
more common at the thoracolumbar and cervicothoracic junctions
recognition of minimally displaced fractures is difficult due to osteopenia and deformity, and it is important to specifically search for disc space widening and discontinuity of the ossified paraspinal ligaments
also known as "chalk stick" or "carrot stick fractures" 19
Andersson lesion: inflammatory spondylodiscitis that occurs in association with ankylosing spondylitis and results in a disc pseudarthrosis
Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
A subjective assessment by the patient on a scale of 1- 10 (least to most severe) in the following six parameters 29:
How would you describe the overall level of fatigue/tiredness you have experienced?
How would you describe the overall level of AS neck, back, or hip pain you have had?
How would you describe the overall level of pain/swelling in joints other than neck, back, or hips you have had?
How would you describe the overall level of discomfort you have had from any areas tender to touch or pressure?
How would you describe the overall level of discomfort you have had from the time you wake up?
How long does your morning stiffness last from the time you wake up?
- 1. Riley M, Ansell B, Bywaters E. Radiological Manifestations of Ankylosing Spondylitis According to Age at Onset. Ann Rheum Dis. 1971;30(2):138-48. doi:10.1136/ard.30.2.138 - Pubmed
- 2. Resnick D & Niwayama G. Entheses and Enthesopathy. Anatomical, Pathological, and Radiological Correlation. Radiology. 1983;146(1):1-9. doi:10.1148/radiology.146.1.6849029 - Pubmed
- 3. Wilkinson M & Bywaters E. Clinical Features and Course of Ankylosing Spondylitis; as Seen in a Follow-Up of 222 Hospital Referred Cases. Ann Rheum Dis. 1958;17(2):209-28. doi:10.1136/ard.17.2.209 - Pubmed
- 4. Mayberry J, Primack S, Müller N. Thoracic Manifestations of Systemic Autoimmune Diseases: Radiographic and High-Resolution CT Findings. Radiographics. 2000;20(6):1623-35. doi:10.1148/radiographics.20.6.g00nv031623 - Pubmed
- 5. Wang Y, Teng M, Chang C, Wu H, Wang S. Imaging Manifestations of Spinal Fractures in Ankylosing Spondylitis. AJNR Am J Neuroradiol. 2005;26(8):2067-76. PMC8148850 - Pubmed
- 6. Jacobson J, Girish G, Jiang Y, Resnick D. Radiographic Evaluation of Arthritis: Inflammatory Conditions. Radiology. 2008;248(2):378-89. doi:10.1148/radiol.2482062110 - Pubmed
- 7. Baraliakos X, Landewé R, Hermann K et al. Inflammation in Ankylosing Spondylitis: A Systematic Description of the Extent and Frequency of Acute Spinal Changes Using Magnetic Resonance Imaging. Ann Rheum Dis. 2005;64(5):730-4. doi:10.1136/ard.2004.029298 - Pubmed
- 8. Bennett D, Ohashi K, El-Khoury G. Spondyloarthropathies: Ankylosing Spondylitis and Psoriatic Arthritis. Radiol Clin North Am. 2004;42(1):121-34. doi:10.1016/S0033-8389(03)00156-8 - Pubmed
- 9. Cawley M, Chalmers T, Kellgren J, Ball J. Destructive Lesions of Vertebral Bodies in Ankylosing Spondylitis. Ann Rheum Dis. 1972;31(5):345-58. doi:10.1136/ard.31.5.345 - Pubmed
- 10. Dihlmann W. Current Radiodiagnostic Concept of Ankylosing Spondylitis. Skeletal Radiol. 1979;4(4):179-88. doi:10.1007/BF00347211 - Pubmed
- 11. Fam A, Rubenstein J, Chin-Sang H, Leung F. Computed Tomography in the Diagnosis of Early Ankylosing Spondylitis. Arthritis Rheum. 1985;28(8):930-7. doi:10.1002/art.1780280813 - Pubmed
- 12. Graham B & Van Peteghem P. Fractures of the Spine in Ankylosing Spondylitis. Diagnosis, Treatment, and Complications. Spine (Phila Pa 1976). 1989;14(8):803-7. doi:10.1097/00007632-198908000-00005 - Pubmed
- 13. Hanson J & Mirza S. Predisposition for Spinal Fracture in Ankylosing Spondylitis. AJR Am J Roentgenol. 2000;174(1):150. doi:10.2214/ajr.174.1.1740150 - Pubmed
- 14. Francis A. Burgener, Martti Kormano, Tomi Pudas. Differential Diagnosis in Conventional Radiology. (2008) ISBN: 9781588902757 - Google Books
- 15. Diekhoff T, Hermann K, Greese J et al. Comparison of MRI with Radiography for Detecting Structural Lesions of the Sacroiliac Joint Using CT as Standard of Reference: Results from the SIMACT Study. Ann Rheum Dis. 2017;76(9):1502-8. doi:10.1136/annrheumdis-2016-210640 - Pubmed
- 16. Khmelinskii N, Regel A, Baraliakos X. The Role of Imaging in Diagnosing Axial Spondyloarthritis. Front Med (Lausanne). 2018;5:106. doi:10.3389/fmed.2018.00106 - Pubmed
- 17. Puhakka K, Jurik A, Egund N et al. Imaging of Sacroiliitis in Early Seronegative Spondylarthropathy. Assessment of Abnormalities by MR in Comparison with Radiography and CT. Acta Radiol. 2003;44(2):218-29. doi:10.1034/j.1600-0455.2003.00034.x - Pubmed
- 18. Hermann K, Althoff C, Schneider U et al. Spinal Changes in Patients with Spondyloarthritis: Comparison of MR Imaging and Radiographic Appearances. Radiographics. 2005;25(3):559-69; discussion 569. doi:10.1148/rg.253045117 - Pubmed
- 19. Chittem L, Bhattacharjee S, Harshavardhan K. Carrot Stick Fracture of Cervical Spine in Ankylosing Spondylitis. Neurol India. 2013;61(3):337. doi:10.4103/0028-3886.115102 - Pubmed
- 20. Oh D, Jun J, Kim H et al. Transverse Myelitis in a Patient with Long-Standing Ankylosing Spondylitis. Clin Exp Rheumatol. 2001;19(2):195-6. - Pubmed
- 21. Lan H, Chen D, Chen C, Lan J, Hsieh C. Combination of Transverse Myelitis and Arachnoiditis in Cauda Equina Syndrome of Long-Standing Ankylosing Spondylitis: MRI Features and Its Role in Clinical Management. Clin Rheumatol. 2007;26(11):1963-7. doi:10.1007/s10067-007-0593-2 - Pubmed
- 22. Evans D, Spencer C, Pointon J et al. Interaction Between ERAP1 and HLA-B27 in Ankylosing Spondylitis Implicates Peptide Handling in the Mechanism for HLA-B27 in Disease Susceptibility. Nat Genet. 2011;43(8):761-7. doi:10.1038/ng.873 - Pubmed
- 23. Molnar C, Scherer A, Baraliakos X et al. TNF Blockers Inhibit Spinal Radiographic Progression in Ankylosing Spondylitis by Reducing Disease Activity: Results from the Swiss Clinical Quality Management Cohort. Ann Rheum Dis. 2018;77(1):63-9. doi:10.1136/annrheumdis-2017-211544 - Pubmed
- 24. Sieper J & Poddubnyy D. Axial Spondyloarthritis. Lancet. 2017;390(10089):73-84. doi:10.1016/S0140-6736(16)31591-4 - Pubmed
- 25. Haywood K, Garratt A, Dawes P. Patient-Assessed Health in Ankylosing Spondylitis: A Structured Review. Rheumatology (Oxford). 2005;44(5):577-86. doi:10.1093/rheumatology/keh549 - Pubmed
- 26. Moser T, Lecours J, Michaud J, Bureau N, Guillin R, Cardinal É. The Deltoid, a Forgotten Muscle of the Shoulder. Skeletal Radiol. 2013;42(10):1361-75. doi:10.1007/s00256-013-1667-7 - Pubmed
- 27. Lambert R, Dhillon S, Jhangri G et al. High Prevalence of Symptomatic Enthesopathy of the Shoulder in Ankylosing Spondylitis: Deltoid Origin Involvement Constitutes a Hallmark of Disease. Arthritis Rheum. 2004;51(5):681-90. doi:10.1002/art.20681 - Pubmed
- 28. Lee W, Reveille J, Davis J, Learch T, Ward M, Weisman M. Are There Gender Differences in Severity of Ankylosing Spondylitis? Results from the PSOAS Cohort. Ann Rheum Dis. 2007;66(5):633-8. doi:10.1136/ard.2006.060293 - Pubmed
- 29. Garrett S, Jenkinson T, Kennedy L, Whitelock H, Gaisford P, Calin A. A New Approach to Defining Disease Status in Ankylosing Spondylitis: The Bath Ankylosing Spondylitis Disease Activity Index. J Rheumatol. 1994;21(12):2286-91. - Pubmed
- 30. Chaudhary S, Hullinger H, Vives M. Management of Acute Spinal Fractures in Ankylosing Spondylitis. ISRN Rheumatol. 2011;2011:150484. doi:10.5402/2011/150484 - Pubmed