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    What are the signs and symptoms of Ankylosing Spondylitis?

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    Ankylosing Spondylitis usually presents with inflammatory spinal pain and stiffness. The most common site of spinal involvement is the sacroiliac joints, with the thoracic spine (midback), lumbar (low back) and cervical spine (neck) becoming affected as the disease progresses. What defines inflammatory back pain has been debated for many years. Most recently the Assessment of SpondyloArthritis international Society (ASAS) suggested that the following features of back pain are most suggestive of an inflammatory spinal disease, such as AS;

    • Age at onset <40 years
    • Insidious onset
    • Improvement with exercise
    • No improvement with rest
    • Pain at night with improvement upon getting out of bed

    When at least 4 of these 5 features are present, the back pain is essentially related to inflammation of the spine. A number of other features have also been considered suggestive of inflammation at the spine and sacroiliac joints, such as;

    • Duration of back pain extending beyond 3 months
    • Morning stiffness lasting more than 30 minutes
    • Alternating buttock pain
    • Waking during the second half of the night only
    • Overtime the spine progressively stiffens as inflammation settles and extra bone formation develops. This results in a loss of motion and often deformity, especially in the spine where the patient develops a stooped flexed hip posture. This can make it difficult to perform usual daily activities such as walking. Loss of movement and deformity is usually a late manifestation of the disease.

    In addition to inflammation at the spine, those affected with AS and the related condition also develop inflammation at the enthesis, which the site where tendons or ligaments joint onto bone. This is termed enthesitis. The most common sites of involvement include the insertion of the Achilles tendon and the Plantar fascia on the calcaneus (heel bone). A special type of enthesitis, where tendons and ligaments of the fingers or toes are involved is termed Dactylitis. This can also be referred to as ‘sausage’ fingers or toes because of the appearance.

    Arthritis of joints not involving the spine can also occur, termed peripheral arthritis. This can occur in up to 20-50% of patients. This is less commonly the case in AS compared to the other Spondyloarthritides, which when present often affects a small number of joints in an asymmetrical pattern, with the most commonly affected joints being the hips and knees.

    AS can also be associated with inflammation affecting other body organs in addition to joints. The most common extra-articular manifestation of the disease is acute anterior uveitis, which occurs in up to 20-30% of patients. This usually presents with a sudden onset of eye pain that is often accompanied by visual changes, sensitivity to light, and increased lacrimation (tears). The development of such symptoms should prompt an urgent referral to the ophthalmologist.

    Less common extra-articular problems in AS include insufficiency of the aortic valve due to aortitis, disturbance in the conduction of electrical signal in the heart, inflammation of the lung termed pneumonitis, and rarely secondary amyloidosis where abnormal insoluble proteins are deposited in various bodily tissues.

    Finally, AS is a systemic disease and as such fatigue is often reported. Less commonly fever and weight loss can occur, especially during periods of very active disease. 
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