Summary
Definition
Axial spondyloarthritis (axSpA) is a chronic progressive inflammatory arthropathy. Patients present with severe pain and spinal stiffness, which ultimately may lead to radiographic changes in the spine and sacroiliac joints. This radiographic stage is known as ankylosing spondylitis (AS). Progression of disease may lead to spinal fusion. Patients with complete spinal fusion suffer extreme disability.
AS mainly affects the axial skeleton, although peripheral joints, entheses (tendon or ligament attachments to bone), and extra-articular sites such as the eye and bowel are frequently affected.[1][2]
Nonradiographic axial spondyloarthritis (nr-axSpA) describes axial inflammation visible on magnetic resonance imaging (MRI) that has not caused substantial erosive damage to the sacroiliac joints.[Figure caption and citation for the preceding image starts]: Bamboo spineStudent BMJ 2002;10:303-52. © BMJ Publishing Group Ltd 2008 [Citation ends].
History and exam
Key diagnostic factors
- HLA-B27 positive
- inflammatory back pain
- iritis/uveitis
- enthesitis
- presentation in late teens and early 20s
- male sex
- positive family history of ankylosing spondylitis (AS)
Other diagnostic factors
- fatigue
- sleep disturbance
- tenderness at sacroiliac joint
- dyspnea
- loss of lumbar lordosis
- peripheral joint involvement
- kyphosis
- psoriasis
- symptoms of inflammatory bowel disease
Risk factors
- HLA-B27
- endoplasmic reticulum aminopeptidase 1 (ERAP1) and interleukin-23 receptor (IL23R) gene polymorphisms
- positive family history of ankylosing spondylitis (AS)
- male sex
Diagnostic tests
1st tests to order
- pelvic x-ray
Tests to consider
- HLA-B27
- MRI
- cervical spine x-ray (lateral)
- lumbar spine x-ray (lateral)
- thoracic spine x-ray (lateral)
- ultrasound
Treatment algorithm
adults with pain and/or stiffness
adults without pain and/or stiffness
children
adults with pain and/or stiffness refractory to 2 NSAIDs and nonpharmacologic measures
Contributors
Authors
Antoni Chan, MBChB, FRCP, PhD
Consultant
Rheumatology Department
Royal Berkshire NHS Foundation Trust
Reading
UK
Disclosures
AC has served on the advisory boards for MSD, Novartis, and Sanofi; contributed to educational events for Janssen, MSD, Novartis, Sanofi, and Celgene; been on the speaker bureau for Janssen, Pfizer, and Novartis; and received travel grants from AbbVie, UCB, Lilly, and Pfizer to attend educational conferences.
Sarah Sacks, MBBS, BSc
Specialist Registrar in Rheumatology
Stoke Mandeville Hospital
Aylesbury
UK
Disclosures
SS declares that she has no competing interests.
Acknowledgements
Dr Antoni Chan and Dr Sarah Sacks would like to gratefully acknowledge Dr Jessica Gunn, Dr Sarah Keidel, Dr Millicent Stone, Dr Raj Sengupta, Dr Athimalaipet V. Ramanan, and Dr Emma Pomeroy, the previous contributors to this topic. We would like to gratefully acknowledge the late Dr Andrew Keat, Consultant Physician and Rheumatologist at Northwick Park Hospital for his contribution to this topic as a peer reviewer.
Disclosures
JG, SK, RS, and AVR declare that they have no competing interests. MS is an author of several references cited in this topic. EP is an author of a reference cited in this topic.
Peer reviewers
Roger Sturrock, MD, FRCP
Professor of Rheumatology
Centre for Rheumatic Diseases
University Department of Medicine
Glasgow Royal Infirmary University Trust
Glasgow
UK
Disclosures
RS is an author of a reference cited in this topic.
Karl Gaffney, BCh, BAO (Hons), FRCPI, FRCP
Consultant
Norfolk and Norwich University Hospital
Norwich and the Cromer & District Hospital
Cromer
UK
Disclosures
KG is an author of a reference cited in this topic.
Alexios G. Carayannopoulos, DO, MPH
Interventional Spine Physiatrist
Pain Medicine Specialist
Medical Director
Spine Center
Lahey Clinic
Burlington
MA
Disclosures
AGC declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Ramiro S, Nikiphorou E, Sepriano A, et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis. 2023 Jan;82(1):19-34.Full text Abstract
Ward MM, Deodhar A, Gensler LS, 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 andnonradiographic axial spondyloarthritis. Arthritis Rheumatol. 2019 Oct;71(10):1599-613.Full text Abstract
National Institute for Health and Care Excellence (UK). Spondyloarthritis in over 16s: diagnosis and management. Jun 2017 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Osteoarthritis
- Diffuse idiopathic skeletal hyperostosis (DISH)
- Psoriatic arthritis
More DifferentialsGuidelines
- ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update
- EULAR points to consider for therapeutic drug monitoring of biopharmaceuticals in inflammatory rheumatic and musculoskeletal diseases
More GuidelinesPatient information
Axial spondyloarthritis: what are the treatment options?
Axial spondyloarthritis: what is it?
More Patient informationVideos
Aspiration and injection of the knee: animated demonstration
Aspiration and injection of the shoulder animated demonstration
More videos
Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer