Download Ankylosing Spondylitis

Consideration of Ankylosing Spondylitis
Inflammatory disease is a less common cause of low back pain, but it is
nonetheless important to differentiate it from the more common mechanical
low back pain.
Ankylosing Spondylitis is a chronic inflammatory disease. Clinically more
common in men than women, approximately 5% of patients presenting with
back pain have ankylosing spondylitis. Characteristic symptoms are low back
pain with prolonged early morning stiffness that improves with exercise.
It usually occurs in the third decade of life and onset after 45 years of age is
exceptional.
Information sheet developed by Pennine MSK Partnership, and kindly supplied for inclusion in
the toolkit.
Clinical suspicion
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ASAS Criteria 2009
Age at onset < 40yrs
Insidious onset
Improvement with exercise
No improvement with rest
Pain in night (with improvement on getting up)
Other considerations
Clinical Knowledge Summary 2008 suggest Ankylosing Spondylitis should be suspected in anyone with
chronic or recurrent low back pain, fatigue and stiffness, especially if:
They have current or previous:
 Buttock pain, felt sometimes on one side and sometimes on the other side — the pain is from
sacroiliitis and to be distinguished from sciatica.
 Arthritis — usually asymmetric, in the lower limbs; occasionally in the upper limbs.
 Enthesitis: Common sites are Achilles tendon, plantar fasciitis and the tibial tuberosity
 Costochondritis or epicondylitis
 Anterior uveitis (iritis): acutely painful red eye and severe photophobia. If treatment is delayed,
vision may be lost.
 Psoriasis or inflammatory bowel disease, or recent infective diarrhoea or sexually transmitted
disease (Chlamydia).
Physical examination (including Schober’s test)
Confident in assessing clinical suspicion of inflammatory back condition
YES
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Examination
Spinal examination
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Investigations
ESR, CRP
Consider X-ray
Start NSAID if no
contraindications
NO
Refer to GPsi if available/
Secondary Care
Appointment with Rheumatology consultant
To review with results
Review NSAID
Further investigations, such as MRI & HLA B27 may be considered
Refer AS physiotherapist, for BASDAI and Spinal VAS
measurements
Refer Rheumatology nurse for education and contact if available
Information sheet developed by Pennine MSK Partnership, and kindly supplied for inclusion in
the toolkit.