Ankylosing Spondylitis: The Invisible Back Pain Disease That Strikes Young Men

Ankylosing spondylitis (AS) — now classified under the broader term axial spondyloarthritis (axSpA) — is a chronic inflammatory arthritis primarily affecting the spine and sacroiliac joints. It is characterised by inflammatory back pain, progressive spinal stiffness, and ultimately, in severe uncontrolled cases, fusion of the spinal vertebrae. AS predominantly affects young men (onset typically 20–40 years), is significantly underdiagnosed in India, and causes an average diagnostic delay of 8–10 years from symptom onset.

How to Distinguish Inflammatory Back Pain from Mechanical Back Pain

Most back pain is mechanical — caused by muscle strain, disc disease, or postural problems. Inflammatory back pain from AS has a completely different character:

Feature	AS / Inflammatory	Mechanical
Age of onset	Under 40	Any age
Morning stiffness	Over 45 minutes	Under 30 minutes
Effect of rest	Worsens (stiffness)	Improves
Effect of exercise	Improves	Worsens
Night pain	Often wakes from sleep	Rarely
Alternating buttock pain	Characteristic	Rare

Extra-Articular Features of AS

AS is a systemic condition — it can cause: uveitis (recurrent painful red eye — the eye specialist seeing recurrent uveitis should screen for AS); psoriasis; inflammatory bowel disease (Crohn's, ulcerative colitis); heel pain (enthesitis at the Achilles insertion); peripheral arthritis.

Diagnosis

MRI sacroiliac joints (the most sensitive early test — detects bone marrow oedema before X-ray changes appear); X-ray pelvis (sacroiliitis in established disease); HLA-B27 (positive in 90% of AS, but also positive in 8% of the general population — not diagnostic alone); inflammatory markers (CRP, ESR — elevated in active disease but normal in 50% of AS). The diagnosis is clinical — based on inflammatory back pain pattern, MRI findings, and response to NSAIDs.

Treatment

NSAIDs (anti-inflammatory medicines): First-line — significant anti-inflammatory effect and potential to slow radiographic progression with continuous use. Physiotherapy: absolutely essential — daily spinal extension exercises maintain spinal mobility. TNF-alpha inhibitors (adalimumab, etanercept): highly effective in NSAID-refractory AS, dramatically reduce inflammation and prevent fusion. IL-17 inhibitors: effective alternative biological therapy.

For AS diagnosis and management: Sri Anand CNC, Chanda Nagar, Hyderabad. Call +91 90633 66983.