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Clinical manifestations of ankylosing spondylitis in adults

David T Yu, MD
Astrid van Tubergen, MD, PhD
Section Editor
Joachim Sieper, MD
Deputy Editor
Paul L Romain, MD


Ankylosing spondylitis (AS), a form of spondyloarthritis (SpA), is a chronic inflammatory disease of the axial skeleton manifested by back pain and progressive stiffness of the spine; it can also involve the hips, shoulders, peripheral joints, entheses, and digits. Extraarticular manifestations, including uveitis, may also be seen in patients with AS and other forms of SpA. AS typically develops in young adults, with a peak age of onset between 20 and 30 years. The endpoint, which occurs in only a subset, is complete spinal fusion with hyperkyphosis.

The name “ankylosing spondylitis” is derived from the Greek root “ankylosis,” meaning stiffening of a joint, and “spondylos,” which refers to a vertebra. “Ankylosing spondylitis” thus refers to the inflammatory disorder associated with fibrous or bony bridging of joints in the spine, including the bridging of intervertebral discs.

The epidemiology and clinical manifestations of AS are reviewed here. The pathogenesis, classification criteria, diagnosis, and treatment of AS and other SpA in adults, and SpA in children, are discussed separately. (See "Pathogenesis of spondyloarthritis" and "Diagnosis and differential diagnosis of axial spondyloarthritis (ankylosing spondylitis and non-radiographic axial spondyloarthritis) in adults" and "Assessment and treatment of ankylosing spondylitis in adults" and "Spondyloarthritis in children".)


Ankylosing spondylitis (AS) is the prototypic form of spondyloarthritis (SpA), a family of disorders characterized by inflammation around the entheses (the sites of ligament insertion into bone), an association with the human leukocyte antigen (HLA)-B27, and radiographic sacroiliitis.

Classically, the diseases which comprise the SpA are AS, undifferentiated SpA, reactive arthritis, psoriatic arthritis, juvenile SpA, and arthritis/spondylitis associated with inflammatory bowel diseases (IBD). (See "Reactive arthritis" and "Clinical manifestations and diagnosis of peripheral spondyloarthritis in adults" and "Clinical manifestations and diagnosis of psoriatic arthritis" and "Spondyloarthritis in children" and "Clinical manifestations and diagnosis of arthritis associated with inflammatory bowel disease and other gastrointestinal diseases".)


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Literature review current through: May 2017. | This topic last updated: Sep 28, 2015.
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  1. Dean LE, Jones GT, MacDonald AG, et al. Global prevalence of ankylosing spondylitis. Rheumatology (Oxford) 2014; 53:650.
  2. Reveille JD. Epidemiology of spondyloarthritis in North America. Am J Med Sci 2011; 341:284.
  3. Reveille JD, Hirsch R, Dillon CF, et al. The prevalence of HLA-B27 in the US: data from the US National Health and Nutrition Examination Survey, 2009. Arthritis Rheum 2012; 64:1407.
  4. Brown MA, Laval SH, Brophy S, Calin A. Recurrence risk modelling of the genetic susceptibility to ankylosing spondylitis. Ann Rheum Dis 2000; 59:883.
  5. Carter N, Williamson L, Kennedy LG, et al. Susceptibility to ankylosing spondylitis. Rheumatology (Oxford) 2000; 39:445.
  6. El Maghraoui A, Bensabbah R, Bahiri R, et al. Cervical spine involvement in ankylosing spondylitis. Clin Rheumatol 2003; 22:94.
  7. Rudwaleit M, Haibel H, Baraliakos X, et al. The early disease stage in axial spondylarthritis: results from the German Spondyloarthritis Inception Cohort. Arthritis Rheum 2009; 60:717.
  8. Jang JH, Ward MM, Rucker AN, et al. Ankylosing spondylitis: patterns of radiographic involvement--a re-examination of accepted principles in a cohort of 769 patients. Radiology 2011; 258:192.
  9. van Tubergen A, van der Heijde D, Dougados M, et al. Are syndesmophytes most prevalent in the lumbar or in the cervical spine in patients with ankylosing spondylitis and do they develop in a specific direction? Rheumatology (Oxford) 2012; 51:1432.
  10. Gran JT, Husby G, Hordvik M, et al. Radiological changes in men and women with ankylosing spondylitis. Ann Rheum Dis 1984; 43:570.
  11. Atagunduz P, Aydin SZ, Bahadir C, et al. Determinants of early radiographic progression in ankylosing spondylitis. J Rheumatol 2010; 37:2356.
  12. Brophy S, Mackay K, Al-Saidi A, et al. The natural history of ankylosing spondylitis as defined by radiological progression. J Rheumatol 2002; 29:1236.
  13. Calin A, Garrett S, Whitelock H, et al. A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. J Rheumatol 1994; 21:2281.
  14. Underwood MR, Dawes P. Inflammatory back pain in primary care. Br J Rheumatol 1995; 34:1074.
  15. Sieper J, van der Heijde D, Landewé R, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Ann Rheum Dis 2009; 68:784.
  16. Rudwaleit M, van der Heijde D, Khan MA, et al. How to diagnose axial spondyloarthritis early. Ann Rheum Dis 2004; 63:535.
  17. Weisman MH. Inflammatory back pain: the United States perspective. Rheum Dis Clin North Am 2012; 38:501.
  18. Roussou E, Sultana S. Spondyloarthritis in women: differences in disease onset, clinical presentation, and Bath Ankylosing Spondylitis Disease Activity and Functional indices (BASDAI and BASFI) between men and women with spondyloarthritides. Clin Rheumatol 2011; 30:121.
  19. Sawacha Z, Carraro E, Del Din S, et al. Biomechanical assessment of balance and posture in subjects with ankylosing spondylitis. J Neuroeng Rehabil 2012; 9:63.
  20. Carette S, Graham D, Little H, et al. The natural disease course of ankylosing spondylitis. Arthritis Rheum 1983; 26:186.
  21. McEwen C, DiTata D, Lingg C, et al. Ankylosing spondylitis and spondylitis accompanying ulcerative colitis, regional enteritis, psoriasis and Reiter's disease. A comparative study. Arthritis Rheum 1971; 14:291.
  22. Rudwaleit M, Metter A, Listing J, et al. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum 2006; 54:569.
  23. Vander Cruyssen B, Muñoz-Gomariz E, Font P, et al. Hip involvement in ankylosing spondylitis: epidemiology and risk factors associated with hip replacement surgery. Rheumatology (Oxford) 2010; 49:73.
  24. Vander Cruyssen B, Ribbens C, Boonen A, et al. The epidemiology of ankylosing spondylitis and the commencement of anti-TNF therapy in daily rheumatology practice. Ann Rheum Dis 2007; 66:1072.
  25. Ciurea A, Scherer A, Exer P, et al. Tumor necrosis factor α inhibition in radiographic and nonradiographic axial spondyloarthritis: results from a large observational cohort. Arthritis Rheum 2013; 65:3096.
  26. Sampaio-Barros PD, Bertolo MB, Kraemer MH, et al. Primary ankylosing spondylitis: patterns of disease in a Brazilian population of 147 patients. J Rheumatol 2001; 28:560.
  27. Ramos-Remus C, Major P, Gomez-Vargas A, et al. Temporomandibular joint osseous morphology in a consecutive sample of ankylosing spondylitis patients. Ann Rheum Dis 1997; 56:103.
  28. Pérez Alamino R, Maldonado Cocco JA, Citera G, et al. Differential features between primary ankylosing spondylitis and spondylitis associated with psoriasis and inflammatory bowel disease. J Rheumatol 2011; 38:1656.
  29. Maksymowych WP, Chou CT, Russell AS. Matching prevalence of peripheral arthritis and acute anterior uveitis in individuals with ankylosing spondylitis. Ann Rheum Dis 1995; 54:128.
  30. Zeboulon N, Dougados M, Gossec L. Prevalence and characteristics of uveitis in the spondyloarthropathies: a systematic literature review. Ann Rheum Dis 2008; 67:955.
  31. Stolwijk C, van Tubergen A, Castillo-Ortiz JD, Boonen A. Prevalence of extra-articular manifestations in patients with ankylosing spondylitis: a systematic review and meta-analysis. Ann Rheum Dis 2015; 74:65.
  32. Rosenbaum JT. Uveitis in spondyloarthritis including psoriatic arthritis, ankylosing spondylitis, and inflammatory bowel disease. Clin Rheumatol 2015; 34:999.
  33. Muñoz-Fernández S, Martín-Mola E. Uveitis. Best Pract Res Clin Rheumatol 2006; 20:487.
  34. Tay-Kearney ML, Schwam BL, Lowder C, et al. Clinical features and associated systemic diseases of HLA-B27 uveitis. Am J Ophthalmol 1996; 121:47.
  35. Leirisalo-Repo M, Turunen U, Stenman S, et al. High frequency of silent inflammatory bowel disease in spondylarthropathy. Arthritis Rheum 1994; 37:23.
  36. De Keyser F, Mielants H. The gut in ankylosing spondylitis and other spondyloarthropathies: inflammation beneath the surface. J Rheumatol 2003; 30:2306.
  37. El Maghraoui A. Extra-articular manifestations of ankylosing spondylitis: prevalence, characteristics and therapeutic implications. Eur J Intern Med 2011; 22:554.
  38. Palm O, Moum B, Ongre A, Gran JT. Prevalence of ankylosing spondylitis and other spondyloarthropathies among patients with inflammatory bowel disease: a population study (the IBSEN study). J Rheumatol 2002; 29:511.
  40. Bandinelli F, Terenzi R, Giovannini L, et al. Occult radiological sacroiliac abnormalities in patients with inflammatory bowel disease who do not present signs or symptoms of axial spondylitis. Clin Exp Rheumatol 2014; 32:949.
  41. Rudwaleit M, Baeten D. Ankylosing spondylitis and bowel disease. Best Pract Res Clin Rheumatol 2006; 20:451.
  42. Edmunds L, Elswood J, Kennedy LG, Calin A. Primary ankylosing spondylitis, psoriatic and enteropathic spondyloarthropathy: a controlled analysis. J Rheumatol 1991; 18:696.
  43. Li Y, Zhang S, Zhu J, et al. Sleep disturbances are associated with increased pain, disease activity, depression, and anxiety in ankylosing spondylitis: a case-control study. Arthritis Res Ther 2012; 14:R215.
  44. Ward MM, Reveille JD, Learch TJ, et al. Impact of ankylosing spondylitis on work and family life: comparisons with the US population. Arthritis Rheum 2008; 59:497.
  45. Brionez TF, Assassi S, Reveille JD, et al. Psychological correlates of self-reported disease activity in ankylosing spondylitis. J Rheumatol 2010; 37:829.
  46. Wu Q, Inman RD, Davis KD. Fatigue in ankylosing spondylitis is associated with the brain networks of sensory salience and attention. Arthritis Rheumatol 2014; 66:295.
  47. Jang JH, Green CE, Assassi S, et al. The contribution of disease activity on functional limitations over time through psychological mediators: a 12-month longitudinal study in patients with ankylosing spondylitis. Rheumatology (Oxford) 2011; 50:2087.
  48. Baysal O, Durmuş B, Ersoy Y, et al. Relationship between psychological status and disease activity and quality of life in ankylosing spondylitis. Rheumatol Int 2011; 31:795.
  49. Gordeev VS, Maksymowych WP, Evers SM, et al. Role of contextual factors in health-related quality of life in ankylosing spondylitis. Ann Rheum Dis 2010; 69:108.
  50. Moyssakis I, Gialafos E, Vassiliou VA, et al. Myocardial performance and aortic elasticity are impaired in patients with ankylosing spondylitis. Scand J Rheumatol 2009; 38:216.
  51. Eder L, Sadek M, McDonald-Blumer H, Gladman DD. Aortitis and spondyloarthritis--an unusual presentation: case report and review of the literature. Semin Arthritis Rheum 2010; 39:510.
  52. Slobodin G, Naschitz JE, Zuckerman E, et al. Aortic involvement in rheumatic diseases. Clin Exp Rheumatol 2006; 24:S41.
  53. Vinsonneau U, Brondex A, Mansourati J, et al. Cardiovascular disease in patients with spondyloarthropathies. Joint Bone Spine 2008; 75:18.
  54. Brunner F, Kunz A, Weber U, Kissling R. Ankylosing spondylitis and heart abnormalities: do cardiac conduction disorders, valve regurgitation and diastolic dysfunction occur more often in male patients with diagnosed ankylosing spondylitis for over 15 years than in the normal population? Clin Rheumatol 2006; 25:24.
  55. Essers I, Stolwijk C, Boonen A, et al. Ankylosing spondylitis and risk of ischaemic heart disease: a population-based cohort study. Ann Rheum Dis 2016; 75:203.
  56. Haroon NN, Paterson JM, Li P, et al. Patients With Ankylosing Spondylitis Have Increased Cardiovascular and Cerebrovascular Mortality: A Population-Based Study. Ann Intern Med 2015; 163:409.
  57. Berdal G, Halvorsen S, van der Heijde D, et al. Restrictive pulmonary function is more prevalent in patients with ankylosing spondylitis than in matched population controls and is associated with impaired spinal mobility: a comparative study. Arthritis Res Ther 2012; 14:R19.
  58. Boushea DK, Sundstrom WR. The pleuropulmonary manifestations of ankylosing spondylitis. Semin Arthritis Rheum 1989; 18:277.
  59. Kchir MM, Mtimet S, Kochbati S, et al. Bronchoalveolar lavage and transbronchial biopsy in spondyloarthropathies. J Rheumatol 1992; 19:913.
  60. Quismorio FP Jr. Pulmonary involvement in ankylosing spondylitis. Curr Opin Pulm Med 2006; 12:342.
  61. Kiris A, Ozgocmen S, Kocakoc E, et al. Lung findings on high resolution CT in early ankylosing spondylitis. Eur J Radiol 2003; 47:71.
  62. Lee CC, Lee SH, Chang IJ, et al. Spontaneous pneumothorax associated with ankylosing spondylitis. Rheumatology (Oxford) 2005; 44:1538.
  63. van der Weijden MA, Claushuis TA, Nazari T, et al. High prevalence of low bone mineral density in patients within 10 years of onset of ankylosing spondylitis: a systematic review. Clin Rheumatol 2012; 31:1529.
  64. Geusens P, Lems WF. Osteoimmunology and osteoporosis. Arthritis Res Ther 2011; 13:242.
  65. Roux C. Osteoporosis in inflammatory joint diseases. Osteoporos Int 2011; 22:421.
  66. Gratacós J, Collado A, Pons F, et al. Significant loss of bone mass in patients with early, active ankylosing spondylitis: a followup study. Arthritis Rheum 1999; 42:2319.
  67. Dos Santos FP, Constantin A, Laroche M, et al. Whole body and regional bone mineral density in ankylosing spondylitis. J Rheumatol 2001; 28:547.
  68. El Maghraoui A, Borderie D, Cherruau B, et al. Osteoporosis, body composition, and bone turnover in ankylosing spondylitis. J Rheumatol 1999; 26:2205.
  69. Karberg K, Zochling J, Sieper J, et al. Bone loss is detected more frequently in patients with ankylosing spondylitis with syndesmophytes. J Rheumatol 2005; 32:1290.
  70. Vosse D, Feldtkeller E, Erlendsson J, et al. Clinical vertebral fractures in patients with ankylosing spondylitis. J Rheumatol 2004; 31:1981.
  71. Vosse D, van der Heijde D, Landewé R, et al. Determinants of hyperkyphosis in patients with ankylosing spondylitis. Ann Rheum Dis 2006; 65:770.
  72. Vosse D, Landewé R, van der Heijde D, et al. Ankylosing spondylitis and the risk of fracture: results from a large primary care-based nested case-control study. Ann Rheum Dis 2009; 68:1839.
  73. Mundwiler ML, Siddique K, Dym JM, et al. Complications of the spine in ankylosing spondylitis with a focus on deformity correction. Neurosurg Focus 2008; 24:E6.
  74. Khedr EM, Rashad SM, Hamed SA, et al. Neurological complications of ankylosing spondylitis: neurophysiological assessment. Rheumatol Int 2009; 29:1031.
  75. Chaudhary SB, Hullinger H, Vives MJ. Management of acute spinal fractures in ankylosing spondylitis. ISRN Rheumatol 2011; 2011:150484.
  76. Thumbikat P, Hariharan RP, Ravichandran G, et al. Spinal cord injury in patients with ankylosing spondylitis: a 10-year review. Spine (Phila Pa 1976) 2007; 32:2989.
  77. Ramos-Remus C, Gomez-Vargas A, Guzman-Guzman JL, et al. Frequency of atlantoaxial subluxation and neurologic involvement in patients with ankylosing spondylitis. J Rheumatol 1995; 22:2120.
  78. Bartleson JD, Cohen MD, Harrington TM, et al. Cauda equina syndrome secondary to long-standing ankylosing spondylitis. Ann Neurol 1983; 14:662.
  79. Sant SM, O'Connell D. Cauda equina syndrome in ankylosing spondylitis: a case report and review of the literature. Clin Rheumatol 1995; 14:224.
  80. Lee SH, Lee EJ, Chung SW, et al. Renal involvement in ankylosing spondylitis: prevalence, pathology, response to TNF-a blocker. Rheumatol Int 2013; 33:1689.
  81. Strobel ES, Fritschka E. Renal diseases in ankylosing spondylitis: review of the literature illustrated by case reports. Clin Rheumatol 1998; 17:524.
  82. Levy AR, Szabo SM, Rao SR, et al. Estimating the occurrence of renal complications among persons with ankylosing spondylitis. Arthritis Care Res (Hoboken) 2014; 66:440.
  83. Gratacós J, Collado A, Sanmartí R, et al. Coincidental amyloid nephropathy and IgA glomerulonephritis in a patient with ankylosing spondylitis. J Rheumatol 1993; 20:1613.
  84. Lance NJ, Curran JJ. Amyloidosis in a case of ankylosing spondylitis with a review of the literature. J Rheumatol 1991; 18:100.
  85. Ostensen M, Ostensen H. Ankylosing spondylitis--the female aspect. J Rheumatol 1998; 25:120.
  86. Sieper J, Braun J, Rudwaleit M, et al. Ankylosing spondylitis: an overview. Ann Rheum Dis 2002; 61 Suppl 3:iii8.
  87. Niccoli L, Nannini C, Cassarà E, et al. Frequency of anemia of inflammation in patients with ankylosing spondylitis requiring anti-TNFα drugs and therapy-induced changes. Int J Rheum Dis 2012; 15:56.
  88. Maksymowych WP. What do biomarkers tell us about the pathogenesis of ankylosing spondylitis? Arthritis Res Ther 2009; 11:101.
  89. Kang KY, Hong YS, Park SH, Ju JH. Increased serum alkaline phosphatase levels correlate with high disease activity and low bone mineral density in patients with axial spondyloarthritis. Semin Arthritis Rheum 2015; 45:202.
  90. Laurent MR, Panayi GS. Acute-phase proteins and serum immunoglobulins in ankylosing spondylitis. Ann Rheum Dis 1983; 42:524.
  91. Franssen MJ, van de Putte LB, Gribnau FW. IgA serum levels and disease activity in ankylosing spondylitis: a prospective study. Ann Rheum Dis 1985; 44:766.
  92. Poddubnyy D, Brandt H, Vahldiek J, et al. The frequency of non-radiographic axial spondyloarthritis in relation to symptom duration in patients referred because of chronic back pain: results from the Berlin early spondyloarthritis clinic. Ann Rheum Dis 2012; 71:1998.
  93. van Tubergen A, Heuft-Dorenbosch L, Schulpen G, et al. Radiographic assessment of sacroiliitis by radiologists and rheumatologists: does training improve quality? Ann Rheum Dis 2003; 62:519.
  94. Marzo-Ortega H, McGonagle D, O'Connor P, et al. Baseline and 1-year magnetic resonance imaging of the sacroiliac joint and lumbar spine in very early inflammatory back pain. Relationship between symptoms, HLA-B27 and disease extent and persistence. Ann Rheum Dis 2009; 68:1721.
  95. Lee JS, Lee S, Bang SY, et al. Prevalence and risk factors of anterior atlantoaxial subluxation in ankylosing spondylitis. J Rheumatol 2012; 39:2321.
  96. van der Heijde D, Landewé R. Imaging in spondylitis. Curr Opin Rheumatol 2005; 17:413.
  97. Rudwaleit M, van der Heijde D, Landewé R, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis 2009; 68:777.
  98. van der Heijde D, Sieper J, Maksymowych WP, et al. Spinal inflammation in the absence of sacroiliac joint inflammation on magnetic resonance imaging in patients with active nonradiographic axial spondyloarthritis. Arthritis Rheumatol 2014; 66:667.
  99. Hermann KG, Baraliakos X, van der Heijde DM, et al. Descriptions of spinal MRI lesions and definition of a positive MRI of the spine in axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI study group. Ann Rheum Dis 2012; 71:1278.
  100. Ramiro S, van Tubergen A, van der Heijde D, et al. Brief report: erosions and sclerosis on radiographs precede the subsequent development of syndesmophytes at the same site: a twelve-year prospective followup of patients with ankylosing spondylitis. Arthritis Rheumatol 2014; 66:2773.
  101. Ramiro S, Stolwijk C, van Tubergen A, et al. Evolution of radiographic damage in ankylosing spondylitis: a 12 year prospective follow-up of the OASIS study. Ann Rheum Dis 2015; 74:52.
  102. Ward MM, Learch TJ, Gensler LS, et al. Regional radiographic damage and functional limitations in patients with ankylosing spondylitis: differences in early and late disease. Arthritis Care Res (Hoboken) 2013; 65:257.
  103. Gandjbakhch F, Terslev L, Joshua F, et al. Ultrasound in the evaluation of enthesitis: status and perspectives. Arthritis Res Ther 2011; 13:R188.