Axial Spondyloarthritis Is Inflammatory Spinal Arthritis

I’ve Been Diagnosed with Axial Spondyloarthritis — Now What?

Back and neck pain are among the world’s most common health concerns, and spinal inflammatory arthritis—which is now known as axial spondyloarthritis (AxSpA)—may be the underlying cause of spine pain. Ankylosing spondylitis is a type of AxSpA affecting the spine.

How common is AxSpA? Some experts peg inflammatory arthritis as the cause of as many as a third of low back pain cases,1 while another study found that about 1% of the United States’ population has axial spondyloarthritis.2

This article covers the basics of AxSpA, including the different types of spinal inflammatory arthritis, symptoms, risk factors, and treatments.

man with lower back painAxial spondyloarthritis is a newer term to describe inflammatory arthritis that develops in the spine and/or sacroiliac joints. Photo Source:

Axial Spondyloarthritis Defined

Spondyloarthritis is a large category of arthritis diseases that features two subcategories: axial spondyloarthritis and peripheral spondyloarthritis. Axial spondyloarthritis is a newer term to describe inflammatory arthritis that develops in the spine and/or sacroiliac (SI) joints. Peripheral spondyloarthritis refers to inflammation that occurs elsewhere in your body. If you have AxSpA, you may also develop peripheral spondyloarthritis (and vice versa).

It is important to understand that inflammatory causes of back pain are different than mechanical back pain. Mechanical back pain is movement-related pain caused by injury, wear and tear, or lifestyle factors (eg, a sports injury, car accident, or prolonged poor posture), whereas inflammatory back pain is a result of a disease process that attacks the facet joints and the entheses, which is where your tendons and ligaments connect to your spinal bones (vertebrae).

There are many types of AxSpA. Below are the common types of AxSpA:

  • Ankylosing spondylitis (AS) is also called radiographic axial spondyloarthritis, as this form of AxSpA causes changes in the SI joints that are clearly visible on x-ray. In severe cases, AS can cause new bone formation that leads to spinal bones fusing together.
  • Psoriatic arthritis is associated with the flaky, scaly skin rash known as psoriasis, which can present either before or after it is associated with joint damage. Psoriatic arthritis may develop in the spine, although it is more common the smaller joints (eg, fingers, toes).
  • Enteropathic arthritis is linked to inflammatory bowel disease (IBD). When IBD flare-ups occurs, so, too, do joint pain flare-ups.
  • Reactive arthritis, also known as Reiter’s syndrome, is a form of inflammatory arthritis caused by an infection. Reactive arthritis usually causes pain in the low back, and it will subside without treatment.
  • Juvenile spondyloarthritis is diagnosed when symptoms of spinal inflammatory arthritis begin in childhood.

Axial Spondyloarthritis Symptoms

Although spinal inflammatory arthritis produces varied levels of pain and disability, most people with the condition experience some combination of the following symptoms:

  • Back and/or neck pain
  • Spinal stiffness/reduced range of motion in the back and neck (severe forms of ankylosing spondylitis can lead to total loss of spinal flexibility)
  • Spine pain that started gradually and has persisted more than 3 months
  • Pain that worsens after rest and eases with activity
  • Areas of swelling or tenderness in the spine
  • Headaches (caused by joint inflammation in the neck)
  • Hip pain (linked to AS-related SI joint pain)
  • Neurological symptoms (eg, pain, numbness, weakness) in the arms and legs (this may indicate that inflammation is compressing spinal nerves)
  • Weakness and fatigue
  • Eye-related symptoms, including blurred vision, eye pain, and watery eyes (some forms of AxSpA may cause eye inflammation)
  • Arthritis in other joints in your body, including knees, heels, and feet

Axial Spondyloarthritis Causes and Risk Factors

The disease processes that lead to spinal inflammatory arthritis aren’t well understood, so in many cases, the exact cause of AxSpA isn’t known.

Some forms of spinal inflammatory arthritis have genetic ties, so doctors believe that the condition may be inherited. People who have the human leukocyte antigen (HLA) B27 gene have a heightened risk for developing axial spondyloarthritis.

Although the cause isn’t clear, doctors have linked spinal inflammatory arthritis to several other risk factors:

  • Age: AxSpA usually develops in younger people, before age 45. Symptoms typically begin between 20 and 30 years of age.
  • Sex: Men are more likely to develop AS, but men and women develop other forms of AxSpA at equal rates.
  • Weight: People who are obese are at a greater risk of developing the condition.
  • Comorbidities: Having other medical conditions, such as diabetes, psoriasis, and irritable bowel syndrome, puts people at a greater risk for developing AxSpA.
  • Smoking: Smokers experience more severe symptoms of spinal inflammatory arthritis compared to nonsmokers.

How Doctors Diagnose Axial Spondyloarthritis

Diagnosing spinal inflammatory arthritis typically requires a combination of diagnostic tools. Your doctor will first review your medical history and symptoms with you. Then, he or she will perform a physical exam to understand your functional abilities, pain location, and pain severity.

Next, your doctor may order blood tests, which will reveal whether you have any genetic markers for inflammatory arthritis.

Your doctor may also order imaging scans to confirm and/or rule out other causes of your pain. X-ray is a typical first-line imaging test, and it may reveal joint damage. Your doctor may also order more involved imaging tests — MRI, CT scan, myelography, ultrasound, or bone scan — for a detailed look at the bones and soft tissues (eg, joints, nerves) of your spine.

Your doctor may also perform tests on specific joints, including joint aspiration (collecting the synovial fluid from a joint) and/or diagnostic injection (injecting a joint with a numbing agent to determine if it eases pain).

I’ve Been Diagnosed with Axial Spondyloarthritis — Now What?

Learning you have a form of spinal inflammatory arthritis can bring a mix of emotions, including relief at knowing why you’ve been in pain and fear about how the condition can change your future. Fortunately, therapies are available today that can stop the progression of joint damage and minimize the affect axial spondyloarthritis has on your life.

Axial Spondyloarthritis Treatment Goals

Upon being diagnosed with AxSpA, you will work with your spine specialist and rheumatologist to discuss a treatment plan. Your doctor has several therapies to explore, but the goals will likely be two-fold:

  1. Manage your pain
  2. Stop further joint damage

Treatment plans are not one-size-fits-all. Your doctor will consider your personal medical history and inflammatory arthritis experience (eg, type, severity) when crafting your treatment plan.

Medications for Axial Spondyloarthritis

No treatment can reverse joint damage, but medications are effective in slowing further joint damage. That’s why medication therapy is considered a cornerstone of most spinal inflammatory arthritis treatment plans.

Your doctor may recommend one or a combination of the following drugs to manage your inflammatory pain and slow further joint damage:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), which reduce pain and inflammation, are available over-the-counter or by prescription.
  • Corticosteroid injections provide targeted pain and inflammation relief in a specific joint.
  • Disease-modifying anti-rheumatic drugs (DMARDs), such as sulfasalazine, are prescription medications that provide long-term inflammation control.
  • Biologics: Biologic agents work on limiting the immune system’s overactive inflammatory response. Types of biologics commonly prescribed for AxSpA are tumor necrosis factor (TNF) inhibitors, B-cell inhibitors, interleukin (IL) inhibitors, and T-cell inhibitors. If you don’t respond to one type of biologic, your doctor may try a different biologic to see if it manages pain and inflammation better.

Physical Therapy, Exercise, Posture, and Lifestyle Changes for Axial Spondyloarthritis

Medications will help slow further joint damage, but they aren’t your only therapeutic option.

AxSpA can cause rigidity, stiffness, and pain that can make daily activities like getting dressed, walking up stairs, and even turning your head difficult. Your doctor may recommend physical therapy, exercise, posture training, and/or lifestyle modifications to provide improved mobility and sustainable pain management for your spinal inflammatory arthritis. These nonsurgical treatments may also help prevent serious arthritis-related spinal complications.

Your doctor may refer you to a physical therapist to develop a physical therapy and exercise regimen that takes your specific condition and goals into account. Although the activity program created is especially for you, it will likely focus on strengthening your spine and improving your range of motion and mobility. You may work with a physical therapist in a clinic, where you will learn the activities and exercises that will best preserve your function. You’ll then be able to perform those exercises at home. Incorporating exercise and physical therapy into your daily routine is among the best ways to minimize your pain and maximize your mobility.

Posture training is another physical therapy element that may be part of an AxSpA treatment plans. If you’ve been diagnosed with ankylosing spondylitis (AS), a type of AxSpA, posture training is particularly important to mitigate the formation of a rigid “hunchback” posture in your upper back. This spinal deformity can have a huge effect on your quality of life, but posture training can minimize this serious AS complication.

If you have certain lifestyle factors or habits that may hinder your treatment, such as smoking, being overweight, or struggles with mental and emotional health, your doctor may also include lifestyle changes as part of your AxSpA treatment plan. Smoking cessation, weight management programs, and arthritis support groups may help you achieve your long-term treatment goals.

Does Axial Spondyloarthritis Warrant Spine Surgery?

Most cases of AxSpA do not require spine surgery. However, if you have tried nonsurgical treatments without success, your arthritis has put your spinal cord at risk (eg, from the formation of a spinal fracture), and/or your condition is having a major, negative impact on your quality of life, you may be a candidate for surgery.

The goals of spine surgery for AxSpA include:

  • Decompressing the spine: Arthritis can lead to spinal fractures and bone spurs that press on the spinal cord and/or surrounding nerve roots. This can cause radiating nerve pain and, on the most serious end of the spectrum, paralysis.
  • Realigning the spine: In severe cases of AS, the spine can curve into a “hunchback” deformity.
  • Stabilizing the spine: Stabilization spine surgery is known as a spinal fusion (with or without instrumentation). Fusing spinal bones together can eliminate problematic motion in the spine, preventing damage to the spinal cord.

Several surgical procedures may accomplish these goals, including:

  • Laminectomy: This procedure decompresses your spinal nerve roots by removing the lamina, a bony section on the back of each vertebra. This procedure helps relieve nerve pain.
  • Osteotomy: In this procedure, the surgeon cuts the spinal bones and realigns them to correct spinal deformity. To ensure the spine heals properly and doesn’t move, your surgeon may perform a spinal fusion after the procedure.

If your doctor recommends spine surgery, it’s important to understand as much about the procedure as you can beforehand: why it’s recommended, what the recovery will be like, and the expected outcome.

Keep Communication Lines Open with Your Doctor

If you’ve been diagnosed with axial spondyloarthritis, know that several treatment options are available to help manage your pain and prevent further joint damage. Medications, physical therapy, exercise, and even spine surgery may help you live better with spinal inflammatory arthritis. It’s important to have an open, honest relationship with your doctor throughout your treatment journey—don’t ignore or hide your pain. If a treatment is not working as expected, tell your doctor. If one treatment doesn’t work, there may be another that will give you a better quality of life.

Updated on: 03/11/20
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