Axial spondyloarthritis

Axial spondyloarthritis is a long-term inflammatory condition in which the body's own immune system targets the spine, the sacroiliac joints of the pelvis, and the points where ligaments and tendons attach to bone. Over time this inflammation can prompt new bone to form, which is what may stiffen the spine. The exact trigger is not known, but genetics play a large part. A gene marker called HLA-B27 is carried by most people affected, although many who carry it never develop the condition, so it is not the whole story.

It tends to begin in early adulthood and runs in some families. There are recognised links with psoriasis, with inflammatory bowel conditions, and with reactive arthritis and psoriatic arthritis, which belong to the same family of disorders.

The pattern of back pain is the most telling feature. Typical signs include:

• Back or buttock pain that came on gradually, often before the age of 45
• Pain and stiffness that are worse with rest and in the morning, and improve with movement
• Stiffness in the morning lasting more than half an hour
• Pain that can wake you in the second half of the night
• Sometimes pain in other joints, the heels or the chest wall (which can feel like costochondritis), or inflammation in the eye

Diagnosis brings together your history, examination, blood tests and imaging. The distinctive history of inflammatory back pain is often the first clue, and imaging of the spine and pelvis helps confirm the picture. A high-quality MRI is particularly important in axial spondyloarthritis, as it can show inflammation early, before changes appear on ordinary X-rays. Dr Borukhson will be glad to arrange or refer for the appropriate MRI promptly, so that the diagnosis is not held up.

Ultrasound can add useful information about inflammation where tendons attach to bone, a common feature of this group of conditions. Dr Borukhson uses point-of-care ultrasound during the consultation, so relevant areas can often be examined in the same visit. You can read more on the ultrasound clinic page.

The aims are to control inflammation, relieve pain and stiffness, and maintain mobility and posture over the long term. A consistent exercise and movement programme is an important part of care, alongside medication where needed, and the plan is agreed with you. The usual first medicines are anti-inflammatory tablets (NSAIDs), which often settle spinal pain and stiffness well, though they are used with some caution because of their possible effects on the stomach and kidneys.

Where inflammation persists despite these, biologic medicines that target the immune signals driving the condition, such as anti-TNF and anti-IL-17 therapies, are effective options given under specialist supervision; they can increase the risk of infection, so screening is carried out before starting. Conventional disease-modifying tablets such as sulfasalazine, methotrexate and leflunomide, which need regular blood-test monitoring, can help when joints outside the spine are involved, but do not settle inflammation in the spine itself. All of these treatments are reviewed over time. Because the condition is long-term, regular specialist input helps keep it well controlled.

Day to day, keeping moving is the single most valuable thing you can do. Regular activity that works on posture, flexibility and core strength helps maintain mobility and ease stiffness, and many people benefit from guidance from a physiotherapist experienced in this condition. Gentle daily stretching, good sleeping posture and attention to how you sit at work all add up over the years.

Not smoking matters particularly here, as smoking is linked to faster progression and a poorer response to treatment.

Because axial spondyloarthritis is a long-term inflammatory condition, it carries a somewhat higher risk to the heart and circulation over the years, chiefly a raised chance of heart attack and stroke, though the evidence for this is not as strong as it is in rheumatoid arthritis. Much of that risk is within your control: keeping the inflammation well managed, staying active, eating well, keeping to a healthy weight and not smoking all help, as do regular checks of your blood pressure, cholesterol and blood sugar with your GP. Our guide to inflammation and your heart explains the simple checks worth asking about.

Much less often, and usually only after many years, the inflammation can involve the heart itself. It can affect the aortic root and valve, where the body's main blood vessel leaves the heart, or the electrical wiring that keeps the heart in rhythm. Most people are never affected, and there is no routine heart screening for this in the UK; it is looked into only when symptoms such as new breathlessness, palpitations or blackouts, or a finding during an examination, give a reason to. Where it does happen, it is managed together with a cardiologist.

With modern treatment and a consistent exercise habit, the long-term outlook is good and most people stay active and working. Symptoms can flare and settle, so pacing yourself and keeping in touch with your specialist helps you stay ahead of them.

Most changes can wait for a routine review, but some warrant prompt attention. Arrange an urgent eye assessment the same day if you develop a painful, red, light-sensitive eye or blurred vision, as this can signal inflammation (uveitis) that needs quick treatment.

Seek emergency care (A&E or 999) for any new weakness, numbness or tingling in the limbs, problems controlling your bladder or bowels, or numbness around the back passage, as these can point to pressure on the nerves. A stiffened spine also fractures more easily, so a sudden severe increase in spinal pain after a fall or injury needs urgent assessment and imaging before it is assumed to be a flare.

Contact your specialist team sooner rather than later if a flare is not settling, if pain or stiffness is steadily worsening, or if you feel generally unwell with fever while on treatment that affects the immune system.

Inflammatory back pain is frequently missed for years. In the UK it takes around eight and a half years on average to reach a diagnosis of axial spondyloarthritis, and that delay matters: left untreated, the condition can cause permanent, irreversible damage to the spine. Recognising it early allows treatment and exercise to begin sooner, which helps protect movement and quality of life. For this reason it is important not to put off a review. If you have long-standing back pain that improves with activity or started before 45, it is worth seeing a specialist sooner rather than later.

How do I know if my back pain is inflammatory?

The pattern of the pain is the main clue. Back or buttock pain that began gradually before the age of 45, feels worse after rest, eases with movement and can wake you in the second half of the night points towards inflammation, particularly when morning stiffness lasts more than half an hour. If that pattern sounds familiar, a specialist assessment is worthwhile rather than assuming the cause is mechanical.

Will I need an MRI, and how quickly can it be arranged?

MRI plays a central role, because it can show inflammation in the spine and pelvis early, before any changes appear on ordinary X-rays. Dr Borukhson arranges or refers for the appropriate scan promptly so the diagnosis is not held up. Ultrasound of the places where tendons attach to bone can also be carried out during the consultation itself.

How important is exercise?

Very. A consistent exercise and movement programme is a core part of treatment, working alongside any medication to maintain mobility and posture over the long term. It is not an optional extra, and the approach is agreed with you as part of the overall plan.

Is it too late to be assessed if I have had back pain for years?

No. In the UK it takes around eight and a half years on average to reach this diagnosis, so long-standing symptoms are very common. Treatment can still calm inflammation, relieve pain and stiffness and help protect mobility, and the sooner the condition is recognised, the sooner that work can begin.

What does long-term treatment involve?

Anti-inflammatory tablets are usually the first medicines, and where inflammation persists, biologic therapies that target the immune signals driving the condition are effective options, with screening carried out before they begin. Conventional disease-modifying tablets such as sulfasalazine, methotrexate and leflunomide are sometimes used when joints outside the spine are affected, though they do not help spinal inflammation. Because this is a long-term condition, regular specialist review keeps treatment on track and allows it to be adjusted over time.