- Ankylosing spondylitis affects about 24 people per 10,000 in Europe, roughly 1.3–1.6 million Europeans (Rheumatology, 2014).
- Low back pain affected 619 million people in 2020; only a small share is inflammatory, but that is the kind that needs a rheumatologist (Lancet Rheumatology, 2023).
- The average diagnostic delay is still 5–7 years from the first symptoms.
Two kinds of back pain
Almost everyone has back pain at some point. The vast majority is mechanical: it appears after exertion, worsens with prolonged standing and eases with rest. There is, however, a different type of pain, inflammatory, which behaves exactly the opposite way, and recognising it can change a patient's life.
Inflammatory back pain is the main sign of axial spondyloarthritis, whose advanced stage is called ankylosing spondylitis. The disease affects the sacroiliac joints (where the spine meets the pelvis) and the spine itself, and over time can lead to their stiffening.
How to recognise inflammatory back pain
Specialists use a few simple criteria (ASAS) to identify inflammatory pain. If you have at least four of the following, it is worth talking to a rheumatologist.
- Onset before the age of 40–45
- Gradual onset, not sudden after exertion
- Improvement with movement and exercise, not with rest
- No improvement, or even worsening, with rest
- Night pain, especially in the second half of the night, forcing you out of bed
- Morning stiffness of the back lasting over 30 minutes and alternating buttock pain (sometimes left, sometimes right)
Not just the spine: other signs of the disease
Spondyloarthritis is a systemic disease and leaves clues beyond the back. An episode of a red, painful eye (uveitis), psoriasis, Crohn's disease or ulcerative colitis, heel pain (enthesitis) or a whole finger or toe swollen like a sausage (dactylitis) are important pieces of the diagnosis.
Fatigue is often underestimated, but it can be as disabling as the pain. If you have inflammatory back pain and one of these signs, the likelihood of spondyloarthritis rises considerably.
Diagnosis: HLA-B27, MRI and clinical examination
The diagnosis is based on the combination of symptoms, clinical assessment of spinal mobility, blood tests and imaging. HLA-B27 is a genetic marker present in most patients with ankylosing spondylitis, but also in about 6–8% of the healthy general population, so it does not make the diagnosis by itself.
A pelvic X-ray shows changes in the sacroiliac joints, but these appear after years of disease. MRI can reveal active inflammation much earlier, sometimes within the first year, and is the investigation that has radically sped up diagnosis. ESR and CRP may be raised, but are normal in almost half of patients.
Treatment: movement and medication go together
Regular exercise is a pillar of treatment and the only one that directly prevents spinal stiffening. Physiotherapy programmes, swimming, deep-breathing exercises and back-extension exercises are recommended daily, including during good periods.
Non-steroidal anti-inflammatories are the first line of medication and control symptoms well in many patients. When they are not enough, biologic therapies (TNF inhibitors, IL-17 inhibitors) and JAK inhibitors have transformed the outlook of the disease, allowing a normal active and working life. Quitting smoking is essential: smokers see faster progression of damage.
When to see a doctor
- You are under 45 with back pain lasting over 3 months that improves with movement
- Back pain wakes you in the second half of the night
- You have had uveitis, psoriasis or inflammatory bowel disease and your back or heel hurts
- A close relative has ankylosing spondylitis and you have similar symptoms
Frequently asked questions
Does a positive HLA-B27 mean I have spondylitis?
No. Most HLA-B27-positive people never develop the disease. The test is useful only in the context of suggestive symptoms, to raise or lower the likelihood of the diagnosis.
Will my spine end up completely rigid?
With modern treatment and regular exercise, complete fusion of the spine has become rare. Early diagnosis and control of inflammation significantly reduce the risk of deformity.
Can women have spondyloarthritis?
Yes. For a long time the disease was thought to be male, but the forms without X-ray changes affect women almost as often. In women, the diagnosis is unfortunately delayed even longer.
Sources
- Dean LE et al. – Global prevalence of ankylosing spondylitis (Rheumatology, 2014)
- GBD 2021 – Global, regional, and national burden of low back pain, 1990–2020, projections to 2050 (Lancet Rheumatology, 2023)
- Sieper J et al. – New criteria for inflammatory back pain in patients with chronic back pain (ASAS, Annals of the Rheumatic Diseases, 2009)
The data presented come from public sources and published scientific studies; they describe populations, not individuals. A diagnosis is made only after a medical consultation. Laromed Clinic updates this page periodically as new data become available.
