More accurately categorised under the umbrella term of spondyloarthritis, spondylitis represents a group of chronic inflammatory diseases that primarily affect the spine and the sacroiliac (SI) joints connecting the spine to the pelvis. However, its reach often extends beyond the bones, impacting other joints, tendons, and various body organs. Far from being a simple backache, spondylitis can lead to debilitating pain, stiffness, and progressive loss of mobility, significantly diminishing a person’s quality of life.

A study published in Medical News Today suggests a prevalence of 24.3 cases of spondylitis (specifically ankylosing spondylitis) per 10,000 people in Malaysia. Studies have also shown that back pain, including inflammatory back pain associated with ankylosing spondylitis, is a common complaint in Malaysia. A survey found that 11.6% of respondents reported pain in the lower back, highlighting a significant prevalence of back pain in the Malaysian population.

Understanding the complications of these conditions – their underlying causes, diverse symptoms, and the remarkable evolution of modern treatment approaches – is paramount for early diagnosis, effective management, and ultimately, empowering individuals to live more fulfilling lives.

Let’s explore this condition together in this article.

What is Spondylitis?

Spondylitis is a term commonly used to refer to spondyloarthritis (SpA), a family of chronic inflammatory rheumatic diseases. Unlike typical arthritis that often affects peripheral joints symmetrically, spondyloarthritis predominantly targets the axial skeleton (the spine, from the neck down to the pelvis, and the sacroiliac joints). A hallmark feature is inflammation at the entheses – the points where tendons and ligaments attach to bone. Over time, this chronic inflammation can lead to new bone formation, eventually causing parts of the spine or other joints to fuse, a process known as ankylosis.

The main spondylitis types include:

• Ankylosing Spondylitis (AS): The most recognised form, primarily affecting the spine and SI joints, often leading to progressive stiffness and potential fusion.
• Psoriatic Arthritis (PsA): Affects individuals with psoriasis, causing both joint inflammation (spinal and/or peripheral) and skin lesions.
• Reactive Arthritis (ReA): Joint inflammation triggered by an infection in another part of the body, often the gut or genitourinary tract.
• Enteropathic Arthritis (EA): Associated with inflammatory bowel diseases (IBD) such as Crohn’s disease and ulcerative colitis, causing joint inflammation alongside bowel symptoms.
• Undifferentiated Spondyloarthritis (uSpA): When a patient exhibits features of spondyloarthritis but doesn’t fully meet the diagnostic criteria for any of the specific types.

Despite their differences, these conditions share genetic predispositions, clinical features, and responses to certain treatments, making a comprehensive understanding crucial for diagnosis and management.

Spondylitis Causes and Risk Factors

The exact cause of spondylitis remains unclear, but it is understood as a complex interplay of genetic predisposition, immune system dysfunction, and environmental triggers. It isn’t contagious.

A strong genetic link exists with the HLA-B27 gene, found in most Ankylosing Spondylitis patients. However, carrying this gene doesn’t guarantee the disease; it only indicates increased susceptibility, requiring other factors to manifest.

Spondylitis is an autoimmune or autoinflammatory condition where the immune system mistakenly attacks healthy tissues like joints and the spine, causing chronic inflammation. Researchers are actively studying these immune pathways.

Environmental triggers initiate the disease in predisposed individuals. These can include certain bacterial infections (e.g., gut or genitourinary), imbalances in the gut microbiome, and smoking, which is linked to more severe disease. While not a direct cause, physical stress or trauma might precede symptoms or trigger flares.

Spondylitis typically appears in young adults, from late teens to early forties. Ankylosing Spondylitis is generally more prevalent and severe in males, though women can be affected differently. A family history of spondylitis also significantly increases an individual’s risk due to the strong genetic component.

Symptoms of Spondylitis

Spondylitis symptoms vary widely based on the specific type, inflammation severity, and affected body parts, but common features exist.

• Axial Symptoms (Spine and Sacroiliac Joints) include chronic inflammatory back pain and stiffness which get worse with rest and better with activity as well as nocturnal, prolonged morning stiffness), deep sacroiliac joint pain, and neck pain.
• Peripheral Joint Pain can affect limbs (hips, knees, shoulders, ankles), often asymmetrically, causing swelling and tenderness; hip involvement can be severe.
• Enthesitis is characteristic, causing pain where tendons/ligaments attach to bone, commonly in the Achilles tendon, plantar fascia, rib cage, elbows, and knees.
• Profound fatigue is also a common, debilitating symptom, stemming directly from chronic inflammation.

Extra-articular Manifestations (non-joint related) can affect other organs:

• Eye Inflammation (Uveitis/Iritis): A serious complication causing red, painful, light-sensitive eyes, requiring urgent care.
• Skin (Psoriasis): Common in Psoriatic Arthritis, presenting as scaly patches.
• Bowel Inflammation: Associated with inflammatory bowel diseases like Crohn’s or ulcerative colitis.
• Heart and Lungs: Rarely, severe long-standing disease can affect the heart (e.g., aortic issues) or lungs (e.g., fibrosis).
• Digestive Issues: General digestive complaints are often reported.

In advanced Ankylosing Spondylitis, chronic inflammation can lead to spinal fusion, causing stiffness, inflexibility, and a hunched “question mark posture,” severely limiting mobility and potentially breathing.

Spondylitis Diagnosis

Diagnosing spondylitis, especially in its early stages, can be challenging due to the variability of symptoms and its overlap with more common back pain conditions. A rheumatologist, a specialist in inflammatory arthritis, is usually key to diagnosis.

Clinical Assessment

The diagnostic process begins with a detailed patient history, focusing on the characteristics of pain and stiffness, family history, and any other relevant symptoms (e.g., eye inflammation, skin rash, bowel issues). A physical examination assesses spinal mobility, tenderness at entheses, and peripheral joint involvement.

Blood Tests

• Inflammatory Markers: Blood tests for erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) can indicate general inflammation in the body. While elevated levels support a diagnosis, they can be normal even in active disease.
• HLA-B27 Genetic Testing: This test identifies the presence of the HLA-B27 gene. While highly associated with spondylitis, it is not diagnostic on its own. It’s helpful in conjunction with other clinical and imaging findings.

Imaging

• X-rays: Conventional X-rays of the sacroiliac joints and spine are often performed. They can show characteristic changes of sacroiliitis (inflammation of the SI joints) or spinal fusion in later stages. However, X-ray changes might not be evident in the early years of the disease.
• Magnetic Resonance Imaging (MRI): MRI is much more sensitive than X-rays for detecting early inflammatory changes, particularly in the sacroiliac joints and spine (oedema, bone marrow inflammation). This allows for earlier diagnosis and intervention, even before structural damage is visible on X-rays.

Differential Diagnosis

Part of the diagnostic process involves ruling out other conditions that can cause similar symptoms, such as mechanical back pain, disc problems, fibromyalgia, or other forms of arthritis.

Modern Approaches in Spondylitis Treatment

While there is currently no cure for spondylitis, modern treatment approaches have revolutionised disease management, aiming to control inflammation, reduce pain, improve function, prevent structural damage, and maintain quality of life. A multidisciplinary approach is crucial.

Non-pharmacological treatments

These form the foundation of management for all patients.

Exercise and Physiotherapy

Regular exercise, tailored by a physiotherapist, is essential for maintaining spinal mobility, strength, and posture. Specific exercises focus on spinal extension, deep breathing, and core strengthening. Hydrotherapy (water exercises) is often highly beneficial due to buoyancy reducing joint stress.

Lifestyle Modifications

• Smoking Cessation: Smoking is strongly linked to more severe disease and poorer treatment response. Quitting is vital.
• Healthy Diet: While no specific “spondylitis diet” exists, a balanced, anti-inflammatory diet rich in fruits, vegetables, and lean protein, and mindful of gut health, may be beneficial.
• Weight Management: Maintaining a healthy weight reduces stress on joints and overall inflammation.

Heat/Cold Therapy

Applying heat (e.g., warm baths, heat packs) can help relax stiff muscles and relieve pain, while cold packs may reduce inflammation during flares.

Patient Education

Understanding the disease, its progression, and management strategies empowers patients to take an active role in their care.

Pharmacological Treatments

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

These are often the first-line treatment for pain and stiffness, particularly for axial symptoms. Examples include ibuprofen, naproxen, and celecoxib. Regular, consistent use (as prescribed) can be more effective than intermittent use for some patients in controlling inflammation and slowing disease progression.

DMARDs (Disease-Modifying Anti-Rheumatic Drugs)

Traditional DMARDs like sulfasalazine and methotrexate are generally effective for peripheral arthritis (e.g., in PsA, ReA, EA) but tend to be less effective for axial (spinal) symptoms of AS.

Biologics (Targeted Therapies)

These have transformed the outlook for many individuals with spondylitis. Biologics are proteins manufactured using biotechnology that target specific components of the immune system involved in the inflammatory process.

• TNF inhibitors (Tumour Necrosis Factor inhibitors): These block the action of TNF-alpha, a key inflammatory cytokine. Examples include adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), golimumab (Simponi), and certolizumab pegol (Cimzia). They are highly effective for axial and peripheral symptoms, reducing pain, and stiffness, and preventing structural damage.
• IL-17 inhibitors (Interleukin-17 inhibitors): These block the IL-17 pathway, another important inflammatory mediator. Examples include secukinumab (Cosentyx) and ixekizumab (Taltz). They offer another effective option, particularly for axial spondyloarthritis and psoriasis.
• Biologics are typically administered via subcutaneous injections (self-administered at home) or intravenous infusions in a clinic setting. They have potential side effects, including increased risk of infections, and require careful monitoring.

JAK Inhibitors (Janus Kinase Inhibitors)

These are newer oral small molecule drugs that target intracellular signalling pathways involved in inflammation. Examples include tofacitinib (Xeljanz) and upadacitinib (Rinvoq). They offer an alternative targeted therapy option, particularly for those who may not respond to biologics or prefer an oral medication. Like biologics, they require careful monitoring for side effects.

• Corticosteroids: Oral corticosteroids (e.g., prednisone) are generally used sparingly for acute flares due to long-term side effects. Local corticosteroid injections (e.g., into sacroiliac joints or inflamed entheses) can provide temporary relief.

Surgery

Surgery is generally reserved for severe cases or complications:

• Joint Replacement: For severely damaged peripheral joints (e.g., hip or knee replacements) due to chronic inflammation.
• Spinal Osteotomy: In rare cases of severe spinal deformity (kyphosis) caused by extensive fusion, surgery may be performed to correct the posture, but this is complex and carries significant risks.
• Multidisciplinary Team: Effective management relies on a harmonised approach involving a team of healthcare professionals: a rheumatologist (for diagnosis and medical treatment), a physiotherapist (for exercise and mobility), an occupational therapist (for adapting daily activities), a nurse specialist (for education and support), and the general practitioner (for overall care coordination).

Living with Spondylitis and Future Outlook

Living with spondylitis can be challenging, but with early diagnosis and access to modern treatment approaches, many individuals can manage their symptoms effectively and maintain a good quality of life. The landscape of spondylitis treatment has dramatically improved over the last two decades, particularly with the advent of biologics and JAK inhibitors, which offer potent anti-inflammatory effects and the potential to prevent irreversible structural damage.

Ongoing research continues to deepen our understanding of the disease mechanisms and is leading to the development of even newer targeted therapies. Patient advocacy groups and support networks also play a crucial role in empowering individuals to navigate their condition, share experiences, and access resources. Proactive self-management, consistent adherence to treatment plans, and regular communication with the healthcare team are vital for long-term well-being.

Sources:

• https://versusarthritis.org/about-arthritis/conditions/ankylosing-spondylitis/
• https://my.clevelandclinic.org/health/diseases/24843-axial-spondyloarthritis
• https://www.mayoclinic.org/diseases-conditions/reactive-arthritis/symptoms-causes/syc-20354838
• https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/ankylosing-spondylitis
• https://pmc.ncbi.nlm.nih.gov/articles/PMC9608452/