Ankylosing spondylitis. Not just another pain in the back.

OBJECTIVE To review recent developments in diagnosis and treatment of ankylosing spondylitis (AS).

QUALITY OF EVIDENCE Level I evidence from three randomized placebo-controlled trials shows that AS is highly responsive to anti-tumour necrosis factor-alpha (anti-TNFalpha) therapies when the standard approach of nonsteroidal anti-inflammatory drugs (NSAIDs) and physical modalities fails.

MAIN MESSAGE Ankylosing spondylitis is associated with disability comparable to that of rheumatoid arthritis. Diagnosis should first focus on eliciting a history of nocturnal back pain, diurnal variation in symptoms with prolonged morning stiffness, and a good response to NSAID therapy. Physical examination is often unrevealing. Pelvic x-ray results are often normal in early disease. Magnetic resonance imaging is the most sensitive imaging technique for detecting early inflammatory lesions and should be considered when history supports the diagnosis but results of plain radiography are normal. When patients have failed at least two courses of NSAID therapy, anti-TNF(alpha)therapies are of proven benefit.

CONCLUSION New magnetic resonance imaging techniques and highly effective therapies make AS more readily detectable and managable.