Bekhterev's disease, ankylosing spondylitis 4.38/5 (21)

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Ankylosing spondylitis / Bechterews (Icd-10: M45.0)

Definition This image is missing alt text; its filename is Bekhetervs-sakroiliitt-SpA-iStock-1044935890-1024x742.jpg

Ankylosing spondylitis (ankylosing spondylitis) is a chronic rheumatic inflammation of the spine and in the joints between the back and pelvis (sacroiliac joints). The disease usually affects men (three out of four are men) and begins at the age of 2030. The symptoms are chronic back pain and stiffness. It is considered among spondyloarthropathies (SpA) together with Psoriatic arthritis, Reactive Arthritis, arthritis by Ulcerative colitis or Crohn's disease) and is almost identical to radiological spondyloarthritis. Ankylosing spine has a known hereditary disposition via the tissue type HLA-B27. The disease starts less frequently in children (usually boys) and is then called entesite-related arthritis which is kind of Juvenile arthritis.

Illustration: Low back pain, mostly in the morning are symptoms of Ankylosing Spondylitis, most often in younger men. iStock.


In the early stages of the disease, most often at the age of 20-30, there is usually "Inflammatory back pain”Which can be defined according to the ASAS criteria (reference: Rudwaleit M, 2009):

  • Back pain with symptom onset before 40 years of age
  • Duration at least 3 months
  • Improvement by physical activity
  • No relief of rest
  • Night pain relieves when one gets up and moves

However, only about 30% with such symptoms develop Ankylosing Spondylitis (high sensitivity, low specificity).

After prolonged symptoms, most will experience more or less stiffness in the spine. Often, the natural curvature of the lower back is flattened and the vertebral column is curved into a bent position. Pain and joint inflammation (Arthritis) of the hips are also common.

Reduced mobility

In case of suspicion of ankylosing spondylitis, the mobility of the spine is examined. One measures the lumbar bending ability Schober's test and by looking at the side movement. Reduced movement rash is most often detected. The ability of the thorax to expand when a breathing can be measured by looking at changes in circumference at maximum exhalation and inhalation (thoracic excursion) Also the neck movement is considered.

Ankylosing spondylitis. MRI examination of sacroiliac joints. The arrows show typical edema changes (white areas) on both sides (arrows). Weber U, Arthritis Res. Ther. (2012). CC BY 2.0)


X-ray, CT or MRI examinations are required for the diagnosis. Typical signs of illness appear at the earliest on MRI examination sacroiliac joints (between spine and pelvis), but CT or X-ray changes are considered safer for final diagnosis. Radiological changes, especially MRI results can be misinterpreted. After physical exercise, MRI results may resemble inflammatory changes in the iliosacral joint. Among children, normal growth zones may resemble inflammation, and in old age, natural storage of fat in the joints can also be misinterpreted as inflammation by MRI examinations. After birth, the incidence of MRI changes in the iliosacral joint is high (33%), after 2 years from birth, the same is seen in 21%. Even in women who have never given birth, the incidence of MRI changes is 14% (reference: Hoballah A, 2020). One must therefore never base a diagnosis on MRI changes alone.

Ankylosing spondylitis differs from the spinal cord disease DISH which do not attack the iliosacral joints, are not specifically associated with HLA-B27 (see below) and have a different course of disease.

  • In Bekhterev's disease there are obvious changes in the course of the disease, which are also seen with the use of CT or regular x-ray examination, both in the iliosacral joints and in the spine.


This type of tissue can be detected in a blood sample and is a hereditary factor that predisposes to ankylosing spondylitis. However, HLA-B27 occurs in approximately 8-10% of the population in southern Norway and 15% in the north. In classical ankylosing spondylitis, HLA-B 27 is detected in more than 95%. If the disease is related to chronic intestinal disease (ulcerative colitis, Crohn's disease) HLAB 27 is present at 73% (reference: Palm O, 2002). At the simultaneous Psoriatic arthritis HLA-B27 is seen at about 50%.

  • However, the diagnosis should also be based on symptoms and other examination findings (please see above)


Disease history with Inflammatory back pain (please see above), reduced mobility at examination and radiological changes in sacroiliac joints is essential for a safe diagnosis.

Other characteristics

  • The symptoms (stiffness, pain) are most noticeable in the first 30-XNUM minutes in the morning
  • NSAID drugs (for example Ibux, Voltaren, Naproxen) affects the symptoms
  • In blood sample is available HLA B27 in more than 95%, while the equivalent in the population in general is approx. 8-10% in southern Norway (higher in northern Norway)
  •  Eye inflammation (uveitis, iridocyclitis) which are painful occur in approx. 25% and must be treated by an ophthalmologist
  • In active disease phase, blood tests often show signs of rheumatic inflammation with increased CRP and sedimentation rate (ESR)

Disease history and clinical examination

Classification criteria


Ophthalmic complications


  • Swollen joints (Arthritis) may occur, most often in the knee and hip joints and should be treated by rheumatologists

Aneurysms of the major artery (aortic aneurysm)

Heart disease

  • Leakage in heart valves may occur and be detected by clinical assessment and by ultrasound of the heart and / or CT or MRI examinations

Photo of the intestine in Ankylosing Spondylitis with concomitant Crohn's disease. Swelling and bleeding intestinal mucosa. Kim HY, Intest Res. 2017. CC BY-NC 4.0

Intestinal System

Varying inflammatory changes in the intestine are common (about 50%) in ankylosing spondylitis, but few (about 5%) develop chronic intestinal inflammation. Still, an over-frequency of chronic intestinal inflammation Ulcerative colitis og Crohn's disease occur.

Psoriasis of the skin

Backache for other reasons


The treatment options have become much better in recent years. Before starting treatment, it is important to be informed about the disease, what the treatment goal is and what side effects may occur. Treatment goals are to completely stop the disease, that is, achieve remission. Unfortunately, treatment does not cure the disease. The treatment should be adapted to the individual and have a clear goal within a certain period of time. The treatment goal may be to achieve reduced pain and stiffness, measurable better physical activity or absence of arthritis.

  • NSAIDs (anti-inflammatory as Ibux, Voltaren) has effects on the symptoms and hence physical mobility and quality of life
  • TNF inhibitors are Biological drugs  (Rixathon / Remicade / Remsima, Humira, Benepali / Enbrel and others) that have a good effect on the symptoms and inflammation. In the absence of efficacy and high disease activity, IL-17 inhibitor Cosentyx can be used
    • Improves muscle strength that counteracts bent back and stiffness
    • Improves fitness and quality of life
    • Improves the mobility of the joints
    • Reduces the risk of subsequent cardiovascular disease
    • Reduces risk of Osteoporosis Important are also adapted exercise and exercises that are started in collaboration with physiotherapist
    • Reference: Scalapino KS 2003
  • The drugs will help to make it easier to carry out a regular exercise and activity program
  •  Arthritis (joint inflammation) may cause major hip joint injuries. When physiotherapy and drugs are no longer sufficient, the insertion of hip prostheses is relevant
  • Sometimes used Salazopyrin tablets for arthritis. However, the drug needs 3-6 months before effect can be expected. Salazopyrin is also used in chronic intestinal inflammation (ulcerative colitis, Crohn's disease) as someone is hit by at the same time.
  • Operation of deviations of the spine is possible, but is rarely necessary when a treatment schedule is followed over time
Ankylosing spondylitis operated

Ankylosing spondylitis after surgery due to major malpositions. Kim KT, Jo DJ, Lee SH, Park KJ, Sin JH - Eur Spine J (2011). open-i CC BY NC 3.0


No diet is shown to affect the inflammation process, but proper diet can still be useful. Despite the calcification in the back, there is an increased risk of osteoporosis (low bone mass). A sufficient intake of calcium and Vitamin D through the diet has preventive effect. Milk and dairy products are also important calcium sources. Fat fish and fish oil contain a lot of vitamin D and increases the absorption of calcium. If you do not ingest enough milk products, supplements should be considered (for example, Calcigran Forte).

Systematic studies have shown small inflammatory changes in the gut of most people with ankylosing spondylitis. However, few (about 6%) develop chronic intestinal diseases such as Ulcerative colitisCrohn's disease. Symptoms of such chronic intestinal inflammation are persistent pain in the stomach and intestine (stomach ache), loose stools that may contain blood, weight loss and lethargy. Blood tests may show signs of increased inflammation (blood count / SR and CRP increased). Closer medical examinations are then necessary. Effective drugs help many, but the diet also matters. Nutritionist advice is recommended.


The referral to specialist for possible Ankylosing spondylitis

Journal writing at Ankylosing spondylitis

More patient information via Norwegian Bekhterev's Association In the Norwegian Rheumatism Association

Recommendations / Guidelines for treatment and follow-up

EULAR: Van der Heijde 2017:

EULAR: Mandi P, 2014 (Imaging)

ACR 2019: Ward MM, 2019

ASAS (MRI lesions) Maksymowych WP, 2019

Norwegian Rheumatological Association / The Norwegian Medical Association

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