Case 26.2 – Ankylosing Spondylitis

Definition:

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis that primarily affects the axial skeleton (spine and sacroiliac joints), belonging to a group of conditions called spondyloarthropathies (SpA). It is characterized by inflammation at the sites where ligaments and tendons attach to bone (enthesitis), and can lead to fusion of the spine if untreated.

Epidemiology:

• Prevalence: 0.1-1.4% depending on population
• Male:female ratio historically 3:1, but increasingly recognized in women (may be underdiagnosed)
• Typical onset: late teens to early 30s (peak 20-30 years)
• Strong genetic association with HLA-B27
• More common in certain ethnic groups (e.g., Native Americans)

Key Clinical Features:

Axial (Spinal) Manifestations:

• Inflammatory back pain (IBP): Cardinal feature
  • Characteristics distinguishing from mechanical back pain:
    • Age of onset <40 years (usually <30)
    • Insidious onset (gradual, not acute)
    • Duration >3 months
    • Morning stiffness >30 minutes (often several hours)
    • Improves with exercise, worsens with rest
    • Pain at night (second half of night), improves on getting up
    • Responds well to NSAIDs
• Sacroiliitis:
  • Inflammation of sacroiliac (SI) joints
  • Usually the first site of involvement
  • Causes buttock pain, often alternating sides
  • Tenderness on examination (FABER test, sacroiliac compression)
• Progressive spinal involvement:
  • Ascends from lumbar to thoracic to cervical spine
  • Loss of lumbar lordosis
  • Increased thoracic kyphosis
  • Eventually can lead to fixed flexed posture ("question mark" spine)
• Reduced spinal mobility:
  • Progressive limitation of spinal movements
  • Reduced lumbar flexion (Schober's test <5cm)
  • Reduced lateral flexion
  • Reduced chest expansion (\<5cm) - from costovertebral joint involvement

Peripheral Manifestations:

• Enthesitis:
  • Inflammation at tendon/ligament insertions into bone
  • Hallmark of spondyloarthropathy
  • Common sites: Achilles tendon, plantar fascia (heel pain), greater trochanter, iliac crest, costochondral junctions
  • Can cause significant pain and functional impairment
• Peripheral arthritis:
  • Occurs in ~30% of AS patients
  • Usually asymmetrical
  • Lower limb joints more commonly affected (hips, knees, ankles)
  • Hip involvement in 20-30% - associated with worse prognosis
• Dactylitis ("sausage digit"):
  • Diffuse swelling of entire finger or toe
  • Less common in AS than other SpA (e.g., psoriatic arthritis)

Extra-Articular Manifestations:

• Acute anterior uveitis (AAU):
  • Most common extra-articular manifestation (25-40% of patients)
  • May be presenting feature
  • Painful red eye, photophobia, blurred vision
  • Usually unilateral (but can alternate)
  • Requires urgent ophthalmology assessment
  • Treated with topical steroids and mydriatics
• Cardiovascular:
  • Aortic regurgitation (rare, in long-standing disease)
  • Conduction defects (AV block)
  • Increased cardiovascular risk
• Pulmonary:
  • Restrictive lung defect (from reduced chest expansion and thoracic spine fusion)
  • Apical pulmonary fibrosis (rare, late complication)
• Inflammatory bowel disease (IBD):
  • Subclinical gut inflammation in up to 50%
  • Clinical IBD (Crohn's or UC) in 5-10%
• Neurological:
  • Cauda equina syndrome (very rare, late complication)
  • Spinal fractures (increased risk due to osteoporosis and fused rigid spine)
  • Atlantoaxial subluxation (less common than RA)
• Renal:
  • IgA nephropathy (rare association)
  • AA amyloidosis (very rare)

Clinical Course:

• Chronic, progressive disease
• Variable course - some have mild disease, others severe with significant disability
• Disease activity usually highest in first 10 years
• Ankylosis (fusion) of spine develops over years to decades if untreated
• Early diagnosis and treatment can prevent or slow progression

Prognosis Indicators (Poor):

• Hip involvement
• Young age at onset
• Elevated ESR/CRP at presentation
• Poor response to NSAIDs
• Peripheral arthritis
• Smoking

Spondyloarthropathies (SpA):

A group of inflammatory arthritides that share common clinical, radiological, and genetic features, but are seronegative (RF and anti-CCP negative).

Members of the Spondyloarthropathy Family:

• Ankylosing spondylitis (AS): Prototype, primarily axial disease
• Psoriatic arthritis (PsA): Associated with psoriasis, diverse patterns
• Reactive arthritis (ReA): Following infection (GI or GU), "can't see, can't pee, can't climb a tree"
• Enteropathic arthritis: Associated with IBD (Crohn's, UC)
• Undifferentiated spondyloarthropathy: Features of SpA but doesn't fit specific category

Shared Features of Spondyloarthropathies (A-E-S-P):

• Axial arthritis (inflammatory back pain, sacroiliitis)
• Enthesitis (inflammation at tendon/ligament insertions)
• Seronegative (RF and anti-CCP negative)
• Peripheral arthritis (asymmetrical, lower limb predominant)

Additional shared features:

• HLA-B27 association (though not all patients are positive)
• Familial aggregation
• Extra-articular features:
  • Acute anterior uveitis
  • Mucocutaneous lesions (psoriasis, oral ulcers, genital ulcers)
  • Inflammatory bowel disease
  • Aortitis/aortic regurgitation
• Asymmetrical oligoarthritis (when peripheral joints involved)
• Dactylitis
• Male predominance (except PsA which is equal)
• Young age of onset

Comparison: Spondyloarthropathies vs Rheumatoid Arthritis:

Feature	Spondyloarthropathies	Rheumatoid Arthritis
Primary site	Axial skeleton (spine, SI joints)	Peripheral joints (hands, feet, wrists)
Pattern	Asymmetrical (when peripheral)	Symmetrical polyarthritis
Serology	Seronegative (RF-, anti-CCP-)	Often seropositive (RF+, anti-CCP+)
Genetic association	HLA-B27 (80-90% in AS)	HLA-DR4 shared epitope
Pathological process	Enthesitis, new bone formation, ankylosis	Synovitis, erosions, joint destruction
DIP joints	May be involved (especially PsA)	Spared
Gender	Male predominant (AS, ReA)	Female predominant (3:1)
Age of onset	Younger (\<40, often <30)	Any age, peak 40-60
Enthesitis	Hallmark feature	Not a feature
Dactylitis	Common (PsA, ReA)	Rare
Uveitis	Acute anterior (common)	Rare (scleritis more common)
Skin involvement	Psoriasis, keratoderma	Rheumatoid nodules
Radiological	Sacroiliitis, syndesmophytes, ankylosis, new bone formation	Erosions, joint space narrowing, osteopenia
Response to MTX	Limited benefit for axial disease	Cornerstone of treatment
Treatment	NSAIDs, TNF/IL-17 inhibitors, JAK inhibitors	DMARDs (MTX), biologics, JAK inhibitors

Clinical Significance:

• Recognizing SpA pattern important for correct diagnosis and treatment
• Different treatment approaches compared to RA
• NSAIDs more effective in SpA (may slow radiographic progression in AS)
• MTX effective for peripheral arthritis in SpA but NOT for axial disease
• TNF inhibitors and IL-17 inhibitors effective for both axial and peripheral SpA
• HLA-B27 testing useful but not diagnostic (present in ~8% of healthy population)

Diagnosis of AS is based on combination of clinical features, laboratory tests, and imaging. No single test is diagnostic.

Clinical Assessment Tools:

Assessment of Inflammatory Back Pain (Berlin criteria):

At least 4 of 5 features suggest IBP:

• Age of onset <40 years
• Insidious onset
• Improvement with exercise
• No improvement with rest
• Pain at night (with improvement on getting up)

Physical examination findings:

• Schober's test: Measures lumbar spine flexion
  • Mark skin 10cm above and 5cm below L5 (total 15cm)
  • Patient bends forward maximally
  • Measure increase in distance
  • Normal: ≥5cm increase (total ≥20cm)
  • Reduced in AS due to loss of lumbar mobility
• Chest expansion:
  • Measure at 4th intercostal space
  • Difference between full inspiration and expiration
  • Normal: >5cm
  • Reduced due to costovertebral joint involvement
• Lateral spinal flexion, cervical rotation: Reduced in AS
• Sacroiliac joint tests: FABER test, sacroiliac compression - reproduce pain

Laboratory Investigations:

HLA-B27:

• Present in 80-90% of AS patients (vs 8% general population)
• Important limitations:
  • NOT diagnostic - most HLA-B27+ people don't have AS
  • 10-20% of AS patients are HLA-B27 negative
  • Positive predictive value low in general population
• Useful when:
  • Clinical suspicion high but imaging equivocal
  • Young patient with inflammatory back pain
  • Family history of SpA
  • Risk stratification (HLA-B27+ have higher risk of uveitis, more severe disease)
• Should be interpreted in clinical context, not used as screening test

Inflammatory markers:

• ESR and CRP:
  • Elevated in only 50-70% of active AS
  • Normal inflammatory markers do NOT exclude AS
  • Useful for monitoring disease activity and treatment response
  • Elevated CRP at baseline associated with worse prognosis

Other blood tests:

• RF and anti-CCP: Negative (seronegative spondyloarthropathy)
• FBC: May show anaemia of chronic disease
• Baseline renal and liver function before starting treatment

Imaging:

Plain Radiographs:

Pelvis X-ray (AP view):

• Sacroiliitis: Hallmark of AS
  • Graded 0-4:
    • Grade 0: Normal
    • Grade 1: Suspicious
    • Grade 2: Minimal (sclerosis, some erosions)
    • Grade 3: Moderate (erosions, sclerosis, joint space widening/narrowing)
    • Grade 4: Severe (complete ankylosis/fusion)
  • Bilateral grade ≥2 or unilateral grade ≥3 diagnostic
  • May take 5-10 years to develop - insensitive for early disease

Spine X-rays (lateral lumbar and cervical):

• Early changes:
  • Squaring of vertebral bodies (loss of normal concavity)
  • Shiny corners (Romanus lesions) - inflammation at vertebral edges
• Later changes:
  • Syndesmophytes: Vertical bony bridges between vertebrae (vs osteophytes in degenerative disease which are horizontal)
  • "Bamboo spine": Complete fusion of spine in advanced disease
  • Ossification of ligaments
  • Atlantoaxial subluxation (cervical spine involvement)
• Changes may take years to develop

MRI Spine and Sacroiliac Joints:

• Most sensitive imaging modality for early AS
• Detects:
  • Active inflammation (bone marrow oedema) on STIR/T2 fat-suppressed sequences
  • Chronic changes (erosions, sclerosis, fat deposition) on T1
• Can identify sacroiliitis years before visible on X-ray
• Allows earlier diagnosis and treatment (non-radiographic axial SpA)
• Useful for monitoring disease activity
• Recommended if:
  • Clinical suspicion high but X-rays normal
  • Young patient with inflammatory back pain
  • To confirm early disease

Diagnostic Criteria:

Modified New York Criteria (1984) for Ankylosing Spondylitis:

Requires: Radiographic sacroiliitis PLUS at least 1 clinical criterion

Radiographic criterion:

• Bilateral sacroiliitis grade ≥2, OR
• Unilateral sacroiliitis grade ≥3

Clinical criteria (need at least 1):

• Low back pain and stiffness >3 months, improves with exercise, not relieved by rest
• Limitation of lumbar spine in sagittal and frontal planes
• Limitation of chest expansion (age and sex adjusted)

Limitations:

• Requires definite radiographic changes (may take years)
• Misses early disease (non-radiographic axial SpA)

ASAS (Assessment of SpondyloArthritis international Society) Criteria:

More recent, includes non-radiographic axial SpA:

For patients with chronic back pain (≥3 months), age of onset <45 years:

Imaging arm: Sacroiliitis on imaging (X-ray or MRI) PLUS ≥1 SpA feature

Clinical arm: HLA-B27 positive PLUS ≥2 other SpA features

SpA features include: inflammatory back pain, arthritis, enthesitis, uveitis, dactylitis, psoriasis, Crohn's/UC, good response to NSAIDs, family history of SpA, HLA-B27, elevated CRP

Other Investigations (as indicated):

• Ophthalmology assessment: If symptoms of uveitis
• Cardiac investigations: ECG (conduction defects), echo (aortic regurgitation) in long-standing disease
• Pulmonary function tests: If respiratory symptoms
• DEXA scan: Assess for osteoporosis (increased risk)
• TB screening: Before starting biologics

Diagnostic Approach:

1. Clinical assessment: inflammatory back pain features, examination findings
2. Basic bloods: ESR/CRP, consider HLA-B27
3. Imaging:
   • Start with plain X-rays (pelvis, spine)
   • If X-rays negative but high suspicion → MRI sacroiliac joints
4. Apply diagnostic criteria
5. Early referral to rheumatology if suspected

Key Point: Diagnosis is clinical, supported by investigations. High index of suspicion needed in young patients with chronic inflammatory back pain. Early diagnosis allows early treatment to prevent irreversible spinal fusion.

Management of AS aims to reduce pain and stiffness, maintain function and mobility, prevent deformity, and improve quality of life. Requires combination of pharmacological and non-pharmacological approaches.

1. Non-Pharmacological Management (ESSENTIAL - Foundation of Treatment):

Exercise and Physiotherapy:

• CRUCIAL for maintaining mobility and preventing deformity
• Daily exercises:
  • Spinal extension exercises
  • Deep breathing exercises (maintain chest expansion)
  • Stretching exercises (hamstrings, hip flexors)
  • Postural exercises
  • Core strengthening
• Regular physical activity:
  • Swimming (ideal - non-weight bearing, promotes extension)
  • Pilates, yoga (with modifications)
  • Walking, cycling
  • Avoid high-impact contact sports
• Physiotherapy: Supervised exercise programs, hydrotherapy
• Benefits: maintains mobility, reduces pain, prevents spinal fusion, improves function

Lifestyle modifications:

• Smoking cessation:
  • Critical - smoking associated with worse outcomes
  • Increased radiographic progression
  • Worse functional outcomes
  • Reduced response to treatment
• Posture:
  • Maintain good posture throughout day
  • Firm mattress, single pillow (prevent flexed posture)
  • Regular postural checks
  • Ergonomic workplace setup
• Maintain healthy weight

Patient education:

• Understanding disease and prognosis
• Importance of lifelong exercise
• Self-management strategies
• Support groups

2. Pharmacological Management:

First-line: NSAIDs

• Cornerstone of pharmacological treatment for AS
• More effective in AS than in other arthritides
• Reduce pain and stiffness significantly
• May slow radiographic progression (unique to AS - not true for other arthritides)
  • Continuous daily NSAID use may be more effective than on-demand use
  • Balance benefits vs GI/CV risks
• Dosing:
  • Full anti-inflammatory dose (not just analgesic dose)
  • Often need regular dosing rather than as-needed
  • Evening dose helpful for morning stiffness
• Examples: Naproxen, diclofenac, indomethacin, etoricoxib (COX-2 selective)
• Side effects: GI (ulcers, bleeding), CV risk, renal impairment
  • Co-prescribe PPI for gastroprotection
  • Assess CV and GI risk before starting
  • Monitor renal function
  • Use lowest effective dose

Analgesics:

• Paracetamol for additional pain relief
• Weak opioids (codeine, tramadol) - short-term use only if inadequate response to NSAIDs
• Avoid long-term opioid use

Corticosteroids:

• NOT effective for axial disease (unlike RA)
• Local injections: May be useful for:
  • Peripheral arthritis (intra-articular)
  • Enthesitis (local injection)
• Avoid systemic steroids in AS (ineffective for spine, multiple side effects)

Conventional DMARDs:

• Methotrexate, sulfasalazine:
  • NOT effective for axial disease (major difference from RA)
  • May be helpful for peripheral arthritis if present
  • Sulfasalazine dose: 2-3g daily
• Limited role in pure axial AS

Biological DMARDs (for active disease despite NSAIDs and physiotherapy):

TNF-α inhibitors:

• Highly effective for both axial and peripheral disease
• Examples: Adalimumab, etanercept, infliximab, golimumab, certolizumab
• Indications:
  • Active disease despite optimal NSAIDs (≥4 weeks at full dose)
  • BASDAI (Bath AS Disease Activity Index) ≥4
  • Elevated CRP or spinal inflammation on MRI
• Efficacy:
  • Rapid improvement in symptoms (often within 2 weeks)
  • Reduce inflammation on MRI
  • Improve function and quality of life
  • Evidence for slowing radiographic progression less clear than symptom benefit
• Monitoring: Before each infusion/at regular intervals for infections
• TB screening essential before starting

IL-17 inhibitors:

• Secukinumab, ixekizumab:
  • Highly effective for AS
  • Alternative to TNF inhibitors as first-line biologic
  • May be preferred if comorbidities preclude TNF inhibitors
  • Particularly effective in AS (IL-17 pathway important in pathogenesis)
• Side effects: infections (including candida), IBD (theoretical concern with IL-17 blockade)

JAK inhibitors:

• Tofacitinib, upadacitinib:
  • Oral agents (advantage over injectable biologics)
  • Effective for AS
  • Alternative if biologics failed or not suitable
• Side effects: infections, VTE risk, lipid elevations

Treatment Algorithm:

1. All patients: Exercise + physiotherapy + patient education
2. Add: NSAIDs (continuous or on-demand, full anti-inflammatory dose)
3. If inadequate response: Trial different NSAID, optimize dosing
4. If still inadequate despite optimal NSAIDs + physio: Consider biologic (TNF inhibitor or IL-17 inhibitor)
5. If first biologic fails: Switch to different biologic or JAK inhibitor
6. For peripheral arthritis: May add sulfasalazine or methotrexate (not effective for axial)
7. Adjuncts: Local steroid injections for peripheral joints/enthesitis

3. Surgical Intervention:

• Hip replacement:
  • For severe hip arthritis (occurs in 20-30%)
  • Good outcomes
  • May be needed in younger patients
• Spinal osteotomy:
  • For severe fixed spinal deformity
  • Complex procedure, specialized centres
  • Can significantly improve function and quality of life
  • High risk - spinal cord injury, fracture
• Cervical spine stabilization: If atlantoaxial subluxation with neurological signs

4. Monitoring and Follow-up:

Disease activity assessment:

• BASDAI (Bath AS Disease Activity Index):
  • Patient-reported questionnaire
  • Score 0-10 (higher = more active)
  • Score ≥4 indicates active disease
• ASDAS (AS Disease Activity Score):
  • Incorporates patient-reported outcomes + CRP
  • More objective than BASDAI

Functional assessment:

• BASFI (Bath AS Functional Index): Assesses functional impairment
• Spinal mobility measurements (Schober's, chest expansion)

Regular monitoring:

• Clinical assessment (symptoms, examination, spinal mobility)
• ESR/CRP
• BASDAI/ASDAS
• Imaging not routinely repeated (unless assessing complications or treatment response)
• Screen for extra-articular complications (uveitis, cardiac, pulmonary)

5. Management of Extra-Articular Manifestations:

• Acute anterior uveitis:
  • Urgent ophthalmology referral
  • Topical steroids + mydriatics
  • Optimize systemic AS treatment (biologics reduce uveitis recurrence)
• IBD: Gastroenterology input, treat appropriately
• Cardiovascular: Regular CV risk assessment, echo monitoring if indicated
• Osteoporosis: DEXA scan, calcium/vitamin D, bisphosphonates if indicated

Key Messages:

• Exercise is essential - cannot be replaced by medication alone
• NSAIDs are cornerstone of pharmacological treatment
• Biologics highly effective for refractory disease
• Early diagnosis and treatment important to prevent irreversible ankylosis
• Multidisciplinary approach: rheumatologist, physiotherapist, patient
• Lifelong condition requiring ongoing management

Spinal Complications:

• Spinal ankylosis (fusion):
  • Progressive fusion of spine if untreated
  • Loss of mobility and flexibility
  • "Bamboo spine" - complete fusion
  • Fixed flexed posture ("question mark" spine)
  • Impaired function and quality of life
  • Can be prevented/slowed with early treatment and exercise
• Spinal fractures:
  • Increased risk even with minor trauma
  • Fused spine is rigid and brittle (like "bamboo")
  • Fractures often unstable and can cause spinal cord injury
  • High cervical fractures particularly dangerous
  • High index of suspicion after any trauma
  • CT scan preferred to X-ray for detection
  • Often require surgical stabilization
• Atlantoaxial subluxation:
  • Instability at C1-C2
  • Risk of spinal cord compression
  • May require surgical fixation
• Cauda equina syndrome:
  • Very rare late complication
  • Arachnoiditis affecting lumbar nerve roots
  • Presents with urinary/bowel dysfunction, saddle anaesthesia, lower limb weakness
  • Surgical decompression not usually helpful

Peripheral Joint Complications:

• Hip arthritis:
  • Occurs in 20-30% of AS patients
  • Major cause of disability
  • Poor prognostic indicator
  • May require total hip replacement (often at young age)
• Other peripheral arthritis: Knees, ankles, shoulders less commonly affected

Cardiovascular Complications:

• Accelerated atherosclerosis:
  • Chronic inflammation increases CV risk (similar to RA)
  • Increased risk of MI and stroke
  • Often underrecognized and undertreated
  • Aggressive CV risk factor management essential
• Aortitis and aortic regurgitation:
  • Occurs in ~2-10% of long-standing AS
  • Inflammation of aortic root and valve
  • Progressive aortic regurgitation
  • May require valve replacement
  • Regular clinical assessment; echo if murmur detected
• Conduction defects:
  • AV block (1st, 2nd, or 3rd degree)
  • Bundle branch block
  • Rare but can be serious
  • May require pacemaker

Pulmonary Complications:

• Restrictive lung disease:
  • From reduced chest expansion (costovertebral joint fusion)
  • Thoracic spine fusion
  • Usually mild and asymptomatic
  • Prevented by breathing exercises
• Apical pulmonary fibrosis:
  • Rare (~1% of patients)
  • Late complication (usually >20 years disease duration)
  • Upper lobe predominance
  • May cavitate and become secondarily infected (Aspergillus)
  • Can mimic TB on imaging
• Aspiration risk: If severe cervical spine involvement limits neck movement

Ocular Complications:

• Acute anterior uveitis:
  • 25-40% of patients experience at least one episode
  • Recurrent in many
  • Can lead to complications if untreated:
    • Posterior synechiae (iris adheres to lens)
    • Secondary glaucoma
    • Cataracts
    • Visual impairment
  • Good response to treatment if caught early
  • Patient education to seek urgent care for red painful eye

Neurological Complications:

• Spinal cord injury from fractures (as above)
• Cauda equina syndrome (rare)
• Nerve root compression
• Peripheral neuropathy (rare)

Gastrointestinal:

• Inflammatory bowel disease:
  • Clinical IBD in 5-10%
  • Subclinical gut inflammation much more common (~50%)
  • Crohn's disease or ulcerative colitis
  • May precede or follow AS diagnosis
• IgA nephropathy: Rare association

Musculoskeletal Complications:

• Osteoporosis:
  • Increased risk (chronic inflammation, reduced mobility)
  • Further increases fracture risk in brittle fused spine
  • Screen with DEXA
  • Treat with calcium, vitamin D, bisphosphonates if indicated
• Enthesopathy: Chronic pain and dysfunction from enthesitis

Psychosocial Impact:

• Depression and anxiety:
  • Common with chronic pain and disability
  • Impact on quality of life
  • Affects treatment adherence
  • Screen and treat appropriately
• Work disability:
  • 25-40% experience work disability
  • Related to disease severity, occupation type
  • Early treatment reduces disability
• Social impact: Chronic pain, fatigue, functional limitations

Prognosis and Long-term Outcomes:

Variable outcomes:

• Spectrum from mild disease with minimal impact to severe disability
• ~20-30% develop severe disease with significant functional impairment
• Many can maintain good function with treatment

Factors associated with poor prognosis:

• Hip involvement
• Young age at onset
• Elevated ESR/CRP at presentation
• Poor response to NSAIDs
• Peripheral arthritis
• Smoking
• Limitation of lumbar spine at presentation

Mortality:

• Slightly increased compared to general population
• Main causes:
  • Cardiovascular disease
  • Spinal fractures
  • Infections (especially if on immunosuppression)
  • Respiratory complications
• Overall life expectancy not dramatically reduced with modern treatment

Impact of Modern Treatment:

• Biologics have dramatically improved outcomes:
  • Better symptom control
  • Improved function and quality of life
  • Reduced work disability
  • May slow radiographic progression (though evidence mixed)
• Early diagnosis and treatment crucial:
  • Prevent irreversible ankylosis
  • Maintain function and mobility
  • Improve long-term outcomes

Monitoring for Complications:

• Regular rheumatology follow-up
• Cardiovascular risk assessment
• Eye symptoms - educate patient to seek urgent care
• Respiratory function if symptoms
• Spinal imaging if trauma (low threshold)
• DEXA scan for osteoporosis
• Screen for depression/anxiety
• Regular disease activity and functional assessments

Key Messages:

• AS is chronic but variable in severity
• Complications can affect multiple organ systems
• Spinal fractures are serious - high suspicion after trauma
• CV complications underrecognized - need aggressive risk factor management
• Early treatment and lifelong exercise improve outcomes
• Modern biologics have transformed prognosis
• Multidisciplinary care and patient education essential