Private axial spondyloarthritis clinic in London, same-day GP.

Other features

• Alternating buttock pain, from inflammation of the sacroiliac joints
• Enthesitis — pain where tendons attach, classically the heel (Achilles or plantar fascia)
• Dactylitis — a whole finger or toe swollen like a sausage
• Uveitis — recurrent red painful eye
• Psoriasis or a family history of it
• Inflammatory bowel disease, or unexplained bloody diarrhoea
• Good response to anti-inflammatories, which is itself a diagnostic clue
• fatigue, which is often profound and under-recognised

Diagnosis

• HLA-B27 is positive in most people with the condition — but also in around 8% of the healthy UK population, so it supports rather than proves the diagnosis.
• MRI of the sacroiliac joints detects active inflammation years before any change appears on X-ray. This is the key investigation.
• X-rays show established structural change but are normal early on — a normal X-ray does not exclude the condition, and relying on it is a major reason for delay.
• CRP and ESR are raised in only around half of cases, so normal markers do not exclude it either.
• It affects men and women roughly equally, though women are diagnosed later and are more often told they have fibromyalgia.

Treatment

• Daily exercise is the single most important treatment — spinal mobility, stretching, posture and deep breathing work. Specialist physiotherapy makes a substantial difference and should be arranged early.
• Anti-inflammatories, often taken regularly rather than as needed, which reduce both pain and possibly progression.
• Biologic therapies — anti-TNF and IL-17 inhibitors — have transformed outcomes for people not controlled on NSAIDs.
• Steroid injections into sacroiliac joints or entheses for localised problems.
• Conventional DMARDs such as methotrexate work for peripheral joints but not for spinal disease.
• Stop smoking — smoking is associated with faster structural progression and worse outcomes.

Long term

Not everyone progresses to a fused spine, and modern treatment makes that considerably less likely. Cardiovascular risk is raised by the inflammation and should be monitored. Bone density falls even in a stiff spine, so osteoporosis assessment matters. Tell any anaesthetist about a stiff neck before surgery, and inform the DVLA if neck movement is significantly restricted.