Spondylitis

Spondylitis vs spondylosis vs spondylolisthesis

Inflammatory spondylitis (axial spondyloarthritis)

Axial spondyloarthritis is a group of related autoimmune conditions affecting the spine and sacroiliac joints (where the spine meets the pelvis):

• Ankylosing spondylitis (radiographic axial spondyloarthritis): changes visible on X-ray; may progress to fusion of the spine.
• Non-radiographic axial spondyloarthritis: same symptoms, with inflammation seen on MRI but not X-ray.
• Related spondyloarthritis: psoriatic arthritis, enteropathic arthritis (with Crohn's disease or ulcerative colitis), reactive arthritis, and undifferentiated spondyloarthropathy.

Symptoms of inflammatory back pain

• back pain starting before age 45 and lasting more than 3 months
• gradual onset
• morning stiffness lasting more than 30 minutes
• pain that improves with exercise and worsens with rest
• waking in the second half of the night with pain
• alternating buttock pain
• fatigue

Other features: heel pain (enthesitis), swollen fingers or toes (dactylitis), arthritis of hips or knees, uveitis (painful red eye), psoriasis and inflammatory bowel disease.

Causes

The gene HLA-B27 is strongly associated, present in most people with ankylosing spondylitis, though most people with HLA-B27 never develop it. Gut bacteria and immune pathways involving IL-17 and TNF play a role.

Infectious spondylitis

Infection of the vertebrae and discs, also called vertebral osteomyelitis or spondylodiscitis, usually comes from bacteria spreading through the blood, most often Staphylococcus aureus. Tuberculosis (Pott's disease) and brucellosis are important causes in some regions.

Risk factors: age over 50, diabetes, IV drug use, dialysis, endocarditis, recent spinal surgery or injections, and weakened immunity.

Symptoms:

• constant, severe back or neck pain, worse at night and with movement
• fever, though not always
• tenderness over the spine
• in complications: an epidural abscess pressing on nerves, causing weakness, numbness or bladder problems

Diagnosis

Inflammatory

• blood tests: CRP and ESR (inflammation markers), HLA-B27
• X-ray of the sacroiliac joints
• MRI to detect early inflammation
• rheumatologist assessment using classification criteria

Infectious

• MRI of the spine: the most sensitive test
• blood cultures and inflammatory markers
• CT-guided biopsy to identify the organism if cultures are negative
• echocardiogram if endocarditis is possible

Treatment

Inflammatory spondylitis

• Exercise and physical therapy: daily stretching, posture and strengthening exercises; swimming is excellent.
• NSAIDs: first-line medicines, often taken regularly. Follow your doctor's advice; NSAIDs can affect the stomach, kidneys and blood pressure.
• Biologics: TNF inhibitors (such as adalimumab, etanercept) or IL-17 inhibitors (such as secukinumab, ixekizumab) for persistent symptoms.
• JAK inhibitors: tofacitinib, upadacitinib.
• Stop smoking, which worsens progression.
• Surgery occasionally for severe hip damage or spinal deformity.

Infectious spondylitis

• Antibiotics for at least 6 weeks, often starting intravenously, chosen based on the organism.
• Anti-tuberculosis treatment for 9 to 12 months or longer for TB spondylitis.
• Surgery for abscesses, nerve compression, spinal instability or failure of antibiotics.

Outlook

Inflammatory spondylitis is lifelong, but modern treatment controls symptoms and may slow spinal fusion; most people work and stay active. Infectious spondylitis is usually curable with prolonged antibiotics, though some people have lasting pain or nerve damage, particularly if diagnosis was delayed.

Frequently asked questions

What is the difference between spondylitis and spondylosis?

Spondylitis is inflammation of the vertebrae, caused by autoimmune disease such as ankylosing spondylitis or by infection. Spondylosis is age-related wear and tear of the spine's discs and joints. They have different causes and treatments.

What are the first symptoms of spondylitis?

For inflammatory spondylitis, the first symptoms are usually long-lasting lower back or buttock pain and morning stiffness starting before age 45, which improve with activity. Infectious spondylitis causes constant, severe back pain, often with fever.

Is spondylitis curable?

Infectious spondylitis is usually curable with a long course of antibiotics. Inflammatory spondylitis, such as ankylosing spondylitis, is lifelong but can be well controlled with exercise, NSAIDs and biologic medicines.

What is the best exercise for spondylitis?

For inflammatory spondylitis, daily stretching, posture exercises, back extension exercises and low-impact activities such as swimming, cycling and walking are recommended. A physical therapist can design a routine. Avoid high-impact contact sports if the spine has fused.