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Ankylosing spondylitis: introductory comments on its diagnosis and treatment
  1. M A Khan
  1. Case Western Reserve University, Cleveland, Ohio, USA
  1. Correspondence to:
    Dr M A Khan, Case Western Reserve University, University School of Medicine, Division of Rheumatology, 2500 MetroHealth Drive, Cleveland, Ohio 44145, USA;
    mak9{at}po.cwru.edu

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A nkylosing spondylitis (AS) is a chronic systemic inflammatory rheumatic disorder of uncertain aetiology that primarily affects the axial skeleton (sacroiliac joints and spine). Sacroiliac joint involvement (sacroiliitis) is its hallmark.1 The course of AS is highly variable and can be characterised by spontaneous remissions and exacerbation, particularly in early disease. The disease activity, however, generally persists for many decades, rarely entering a long term remission. The disease in some patients may be relatively mild or stay limited to the sacroiliac joints and the lumbar spine. Many patients may not seek medical help, which combined with the insidious nature of AS, may preclude an early diagnosis. There is currently no cure for AS, nor is there any medical intervention which can prevent or retard its progression.

DISEASE ONSET TO DIAGNOSIS: A BRIDGE TOO FAR

Only a doctor who is fully cognisant of the clinical nature of AS might consider the possibility of a spondyloarthropathy (SpA), much less AS, when presented with a young individual in their teens or early to mid-20s with chronic back pain.1,2 Yet, this is a typical initial presentation of AS. Unfortunately, the presence of inflammatory back pain during the clinically unrecognised “pre-spondylitic” phase, which on average might last 5–10 years or longer, is accompanied by progressive structural damage that may take place inconspicuously.1–8 Diagnosis is often established when AS reaches the stage where structural damage has led to easily recognisable abnormal physical findings or readily apparent radiographic abnormalities of the sacroiliac joints and spine, or both.1–4

Figure 1, which represents data collected by a 78 item professional survey of patients with AS conducted by the German AS society in 1996, illustrates well the protracted time delay between onset of AS and its diagnosis.5 A total of 1614 patients with AS responded to the questionnaire. The average …

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