Nonsurgical management of ankylosing spondylitis

The aim of this study was to review the current evidence-based nonsurgical management strategies of ankylosing spondylitis (AS) for spine surgeons. Whereas surgical management is indicated in a highly selected group, nonsurgical management is itself a useful measure for nearly all patients with AS.

The authors conducted a literature review of PubMed using relevant search words. All the articles published in English in the last 15 years were reviewed and the level of evidence provided by them was noted.

Nonpharmacological treatments in the form of physical therapy and patient education have Level Ib evidence in maintaining function in AS. There is Level Ib evidence supporting the use of nonsteroidal antiinflammatory drugs (NSAIDs) and coxibs for treatment in patients with symptoms. There is not enough evidence to support the use of conventional disease-modifying antirheumatoid arthritis drugs. Tumor necrosis factor (TNF)alpha inhibitors (infliximab, etanercept, and adalimumab) are associated with Level Ib evidence in improving spinal pain, function, inflammatory biomarkers, and spinal inflammation detected by magnetic resonance imaging in patients in whom symptom duration has exceeded 3 months.

Physical therapy and patient education are useful for all patients diagnosed with AS. If symptomatic, patients are started with either a course of nonselective NSAIDs or a selective cyclooxygenase-2 inhibitor. The role of NSAIDs as a disease-modifying therapy in the treatment of AS is increasingly being understood. The central role of TNF in the pathogenesis of AS is now known, and the advent of biological treatment in the form of anti-TNFalpha factors has revolutionized the medical management of AS and is used in patients with axial disease whose symptoms persist despite an adequate dose of NSAIDs.