Ankylosing spondylitis (AS) is a chronic inflammatory arthritis that primarily affects the spine and sacroiliac joints. It can be difficult to diagnose early, and many patients go years before receiving the right diagnosis. Here’s a real case that highlights key aspects of AS—its symptoms, testing, and treatment decisions.

A 43-year-old man of South Asian descent came in with long-standing back and neck stiffness, lasting for hours each morning. His pain improved with movement but worsened with rest—classic signs of inflammatory back pain. The symptoms began in his late twenties and had persisted for over 15 years.

He had already been diagnosed with ankylosing spondylitis by another rheumatologist and came for a second opinion. His lab work showed mild inflammation (elevated ESR and CRP), though his HLA-B27 test was negative. While this genetic marker is commonly associated with AS, its absence does not rule out the disease. About 6–8% of the general population test positive for HLA-B27, but only a fraction develop AS.

Confirming the Diagnosis

The patient’s MRI was a key factor. It revealed partial fusion in both sacroiliac joints, a hallmark of ankylosing spondylitis. Although no active inflammation (bone marrow edema) was seen, these structural changes confirmed chronic AS. Combined with his family history—his father also had AS with severe progression—the diagnosis was clear.

Treatment Considerations

The patient’s biggest question was whether biologic medications were necessary or if regenerative treatments like platelet-rich plasma (PRP) or bone marrow cell therapy could help. While regenerative therapies may improve pain, current evidence shows they do not stop disease progression.

For conditions like AS, biologic medications remain the only proven disease-modifying treatments, helping prevent further joint damage and spinal fusion. Given that this patient already showed moderate structural changes on MRI and had a strong family history, biologic therapy was the appropriate next step.

The Role of AI and Clinical Judgment

Interestingly, when this case was entered into an AI-based medical tool, it suggested NSAIDs as first-line therapy. While NSAIDs are helpful for pain relief in AS, they don’t prevent long-term progression. Because this patient’s main concern was preventing future damage—not just pain relief—biologic therapy was the more suitable choice.

This highlights the importance of human clinical judgment in medicine. AI can assist with information, but the nuances of each patient’s history, imaging, and goals require an experienced physician’s insight.

Key Takeaway

For patients with ankylosing spondylitis, early recognition and appropriate treatment are critical. Lifestyle measures like exercise and diet are valuable for symptom management, but biologics remain the cornerstone of disease control and progression prevention.

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