Ankylosing Spondylitis Neuropathy: Causes, Symptoms, & Management

The combination of neuropathy and ankylosing spondylitis (AS) can be particularly challenging.

Ankylosing spondylitis is an inflammatory condition that primarily affects the spine and can sometimes lead to nerve damage, known as neuropathy.

In this article, we will explore what ankylosing spondylitis is, how neuropathy may arise because of this condition, how it's detected and how to treat it. You will walk away with a deeper knowledge of how this chronic condition is intertwined with neuropathic pain.

What is ankylosing spondylitis?

Ankylosing spondylitis (AS) is a long-term inflammatory condition that mainly affects the spine, lower back, and the joints that connect the spine to the pelvis. This condition can cause significant discomfort and stiffness, making it hard to move and affecting overall quality of life. People with AS often experience chronic back pain, neck and hip discomfort, and sometimes numbness or weakness in the legs. These symptoms are similar to those caused by rheumatoid arthritis, which also impacts daily activities.

While the pain in ankylosing spondylitis is mostly due to inflammation, there are also neuropathic symptoms that may arise.

What is ankylosing spondylitis neuropathy?

Neuropathy, which is nerve damage, can occur as a secondary complication of ankylosing spondylitis due to factors like bone growth or surgeries involving spinal fusion^1,2. This nerve damage often causes sharp, stabbing pains or burning sensations.

Axial spondyloarthritis (axSpa) is a broader term that includes different types of inflammatory arthritis that primarily affect the spine and the joints that connect the lower spine to the pelvis³. Ankylosing spondylitis is a specific type of axial spondyloarthritis.

Both conditions cause inflammation in these areas, leading to pain and stiffness. About one-third of people diagnosed with axial spondyloarthritis, including those with AS, show signs of nerve-related pain.

What are the symptoms of neuropathic pain?

People with ankylosing spondylitis may experience neuropathic pain, which includes a variety of uncomfortable sensations. One common symptom is tingling, which can affect areas like the legs and lower back. This tingling often comes with numbness, making these areas less sensitive to touch or pressure.

Another frequent symptom is a burning sensation, which many people with AS find deeply troubling. This relentless burning can complicate daily routines. Additionally, some individuals experience shooting pains that feel like electric shocks, which can be intensely sharp and incapacitating.

People with AS might also endure other nerve-related symptoms such as:

• piercing stings
• throbbing
• searing pain
• prickling
• reduced sensitivity.

These stabbing feelings can spread through the legs, suggesting that nerve involvement goes beyond just the joints and bones. Muscle weakness paired with prickling may indicate that peripheral nerves are also affected.

How does ankylosing spondylitis cause neuropathy?

Ankylosing spondylitis (AS) can cause nerve damage through several complex processes. One major factor is the compression of the spinal cord, which can lead to back pain, muscle weakness, and problems with bladder control. Inflammation and the growth of new bone can create bony bumps that press on the spinal cord and its nerves.

Another issue related to AS is cauda equina syndrome. This happens when nerves at the base of the spine are compressed, causing lower back and leg pain or numbness, and changes in bowel or urinary function.

Inflammation from AS can also press on different nerves coming from the spine, leading to symptoms like reduced feeling or strength, especially in the legs.

How do you diagnose ankylosing spondylitis?

Identifying neuropathic pain in people with ankylosing spondylitis involves both clinical assessments and diagnostic tools. Common tools include the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)⁴ and the CRP-based Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP)⁵, which help measure pain and overall disease activity. BASDAI includes questions specifically aimed at identifying peripheral pain.

For screening neuropathic pain, the PainDETECT Questionnaire (PDQ) is very useful⁶. It evaluates both the presence and severity of neuropathic pain symptoms. Other tools like the Hospital Anxiety and Depression Scale (HAD)⁷ and a visual analog scale (VAS)⁸ help assess the psychological impact and the intensity of pain.

To differentiate between inflammatory and neuropathic pain in AS, doctors may use nerve conduction studies and brain imaging techniques, along with clinical symptoms and X-rays. Nerve conduction studies can assess how well nerves and muscles are working, highlighting any damage. Imaging techniques like MRI or CT scans provide detailed views of the spine, helping doctors diagnose and treat the underlying causes of pain in AS.

How do I treat neuropathic pain related to ankylosing spondylitis?

A comprehensive multidisciplinary strategy is required to manage neuropathic pain associated with ankylosing spondylitis. This may include retraining how the body responds to pain, participating in physical therapy and exercise, as well as taking medications for short-term pain relief.

Other mind and body practices, such as counseling sessions, stress reduction and improved sleep quality can also aid in managing pain, and its impact on your life.

Medication as an enabler

While medication can be a part of your comprehensive pain management plan, it’s important not to rely on it as the primary treatment. Medication should be seen as a tool that helps you engage in other effective pain management strategies to improve your condition. These strategies may include education, lifestyle adjustments, and psychological support.

Common medications prescribed for ankylosing spondylitis include:

• over-the-counter medications such as aspirin and ibuprofen
• nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen and indomethacin, which help manage pain and reduce inflammation
• disease-modifying antirheumatic drugs (DMARDs) like sulfasalazine, which help manage inflammation and slow disease progression.

Your doctor is the best person to speak to about which medications or pain relievers may be suitable for your individual situation.

Furthermore, recent studies suggest that tumor necrosis factor (TNF) inhibitors may not be as effective in treating neuropathic pain in AS patients, though they do help with inflammatory pain. This highlights the need for personalized treatment plans that address both pain types.

Physical therapy & exercise

Physical therapy and exercise play a key role. These interventions can help reduce discomfort, maintain joint flexibility, and improve movement while strengthening muscles. The recommended exercise plan for those with AS includes:

• cardiovascular exercises to boost heart health
• stretching routines to increase range of motion
• strength-building workouts
• balance-improving activities.

Flexibility exercises are especially beneficial in preventing spinal stiffness and maintaining joint fluidity, making movement easier.

Aquatic activities, like water aerobics, can ease joint discomfort and improve agility. Warm water hydrotherapy can also reduce pain and make joints more flexible.

Movement and exercise can also reduce pain, boost your mood and energy levels, and improve your sleep quality. You can tailor movement to your own limitations and symptoms and it doesn't have to be a formal exercise either! Any active hobbies count, including yoga, dancing, or even gardening.

Our two top tips are to start slowly and be kind to yourself. Starting with small, low-impact exercises and gradually increasing intensity and duration allows the body to adapt safely. And practicing self-compassion will allow you to embrace challenges with resilience and confidence.

Retraining your pain response

To retrain your pain response, it's important to realize that pain isn't just about physical sensations; it's influenced by the full range of your biological, psychological and social circumstances.

Taking the time to understand your pain triggers, whether they're caused by stress, beliefs or behaviors can help. Once you've identified our triggers, you can start to change them, for example through nutrition, sleep and movement, or use techniques based on neuroplasticity to change how your brain reacts to these triggers. With practice and dedication, you can gradually reshape your brain's response, leading to a reduction in the intensity and impact of your chronic pain.

These include the following.

Stress management

Stress hormones such as cortisol can heighten the body's pain response, exacerbating discomfort. While avoiding stress entirely may not be feasible, there are ways to reduce stress and reduce your reaction to stressful situations. These include cognitive behavior therapy (CBT), mindfulness meditation, relaxation practices, and emotional and social support from a friend, therapist, or community.

Sleep quality

Sleep plays a crucial role in managing your ankylosing spondylitis, forming a vital component of self-care strategies for pain reduction. The interplay between ankylosing spondylitis symptoms and sleep quality creates a challenging cycle, where poor sleep exacerbates symptoms, and symptoms cause sleep disturbances.

Improving your sleeping patterns can help alleviate many ankylosing spondylitis symptoms, including associated pain. Tips for improving your sleeping patterns include:

• Establish a consistent sleep routine with fixed sleep and wake times, aiming for eight hours of sleep each night.
• Limit daytime naps to short durations to avoid disrupting nighttime sleep patterns, ensuring they remain refreshing power naps.
• Engage in physical activity during the day to promote better sleep onset.
• Reduce screen time before bed to create a conducive environment for restful sleep.
• Create a dark, quiet sleep environment to support uninterrupted sleep.
• Moderate caffeine intake, especially in the afternoon and evening, as it can linger in the body for hours and interfere with sleep.
• Avoid consuming large meals and alcohol close to bedtime to improve sleep quality.
• Incorporate various forms of rest for the heart, body, and mind to complement sleep hygiene practices and manage ankylosing spondylitis symptoms effectively.