Non-radiographic spondyloarthritis typically causes pain in the lower back and buttocks. As a chronic condition stemming from persistent inflammation, co-occurring conditions and symptoms in other parts of the body are common.

Non-radiographic axial spondyloarthritis (nr-axSpA) is a chronic inflammatory condition of the spine and sacroiliac (SI) joints of the pelvis.

It’s part of the spectrum of axial spondyloarthritis (axSpA) and represents axSpA when there’s no visible damage to the SI joints on plain radiographs (X-rays).

The exact causes of nr-axSpA aren’t clear, but overactive immune responses, genetics, and environmental factors may all play a role. Similar to other arthritic conditions, nr-axSpA involves persistent inflammation of the musculoskeletal system that causes discomfort and functional limitations.

Chronic inflammation can underpin many different conditions. Although the exact links aren’t fully understood, nr-axSpA is associated with inflammatory complications and co-occurring conditions throughout the body.

Enthesitis is inflammation of the connection point where bone joins with tendons or ligaments, known as the entheses. You can develop enthesitis in one or multiple entheses sites, and it’s considered a central feature of inflammatory conditions, such as axSpA and psoriatic arthritis.

In nr-axSpA, enthesitis often causes pain and swelling within the spine, chest, and pelvis, but it can also affect connection sites at the heels, such as where the Achilles tendon attaches to the bone.

Symptoms include:

  • pain
  • swelling
  • tenderness
  • localized warmth
  • stiffness
  • reduced functionality

Eye inflammation in nr-axSpA is common. According to a 2020 review, uveitis is one of the most common non-joint complications of nr-axSpA, affecting approximately 33% of people living with the condition.

Uveitis is inflammation of the middle layer of the eye, the uvea. It can cause symptoms of:

  • eye pain
  • blurry vision
  • eye redness
  • light sensitivity
  • “floaters” in the field of vision

Anterior uveitis, also known as iritis, is the subtype of uveitis typically seen in axSpA. It’s a serious condition that should be treated as soon as possible to prevent vision loss.

Inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis, is another common complication of nr-axSpA.

According to research from 2019, people living with nr-axSpA have an estimated 5.3 times higher chance of developing IBD compared to the general population.

While both types of IBD are possible complications in nr-axSpA, the research notes that Crohn’s disease is the more common of the two.

Symptoms of IBD include:

  • abdominal cramping and pain
  • weight loss
  • persistent diarrhea
  • rectal bleeding or bloody stool
  • appetite changes
  • bowel urgency or incontinence
  • fever
  • fatigue

Psoriatic disease is the collective term for conditions, such as psoriasis and psoriatic arthritis, immune-mediated inflammatory conditions of the skin and joints.

According to a 2023 study, rates of psoriasis in axSpA range from 3.1–18.9% in research, with a general prevalence of about 10%.

Symptoms of psoriasis differ depending on the type but include varying presentations of:

  • thickened, discolored patches of skin, often with gray or silvery scales
  • thick, ridged, or pitted nail changes
  • dry skin
  • itching or burning skin sensation
  • cracked and bleeding skin

The prevalence of psoriatic arthritis in nr-axSpA is less clear due to the significant overlap of symptoms between these conditions. A 2020 study indicates that as many as 70% of people living with psoriatic arthritis experience axial spine involvement.

Psoriatic arthritis symptoms include:

  • joint pain and stiffness
  • enthesitis
  • fatigue
  • skin and nail changes
  • swollen fingers and toes
  • uveitis
  • lower back pain
  • limited range of motion

Chronic fatigue, sometimes appearing as “brain fog,” can happen in nr-axSpA. Constant inflammatory processes in your body require energy to maintain, which can make you feel more tired than usual or not as mentally sharp.

Living with a chronic condition, such as nr-axSpA, may also contribute to depression, a mental health condition that creates a state of low energy and disrupts sleeping patterns, exacerbating fatigue.

Inflammation can hurt. Your body’s inflammatory response includes features such as increased nerve sensitivity and tissue swelling, which can create pressure and pain in musculoskeletal locations.

A 2020 study involving subjects with axSpA found that 44% reported chronic, widespread pain.

People living with axSpA have a higher risk for cardiovascular diseases. While much of this is attributed to inflammatory processes in the body, nonsteroidal anti-inflammatory drugs (NSAID) may also be to blame.

Nr-axSpA and other axSpA conditions respond well to NSAID therapy, but it can take higher-than-average doses to achieve the desired results for some people. High doses of NSAIDs over prolonged periods of time have been associated with increased cardiovascular risks, such as heart attack and stroke.

Symptoms of cardiovascular disease are varied across conditions but include:

  • chest pain, pressure, or discomfort
  • heart palpitations or irregular heartbeat
  • shortness of breath
  • weakness and fatigue
  • dizziness and lightheadedness
  • swelling in the legs or feet
  • cold sweats
  • sharp pains in the jaw, neck, shoulder, or upper abdomen

Chronic inflammatory processes in your musculoskeletal system have long-term effects. Your body responds to inflammation by initiating tissue repair, which can lead to scarring, calcification, bone deterioration, and structural changes that create pain in unrelated areas.

Complications of this nature include:

  • hip and shoulder pain
  • chest pain caused by rib cartilage inflammation (costochondritis)
  • pain when breathing deeply (pleurisy)
  • bone weakening (osteoporosis)
  • jaw swelling (spondylitis of the jaw)

In rare cases, long-established axSpA can be associated with serious complications, such as cauda equina syndrome and decreased vital capacity.

Cauda equina syndrome is a neurological condition that develops when the nerves at the base of your spinal cord become compressed. In nr-axSpA, this compression likely happens from post-inflammation scarring.

Symptoms of cauda equina syndrome include:

  • severe or progressive loss of sensation in the lower body
  • bladder or bowel incontinence

Decreased vital capacity is caused when scarring of the lungs decreases the maximum amount of air you can inhale and exhale.

Symptoms include:

  • shortness of breath
  • shallow breathing
  • coughing
  • fatigue
  • wheezing
  • chest discomfort
  • poor exercise tolerance

Nr-axSpA is a presentation of axSpA, a chronic inflammatory condition affecting the spine and pelvis. For reasons not fully understood, nr-axSpA and other axSpA conditions often present with complications in other areas of the body.

For some people, nr-axSpA co-occurs with inflammatory conditions, such as psoriatic arthritis.

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