A Rare Presentation of chronic lower back ache radiating to lower limb in a patient with Ankylosing Spondylitis with Andersson Lesion managed by Methotrexate: A Case Report

A Rare Presentation of chronic lower back ache radiating to lower limb in a patient with Ankylosing Spondylitis with Andersson Lesion managed by Methotrexate: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Rare Presentation of chronic lower back ache radiating to lower limb in a patient with Ankylosing Spondylitis with Andersson Lesion managed by Methotrexate: A Case Report Chandan Singh Tanwar, Vivek Jain, Parikshit Nagda, Kaushal Ramani, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6459382/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : Ankylosing spondylitis (AS) is a chronic inflammatory disorder primarily affecting the axial skeleton, leading to lower back pain, stiffness, and progressive spinal immobility. A rare but serious complication is the formation of Andersson lesions—aseptic, destructive discovertebral abnormalities that can mimic infectious spondylitis. Case Presentation : We report the case of a 25-year-old male with chronic lower back pain radiating to the left lower limb. MRI revealed a focal hyperintense lesion at the lower endplate of the D3 vertebra, sacroiliitis, and edema in the sacroiliac joints—findings consistent with an Andersson lesion. Laboratory results showed positive Human Leukocyte Antigen B27 (HLA-B27), elevated C-reactive protein (CRP), and negative antinuclear antibody (ANA). The patient was treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and methotrexate (MTX), a disease-modifying antirheumatic drug (DMARD) not typically used for axial AS. Over three months of MTX therapy, the patient showed substantial symptomatic improvement. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores progressively decreased, and inflammatory markers normalized. Conclusions : Although methotrexate’s role in axial AS remains controversial, this case demonstrates its potential efficacy in managing rare complications such as Andersson lesions. The positive therapeutic outcome highlights the importance of individualized treatment approaches and supports the need for further research into the broader use of DMARDs in complex AS presentations. Ankylosing Spondylitis Andersson Lesion Methotrexate Axial Spondyloarthritis Management Chronic Lower Back Pain Sacroiliitis Figures Figure 1 Figure 2 Introduction Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the axial skeleton, leading to lower back pain and progressive spinal stiffness. Because the disease can affect other areas of the body, other symptoms like pain, stiffness, inflammation of joints (such as the ribs, shoulders, knees, or feet), skin rashes, abdominal pain, and loose bowel movements, fatigue may develop, etiology not fully understood. HLA-B27 a gene variant, is implicated in the pathogenesis of ankylosing spondylitis (AS) as well as frequent gastrointestinal infections may also lead to AS. The exact mechanisms remain under investigation, but several. The global prevalence of AS is estimated to be between 0.01% and 2.5%. A rare but significant complication of AS is the development of Andersson (disco vertebral) lesions (AL). ALs are aseptic, inflammatory complications in ankylosing spondylitis (AS). Reported prevalence varies from 1.5% to 28%, likely due to differing diagnostic criteria and imaging techniques. [1-4] The most used criteria for the classification of ankylosing spondylitis were developed in 1966 and modified in 1984: 1. Persistent low back pain lasts for a minimum of three months and exhibits inflammatory features such as improvement with physical activity and lack of relief with rest. 3. Restricted movement of the lumber spine in both the sagittal and frontal planes. 4. Reduced chest expansion compared to the normal range expected for age and sex. 5. Bilateral sacroiliitis of grade 2 or higher 6. Unilateral sacroiliitis of grade 3 or higher A confirmed diagnosis of ankylosing spondylitis is established when the fourth or fifth criterion is present alongside any clinical criteria. However, radiographic evidence of sacroiliitis may take several years to appear. To facilitate early diagnosis, newer criteria -such as magnetic resonance imaging have been proposed for identifying the condition in its initial stages.[5] The management of AS typically involves nonsteroidal anti-inflammatory drugs (NSAIDs) as the first-line treatment, with biologic agents considered for patients with inadequate response. The role of disease-modifying antirheumatic drugs (DMARDs) like methotrexate (MTX) in treating axial manifestations of AS remains controversial. While MTX is effective in conditions such as rheumatoid arthritis, its efficacy in AS, especially concerning axial symptoms, is not well established. [6-8] In this case, however, MTX demonstrated unexpectedly positive results. The patient showed significant clinical improvement after three months of low-dose MTX therapy. Case Presentation A 25-year-old male presented to the general medicine OPD with chronic back pain (for over 8 months) radiating pain to the left lower leg. On a general examination, the patient’s vital signs were normal with no family history and no mental instability. Tenderness was noted over the lumbar spine and sacroiliac joints, with a restricted range of motion in the lower back. No sensory or motor deficits in both legs. All relevant investigations revealed elevated CRP (18.7mg/L) and mild reactive thrombocytosis with negative antinuclear antibody (ANA) and positive HLA-B27. MRI of the pelvis and screening of the whole spine revealed a focal short tau inversion recovery hyperintense area along the lower endplate of the D3 vertebra, suggesting an Andersson lesion. Minor posterior disc bulges were also observed in the lumbar spine, indenting the thecal sac without significant neural foraminal narrowing. Abnormal signal intensities were seen in the sacral and iliac regions of both sacroiliac joints. STIR hyperintensity with articular surface irregularity and erosions suggested significant edema. T1/T2 hyperintense and STIR hypointense areas in the anterior sacroiliac joints (Fig: 1). Additional findings included STIR hyperintense signals in the left acetabulum, minimal left hip joint effusion, and edema signals along the pubic symphysis. X-ray confirmed the additional diagnosis of Sacroiliitis associated with AS (Fig: 2). The patient was diagnosed with Ankylosing Spondylitis with radiating pain to the lower limb. He was prescribed Aceclofenac 100 mg twice daily for 5 days, followed by SOS, Methotrexate 5 mg once a week for 3 months and folic acid 5 mg once daily for 15 days. Despite methotrexate not being a primary treatment option for AS, its use in this case yielded unexpected but positive results. Following this treatment regimen, the patient showed significant improvement, with reduced pain, decreased stiffness, and improved mobility. Patients Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores were closely monitored: 7.1 in the first month, 5.6 in the second month, and 4.1 in the third month, with normal CRP levels (0.23 mg/dL), reflecting a steady reduction in disease activity and symptom severity. Discussion Methotrexate in Ankylosing Spondylitis: A Controversial Role Methotrexate, a disease-modifying antirheumatic drug (DMARD), is widely used in autoimmune conditions such as rheumatoid arthritis and psoriatic arthritis. However, its efficacy in AS, particularly for axial disease, remains controversial [ 9 ]. Studies have yielded conflicting results. A randomized, double-blind, placebo-controlled trial demonstrated that low-dose MTX (7.5 mg/week) improved BASDAI scores and reduced spinal pain in AS patients by the 24th week of treatment (The Journal of Rheumatology). Another study noted significant reductions in inflammatory markers and subjective pain relief in a subset of AS patients treated with MTX.[ 10 ] Additionally, a 24-week, double-blind, placebo-controlled study comparing MTX with placebo found no statistically significant difference in axial symptom improvement.[ 11 ] Similarly, a Cochrane review highlighted insufficient evidence to recommend MTX for axial AS, emphasizing the need for well-designed clinical trials.[ 12 ] In this case, the presence of ALs was a key radiological finding. ALs are destructive discovertebral lesions associated with AS, resulting from chronic inflammation leading to vertebral erosions or mechanical stress-induced fractures in an ankylosed spine, which can progress to pseudarthrosis.[ 4 ] ALs are rare, often mimicking infectious spondylitis; [ 6 , 13 , 14 ] management includes NSAIDs, physical therapy, and surgery for refractory cases. The use of MTX in this case, leading to symptom improvement and reduction in inflammatory markers, is intriguing, as it suggests a potential role for MTX in managing inflammatory activity associated with ALs. This case aligns with findings from smaller case studies reporting benefits of DMARDs in specific AS complications which is controversial but unique, highlights the need for further research to explore the potential role of MTX in managing complex AS cases, particularly those involving ALs. Implications and Future Directions This case underscores the importance of personalized treatment approaches in AS, particularly in the context of rare complications like Andersson lesions. While biologics are the gold standard for refractory AS, the observed efficacy of MTX in this patient suggests that it may serve as a cost-effective alternative or adjunct in select cases. However, these findings warrant further investigation through larger, controlled studies to establish the efficacy and safety of MTX for ALs and axial AS. Conclusion The management of pain associated with Andersson lesions in AS remains complex, with conservative treatments often falling short. This case highlights the potential role of methotrexate in alleviating symptoms and controlling inflammation, even though it is not conventionally indicated for AS. The findings advocate for more research into the utility of DMARDs in managing complicated AS cases, paving the way for more inclusive and individualized therapeutic strategies. Declarations Consent for Publication: Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. Competing interests The authors declare that they have no competing interests. Patient Perspective The patient expressed that he is feeling significantly better after undergoing methotrexate therapy. He reported reduced back pain, improved mobility, and a noticeable decrease in stiffness. He is satisfied with the treatment outcome and is hopeful about continuing recovery. Funding: Nil Author Contribution C.S.T. was the treating doctor and contributed to the clinical management of the case. K.R. was the assessing doctor and provided the relevant clinical data. P.N. wrote the case study and prepared the manuscript. G.D helped in the preparation of the manuscript. V.J., G.B and B.S.C. frequently reviewed and proofread the manuscript.All authors read and approved the final manuscript. Acknowledgement The authors would like to express their sincere gratitude to the patient and Ananta institute of medical sciences and research center for providing consent to share their medical information for academic purposes. We also thank the supporting medical and nursing staff involved in the patient's care. Availability of data and materials: Data sharing does not apply to this article as no datasets were generated or analyzed during the current study. All relevant patient information is included within the article. Code Availability Not applicable. No custom code, software, or algorithm was used in the preparation or analysis of this case report. Ethical approval and consent to participate: Ethical approval was not required for this case report. However, written informed consent was obtained from the patient for the publication of this case. References Huang Z, Guo J, Zhang J, We L, Wang J, Jia Y. Clinical outcomes for andersson lesion in patients with ankylosing spondylitis by transforaminal thoracolumbar intervertebral fusion surgery. Journal of Back and Musculoskeletal Rehabilitation. 2023;36(1):237–244. doi: 10.3233/BMR-220053 Elhai M, Berenbaum F. Andersson lesions in ankylosing spondylitis: an uncommon but clinically significant complication. Joint Bone Spine . 2022;89(1):105278. doi: 10.1016/j.jbspin.2021.105278 . Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8883225 . Mahakkanukrauh, A., Suwannaroj, S., Pongkulkiat, P. et al. The incidence and prevalence of ankylosing spondylitis in Thailand using ministry of public health database. Sci Rep 14, 16981 (2024). https://doi.org/10.1038/s41598-024-67666-7 Bron JL, de Vries MK, Snieders MN, van der Horst-Bruinsma IE, van Royen BJ. Discovertebral (Andersson) lesions of the spine in ankylosing spondylitis revisited. Clin Rheumatol. 2009;28(8):883–92. doi: 10.1007/s10067-009-1151-x . Epub 2009 Mar 18. PMID: 19294478; PMCID: PMC2711912. McVeigh CM, Cairns AP. Diagnosis and management of ankylosing spondylitis. BMJ. 2006;333(7568):581–5. doi: 10.1136/bmj.38954.689583.DE . PMID: 16974012; PMCID: PMC1570004. Van der Heijde D, Landewé R, Baraliakos X, et al. Ankylosing spondylitis and axial spondyloarthritis: similarities and differences. Clin Exp Rheumatol . 2014;32(4 Suppl 85): S-11-4. Available from: https://www.clinexprheumatol.org/abstract.asp?a=4293 . Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Efficacy evaluation of methotrexate in the treatment of ankylosing spondylitis using meta-analysis. 2014. Available from: https://www.ncbi.nlm.nih.gov/books/NBK219411/ Braun J, Sieper J. Ankylosing spondylitis and its prevalence, diagnosis, and treatment: an overview. Arthritis Res Ther . 2009;11(3):212. doi: 10.1186/ar2711 . Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2711912/ . Gonzalez-Lopez L, Garcia-Gonzalez A, Vazquez-Del-Mercado M, Muñoz-Valle JF, Gamez-Nava JI. Efficacy of methotrexate in ankylosing spondylitis: a randomized, double-blind, placebo-controlled trial. J Rheumatol . 2004;31(8):1568–1574. Available from: https://www.jrheum.org/content/jrheum/31/8/1568.full.pdf . Dubash S, McGonagle D, Marzo-Ortega H. New advances in ankylosing spondylitis: From bench to bedside. F1000Res . 2020;9: F1000 Faculty Rev-466. doi: 10.12688/f1000research.22650.1 . Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7382035/ . Papaioannou I, Pantazidou G, Repantis T, Baikousis A, Korovessis P. An infected Andersson lesion presented with incomplete paraplegia in a patient with ankylosing spondylitis: A unique case report with literature review. Spinal Cord Ser Cases. 2022;8(1):73. doi: 10.1038/s41394-022-00541-7 . PMID: 35945214; PMCID: PMC9363441. Jamal AB, Madan R, Khan A, Bhargava S, Ahmed M. Sarcoidosis mimicking ankylosing spondylitis: A diagnostic challenge. J Clin Rheumatol . 2022;28(6): e200-e201. doi: 10.1097/RHU.0000000000001715 . Available from: https://pubmed.ncbi.nlm.nih.gov/35945214/ . Haibel H, Sieper J. Use of methotrexate in patients with ankylosing spondylitis. Clin Exp Rheumatol. 2010 Sep-Oct;28(5 Suppl 61): S128-31. Epub 2010 Oct 28. PMID: 21044446. Dhakad U, Das SK. Andersson lesion in ankylosing spondylitis. BMJ Case Rep. 2013;2013: bcr2012008404. doi: 10.1136/bcr-2012-008404 . PMID: 23559648; PMCID: PMC3644909. Additional Declarations No competing interests reported. Supplementary Files carechecklistAHmanuscript.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6459382","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":452694124,"identity":"98d2d41b-c8d8-4547-ab19-a6b3c2594fc8","order_by":0,"name":"Chandan Singh Tanwar","email":"","orcid":"","institution":"AIMS and RC","correspondingAuthor":false,"prefix":"","firstName":"Chandan","middleName":"Singh","lastName":"Tanwar","suffix":""},{"id":452694125,"identity":"d14c2506-9f54-4625-b7ac-a044f5c91643","order_by":1,"name":"Vivek Jain","email":"","orcid":"","institution":"Mohanlal Sukhadia university 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Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnkylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the axial skeleton, leading to lower back pain and progressive spinal stiffness. Because the disease can affect other areas of the body, other symptoms like pain, stiffness, inflammation of joints (such as the ribs, shoulders, knees, or feet), skin rashes, abdominal pain, and loose bowel movements, fatigue may develop, etiology not fully understood. HLA-B27 a gene variant, is implicated in the pathogenesis of ankylosing spondylitis (AS) as well as frequent gastrointestinal infections may also lead to AS. The exact mechanisms remain under investigation, but several. The global prevalence of AS is estimated to be between 0.01% and 2.5%. A rare but significant complication of AS is the development of Andersson (disco vertebral) lesions (AL). ALs are aseptic, inflammatory complications in ankylosing spondylitis (AS). Reported prevalence varies from 1.5% to 28%, likely due to differing diagnostic criteria and imaging techniques. [1-4]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe most used criteria for the classification of ankylosing spondylitis were developed in 1966 and modified in 1984:\u003c/p\u003e\n\u003cp\u003e1. Persistent low back pain lasts for a minimum of three months and exhibits inflammatory features such as improvement with physical activity and lack of relief with rest.\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Restricted movement of the lumber spine in both the sagittal and frontal planes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Reduced chest expansion compared to the normal range expected for age and sex.\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bilateral sacroiliitis of grade 2 or higher\u003c/p\u003e\n\u003cp\u003e6.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Unilateral sacroiliitis of grade 3 or higher\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA confirmed diagnosis of ankylosing spondylitis is established when the fourth or fifth criterion is present alongside any clinical criteria. However, radiographic evidence of sacroiliitis may take several years to appear. To facilitate early diagnosis, newer criteria -such as magnetic resonance imaging have been proposed for identifying the condition in its initial stages.[5]\u003c/p\u003e\n\u003cp\u003eThe management of AS typically involves nonsteroidal anti-inflammatory drugs (NSAIDs) as the first-line treatment, with biologic agents considered for patients with inadequate response. The role of disease-modifying antirheumatic drugs (DMARDs) like methotrexate (MTX) in treating axial manifestations of AS remains controversial. While MTX is effective in conditions such as rheumatoid arthritis, its efficacy in AS, especially concerning axial symptoms, is not well established. [6-8]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this case, however, MTX demonstrated unexpectedly positive results. The patient showed significant clinical improvement after three months of low-dose MTX therapy.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 25-year-old male presented to the general medicine OPD with chronic back pain (for over 8 months) radiating pain to the left lower leg. On a general examination, the patient\u0026rsquo;s vital signs were normal with no family history and no mental instability. Tenderness was noted over the lumbar spine and sacroiliac joints, with a restricted range of motion in the lower back. No sensory or motor deficits in both legs.\u003c/p\u003e \u003cp\u003eAll relevant investigations revealed elevated CRP (18.7mg/L) and mild reactive thrombocytosis with negative antinuclear antibody (ANA) and positive HLA-B27.\u003c/p\u003e \u003cp\u003eMRI of the pelvis and screening of the whole spine revealed a focal short tau inversion recovery hyperintense area along the lower endplate of the D3 vertebra, suggesting an Andersson lesion. Minor posterior disc bulges were also observed in the lumbar spine, indenting the thecal sac without significant neural foraminal narrowing. Abnormal signal intensities were seen in the sacral and iliac regions of both sacroiliac joints. STIR hyperintensity with articular surface irregularity and erosions suggested significant edema. T1/T2 hyperintense and STIR hypointense areas in the anterior sacroiliac joints (Fig: 1). Additional findings included STIR hyperintense signals in the left acetabulum, minimal left hip joint effusion, and edema signals along the pubic symphysis. X-ray confirmed the additional diagnosis of Sacroiliitis associated with AS (Fig: 2).\u003c/p\u003e \u003cp\u003eThe patient was diagnosed with Ankylosing Spondylitis with radiating pain to the lower limb. He was prescribed Aceclofenac 100 mg twice daily for 5 days, followed by SOS, Methotrexate 5 mg once a week for 3 months and folic acid 5 mg once daily for 15 days. Despite methotrexate not being a primary treatment option for AS, its use in this case yielded unexpected but positive results. Following this treatment regimen, the patient showed significant improvement, with reduced pain, decreased stiffness, and improved mobility. Patients Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores were closely monitored: 7.1 in the first month, 5.6 in the second month, and 4.1 in the third month, with normal CRP levels (0.23 mg/dL), reflecting a steady reduction in disease activity and symptom severity.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMethotrexate in Ankylosing Spondylitis: A Controversial Role\u003c/h2\u003e \u003cp\u003eMethotrexate, a disease-modifying antirheumatic drug (DMARD), is widely used in autoimmune conditions such as rheumatoid arthritis and psoriatic arthritis. However, its efficacy in AS, particularly for axial disease, remains controversial [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Studies have yielded conflicting results. A randomized, double-blind, placebo-controlled trial demonstrated that low-dose MTX (7.5 mg/week) improved BASDAI scores and reduced spinal pain in AS patients by the 24th week of treatment (The Journal of Rheumatology). Another study noted significant reductions in inflammatory markers and subjective pain relief in a subset of AS patients treated with MTX.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Additionally, a 24-week, double-blind, placebo-controlled study comparing MTX with placebo found no statistically significant difference in axial symptom improvement.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Similarly, a Cochrane review highlighted insufficient evidence to recommend MTX for axial AS, emphasizing the need for well-designed clinical trials.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn this case, the presence of ALs was a key radiological finding. ALs are destructive discovertebral lesions associated with AS, resulting from chronic inflammation leading to vertebral erosions or mechanical stress-induced fractures in an ankylosed spine, which can progress to pseudarthrosis.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eALs are rare, often mimicking infectious spondylitis; [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] management includes NSAIDs, physical therapy, and surgery for refractory cases. The use of MTX in this case, leading to symptom improvement and reduction in inflammatory markers, is intriguing, as it suggests a potential role for MTX in managing inflammatory activity associated with ALs. This case aligns with findings from smaller case studies reporting benefits of DMARDs in specific AS complications which is controversial but unique, highlights the need for further research to explore the potential role of MTX in managing complex AS cases, particularly those involving ALs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImplications and Future Directions\u003c/h3\u003e\n\u003cp\u003eThis case underscores the importance of personalized treatment approaches in AS, particularly in the context of rare complications like Andersson lesions. While biologics are the gold standard for refractory AS, the observed efficacy of MTX in this patient suggests that it may serve as a cost-effective alternative or adjunct in select cases. However, these findings warrant further investigation through larger, controlled studies to establish the efficacy and safety of MTX for ALs and axial AS.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe management of pain associated with Andersson lesions in AS remains complex, with conservative treatments often falling short. This case highlights the potential role of methotrexate in alleviating symptoms and controlling inflammation, even though it is not conventionally indicated for AS. The findings advocate for more research into the utility of DMARDs in managing complicated AS cases, paving the way for more inclusive and individualized therapeutic strategies.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eConsent for Publication:\u003c/h2\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report and any accompanying images.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003ePatient Perspective\u003c/h2\u003e\n\u003cp\u003eThe patient expressed that he is feeling significantly better after undergoing methotrexate therapy. He reported reduced back pain, improved mobility, and a noticeable decrease in stiffness. He is satisfied with the treatment outcome and is hopeful about continuing recovery.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNil\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eC.S.T. was the treating doctor and contributed to the clinical management of the case. K.R. was the assessing doctor and provided the relevant clinical data. P.N. wrote the case study and prepared the manuscript. G.D helped in the preparation of the manuscript. V.J., G.B and B.S.C. frequently reviewed and proofread the manuscript.All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors would like to express their sincere gratitude to the patient and Ananta institute of medical sciences and research center for providing consent to share their medical information for academic purposes. We also thank the supporting medical and nursing staff involved in the patient\u0026apos;s care.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e\n\u003cp\u003eData sharing does not apply to this article as no datasets were generated or analyzed during the current study. All relevant patient information is included within the article.\u003c/p\u003e\n\u003ch2\u003eCode Availability\u003c/h2\u003e\n\u003cp\u003eNot applicable. No custom code, software, or algorithm was used in the preparation or analysis of this case report.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate:\u003c/strong\u003e \u003cp\u003eEthical approval was not required for this case report. However, written informed consent was obtained from the patient for the publication of this case.\u003c/p\u003e \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHuang Z, Guo J, Zhang J, We L, Wang J, Jia Y. 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PMID: 35945214; PMCID: PMC9363441.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJamal AB, Madan R, Khan A, Bhargava S, Ahmed M. Sarcoidosis mimicking ankylosing spondylitis: A diagnostic challenge. \u003cem\u003eJ Clin Rheumatol\u003c/em\u003e. 2022;28(6): e200-e201. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/RHU.0000000000001715\u003c/span\u003e\u003cspan address=\"10.1097/RHU.0000000000001715\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/35945214/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/35945214/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaibel H, Sieper J. Use of methotrexate in patients with ankylosing spondylitis. Clin Exp Rheumatol. 2010 Sep-Oct;28(5 Suppl 61): S128-31. Epub 2010 Oct 28. PMID: 21044446.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhakad U, Das SK. Andersson lesion in ankylosing spondylitis. BMJ Case Rep. 2013;2013: bcr2012008404. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bcr-2012-008404\u003c/span\u003e\u003cspan address=\"10.1136/bcr-2012-008404\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 23559648; PMCID: PMC3644909.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ankylosing Spondylitis, Andersson Lesion, Methotrexate, Axial Spondyloarthritis Management, Chronic Lower Back Pain, Sacroiliitis","lastPublishedDoi":"10.21203/rs.3.rs-6459382/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6459382/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Ankylosing spondylitis (AS) is a chronic inflammatory disorder primarily affecting the axial skeleton, leading to lower back pain, stiffness, and progressive spinal immobility. A rare but serious complication is the formation of Andersson lesions—aseptic, destructive discovertebral abnormalities that can mimic infectious spondylitis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e: We report the case of a 25-year-old male with chronic lower back pain radiating to the left lower limb. MRI revealed a focal hyperintense lesion at the lower endplate of the D3 vertebra, sacroiliitis, and edema in the sacroiliac joints—findings consistent with an Andersson lesion. Laboratory results showed positive Human Leukocyte Antigen B27 (HLA-B27), elevated C-reactive protein (CRP), and negative antinuclear antibody (ANA). The patient was treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and methotrexate (MTX), a disease-modifying antirheumatic drug (DMARD) not typically used for axial AS. Over three months of MTX therapy, the patient showed substantial symptomatic improvement. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores progressively decreased, and inflammatory markers normalized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Although methotrexate’s role in axial AS remains controversial, this case demonstrates its potential efficacy in managing rare complications such as Andersson lesions. The positive therapeutic outcome highlights the importance of individualized treatment approaches and supports the need for further research into the broader use of DMARDs in complex AS presentations.\u003c/p\u003e","manuscriptTitle":"A Rare Presentation of chronic lower back ache radiating to lower limb in a patient with Ankylosing Spondylitis with Andersson Lesion managed by Methotrexate: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 06:37:58","doi":"10.21203/rs.3.rs-6459382/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3a091631-548b-4c40-89fe-06a896eeeea1","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-02T09:53:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-13 06:37:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6459382","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6459382","identity":"rs-6459382","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}