What Is Nr-axSpA?

What Is Non-Radiographic Axial

Non-radiographic axial spondyloarthritis, or nr-axSpA (pronounced N-R-Ax-Spa), is a chronic inflammatory condition. It’s characterized by active inflammation of the spine and sacroiliac (SI) joints, which are the joints that connect the lower spine and pelvis.

Identifying nr-axSpA

Nr-axSpA belongs to the axial spondyloarthritis (axSpA) family of inflammatory conditions. These conditions affect the spine and SI joints, but signs and symptoms can occur in other parts of the body.

Another condition classified in the axSpA family is ankylosing spondylitis (AS). Many of the signs and symptoms of nr-axSpA and AS overlap, but a rheumatologist can distinguish between these two conditions using x-ray imaging.

Nr-axSpA has the potential to progress into AS, which is why early diagnosis and treatment are important.

Learn more


No visible damage on x-rays
The part of the skeleton that includes the spine and SI joints
A family of chronic inflammatory conditions

SpA Family

Not visible on x-ray
Visible on x-ray

Understanding nr-axSpA



Because back pain is common, nr-axSpA can often be overlooked as the cause. Below are a few key symptoms you can look out for that might point to nr-axSpA:

Signs of inflammatory back pain related to nr-axSpA:

Pain that lasts 3
months or longer

Pain that goes away
with exercise and

Pain while

Age of onset <45

Additional signs and symptoms:

  • Morning stiffness
  • Reduced mobility
  • Limitations at work and home
  • Fatigue

Some people with nr-axSpA may experience more widespread symptoms, such as:

  • Swelling around the joints
  • Diarrhea
  • Abdominal pain
  • Vision problems


Nearly 1.7 million individuals in the US live with nr-axSpA, with women making up 57% of patients and men representing 43%.

On average, it takes 5 to 8 years for those with nr-axSpA to receive an accurate diagnosis.

Since the awareness for nr-axSpA is low, it is often misdiagnosed. Most back-pain conditions are mechanical related, and it’s difficult for many physicians to differentiate between mechanical pain (eg, muscle strain, slipped disc, or pinched nerve) and inflammatory pain.

nr-axSpA is often misdiagnosed as fibromyalgia (a neurological condition) because chronic pain in the back and other parts of the body is often a feature of both conditions.

Misdiagnosis and visits to multiple specialists can be discouraging. However, being aware of the signs of inflammation and working with the right specialist can help uncover the cause. A rheumatologist is the best physician to evaluate you for nr-axSpA, because they are trained to diagnose and treat inflammatory conditions.

If x-rays do not show visible changes in your joints or spine, it could be nr-axSpA. Your rheumatologist may then recommend an MRI (magnetic resonance imaging) to detect inflammation. Additional tests in the diagnostic process may include, but are not limited to:

  • Evaluation of medical history, including family history
  • Laboratory tests for erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels, which indicate inflammation
  • Certain blood tests for genetic markers, such as HLA-B27

nr-axSpA in Women

Women may experience symptoms differently than men. Women tend to have pain that is more widespread, which can result in a diagnostic delay. On average, an nr-axSpA diagnosis takes more than a year longer in women than in men.



From the moment you wake up in the morning, nr-axSpA can have an effect on every part of your day-to-day life.

The CIMZIA doctor discussion guide is available for download to assist with your next conversation with your rheumatologist

Talking to a rheumatologist can help you take control of your condition.

Non-radiographic axial spondyloarthritis can start slowing you down even before you get out of bed; it’s hard to start the day with stiffness, decreased mobility, and debilitating chronic back pain. You may be tired of calling in sick and canceling plans with friends, not to mention the list of things to do around the house. Feeling discouraged and misunderstood with nr-axSpA is understandable.

Talking to a rheumatologist about your symptoms and their impact can help you take control of your condition. Use our Doctor Discussion Guide to help talk to your doctor about your nr-axSpA symptoms.



Some treatments may not address the root cause or help control symptoms of nr-axSpA. For example, some pain relievers may help temporarily relieve pain, but they do not address the underlying spinal inflammation causing the symptoms.


46% of people treated with NSAIDs may have severe symptoms from nr-axSpA and be eligible for anti-TNF treatment.

CIMZIA (certolizumab pegol) is an anti-tumor necrosis factor (TNF) biologic. In people with nr-axSpA, the body makes too much TNF, causing immune cells to attack healthy tissue. This leads to inflammation and the symptoms you may be experiencing. By working to block these extra signals to immune cells, CIMZIA treats nr-axSpA where it starts, inside the body.

CIMZIA is the first and only therapy of its kind for nr-axSpA* proven to improve symptoms and disease activity over time. Learn more about how CIMZIA may work for you.

*CIMZIA is an anti-tumor necrosis factor (TNF) biologic.

At-home care

Whether you are currently not on a treatment plan or are looking for some extra steps you can take to alleviate symptoms, there are other ways to help manage the symptoms of nr-axSpA:

  • Physical therapy: An experienced physical therapist can work with you to create a strength and mobility program that can help preserve range of motion in your neck and back.
  • Exercise: Aside from helping with mobility and maintaining flexibility, exercise also has a positive effect on the fatigue and emotional distress that can accompany nr-axSpA.
  • Stop smoking: With an established association between smoking and inflammation, quitting can help alleviate some of the symptoms of nr-axSpA.

Untreated progression

While some may consider “sticking it out” and ignoring their nr-axSpA symptoms, there is a chance that untreated inflammation could lead to more severe issues. In fact, 10%-40% of nr-axSpA patients convert to ankylosing spondylitis over the course of 2-10 years, with 60%-70% developing irreversible structural damage to their spine.



There are many resources available, from payment assistance to educational tools, if you find yourself needing help or guidance with your nr-axSpA.

Cimplicity logo.

CIMplicity® is a free program that provides support at each step of your experience when treating your nr-axSpA with CIMZIA (certolizumab pegol).†

Enroll Now

Spondylitis Association of America strives to be a leader in the quest to cure nr-axSpA, AS, and related diseases. It has a mission to empower those affected to live life to the fullest. Call 1-818-892-1616 to learn more.

American College of Rheumatology works to advance rheumatology treatment through programs to improve care for people with rheumatic and musculoskeletal diseases and arthritis.

The Arthritis Foundation works to advance the treatment of more than 100 types of arthritis and related conditions. Call 1-800-283-7800 for more information.

The American Journal of Managed Care (AJMC), while a publication for healthcare providers, addressed nr-axSpA from a patient’s perspective in this AJMC Insights video.

†The CIMplicity program is provided as a service of UCB and is intended to support the appropriate use of CIMZIA. The CIMplicity program may be amended or canceled at any time without notice. Some program and eligibility restrictions may apply.


Common nr-axSpA Questions

What is non-radiographic axial spondyloarthritis (nr-axSpA)?

Nr-axSpA is a chronic inflammatory condition. It’s characterized by active inflammation of the spine and sacroiliac (SI) joints, which are the joints that connect the lower spine and pelvis.

What does non-radiographic mean?

“Non-radiographic” means that any damage will not be visible on x-ray.

Is nr-axSpA an autoimmune disease?

Nr-axSpA is a cross between an autoinflammatory and an autoimmune condition, where your immune system thinks it is under attack and creates inflammation to protect against the nonexistent danger.

What causes nr-axSpA?

In people with nr-axSpA, the body makes too much of a protein called Tumor Necrosis Factor (TNF), causing immune cells to attack healthy tissue. This leads to inflammation and the symptoms you may be experiencing.

What are symptoms of nr-axSpA?

Some signs of inflammatory back pain related to nr-axSpA include pain that lasts 3 months or longer, pain that goes away with exercise and activity, and pain while sleeping. People usually experience the first symptoms before age 45.

How is nr-axSpA treated?

To treat nr-axSpA where it starts, your doctor may prescribe an anti-tumor necrosis factor (TNF) biologic, such as CIMZIA. In people with nr-axSpA, the body makes too much TNF, causing immune cells to attack healthy tissue. This leads to inflammation and the symptoms you may be experiencing. CIMZIA works by blocking these extra signals to immune cells. To learn more about the effectiveness of CIMZIA with nr-axSpA, visit our Why CIMZIA? page.

Is nr-axSpA the same as ankylosing spondylitis?

Both nr-axSpA and ankylosing spondylitis are chronic inflammatory conditions that can affect the spine and sacroiliac joints. While some symptoms may appear similar, the damage caused by ankylosing spondylitis is visible on x-ray, while the damage caused by nr-axSpA is not. However, damage from nr-axSpA can be visible when using magnetic resonance imaging (MRI).