I've seen a couple of very rare cases where the spondylitis appeared not-lumbar first. Again, it would not be the stereotypical presentation, but given that it would be such a horrible diagnosis to miss and given you can slow the progress down, why wouldn't you include it on your differential? I'm not saying that it's at the top of my differential, and I would definitely go through my family physician to ask about whether or not it would even be worth doing (I've never examined MAXX, nor have I seen his films), but it's not a difficult diagnosis to rule out either.
If you're getting your diagnosis after a bamboo spine x-ray, it's because no one was thinking about it, and you're in the late stage. I've seen a lot of ank spondy, and not one bamboo spine x-ray yet--other than the textbooks.
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