Inflammatory Back Pain

Question 1

Describe general features of inflammatory back pain

Answer 1

• Age of onset is usually below 40,
• Slow onset,
• Early morning stiffness lasts more than 30 mins
• Exercise improves pain,
• No improvement with rest
• May wake in the 2nd half of the night with buttock pain.

Question 2

Name some example of inflammatory back disease

Answer 2

• Axial spondyloarthritis (which is a spectrum where Ankylosing Spondylitis is the most severe)

Question 3

What are diseases associated with axial spondyloarthritis

Answer 3

• It is associated with other inflammatory or autoimmune disease such as:
• Uveitis,
• Psoriatic arthritis,
• Psoriasis,
• Reactive arthritis,
• Inflammatory bowel disease

Question 4

What is the classification criteria for axial spondyloarthritis

Answer 4

• Sacroiliitis on imaging and one other features associated with axial SpA
• HLA-B27 plus 2 other features of SpA features

Question 5

What are the symptoms of axial spondyloarthritis

Answer 5

• Inflammatory back pain,
• Fatigue,
• Arthritis in other joints,
• Enthesitis - Inflammation of the insertions sites of tendons and ligaments.
• Extra-articular symptoms include: Uveitis, psoriasis, IBD, heart, lungs and osteoporosis
• Family history of inflammatory/autoimmune disease

Question 6

What is Syndesmophytes?

Answer 6

Bony growths that grow on the spine in ankylosing spondylosis (bony bridges). Gives the appearence of bamboo spine when diffuse (fusion of the vertebral column)

Question 7

What is the first manifestations of ankylosing spondylitis?

Answer 7

• Sacroiliitis which is symmetrical and bilateral.
• On the spine there are small erosions at the corner of vertebral bodies which appear shiny

Question 8

How is the diagnosis of axial spondyloarthritis made?

Answer 8

• Clinical diagnosis with suggestive symptoms, imaging, associated features (family history or other autoimmune/inflammatory diseases) and other investigations such HLA-B27 status.

Question 9

What pathways are involved in axial spondyloarthritis

Answer 9

• IL-23/17 pathway
• HLA b27 mutations cause an increase in IL23 which in turn results in more IL 17 being produced

Question 10

What are the treatment options for axial spondyloarthritis?

Answer 10

• NSAIDs are first line treatment along with PPI for gastric protection,
• Biologic Drugs (Anti IL-17 and anti TNF)
• Analgesic/surgery,
• Non-medication management = exercise, education, physical therapy, rehabilitation, smoking cessation