Identifying Inflammatory Back Pain - Dr Sangita ... - Parkside Hospital

Identifying Inflammatory BackPainSangita AgarwalLondon Rheumatology ClinicGuy’s and St Thomas’ Hospitals

Objectives• Symptoms/signs of inflammatory back pain• Family of axial Spondyloarthritis• Investigations• Management

Why is inflammatory back painimportant?• Prevalence similar to rheumatoid arthritis ie 1%population• Affects young patients (26-30 years) in the mostproductive years of life• Chronic disabling condition• Significant delay in diagnosis because littleabnormal apart from symptoms• Early diagnosis and goal directed therapyimprove outcomes considerably• Inflammatory back pain is the predominantsymptom of axial spondyloarthritis

What is Axial Spondyloarthritis (axSpA)?• Spondyloarthritis (SpA) is a family of conditions.It can be divided into related members egpsoriasis, IBD• Updated criteria• Radiographic (xray) sacroiliitis may or maynot be presentie AS or non-radiographic axSpA• >50% of non-radiographic axSpA patients arefemale (unlike AS)• Increasing awareness of nonradiographicdisease ie xray normal MRI positive pts• But not milder…similar burden of disease (samepain scores and BASDAI)

Axial SpondyloarthritisThe Spectrum DisorderNon-RadiographicstageRadiographic StageModified New York Criteria 1984Back PainSacroiliitis on MRIBack PainRadiographicSacroillitisBack PainSyndesmophytesRudwaleit .M. et al Arthritis Rheum 2005;52;1000-8 (with permission)Time (yrs)

Diagnosing IBP or Axial SpA?Key Issues• There is an average delay of 8-10 yearsbetween symptom onset and diagnosis(1)• Late diagnosis of AS/nr Axial SpA can contributeto poorer outcome (2)• The key symptom in early disease isinflammatory back pain (3)• Patients with pre radiographic disease carry the same burden as patients with AS• (1) Feldtkeller et al Rheumatol Int 2003; 23;61-6• (2)Looking Ahead; best practice for the care of people with ankylosing spondylitis (AS). National AnkylosingSpondylitis Society 2010• (3) Rudwaleit M et al. Ann Rheum Dis. 2004 May; 63(5): 535–543

What is Inflammatory Back Pain? (>3/12)A Simple screeningQuestionnairedeveloped by ASAS*can be used inPrimary CareIf the patient answers‘yes’ to 4/5 Questionsrefer toRheumatology*ASAS-Assessment of Spondyloarthritis International Society

Case History• 26 yo white man• 1 year of low back pain, alternating buttock pain• 2 hours EMS → afternoon• Better with activity, ear• 6/12 pain in left eye, steroid drops• Father similar complaint• Restriction of movements all directions

Ankylosing Spondylitis• Ankylos ‘bent’ spondylos spine• Sacroiliac joints, spine, peripheral joints• Enthesisinsertion of ligament/tendon/capsule → bone• Inflammatory enthesitis → new bone /fibrosis• 30% peripheral arthritis (girdle)

Ankylosing Spondylitis• Extra axialA aortic insuff/ascending aortitisN neurological (aa sub, cauda equina)K Kidney sec amyloid, chronic prostatitisS Spine spinal stenosis/fractureP UL pulm fibrosis, restrictive defectsO Ocular ant uveitis 25-30%N Nephropathy (IgA)D Disciitis / spondylodisciitis (Andersson lesions)30-60% asymptomatic macroscopic colitis terminal ileum/colon

Ankylosing Spondylitis• HLA B27+ 90% white AS patients• Transgenic HLA B27 rats SpA• Role in pathogenesis?unknown antigen in genetically susceptible indiv

Physical Examination• Peripheral joints• Nails/skin/scalp/eyes/CVS/resp• Spine and SI joints• Occiput to wall dist• Chest expansion• Schober’s test• Metrology

Investigations• Blood tests may be normal, ? ESR/CRP• Xrays normal (if early or limited)erosions/fusion/ankylosis• MRIdiagnosis in early diseaseinflammatory burdenNB nr axial SpA ie normal xrays but positiveMR

Psoriatic arthritis• Heterogeneous condition• Peripheral joints, entheses, axial skeleton• ‘Seronegative’ arthropathies• Extra articular involvement (skin, nails, eyes)• Arthritis precedes skin dis 1/3 (FHx)• ♀=♂

Moll and Wright Classification1973• Arthritis with DIP jt involvementpredominant 5-10%• Arthritis mutilans 5%• Symmetrical polyarthritis-indistinguishablefrom RA 15-25%• Asymmetric oligoarticular arthritis >50%• Predominant spondylitis 20-40%

Axial Spondyloarthritis• ManagementsymptomaticspecificNSAIDSsteroidsBiologicsTNF blockers• AimRemission ~ ‘cure’

Management• Early identification• NSAIDs• Physical therapy• BiologicsTNF blockersetanercept/adalimumab/golimumab

Goals for IBP/Spondyloarthritis• Inflammatory Back Pain is common anddisabling• Physical Examination, blood tests and xrays areoften normal and do not exclude diagnosis• Inflammatory Back Pain can be recognised byuse of a simple questionnaire in primary care• If you identify a patient with IBP, refer toRheumatology• Focused investigation of patients with IBP allowsearly diagnosis of AS/Axial SpA and improveslonger term outcomes

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