Setting: office
CC: “My back is sore.”
VS: normal
HPI: A 22-year-old man comes to the office complaining of several months of intermittent lower back pain and stiffness. He has been seen by two other physicians who have ascribed his symptoms to “drug-seeking” and “malingering.”
PMHX: none
Medications:
Ibuprofen, naproxen (Naprosyn), or sulindac
NSAIDs
• No difference in efficacy
• No difference in adverse effects
PE:
Musculoskeletal: normal
Cardiovascular: normal
Neurological: normal; normal reflexes; no focal neurological deficits; straight leg raise test is normal
Initial Orders:
Ibuprofen as needed
Indications for Radiologic Imaging with Back Pain
• Focal neurological defects
• Hyperreflexia
• Extensor plantar reflexes
• Bowel or bladder abnormalities (e.g., incontinence)
The straight leg raise test does not count as a “focal” neurological deficit.
After you educate and advise the patient on the lack of utility of imaging studies, he agrees to try only NSAIDs for a while longer, but he is frustrated.
Lower back pain: Without focal findings, spine imaging does not help 99% of patients.
Straight Leg Raise
• Cord not compressed
• Nerve root impingement (radiculopathy)
The patient returns in several months. His low back pain is gradually worsening. It is (1) more frequent, (2) associated with stiffness of the back, and (3) radiates into his buttocks.
Order:
Lumbosacral spine x-ray
ESR
RF
Anti-CCP
The patient returns in 2 weeks to discuss results and appears happy that you are taking his pain seriously and not dismissing him as a malingering drug-seeker. The immobility and stiffness of his back are worsening, but are distinctly better with use as the morning goes on.
An ankylosing spondylitis (AS) diagnosis is usually delayed by 2 years.
Human Leukocyte Antigen B27 (HLA-B27)
• Found in 8% of the general population
• Not a specific diagnostic test
Reports:
Lumbosacral spine x-ray: normal
ESR: elevated
RF: negative
Anti-CCP: negative
ESR is the only blood test that is positive in AS, but it is nonspecific.
The patient has had symptoms for about 18 to 24 months at this point. The SI joint and spine x-ray may be falsely normal.
What difference does it make if the diagnosis of AS is made now or later, since the disease is not curable?
a. There is no difference.
b. Pain medications can be increased.
c. TNF inhibitors delay progression of the disease.
d. You can add steroids.
e. You can add sulfasalazine.
Answer c. TNF inhibitors delay progression of the disease.
TNF inhibitors are of near miraculous benefit for patients with AS. They can stop pain in those not responsive to NSAIDs. The benefits can be of long duration, essentially delaying disease progression. Sulfasalazine has no benefit on axial disease. Steroids have no benefit in AS and worsen damage to the bone because they contribute to osteopenia and osteoporosis.
NSAIDs are not controlling the patient’s back and buttock pain. The duration of morning stiffness is increasing.
Orders:
Magnetic resonance imaging (MRI) of SI joint
MRI is based on tissue water content.
Report:
MRI: narrowing and damage of SI joint consistent with AS
Which is most common in AS?
a. Anterior uveitis
b. Aortic regurgitation (AR)
c. Atrioventricular (AV) conduction block
d. Enthesopathy
e. Plantar fasciitis
Answer a. Anterior uveitis
All of the manifestations occur in AS. The most common is anterior uveitis (30–40%). Cardiac abnormalities (AV block, AR) occur in 3% to 4% of patients. Enthesopathy is inflammation of tendinous insertion sites. Enthesopathy can present as plantar fasciitis or “sausage digits” of the fingers and toes.
Schober Test = Immobile “Boardlike” Lower Spine
Sausage digits are more common in psoriatic arthritis than in AS.
The mechanism of eye and heart abnormalities is unknown in AS.
Which of the following is most likely in AS?
a. Obstructive lung disease
b. Restrictive lung disease
c. Apical lung fibrosis
d. Diaphragmatic paralysis
Answer b. Restrictive lung disease
As the chest wall stiffens, it becomes more and more difficult for patients to breathe in. Although apical lung fibrosis does occur, it is not as common as restrictive lung disease.
Spine and rib immobility cause restrictive lung disease.
“Bamboo Spine” = Vertebral Osteophytes
The patient is started on a TNF inhibitor and experiences a tremendous improvement in pain and mobility. AS is the only disease for which TNF inhibitors are first-line therapy. In RA and psoriasis, they are used only after the failure of other medication.