Back Pain and Spinal Disorders 2

Question 1

Contrast mechanical vs inflammatory back pain

Answer 1

• mechanical back pain can occur at any age whereas inflammatory back pain usually affects <40y
• mechanical back pain has a variable onset that can be acute whereas inflammatory back pain is more chronic
• exercise worsens mechanical back pain but improves inflammatory back pain and stiffness
• early morning stiffness is <30 min for mechanical but >30min for inflammatory back pain
• inflammatory back pain can be worse at night, mechanical back pain is not

Question 2

What are the 2 main differentials of inflammatory back pain?

Answer 2

• ankylosing spondylitis (radiographic AxSpA)
• non-radiographic axSpA (inflammation but no damage yet)

Question 3

What are important things to ask about in the history of patient with suspected ankylosing spondylitis?

Answer 3

any personal or family history of:
- psoriasis
- uveitis
- inflammatory bowel disease
- other inflammatory/autoimmune conditions

Question 4

Give an overview of the classification criteria for axial spondyloarthritis

Answer 4

In patients with 3+ months of back pain and <45y:
- sacrioilitis on imaging + 1 SpA feature
or
- HLA-B27 positive + 2 SpA features

Question 5

List some SpA features

Answer 5

• inflammatory back pain
• arthritis
• uveitis
• dactylitis
• psoriasis
• Crohn’s
• family history
• HLA-B27
• elevated CRP

Question 6

List the symptoms of axial spondyloarthritis

Answer 6

• inflammatory back pain
• fatigue
• arthritis in other joints (hip, knees)
• enthesitis (tendon/ligament inflammation)
• extra-articular inflammation (eg. uveitis, psoriasis etc.)
• family history of any of the above

Question 7

What are some radiographic features of ankylosing spondylitis?

Answer 7

• sclerosis (‘shiny corners’)
• syndesmophytes (bony growths that cause fusion of the spine)
• bamboo spine (fused spine)

Question 8

What is the better mode of imaging for early detection of sacroilitis?

Answer 8

• MRI
• can highlight earlier bone marrow oedema
• be aware of normal biomechanics (eg. runners, athletes, postpartum women)

Question 9

How is a diagnosis concluded for AS and axial spondyloarthritis?

Answer 9

Clinical diagnosis:
- suggestive symptoms
- imaging
- associated features present: family history, extra-articular features
- HLA-B27 status, CRP/ESR (usually normal)
- exclusion of other causes

Question 10

What is the management for axSpA?

Answer 10

• education, exercise, physical therapy, rehab, support groups
• NSAIDs
• biologics (TNF and Il-17a inhibitors)
• analgesics
• surgery