Back Pain - Inflammatory Conditions

Question 1

Give 2 examples of inflammatory conditions which cause back pain.

Answer 1

Axial spondyloarthritis (axSpA)

Ankylosing spondylitis (AS)

Question 2

Describe the general features of inflammatory back pain. (5)

Answer 2

Early morning stiffness (30+ minutes)
Wakening in second part of night
Buttock pain
Pain improves with movement
Pain/stiffness worsens on rest

Question 3

Define axial spondyloarthritis (axSpA).

Answer 3

Inflammation in the spine and sacroiliac joints, which is not as severe as ankylosing spondylitis but may develop into AS as a chronic condition

Question 4

What gene is involved in axSpA?

Answer 4

HLA B27

Question 5

What are the 2 types of axial spondyloarthritis?

Briefly describe each.

Answer 5

Non-radiographic axSpA

• No change clinically
• Not detected on x-ray

axSpA worsening into AS
-Deteriorating inflammatory change

Question 6

Describe the clinical features of axial spondyloarthritis (axSpA). (8)

Answer 6

Inflammatory back pain
Sacroiliitis 
Enthesis
Arthritis in other joints
New bone formation
Fatigue
Ankylosis
Extra-articular inflammation

Question 7

Define ankylosis.

Answer 7

Pathological fusion of two bones across a joint space, resulting from prolonged joint inflammation/infection

Can be bony (as in SA) or fibrous

Question 8

List 6 conditions associated with axial spondyloarthritis (axSpA).

Answer 8

Undifferentiated spondyloarthritis
Psoriatic arthritis
Acute anterior uveitis
Reactive arthritis
IBD
Juvenile spondyloarthritis

Question 9

In axial spondyloarthritis (axSpA), which features would you see on an x-ray? (4)

Answer 9

Sclerosis (“shiny corners” of vertebral bodies)
Syndesmophytes
Bridging syndesmophytes (“bamboo spine”)
Spondylophytes

Question 10

Define ankylosing spondylitis (AS).

Answer 10

Persistent inflammation in the spine and sacroiliac joints that can lead to loss of range of movement

Question 11

What is ankylosing spondylitis (AS) caused by? (5)

Answer 11

Progression from axial spondyloarthritis (axSpA)
Genetic predisposition
Infection
Microbiome in gut/skin
Biomechanics

Question 12

List 3 genes associated with ankylosing spondylitis (AS).

Answer 12

HLA B27
IL-23R gene
Th17 response genes

Question 13

Describe the clinical features of ankylosing spondylitis (AS). (4)

Answer 13

Inflammatory back pain
Stiffness
Pain/swelling in other joints
Extreme fatigue

Question 14

Describe the pathophysiology of ankylosing spondylitis (AS). (2)

Answer 14

1. Genetic predisposition causes increased synthesis of pro-inflammatory cytokines
   a. IL-17 stimulates TNF
2. Cytokines cause inflammation in the bones, causing:
   a. Osteoproliferation
   b. Bone loss and destruction
   c. Bone fusion

Question 15

How would you measure the severity of ankylosing spondylitis (AS)?

Describe how to carry out this measurement. (6)

Answer 15

BASDAI (Bath ankylosing spondylitis activity index)

Ask patient to rate (from 1 to 10):

• Fatigue
• Overall pain in neck/back/hips
• Pain in other joints
• Discomfort in tender areas
• Overall discomfort
• Duration of morning stiffness

Question 16

How would you manage axSpA and AS? (7)

Answer 16

Patient education, e.g.

• Exercise programmes
• Physiotherapy
• Self-help groups

NSAIDs
Anti-TNF drugs
Steroids
Surgery