Lower Back Pain

Question 1

What is ankylosing spondylitis?

Answer 1

A seronegative inflammatory spondyloarthropathy

Spondyloarthropathy = family of inflammatory rheumatic diseases.

Question 2

What is the typical patient with AS?

Answer 2

A young, Caucasian in their mid-teens or twenties on first presentation

Question 3

What is the pain pattern in AS?

Answer 3

1. Insidious onset back pain at night and early in the mornings particularly on inactivity
2. Unilateral buttock pain that radiates into the groin

Question 4

What improves AS?

Answer 4

Exercise

Question 5

What findings may be seen on spinal X-ray in patient with AS?

Answer 5

• Sacroiliitis (subchondral sclerosis and erosions)
• Squaring of the lumbar vertebrae
• Syndesmophytes
• Bambboo spine (very late sign)

Syndesmophytes = bony growths that can cause fusion of the joints

Question 6

What finding may be seen on chest X-ray of someone with AS?

Answer 6

Pulmonary apical fibrosis

Rare extra-articular manifestation

Question 7

What may an MRI scan of AS show?

Answer 7

Oedema and sacroiliitis

MRI scan may show oedema at early stage

Question 8

What protein in the blood is AS associated with?

Answer 8

HLA-B27

Question 9

Which other conditions are also associated with HLA-B27 and therefore AS?

Answer 9

• Inflammatory bowel disease
• Psoriatic arthritis
• Anterior uveitis

Check for all of these in family history of AS patient

Question 10

What are the management steps for AS?

Answer 10

1. Regular exercise
2. NSAIDs
3. Physiotherapy
4. DMARDs if there is peripheral joint involvement
5. Specialist consideration for anti-TNF drugs

Question 11

What are the general tips for managing lower back pain?

Answer 11

1. Encourage self-management
2. Continue physical activity
3. NSAIDs as first line and co-prescribe PPI if over 45 years old to protect stomach lining against NSAIDs
4. Physiotherapy

Question 12

Name the 10 key differentials of lower back pain

Answer 12

1. Muscular strain or sprain
2. Herniated nucelus pulposus
3. Sacroiliitis
4. Compression fracture
5. Spinal stenosis
6. Degenerative disc disease or facet arthropathy
7. Cauda equina or spinal cord compression
8. Spondylosis or spondyloisthesis
9. Vertebral discitis or osteomyelitis
10. Malignancy

Question 13

Which condition is most likely if the spinal pain is relieved on leaning forward?

Answer 13

Spinal stenosis