Mechanical Back Pain Or Inflammatory Disease?

Saturday CME Lunch

Frankenstein and Low Back Pain: Mechanical Back Pain or Inflammatory Disease?

Thomas Rennie, MD Psychiatrist, Private Practice Rheumatology Associates of South Texas San Antonio, Texas

Educational Objectives By completing this educational activity, the participant should be better able to: 1. Learn how to distinguish between mechanical and inflammatory back pain. 2. Learn the history and physical exam pearls as well as laboratory and radiographic characteristics of Ankylosing spondylitis, Psoriatic arthritis, Reactive arthritis (Reiter's syndrome), and Enteric arthritis (arthritis associated with Crohn's disease and ulcerative colitis). 3. Learn the various treatment options for Ankylosing spondylitis and Psoriatic arthritis.

Speaker Disclosure Dr. Rennie has disclosed that he is on the speaker’s bureau for Flexion Pharmaceuticals. 11

Low Back Pain: Disclosure Mechanical vs. Inflammatory • Dr. Rennie has disclosed that he is on the speaker’s bureau for Flexion Pharmaceuticals.

Thomas A. Rennie, MD, FACR Rheumatology Associates of South Texas

Game Plan Low Back Pain Overview •Overview • 31 million Americans have low back pain • Mechanical vs. Inflammatory Low Back Pain • Affects men and women equally • Spondyloarthropathies • Average age of onset: 30 - 50 years old – Ankylosing Spondylitis – Psoriatic Arthritis • Over 50% will have recurrence – Reactive Arthritis • 5-10% will develop chronic LBP – Enteric Arthritis • Treatment

Low Back Pain Low Back Pain Overview Overview • $50-100 billion annually • Accounts for 2-6% of visits to Primary Care Physicians • Direct costs – Office visits – Ranks 2nd to upper respiratory symptoms – Imaging • 80% of the population will experience back pain at some – Labs point in their lifetime – Treatment • Leading cause of work-related disability worldwide • Indirect costs: – Absenteeism: 20 million sick days – People older than 45 – Loss of productivity • Evidence for excessive imaging and surgery in U.S. – Employer health care – Worker’s compensation benefits – 85% of costs incurred by only 5-10% patients

1 Causes of Low Back Pain

• Mechanical • Inflammatory / Spondylarthritis – Degenerative disk disease – Ankylosing spondylitis – Degenerative joint disease • Non-radiographic axial spondyloarthropathy Why is it important to distinguish – Muscle strain – Psoriatic arthritis – Pregnancy – Reactive arthritis between inflammatory vs. mechanical – Spondylolisthesis – Enteric arthritis – Spondylolysis low back pain? – Fracture • Referred pain – Spinal stenosis – Abdominal aneurysm – Cholecystitis • Infiltrative – Nephrolithiasis – Cancer – Pancreatitis – Infection • Osteomyelitis • Abscess • Diskitis

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Inflammatory vs. Mechanical Back Pain Inflammatory Back Pain

FEATURE INFLAMMATORY MECHANICAL • Do you have low back stiffness in the morning? Morning stiffness > 1 hour ≤ 30 minutes • Does the back pain get worse or better with activity? Fatigue Significant Minimal Nocturnal pain Moderate Mild • Does the pain wake you up at night? Activity ↓ symptoms ↑ symptoms • Have you noticed increased fatigue? Rest ↑ symptoms ↓ symptoms • Have you noticed any unexplainable weight loss? Systemic symptoms Yes No

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2 Spondyloarthropathies Inflammatory Back Disease Screening Questions

• Peripheral joint pain / arthritis • Acute diarrhea preceding the arthritis • Spondyloarthropathies • Family history • History of STDs –AS • Urethritis or cervicitis preceding the – Ankylosing spondylitis –Psoriasis arthritis • Non-radiographic axial spondyloarthropathy – Uveitis • Enthesitis – Reactive Arthritis – Achilles' tendinitis – Psoriatic arthritis – Inflammatory bowel disease – Plantar fasciitis – Reactive arthritis • Rashes • Alternating buttock pain •Psoriasis • Iritis / uveitis – Enteric arthritis • Inflammatory bowel disease • Sausage digit / dactylitis • Crohn’s – Recurrent diarrhea • Unexplainable weight loss – Hematochezia • Ulcerative colitis – Abdominal pain • History of GI infections

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Ankylosing Spondylitis Ankylosing Spondylitis Epidemiology

• Late adolescence – early adulthood • Onset after age 40 uncommon • Male:Female 3:1 • Manifestations in females less pronounced

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Physical Exam Sacroiliac Pain

• Sacroiliac joint involvement – Pelvic compression – Gaenslen’s test – Patrick’s test • Progression of spinal disease / ankylosis – Schober’s test – Occiput to wall test – Chest expansion

Pelvic Compression Test

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3 Sacroiliac Pain Progression of Spine Disease / Ankylosis

Patrick’s Test (FABER’s Test)

Schober’s Test

Occiput-to-Wall Test Gaenslen’s Test 20 21

Physical Exam

• Peripheral arthritis: 30% of patients with AS – Hips and shoulders common – Rare involvement • Sternoclavicular • Temporomandibular • Cricoarytenoid • Symphysis pubis • Enthesitis – Ligamentous structures of the intervertebral discs – Achilles enthesitis / tendinitis – Plantar fasciitis

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Extra-articular Manifestations Apical Pulmonary Fibrosis • Cardiac • Renal – Aortic insufficiency – Secondary amyloidosis – Aortitis – IgA Nephropathy – Pericarditis (10%) •Ocular • Neurologic – Anterior uveitis (25-30%) – Atlantoaxial subluxations • Pulmonary – Cauda equina syndrome – Upper lobe fibrosis • Osteoporosis – Restrictive lung disease

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4 Audience Polling Question 1 Audience Polling Question 2

How many white ankylosing spondylitis patients have How many non-white patients have a positive a positive HLA-B27? HLA-B27?

1. 10% 1. 0-5% 2. 50% 2. 20-40% 3. 75% 3. 50-80% 4. 90% 4. 90-100%

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Audience Polling Question 3 Laboratory Data A positive HLA-B27 is seen in approximately 8% of •HLA –B27 healthy white people. What percentage of this – 90% of white AS patients – 50-80% of non-white patients population will develop ankylosing spondylitis? – 8% healthy whites • 2% will develop AS 1. 2% • 15 – 20% if they have a 1st degree relative with AS 2. 20% – 3% healthy North American Blacks • ESR and CRP 3. 75% – Elevated in 70% of patients with AS 4. 90% – Normal ESR and/or CRP does not exclude the presence of clinically active AS

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Radiographic Findings Radiographic Findings

• Sacroiliitis • Spinal disease – Bilateral and symmetric – Shiny corners – Involves lower 2/3 of SI joints – Squaring of the vertebrae – Earliest changes on the iliac side of – Ossification of the outer layers of the the SI joint annulus fibrosis • Sclerosis – Syndesmophytes • Pseudo-widening •Thin • Erosions • Marginal • Complete ankylosis / fusion – Fusion of the vertebral body – If x-rays are normal • Bamboo spine •MRI 30 31

5 Radiographic Findings Enteric Arthritis

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Enteric Arthritis Physical Exam Epidemiology Peripheral Arthritis • Any age Ulcerative Colitis Crohn’s Disease • Male = Female Shoulder 20% 20% Elbow 30% 10% ULCERATIVE COLITIS CROHN’S DISEASE Wrist 15% 15% Peripheral arthritis 10% 20% MCP 25% 10% Sacroiliitis 15% 15% Hip 20% Knee 70% 80% Sacroiliitis/spondylitis 5% 5% Ankle 50% 40% MTP / Toes 10%

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Extra-intestinal Manifestations Frequency of HLA-B27 in IBD

• Pyoderma gangrenosum (< 5%) ULCERATIVE COLITIS CROHN’S DISEASE

• Aphthous stomatitis (< 10%) Sacroiliitis/spondyliti 70% 55% s Peripheral arthritis Same as normal Same as normal • Acute anterior uveitis ( 5 – 15%) healthy control healthy control population population

• Erythema nodosum (< 10%)

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6 Laboratory Data Radiographic Findings

• ESR and CRP elevated • Same findings as with AS • ANA and RF negative – Bilateral symmetric sacroiliitis • Iron deficiency anemia – Bamboo spine • Leukocytosis • Thrombocytosis • Activity of inflammatory spine disease does not correlate with IBD activity • pANCA in 50 – 60% of UC patients

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Psoriatic Arthritis Psoriatic Arthritis Epidemiology • 35 – 50 years old • Juvenile psoriatic arthritis: 9 – 12 years • Prevalence – Any arthritis: Male:Female 1:1 – Spinal involvement: Male:Female 3:1 • Less than 30% of patients with psoriasis will develop arthritis • Psoriasis precedes arthritis: 67% • Arthritis precedes psoriasis: 33%

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Occult Psoriasis Psoriatic Arthritis Subtypes

SUBTYPE PERCENTAGE TYPICAL JOINTS • Umbilicus Asymmetric 15-20% DIPs, PIPs, MCPs, •Scalp MTPs, Knees, Hips, oligoarticular Ankles • Anus / cleft of the Predominant DIP 2-5% DIPs buttocks Involvement •Ears Arthritis Mutilans 5% DIPs, PIPs Polyarthritis (RA like) 50-60% MCPs, PIPs, Wrists Axial 2-5% Sacroiliitis, Spondylitis

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7 Clinical Features Asymmetric oligoarthritis: Dactylitis Associated with Subtypes

• Asymmetric oligoarthritis: Dactylitis

• Predominant DIP involvement: Nail changes

• Arthritis mutilans: Osteolysis

• “RA” like disease: Fusion of wrists

• Axial involvement: Asymmetric sacroiliitis

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Predominant DIP Involvement: Arthritis Mutilans: Osteolysis Nail Changes

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Laboratory Data Radiographic Data

• ESR and CRP may be elevated • Sacroiliitis – Unilateral • ANA, RF and CCP typically negative –Asymmetric – Positive RF in 5 – 10% of patients • Spinal disease – Positive CCP in 8 - 16% – Asymmetric involvement – Syndesmophytes • Anemia • Large • Non-marginal

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8 Radiographic Data Audience Polling Question 4

1. Normal 2. Ankylosing spondylitis 3. Degenerative arthritis 4. Psoriatic arthritis

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Audience Polling Question 5 Audience Polling Question 6

1. Normal 1. Normal 2. Ankylosing spondylitis 2. Ankylosing spondylitis 3. Degenerative arthritis 3. Degenerative arthritis 4. Psoriatic arthritis 4. Psoriatic arthritis

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Audience Polling Question 7

1. Normal 2. Ankylosing spondylitis 3. Degenerative arthritis 4. Psoriatic arthritis

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9 Radiographic Data Radiographic Data

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Reactive Arthritis Reactive Arthritis Epidemiology

• 20 – 40 years of age • Enterogenic: Male = Female – Campylobacter – Salmonella – Shigella – Yersinia • Urogenital: Male > Female – Chlamydia trachomatis – Ureaplasma urealyticum

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Sacroiliitis / Spondylitis Peripheral Arthritis

•Asymmetric • Similar to psoriatic arthritis • Oligoarticular – Sacroiliitis: Unilateral or asymmetric • Joints involved – Spondylitis: Nonmarginal syndesmophytes – Knees –Ankles • 5% of patients with reactive arthritis develop x-ray – Feet changes in the SI joints – Wrists – Digits • Enthesitis

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10 Extra-articular Manifestations Keratoderma Blennorrhagicum

• Low-grade fever • Urethritis • Sterile conjunctivitis – Sterile • Anterior uveitis – Infectious • Colitis •Prostatitis – Infectious • Salpingitis – Sterile • Vulvovaginitis • Heart block • Keratoderma blennorrhagicum • Pericarditis • Circinate balanitis • Painless oral ulcers

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Circinate Balanitis Laboratory Data

• Many patients are HLA-B27 (-) • HLA-B27 (+) correlates with increased disease – Severity – Chronicity – Frequency of exacerbations – Aortitis –Uveitis – Spondylitis

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Physiotherapy TREATMENT • Daily exercises – Maintain good posture – Improves chest expansion • Hydrotherapy (swimming) maximizes benefits of exercise therapy • Patients should sleep on a firm mattress • Minimize the number of pillows

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11 Medications NSAIDs

• NSAIDs • Corticosteroids • Disease modifying anti-rheumatic drugs (DMARDs) • Biologic DMARDs

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Steroids Disease Modifying Anti-Rheumatic Drugs (DMARDs)

• Oral steroids • Sulfasalazine – Minimal to no benefit for spine symptoms • Methotrexate associated with spondyloarthropathies – Beneficial for peripheral arthritis • Leflunomide • Intra-articular steroids are beneficial • Tofacitinib – SI joints – Psoriatic Arthritis – Peripheral arthritis – Ulcerative colitis – Enthesitis / tendinitis

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Biologic DMARDs

• TNFα inhibitors • IL-12 / IL-23 inhibitor – Infliximab – Ustekinumab – Certolizumab – Etanercept • IL-23 inhibitor – Golimumab – Guselkumab – Adalimumab • T-cell inhibition (CD 28 block) • IL-17a binder – Abatacept – Secukinumab – Ixekizumab

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12 Notes