Back pain is very frequent complain in rheumatology. How we assess inflammatory back pain vs mechanic back pain?

1. Back
pain
Assessment from
rheumatology
perspective

2. Date of download: 9/30/2020
Copyright 2020 American Medical
Association. All Rights Reserved.
US Health Care Spending 1996-2016
JAMA. 2020;323(9):863-884. doi:10.1001/jama.2020.0734
:
Each of the 3 columns sums to the estimated
$2.7 trillion of 2016 spending.

3. Back pain
 1996 to 2016 total health care spending increased from an
estimated $1.4 trillion to an estimated $3.1 trillion.
 Private insurance 48%; Medicare 42%, CASH 10%
 Out of 154 conditions
1. Low back and neck pain - $134.5 billion
2. Musculoskeletal disorders (joint and limb pain, myalgia,
and osteoporosis) at $129.8 billion
3. Diabetes at $111.2 billion
4. Ischemic heart disease at $89.3 billion

4. Assessing back
pain
HISTORY
IMAGING
MANAGEMENT

5. Common
causes
Mechanical
Radicular
Inflammatory
Infiltrative
Referred pain

6. Questions to ask?
P-Q-R-S-T
 P—Provocative and palliative factors
 Q—Quality of pain
 R—Radiation of pain
 S—Severity of pain or systemic symptoms
 T—Timing

7. SYMPTOMS
Rheumatology Secrets, 3rd edition

8.  FEVER
Bowel/bladder dysfunction
 Night pain unrelieved by rest
 History of cancer
History of trauma in patients
with osteoporosis.

9. Most low back pain is
mechanical in nature and
should slowly improve
over 2 to 6 weeks.
Pain > 4-6 weeks  obtain
plain films

10. Inflammatory vs. mechanical
?

11. Rheumatology Secrets, 3rd edition

12. IMAGING

13. Rheumatology Secrets, 3rd edition

14. Should obtain X-rays in all
cases?
 If your approach is altered
 Red flags (infection? Cancer?
MM vs Lymphoma)
 Suspect sacroiliac involvement

15. When to order MRI?
To diagnose inflammatory arthritis
Patients with previous history of lumbar spine
surgery (to exclude infection or nerve root
compression resulting from scar tissue)
Vertebral fracture

16. When to order EMG?
 Signs and symptoms of a radiculopathy
 If this information will change your approach
 MRI imaging has replaced the need for an EMG
 The EMG is usually carried out at least 3 weeks after
the onset of symptoms

18. Features of
Spondyloarthopaties
 Dactilytis
 Enthesitis ( elbow, Achilles tendon, plantar fascia)
 Eye involvement
 GI involvement (diarrhea, abdominal pain, )
 Skin changes

19. DIAGNOSIS

20. Symptoms – most important!!
 Age of onset <40 years of age
 Symptom duration >3 months
 Morning stiffness >60 min
 Nocturnal pain -frequent
 Improvement with exercise
 Sacroiliac joint tenderness
 No neurological deficit

21. Laboratory testing
HLA-B27
CRP

22. HLA-B27 is not diagnostic!
 HLA-B27 is present 90% of whites and 50%- 80% of
non-white patients with AS
 HLA-B27-+ individual has a 50 to 100X increased
relative risk of developing AS
 Only 2% (1 out of 50) of HLA-B27+ develop AS during
their lifetime.

23. CRP
 Prognostic sign, if high
 Many patients with AS have normal CRP

24. X-rays

25. MRI

26. Inflammatory Bowel Disease –
related arthritis
 Idiopathic, inflammatory bowel disease (ulcerative
colitis, Crohn’s disease)
 Microscopic colitis (lymphocytic colitis and collagenous
colitis).
 Infectious gastroenteritis and pseudomembranous
colitis.
 Whipple’s disease.
 Gluten-sensitive enteropathy (celiac disease)

27. IBD-related arthritis
 Type 1 (arthritis parallels IBD activity) - 4% to 6% of IBD patients, acute in
onset, asymmetric; + extraarticular manifestations (erythema nodosum,
uveitis).
 Most arthritic episodes are self-limited with 80% resolving within 3
months. This type of arthritis does not result in radiographic changes or
deformities.
 Type 2 (arthritis is independent of IBD activity) - 3% to 4% patients;
symmetric (80%), polyarticular (metacarpophalangeal [MCP] joints >
knees and ankles > other joints), runs a course independent of the activity
of the inflammatory bowel disease

28. IBD features
 P—pyoderma gangrenosum
 A—aphthous stomatitis; more common in UC
 I—inflammatory eye disease (acute anterior uveitis): more
common in Crohn’s disease.
 N—nodosum (erythema)

29. Psoriatic Arthritis –easily
missed, diagnosed late!!!
 26% of patients with psoriasis
 Aggressive! 45% to 50% of patients will develop erosions within the first
2 years of their disease and eventually 67% will develop radiographic
changes
 Psoriasis precedes arthritis by an average of 8 to 10 years in 67% of
patients.;
 Arthritis precedes psoriasis or occurs simultaneously in 33% of
patients
 If psoriasis is not obvious, check Umbilicus, scalp, anus, and behind
ears.

30. Features of Psoriatic arthritis
Dactylitis Enthesitis

31. Rx changes in Psoriatic
arthritis
Pencil in a cup Enthesopathy

32. PEARLS

34. North American Spine Society
recommended the following
tests/treatments NOT be done
in patients with back pain:

35.  Do not order MRI of the spine within the first 6
weeks in patients with nonspecific low back
pain in the absence of red flags (trauma, use
of corticosteroids, unexplained weight loss,
progressive neurologic signs, age >50 years
or <age 17 years, fever, IV drug abuse, pain
unrelieved by bed rest, history of cancer).
 Do not order EMG/NCVs to determine the
cause of neck and back pain without radicular
symptoms.

36.  Do not order an MRI before ordering plain
films in a patient presenting with joint or back
pain
 Do not order HLA-B27 unless you suspect an
undifferentiated spondyloarthropathy based on
history and examination but have non-
diagnostic radiographs.

37. Tips for Management
Exercise and weight loss are important in any
rehabilitation program for mechanical low back pain.
Within 1 week of an acute episode: 50% of patients improve;
75% will improve after 1 month; and 87% improve at 3
months. By 6 months, 93% are better.
Prognosis is less favorable among patients receiving
narcotics, disability benefits, and/or workmen’s

38. Tips for management
It is preferable to limit bed rest to 2 days or less and refer
the patient to physical therapy for instructions in the use of
ice, heat, proper lifting techniques, and correct spine
stabilization exercises.
Limited data does NOT support the routine use of facet
injections, acupuncture, or transcutaneous nerve stimulators.
Spinal manipulation may provide some relief in the early
phases of acute nonserious injuries.

39. Inflammatory arthritis
management
 Physical therapy
 NSAIDs
 Biologics: TNF alpha inhibitors and IL-17 inhibitors
 No role for Methotrexate
 Limited response to sulfasalazine

40. DISCLAIMER
 Please note that these rheumatology discussions are for informational and
educational purposes only. The discussions are based on limited information
and exclude patient observation and hands-on clinical evaluation. As such,
comments relating to patient care, evaluation, planning and treatment should
be regarded as a professional dialogue only. Physicians attending the
discussions shall remain in complete control of medical services they provide
to their patients and shall be solely responsible for all acts and decisions in
connection therewith.
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41. Thank you!
Rheumatologist Oncall
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