MAMCOTS | Inflammatory & Infective Back Pain: Diagnosis & Non-Surgical Management | Dr. P. S. Mamtora

A detailed case history, followed by a meticulous physical examination, can never be overrated and often surpasses all investigations. Often the patient's narration of the symptoms points towards diagnosis; for instance, mechanical backache, which demonstrates the spectrum of degenerative spine affections, will present with symptoms of localised spine pain with restriction of motion in one or two directions and with or without radiation to the lower limbs, with or without neurological symptoms. Inflammatory backache presents in young age groups, with chronic backache that is worse with rest and better with activity, and the pain is usually felt diffusely over the spine.

The extra-articular manifestations of SSA vary from enthesopathies, ophthalmic, GIT, GUT, or skin involvement.

Schober's test is significant in ankylosing spondylitis for evaluating lumbar spinal motion during forward lumbar flexion. Disc pathology may cause paraspinal muscle spasm, which may reduce lumbar flexion; however, this cannot be attributed to a positive Schober's test. This test is predominantly used to determine progression and the therapeutic effects of ankylosing spondylitis.

Ankylosing spondylitis (AS), a chronic rheumatic disease that targets the axial skeleton and sacroiliac joints, progressively limits spinal mobility, invariably impairing gait.

The diagnostic criteria, though mostly a compilation of clinical signs and symptoms, require radiological evidence to document the stage of SSA and, during follow-up, to attribute worsening or retardation of the sclerosis.

Enthesopathy will manifest as spot tenderness and localized stretch pain and mostly a full range of motion whereas an articular pathology presentation will be accompanied by synovitis, effusion, diffuse pain around the joint with deranged or painful range of motion.

Though morning stiffness is pathognomonic of SSA, in a patient with chronic backache, an absence of morning stiffness could still be considered for SSA if the patient is a young male, with almost entire spine involvement, with one peripheral joint involved, with clinical examination suggesting restricted range of motion in all directions.

Round back deformity, characterised by flexion of the cervical spine, increased kyphosis of the dorsal spine, and replacement of lumbar lordosis with kyphosis, is classical of ankylosing spondylitis affecting the entire length of the spine.

The basic serological investigations include CBC, ESR, CRP, uric acid, and vitamin D3. Radiological investigations will vary depending on the site of spinal involvement: cervical, dorsal, or lumbar. Sacroiliac joints can be evaluated with an X-ray of the pelvis with a 30-degree caudal tilt.

Diffuse Idiopathic Skeletal Hyperostosis -DISH is one of the differential diagnosis of Ankylosing Spondylitis. However, DISH doesn't display classic morning stiffness of SSA, other joint and no systemic affections. Another differential diagnosis of SSA is mechanical (degenerative) backache, the differentiating features being the latter manifests as asymmetrical range of restriction of spine and with/without neurological and stretch signs.

Inflammatory markers such as CRP and ESR may not always rise after an acute exacerbation of SSA, and vice versa. However, in RA, inflammatory markers do reflect disease activity.

The diagnosis of SSA and RA is clinical. HLA-B27 is a tissue type; although its detection may support the diagnosis of SSA, its absence does not rule it out. However, it is not a routine or screening test and is performed only when SSA is strongly suspected clinically and radiological evidence is negative.

The ever evolving science backed with research will see an addition or deletion of previous norms about the disease however the foundation on which the disease is defined remain the same. In context with inflammatory backache, the basic clinical diagnostic criteria remains the same with new serology, laboratory based additions.

Basic preliminary investigations whether serological or radiological may be asked following the day 1 of examination for documentation and to set up prognosis and follow up criteria. In Sero negative spondylo arthropathy , inflammatory markers do not contribute significantly unlike other inflammatory joint diseases like rheumatoid arthritis.

The presence of the HLA-B27 gene and a family history of ankylosing spondylitis (AS) should make the physician more vigilant and focused on the finer nuances of developing sacroiliitis, and make the patient aware of the types of symptoms and signs to look out for. A predisposition to develop AS, once established, timely management may prevent the progression to a fulminant one.

The myriad of Inflammatory backache comprises of the types- Ankylosing spondylitis, Reiter's syndrome, Reactive arthropathy, Bechet's syndrome, Psoriatic arthropathy, arthropathy with ulcerative colitis, arthropathy with Crohn's disease and cannot be classified (chronic heel pain or single tensosynovitis)

Juvenile Inflammatory arthritis, or Pauciarticular Type 2, affects children under 18 years. The diagnosis is made based on clinical history and examination, while laboratory and radiological studies are done for documentation, confirmation, and follow-up evaluation. A pauciarticular JIA may undergo relapse in adulthood following remission; hence, close surveillance of clinical findings is imperative.

Rheumatoid arthritis is characterised by early onset, symmetrical and multiple joint involvement, and distal rather than proximal involvement, whereas SSA presents with asymmetrical, predominantly proximal and larger-joint involvement, with backache as the chief complaint. Arthritis affecting the first carpometacarpal and distal interphalangeal joints is by rule always primary osteoarthritis.

DISH - Diffuse Idiopathic Skeletal Hyperostosis radiologically will demonstrate the presence of syndesmophytes which are ossification of the tendon or the ligament attachments. Unlike Ankylosing Spondylitis, the disc space is spared in DISH and there is no fusion of the vertebral body.

Differentiating fibromyalgia from Ankylosing spondylitis - Fibromyalgia classically presents as diffuse soft tissue pain not limited to the axial skeleton, without morning stiffness. Physical examination shows a full range of motion and often tenderness not localised to any joint.

The primary goal of the treating physician is to prevent bony ankylosis (irreversible if it occurs), delay the progression from sclerosis to ankylosis and retard inflammation at the joint. It is important to realise that the clinical feel-good should coincide with physical examination findings to suggest that the disease course has been modified for the better.

Compared with mechanical backache, inflammatory backache may have frequent exacerbations, and it is crucial for the treating physician to counsel the patient about the long duration of treatment, whether through medication, physiotherapy, or both. As much as is important is the diagnosis and selection of the right medicine, it is equally important to make the patient aware of the chronicity and progressive nature of the disease for him to stay compliant.

The radiological findings in inflammatory arthritis, such as sclerosis, do not regress or reduce post-therapeutically; however, with appropriate management, they may be retarded or delayed. The inflammation responds to treatment and can be assessed clinically or serologically.

The first line of treatment is NSAIDs, muscle relaxants and physiotherapy. If the condition is recalcitrant or clinically worsening, the second-line treatment is biological injectables, which are disease-modifying agents.

The physiotherapy approach for mechanical backache would incorporate the McKenzie protocol, which consists of specific mechanical movements that reduce inflammation and improve mobility. Inflammatory backache would require appropriate thermal modalities to reduce acute inflammation; once pain is reduced, then proceed to restore a comfortable range of motion and prevent disability or ankylosis in a dysfunctional position.

Both SSA and RA are autoimmune, chronic and progressive; it is important that the treating physician manage the patient on all parameters: mental, emotional and physical. Often, it has been observed that negative emotions are the triggers behind acute exacerbations of inflammatory arthritis; hence, the indicated medicine should also address and manage those aspects in order to maintain remission and retard the pace of the disease.

The apt management of Inflammatory arthritis consists of timely diagnosis, adequate patient counselling to ensure the patient's compliance towards continuing the treatment for the required duration, following recommended physical therapy and doing investigations serially.

Though Koch's spine tops the chart among infective backaches, the other types are brucellosis, non-tuberculous mycobacterial infection, and pyogenic infections.

Pyogenic Spondylodiscitis often results from hematogenous spread of infection from another system or follows an invasive procedure or surgery. The classical clinical presentation includes systemic features such as fever, malaise, severe pain, tenderness and muscle spasm.

Koch's spine is the frontrunner amongst all infective backaches and requires a high index of clinical suspicion, such as a recalcitrant, progressive backache with or without constitutional symptoms. MRI, along with a tissue diagnosis, is mandatory for confirming the diagnosis of Koch's spine.

With a high index of clinical suspicion of an infective backache, a gibbus should suggest Koch's spine; a cold abscess, though pathognomonic of Pott's, occurs much later in the course of the disease. The location of a cold abscess relates to the level of spinal involvement.

Cord compression resulting in paraplegia with Koch's as aetiology can be due to inflammatory or mechanical factors, which occur early (within 2 years) or many years following infection as a result of internal gibbus or the mechanical stretch.