A female patient, aged 29 years, presents for the first time. She works as a cleaning lady. For 2 years she has experienced several episodes of low thoracic pain, which last maximally 3 weeks. There was no prior trauma and the complaints had a gradual onset. She awakes because of pain between 4 and 5 am. During such a pain episode she isn\u2019t able to work.
The patient is evaluated by a rehabilitation medicine doctor. A physical examination shows no specific abnormalities.
Additional examinations are performed:
Laboratory: HLA B27 negative
MRI lumbar spine (with focus on the medulla): intervertebral disc bulging L4-L5
Electromyography of the lower limbs: normal
Treatment:
Step 1: In the case of back pain of inflammatory character NSAIDs are the first choice therapy. A good response of NSAIDS is included in the ASAS classification criteria for axial Spondyloarthritis (axSpA), and therapy with an NSAID would in this case also provide valuable diagnostic information. In about 70% of the SpA-cases, NSAIDs will have a beneficial effect, when given at a daily maximally tolerated anti-inflammatory dosage.
Step 2 physical therapy
After a referral to a us, therapy is started with diclofenac slow release 75 mg twice daily, which provides rapid relief of nocturnal pain and improvement of morning stiffness.
Clinical examination reveals a slightly decreased axial mobility with chest expansion 4 cm and modified Schober\u2019s test 10\/13, 5 cm. Upon skin examination, discrete psoriatic lesions are noted behind the ears. Family history is positive for SpA; the father of the patient also has psoriasis.
Laboratory examination reveals a normal erythrocyte sedimentation rate (4 mm\/1st hour) and a normal CRP 0.3 mg\/dl (normal values <0.5 mg\/dl). MRI of the sacroiliac joints shows minimal bone marrow oedema right-sided on T2-weighted, fat-suppressed images. No structural lesions of the sacroiliac joints could be seen.
In this patient, a diagnosis\/classification of early \u2018non-radiographic\u2019 SpA can be established based on the presence of acute sacroiliitis lesions on MRI and at least 2 additional SpA features (inflammatory back pain, response to NSAIDs, psoriasis).
In psoriatic axial disease, the prevalence of HLA B27 is lower compared to classic AS. NSAIDs are the cornerstone of medical treatment. They should preferentially be given at a daily full anti-inflammatory dose. In case of intolerance or side effects, (1) dose tapering, (2) change of NSAID, or (3) addition of a proton pump inhibitor might be considered.
Lesson 1: Before prescribing TNF-alpha blocking agents, a maximally tolerated anti-inflammatory dosage of at least two NSAIDs should be tested over a period of at least 1 month.
Lesson 2: There is no evidence for DMARDs such as Sulfasalazine or Methotrexate to be effective in the axial disease of SpA.
Case continued…
Axial symptoms remain well controlled for approx. 7 months. There are no signs of peripheral joint, enthesis or dactylitis involvement. However, skin psoriasis is gradually worsening with approx.
10% of the body surface area affected, and despite continuous intake of NSAIDs and regular physical therapy, the patient develops again significant inflammatory pain at the thoracic level. A change from diclofenac to piroxicam 20 mg daily does not provide any relevant symptom relief. The BASDAI is elevated with a value of 6 (on a 0-10 Numeric Rating Scale).
MRI of the spine reveals multiple inflammatory vertebral lesions (Romanus lesions) at the thoracic level.
In patients with active axial SpA (BASDAI >4), not responding to the maximal tolerated anti-inflammatory dosage of at least 2 different NSAIDs, anti-TNF therapy is indicated. A good clinical response both on axial disease and skin involvement might be expected. Although methotrexate and sulfasalazine are used to treat peripheral joint disease and skin involvement in psoriatic arthritis, there is no evidence for any DMARD (sulfasalazine, methotrexate) to be effective in the axial disease of SpA. There is no evidence for corticosteroids at a low or moderate dose to be effective in the axial disease of SpA.<\/p>\n\n\n\n
Suffering from back pain, book your appointment today at www.painx.in or 9717236321.<\/p>\n","protected":false},"excerpt":{"rendered":"
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