I see quite a few inflammatory arthritis patients as part of my practice. That includes patients with inflammatory back pain. Of course many of my patients also have degenerative arthritis related lower back pain. This video is meant to help people understand the difference between inflammatory and degenerative arthritis related back pain, diagnostic differences, and treatment differences.
One of the most common musculoskeletal issues that we see in our society is back pain. I want to discuss how to differentiate between inflammatory back pain and degenerative back pain. It’s important for a number of reasons. Back pain is a humongous problem in our society. Roughly 75% of people in Western societies will have some version of back pain at some point in their life. It’s important to differentiate between inflammatory versus degenerative back pain because the etiologies are very different, the treatments are very different, and even the prognosis can be different as well. From a cost standpoint, if we can make a correct diagnosis and get an individual on the right treatment path and algorithm, we have a better chance of bending the cost curve, rather than spending time on the wrong treatments.
There are very distinct diagnoses that cause inflammatory back pain versus degenerative back pain. The classic diagnoses for inflammatory back pain include ankylosing spondylitis, inflammatory bowel disease related sacroiliitis lower back pain as well as psoriatic arthritis. There’s a number of other conditions, but those are really your core three inflammatory back pain conditions. The cause of inflammatory back pain is related to autoimmune conditions meaning the individual’s immune system is miscommunicating, recognizing it’s own joints and other organs frequently as foreign and basically attacking them. This then leads to inflammation which then results in pain and damage, restriction of range of motion and eventually functional disability.
The prevalence of inflammatory back pain is still relatively less common, essentially ankylosing spondylitis makes up less then one percent of the population. Inflammatory bowel disease related back pain, again, less than one percent. Psoriatic arthritis is a bit more common, psoriatic arthritis affecting the lower back is less common however. So all told, around two percent of the population could have inflammatory back pain.
The presentation is really key here. The presentation for inflammatory back pain is pain that is very definitively worst first thing in the morning, worse with rest, and generally better with low impact physical activity. So a classic description would be someone with significant stiffness first thing in the morning, lasting for more than one hour. That’s fairly classic for inflammatory back pain. It will also be pain that will wake them up at nighttime or wake them up very early in the morning with pain.
Examination findings in an early stage might be limited, but the classic findings would be tenderness over the sacroiliac joints. Also there is a maneuver called a FABER’s test where essentially you externally rotate the hip and it creates pain in the sacroiliac joint area. There’s also the Schober’s test where you can actually get a sense for range of motion in the sacrum and sacroiliac joints to see if there is any restriction. Typically you see that as this condition progresses, not so much early on.
The diagnoses for degenerative back pain are the ones people are more familiar with. This includes facet joint osteoarthritis, strain of the soft tissues including ligaments or muscles in the lower back, a pinched nerve in the lower back from foraminal stenosis and spinal stenosis. These are all very interrelated conditions that can occur primarily after a prior injury or chronic stress that then leads to chronic instability, due to weakness of some of the soft tissue structures, which then eventually leads to a progressive degenerative process including stressing the facet joints, the nerves and some of the other soft tissue structures. The cause is very clearly instability or trauma that progresses. The lifetime prevalence of degenerative back pain is up 70 to 75% of our population at some point of their lifetime.
Presentation is classically pain that is worse with certain activities depending on the condition. Different types of motion will make the pain worse and rest generally makes it better. So in general, degenerative back pain will be very definitively worse with activity and better first thing in the morning and with rest. Examination findings will vary, however, frequently provocative maneuvers can make things worse as well as significant tenderness and findings of subtle instability based on how you position an individual to see if it stresses the back or not.
In terms of some of the other objective findings, labs in inflammatory back pain can sometimes be abnormal, meaning sometimes your inflammatory parameters like sedimentation rate and C-reactive protein can be elevated. This is not true in all inflammatory back pain patients, but in some it can be found. The classic antibody, the HLA-B27 test, can be positive in some people. Again, not 100% and so the labs should not determine a diagnosis of inflammatory back pain, but they can help to confirm.
Of course in degenerative back pain, abnormal labs are really not an issue. If someone has a very high elevated inflammatory parameter and degenerative back pain, consider other potential etiologies as well. As an example, bone metastases if someone has cancer or a history of cancer, or infectious cause should be considered if a high level of inflammation is found on labs.
In contrast imaging is key here. In inflammatory back pain, the classic imaging used to be X-rays, in which someone who has progressive disease over years develops fusion of the spine. This does not occur early on. What you will see early on, however, is inflammation in the sacroiliac joints. This is really best seen under MRI where you can see bone marrow edema in the sacroiliac joints which is called sacroiliitis. There is a question in the medical literature of imaging negative inflammatory arthritis, which is a challenging diagnosis to make strictly based on symptoms and lack of other findings.
Degenerative back pain, of course, is very well understood in terms of what you will see on imaging. Whether that is arthritic changes in the facet joints or slight shifting of the vertebra indicative of chronic instability these can be seen on xray. Some other things you can see on MRI would include foraminal stenosis, where the nerves coming out of the spine are pinched. In addition, a really subtle finding, not always described by radiology would also be multifidus muscle atrophy in a degenerative spine, which is an indication of a slight pinched nerve in the lower back as well.
It’s important to note that inflammatory back pain patients are just as common, probably even more common, to also develop degenerative back pain issues as well. So frequently, in inflammatory back pain patients, you’ll find that they also have findings of degenerative disc disease or degenerative joint disease. It’s important to recognize that a person’s back pain, if they have something like ankylosing spondylitis, a component of it might be inflammatory, but a component may also be degenerative and should be treated appropriately as well.
First line treatment will be very similar with both of these conditions, namely very intensive and purposeful core strengthening, hip strengthening, working on range of motion, doing everything you can to help support the areas that are stressed, chronically inflamed, and unstable. In addition, utilizing certain over the counter supplements can be helpful as well. Glucosamine chondroitin in general can help 50% of people with degenerative. Omega-3 and tumeric/curcumin are low level anti-inflammatory supplements that are low risk, can help with pain in people with arthritis, and are also worthwhile trying. If the over-the-counter supplements can minimize the utilization of narcotics and chronic anti-inflammatory medications, that is worth trying as well. If that’s not adequate, then the escalation of treatment will differ between these two conditions.
For inflammatory back pain, treatment escalation typically utilizes some kind of medication like a biologic medication to help control the systemic inflammation that’s driving this condition. That is certainly worthwhile trying. If a person has really just very inflamed one sacroiliac joint, it can be worthwhile trying an injection, whether that’s an injection of a steroid or with alpha-2-macroglobulin, which is an autologous biologic from a person’s own blood.
Escalating treatment in degenerative back pain generally should be considered with injections if they’re failing conservative management. Rather than utilizing steroid injections, some other options would include, utilizing a person’s own blood and platelets, which can help to strengthen the soft tissue structures, treat the arthritic facet joints, and even reduce the inflammation and pain from a nerve if that has been pinched as well.
So the escalation of treatment is different depending on the etiology of the back pain. That is key because if you want to put an individual down the right path for treatment, you want to make sure you have the right diagnosis first and then appropriately escalate treatment in the correct way based on the actual etiology of the condition.
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