A 26 year old guitar player reluctantly
presents to your office
for persistent low back pain.
Now she reports slowly
progressive back troubles over
the past several years
which has now begun to interfere
with her touring schedule.
It takes over an hour for her to
get moving each morning.
She frequently wakes up from
sleep with back pain
that compelled her to get
up and walk around.
It always feels better over
the course of the day.
She's sometimes afraid to
go to sleep knowing
what the night will bring. Pain
began on the right side
but now it's bilateral radiating
down into her buttocks.
Social History, she's a non-smoker.
She drinks “A few beers nightly”.
She's had several male sexual
partners in various cities
over the past 12 months. Family history;
review systems she has noticed also
some redness in her right eye
over the past few weeks. She
also reports some pain
and swelling to the back of her left
heel but reports no rashes.
So let's highlight some key features
of this case thus far.
First in terms of time course, this has been
going on for several years.
This certainly falls into the
chronic indolent category.
Next, the pattern of
It started off as somewhat asymmetric but
now we've got bilateral symptoms
but we've also got something going
on with the left heel.
I'd call this asymmetric and because we have
more than one joint involved
but not quite five or six, we'd
use the term oligoarticular.
Is there evidence of
Well, anytime a patient tells you
it takes over an hour
for the stiffness to resolve, that's
usually a good indication
that there's some inflammatory
process going on.
We can say yes, there is
Next up systemic involvement. Well,
we clearly have some
other systems involved. There's something
going on with our left heel.
There's something going on
with her right eye.
But it's a little early for us
to say whether or not
she has systemic involvement
the review of systems wasn't too
revealing. More on that later.
Which of the following is the
most likely diagnosis?
Rheumatoid arthritis, a spondyloarthritis,
not otherwise specified.
Osteoarthritis, a Crystalline
arthropathy or lupus?
Well, let's look back at the case. So 26 years old,
she's got the right gender; it is
more common in women.
It's a little unusual to start at age 26,
but absolutely reasonable.
And the fact that she has
well, that's a classic feature of
any of this autoimmune
inflammatory arthrophatis, her age,
like I said, a bit young.
Normally with rheumatoid arthritis,
you're going to have more
upper extremity symptoms, particularly
involving the hands,
the wrists, the PIPs, etc. That's a little unusual.
We're not seeing any of that.
In terms of rheumatoid arthritis in
the back you don't typically
rheumatoid arthritis having anything
to do with the low back.
Next up on our differential is spondyloarthritis
the topic of this lecture.
Her back does seem to be
the primary problem.
I'll remind you that the word
spondylosis comes from
the ancient Greek word for vertebrae.
So anytime we're talking
about the spondyloarthritides, we’re
thinking about involvement
of the axial skeleton, particularly
the low back.
Moreover, she's having morning
stiffness which again,
supports an inflammatory arthropathy.
Her age is actually
spot on for something like ankylosing
spondylitis, for example.
And the fact that she has some
extra articular manifestations,
maybe something going
on with her left heel
may also fit with one
of those diagnoses.
I will mention however, it is
more common in males,
maybe a 2 to 3 to 1 ratio but that's
certainly not a deal breaker.
Next up osteoarthritis or some sort
of degenerative joint disease
I mean, low back pain is extremely common
as a degenerate joint disease.
That being said, all the extra articular
stuff that we're talking about
and particularly that taking an hour
to get going in the morning.
Those things are not
typical of osteoarthritis
or degenerative disease
of the spine.
Her age, that's the biggest ding
She's 26 you don't get
osteoarthritis 26 years old,
so I think that one's really going
to fall off of our list.
Next up a Crystalline athropathy
like gout or CPPD.
That would be a fantastically rare
cause of lower back pain.
I have once seen it involve
the cervical spine,
but those are very rare birds. Moreover,
26 year old woman will be
almost unheard of for her
to get gout or CPPD.
Next up is lupus. Well, in favor of lupus.
She is 26 and she is a woman.
Remember the gender ratio for lupus is
about 9 to 1 in favor of women
she meets the demographic. the extra
articular stuff maybe suggest
a systemic illness of which lupus
is a classic systemic illness.
The arthritis though tends to be
more peripheral with lupus
rather than involving the lumbar spine.
That's counting against lupus.
Alright, so going back to our list here,
we can definitely take off
osteoarthritis and crystalline athropathy.
But we're still kind of left
with rheumatoid arthritis, lupus
even though spondyloarthritis is
the most likely diagnosis.
Let's do a physical exam, get some blood
work and see if that'll help us out.
She's a febrile, heart rate 76,
blood pressures okay.
She does have some evidence of right
eye conjunctival injection.
More on that later. No Lymphadenopathy
is pretty benign
neurologic exam is benign.
Then moving on to her
She has decreased range of
motion of her lumbar spine
with lateral flexion and
She's tended to palpation over her
bilaterals sacral iliac joints
and she has slightly warm, tender
swollen left heel
at the insertion of the achilles tendon,
skin and nail exam
Oh, she's got a bunch of tattoos
but otherwise it's normal.
Then looking at her blood work,
with hemoglobin of 10.4
white counts okay.
Rheumatoid factor is negative. Her NTCCP
antibody is also negative.
ESR 51. CRP is mildly elevated and her ANA
is completely negative.
You might ask at this point, whether
it be reasonable to check
an HLA b 27 haplotype. Knowing
that we're considering
the spondyloarthropathy. Of note,
HLA b 27 is present
in about 7% of North American
with 90% of patients who are diagnosed
with ankylosing spondylitis.
So it can definitely be a helpful
piece of information.
While ankylosing spondylitis is the disease
most associated with HLA b 27.
About 50% of patients with the other
will also have that
Alright, going through a few key
features of this exam,
so the right eye conjuctival
something like ankylosing spondylitis or
any of the other spondyloarthritides
you'll commonly see eye involvement
shown in the top
here is conjunctivitis, which would be
the most common manifestation
but you can have much more significant
pathology like anterior uveitis
as shown in this picture. This is
going to increase
our likelihood of having
Next up the fact that the bowels are normal
that's going to steer us away
from an enteropathic arthritis which
is one of the subtypes
of spondyloarthritides. The decreased range
of motion of the lumbar spine.
Well remember, Ankylosing from the
word ankylosing spondylitis
literally means disease of bending.
So we're going to do some tests
to try and see how well she can bend her
spine and there's a classic test
called the schober’s test. So here's
the Schober test.
The way it's performed is you're
taping a tape measure
to the back of somebody's spine, and
then you're drawing two lines
on the patient's lumbar spine. By having
the patient lean forward
you expect those two lines
to move farther apart.
But in somebody who has
trouble bending forward
that is someone with
The excursion of those two lines
may be less than 10 centimeters
and contrast for a normal spine it should
be more than 15 centimeters.
So that's a quick overview
of the schober test.
The fact that our patient has
decreased range of motion
of the lumbar spine as well as
tenderness to palpation
on those bilateral Sacroiliac joints,
that is definitely
steering us towards an
Next up the swollen left heel, now
you might start thinking
about rheumatoid arthritis because that
can have rheumatoid nodules.
But the rheumatoid nodule should be
painless and it really should just
be a firm integrated area rather
than swelling and tenderness
the way she's describing it. So this
sounds more like enthesitis
which is inflammation at the insertion of
a tendon or ligament into bone
which again is suggestive
of a spondyloarthritides.
Finally, really putting the
nail on the coffin for
rheumatoid arthritis or lupus,
our serologic testing
is completely negative rheumatoid
the ANA is negative. And if you
needed more evidence
the NTCCP antibody is also negative
ESR being 51 is just
a nonspecific inflammatory marker. And
same thing goes with the CRP.
And just to highlight a little bit further
about enthesitis and fasciitis,
both things that we oftentimes see
with the spondyloarthritides.
Enthesitis is inflammation at the insertion
of a ligament into bone.
And shown here in this picture
on the bottom left
is a picture of the adductor muscles
inserting into the femur
and you can see that whitish area
there is basically edema
in the tendon insertion. Likewise on the
right side images there
we have MRI evidence of fasciitis in this
case the plantar fascia.
On the top left image, there is a
picture of the calcaneus
which is where the plantar fascia will insert
into the calcaneus tubercle.
There's thickening and some edema in
the plantar fascia at that site.
Okay, so which of the following is
the most likely diagnosis?
Well, for ankylosing spondylitis,
there is a two to three to one male
predominance, but again
not a deal breaker. She has progressive
back pain, which is typical,
possibly with some evidence of
a peripheral arthritis
and this concern about the
would certainly be suggested,
or stiffness absolutely
supports this diagnosis.
And the fact that
she has evidence of
or worse is definitely
supportive as well.
So we're going to leave this
one on our list.
Next up is psoriatic arthritis. Well, this
can definitely involve
the back though more commonly,
you're also going to have
wrist involvement, with DIPs which
she was not reporting
the stiffness goes along with it.
But most importantly
80% of patients who have developed
already have some evidence
of plaque psoriasis
some cutaneous manifestations well
before they developed arthritis.
So I think we can safely take that
went off the table as well.
Reactive arthritis This is most
common in young men
but can also occur in
in the setting of sexual promiscuity.
And Oligoarthritis is typical
would may be accompanied
it seems like it's going to have to stay
on our list for now as well.
Now for the last one
the last of those four types
you need to have inflammatory
bowel disease type symptoms
she reports no gastrointestinal symptoms,
so that one is immediately X out.
Alright, so let's take a look at some
imaging which will hopefully
make the final diagnosis
for us. First up,
we've got some plane radiographs
of the lumbar spine
first a AP film and then a lateral
film on the far right
by looking at these films
and we can see
a loss of the normal lumbar
lordosis. We have active
inflammatory osteatis particularly
of L4 and L5 vertebrae
with some early squaring of the vertebral
bodies in particular
and that film on the far
right, you can see these
bridging syndesmophytes between
the individual vertebrae
sometimes called bamboo spine.
Then on our MRI of the
Sacroiliac joints. We're seeing contrast
in the right SI joint, shown on this
film with these two arrows
with some early erosions as well.
Okay, at this point
the diagnosis is clear. Our girl rocker
has ankylosing spondylitis