The SpineCommunity Presents: Ask the Expert with Dr. David Borenstein
David G. Borenstein, MD recently answered your questions on ankylosing spondylitis (AS) in TheSpineCommunity. TheSpineCommunity is an online support community for individuals affected with conditions of the spine, join the conversation here.
Dr. Borenstein: The frequency of AS in patients with inflammatory disease varies depending on the study. It is a minority of patients. The percent varies from 10 to 25% depending of the degree of involvement in order to be considered to have the spinal disease. What is most important is to not overlook persistent morning stiffness in the sacroiliac joints or lumbar spine that lasts for hours. These individuals should have radiographic tests to determine if spinal arthritis is present.
Dr. Borenstein: No comparative studies have been completed looking at the relative benefit of tumor necrosis factor antibodies (TNFs) versus anti –IL17 antibodies.
Both categories of biologics are effective in patients with ankylosing spondylitis, psoriasis, and psoriatic arthritis. The usual sequence of drugs on an historical basis is from anti TNFs to anti-IL17 drugs. Usually patients who fail TNFs go on to IL-17 therapy. IL-17 therapy can be effective when TNF’s have not. How many TNF’s to try before switching to anti IL-17 therapy is a discussion between the patient and the doctor. No required number of TNF’s are needed before switching to the anti-IL17 biologic.
Dr. Borenstein: The difficulty with ankylosing spondylitis is that the skeletal structures are inflamed and try to fuse. While this inflammatory process takes place, the muscles surrounding the spine tend to shorten causing pain and limited motion. Drug therapy is used to decrease inflammation and allow the muscles to lengthen.
Any exercises that improve range of motion and strengthen muscles are thought of as being helpful. Yoga exercises try to maximize range of motion from the pelvis through the low back, chest and neck. Pilates exercises tend to strengthen core muscles. If available, a visit to a physical therapist to be sure that specific areas of limited function are treated can also be helpful.
What is most important is the dedication to doing whatever exercises over time. AS is a lifelong disease and does not take a holiday. You should not take a holiday from your exercises.
Sitting in a car seat may not be the best place to decide if a back pain is related to a mechanical or inflammatory disorder. Most car seats are not comfortable once you have been in them for a period of time particularly in stop and go traffic. Both mechanical and inflammatory disorders may cause pain to occur over a period of time. A better way to help differentiate inflammatory from mechanical back pain is when you first get up in the morning. If you have some back stiffness that goes away in 30 minutes or less, a mechanical low back pain is more likely. If you get up stiff and remain stiff for more than 30 minutes, that is a problem more likely associated with an inflammatory disorder. Hopefully, there is a rheumatologist who is 10 minutes away from your house that you can drive to before you get stiffer that can help answer your question.
Question: I have Juvenile Arthritis Spondyloarthritis. Now in my 40’s, I am dealing with lower back and cervical spine issues. In fact, I had imaging yesterday that showed inflammation in my cervical spine. I have been on Xeljanz, but is this an indication that I may need to change treatments?
Individuals who have arthritis as children may go on to have the same illness as adults or may change into another form of inflammatory arthritis like rheumatoid arthritis. In you statement, you mention back and neck pain, but only describe inflammation in the cervical spine. That may mean that the lumbar spine was not studied, or that the cervical spine alone was inflamed and not the lumbar spine. The distinction is important because rheumatoid arthritis will preferentially affect the cervical spine without affecting the lumbar spine. If that is the case, Xeljanz is an appropriate choice and may need to be given at its highest dose for a longer period of time. If the MR inflammation is located in positions that are associated with ankylosing spondylitis, Xeljanz would not be the best choice. In those circumstance an anti-tumor necrosis factor antibody, or an anti-Il 17 antibody might be a more effective choice.
Question: I am a 32 year old woman and I delivered my second baby one year back. Ever since my delivery I have been suffering from a pain in my joints which has still not subsided. What could be the reason behind this pain?
After a delivery, your immune function tries to return to its normal levels of function. In some women, this can result in the start of autoimmune processes. Post-pregnancy can be a time that rheumatoid arthritis or systemic lupus erythematosus can start. You should be evaluated by a physician who is preferably a rheumatologist so they can evaluate your situation to determine if you have developed a generalized arthritis.
Dr. Borenstein: PSA and AS are both diseases that can affect the spine. In AS, basically 100% of patients have involvement of the spine going from the sacroiliac joints to the neck. Only about 30 to 40% of patients with PSA have involvement of the spine. The spinal involvement in PSA may look like AS but there are difference in the involvement of joints (unilateral versus bilateral sacroiliitis, for example) that distinguishes one disease from the other.
In regard to treatment, the biologic therapies that work for AS, are approved for use in PSA. Therefore, the therapies are effective for both illnesses.
Dr. Borenstein: About 40% of patients with AS will develop iritis or uveitis. Iritis that occurs in association with AS, is twice as common in males as females. The iris is the part of the eye that gets smaller or larger depending on the amount of light entering the eye. Since the iris becomes inflamed, light entering the eye will cause the iris to move and cause significant eye pain. The eye may also become red. Decreased vision may also be associated with the onset of iritis. If left untreated, iritis can result in significant loss of vision. Treatment by an ophthalmologist with steroid drops or injections can be helpful. Anti-TNF antibodies may be effective in controlling iritis in individuals who are resistant to steroid treatment.
About Dr. Borenstein: A past President of the American College of Rheumatology and a Clinical Professor of Medicine at the George Washington University Spine Center, Dr. Borenstein currently practices with Arthritis and Rheumatism Associates (ARA). He is a Master of the American College of Rheumatology and the American College of Physicians and has been active in a number of many medical professional organizations. Dr. Borenstein has served as a consultant of lumbar spinal stenosis for the National Institutes of Health, has chaired low back pain symposia for a number of physician groups, and has lectured to the general public on behalf of the Arthritis Foundation. He is a member of the International Society for the Study of the Lumbar Spine.
The Ask the Expert Series is not intended to be a substitute for healthcare professional medical advice, diagnosis, or treatment. Speak to your healthcare provider about any questions you may have regarding your health.