What is Inflammatory Back Pain?
Inflammatory back pain (IBP) is a lasting pain focused in the main parts of your spine and the joints connecting your spine to your pelvis. This type of pain is different from everyday back pain and has special features that help doctors pinpoint if you have it. While it is often connected to inflammation in the body, we can’t absolutely link it to any one specific condition.
Let’s look at some clues that can help identify IBP from other forms of back pain:
– Where is the pain? IBP pain mostly affects the main spine, particularly the lower back, and can move from one side of the buttock to the other.
– Who has the pain? Characteristics about the person, like their age and lasting pain, are key for identifying IBP. This pain often starts before the age of 40 and sticks around for 3 months or more.
– How does the pain behave? The way the pain develops over time is also an important clue. It usually starts slowly and gets worse over a long period of time.
– What happens in the morning? People with IBP usually feel stiff in the morning, but this stiffness gets better as they move or exercise. This is a significant feature that sets it apart from other types of back pain.
– Connection to inflammation: The most common association is with a condition called ankylosing spondylitis, but IBP can be present in other conditions such as psoriatic arthritis, enteropathic arthropathy, juvenile idiopathic arthritis, and reactive arthritis. These are all types of arthritis, a term for conditions that cause pain and inflammation in the joints.
– Unknown causes: In certain situations, the cause of IBP could remain unknown. This is because there are no singular or combined features of any health conditions that could be used to diagnose it.
What Causes Inflammatory Back Pain?
Seronegative spondyloarthropathies, which are diseases that cause inflammation in the joints of the spine, are often identified after someone shows signs of inflammatory back pain (IBP). These conditions come about through a complicated process, usually tied to a body-wide inflammatory response. This response can be set off by a known or unknown source, causing changes in the tissues within the joint.
This inflammation can keep going because of certain biological factors like interleukin-17 (IL-17) and tumor necrosis factor (TNF). These create a looping cycle that throws off the balance of bone remodeling, which is the body’s natural process of removing old bone and forming new bone, leading to a loss of spinal bone.
These inflammatory changes can cause structural changes. For example, in conditions like ankylosing spondylitis, the vertebrae (bones in your spine) fuse together. These changes can be seen on imaging scans and often explain the slow onset of chronic pain in patients with inflammatory back pain. These signs have guided research towards potential treatment strategies.
Risk Factors and Frequency for Inflammatory Back Pain
Inflammatory back pain (IBP) affects around 5% to 6% of adults between the ages of 20 and 69 in the U.S. There is a difference between the number of people with IBP and those with a group of diseases called spondyloarthropathies, which are less common, affecting only 0.9% to 1.4% of people. In Asia, fewer people, about 0.001%, are affected by a specific disease known as ankylosing spondylitis. However, only 36% of Asians with IBP actually fit the diagnosis criteria for spondyloarthropathies. This has led some experts to suggest that IBP may be a separate condition or have different causes.
Studies in different countries show different IBP rates. For example, one study in the UK encountered IBP rates of 1.7% to 3.4% in patients coming into primary care clinics. A similar study in Mexico showed IBP affecting about 3% of people there. However, the rates generally vary depending on how IBP is defined and diagnosed; most studies do not show rates higher than 8%.
- One large study showed that non-Hispanic whites had a higher prevalence of IBP (5.9%) than non-Hispanic blacks (3.3%).
- There is not much evidence to suggest major differences in IBP rates based on gender or age group.
Signs and Symptoms of Inflammatory Back Pain
Inflammatory Back Pain (IBP) differs from usual back pain in several ways. It starts subtly and tends to get better with physical activity. Rest doesn’t improve this type of pain, and it often disturbs sleep. Interestingly, this pain usually improves upon getting up and moving around. The fact that it is connected with a group of diseases called seronegative spondyloarthropathies hints that an initial illness or body-wide inflammation might come before IBP.
Testing for Inflammatory Back Pain
Inflammatory back pain (IBP), diagnosed based on specific criteria, can indicate the need for evaluation by a rheumatology expert. This is particularly important if there’s a positive result for a lab test known as HLA-B27 and evidence of inflammation in the sacroiliac joints — the joints located by your hips — from imaging studies. These factors, in conjunction with the identified pain criteria, can help determine the diagnosis.
About half of the patients with a condition related to their spine and joints, called axial spondyloarthropathy, may show signs of increased inflammation in blood tests. These signs can be elevated levels of proteins called erythrocyte sedimentation rate and C-reactive protein. However, these elevated levels could also be a sign of rheumatoid arthritis, which is another type of inflammatory disorder affecting the joints.
In a condition known as ankylosing spondylitis, a positive Schober test is an indication seen during a physical examination. This test measures how well your lower back can move. It’s done by making two marks on your lower back, one 10 cm above the bottom of your spine (sacrum), and another 5 cm above that. The doctor then measures the distance between these two points while you stand straight and bend forward. If the distance increases less than 5 cm when you bend, the test result is positive. In ankylosing spondylitis, imaging studies of your sacroiliac joints can show varying degrees of damage, ultimately leading to the bones in the joint fusing together. For a diagnosis of ankylosing spondylitis, there must be at least one clinical symptom related to the condition and at least one indication in imaging that are sufficient in severity and duration.
In another condition called psoriatic arthritis, or PsA, a specialized imaging study called magnetic resonance imaging (MRI) can show edema, or swelling, in the bones that make up the sacroiliac joints. It can also show hardened areas in the bone, changes in the fat around the joint, erosions and new bone development.
Patients with inflammatory bowel disease (IBD) can develop joint issues known as enteropathic arthropathy. X-rays can sometimes show swelling and bone loss in the joints, although these changes can also occur in patients who don’t have symptoms of IBD. MRI is used to identify changes in the joints, but it may not always correlate with back pain. Therefore, it is mainly recommended for patients who have both back pain and IBD symptoms.
Juvenile idiopathic arthritis (JIA) can present various signs in patients. Patients with JIA may show a positive result for a test called antinuclear antibody, or ANA. They may also have an elevated erythrocyte sedimentation rate (more than 40 mm/hour), increased gamma globulins (proteins in the blood), and anemia (hemoglobin concentration below or equal to 11 g/dL).
Treatment Options for Inflammatory Back Pain
If you are diagnosed with inflammation causing back pain or stiffness (IBP), your doctor might refer you to a rheumatology specialist. This is particularly true if you test positive for the HLA-B27 gene, a marker for certain autoimmune diseases, and if imaging shows inflammation in the sacroiliac joints, the joints between the spine and the pelvis. Good teamwork between healthcare professionals can help manage the many aspects of IBP better, making your care more personalized and effective.
When you start treatment for IBP, doctors will explain your condition and its likely progress. They will also tell you about related conditions you might have to look for using lab tests and imaging. It’s very important to quit smoking. Furthermore, discussing various psychological and social support systems is crucial. With IBP, physical therapy is often recommended as exercise and movement therapies can drastically improve the disease.
The first drug treatment for IBP, regardless of whether it’s a symptom of a disease characterized by inflammation of the spine joints or not, usually starts with nonsteroidal anti-inflammatory drugs (NSAIDs), often at the highest dose. Doctors will assess whether this treatment is effective after a period of about 2 to 4 weeks. If it works well, it can be used as necessary to control symptoms.
If NSAIDs aren’t effective for symptom control in patients known to have a spinal inflammation disease, there are other medications to consider. TNF inhibitors are one example, or you can use alternative medications like secukinumab. If TNF inhibitors initially provide relief but then stop being effective, doctors often recommend switching to a different TNF inhibitor. If a TNF inhibitor didn’t work despite trying for about three months for each inhibitor used or if they caused side effects, doctors usually suggest changing to a different type of drug. These alternatives include the anti-IL-17 antibodies ixekizumab and secukinumab, or a group of drugs known as JAK inhibitors, including tofacitinib or upadacitinib. These drugs reduce your immune response, so doctors will carefully consider their use if you have any issues with your immune system, a history of cancer, heart disease, or diseases involving damage to the protective sheath of nerve cells.
Surgical interventions may be needed in cases of IBP with spinal inflammation under certain conditions like persistent pain or severe mobility restrictions due to significant hip involvement, slippage of the uppermost neck bone potentially causing neurological impairment, and severe bent posture resulting in inability to look forward.
Considering the unique features of each condition, such as how it progresses and how it responds to treatment, is important for the effective management of the condition. For more detailed information on managing individual conditions, please refer to other resources.
What else can Inflammatory Back Pain be?
When diagnosing inflammatory back pain (IBP), physicians consider several potential causes such as mechanical, nonmechanical, and visceral origins. It’s vital they exclude pain that could be due to cancer or fractures in the vertebral body, the main part of the spine. Symptoms of IBP may include pain beginning before the age of 40, a history of back pain for more than three months, gradual onset, stiffness in the morning, and improvement with activity. On the contrary, mechanical back pain typically worsens with movement and is often linked to injury, appearing rather abruptly.
Doctors should also perform an assessment to spot any signs that could signal pressure on the spinal cord or cauda equina syndrome, a serious condition affecting the nerves at the end of the spinal cord. Furthermore, patients who exhibit strong signs of vertebral osteomyelitis (a bacterial infection) or an epidural abscess (infection near the spinal cord) should have an immediate MRI scan.
A study investigating signs that may suggest cancer as the cause of back pain found that a history of cancer and strong suspicion of cancer were the most revealing elements guiding the evaluation towards a potential cancer-related cause of the back pain.
What to expect with Inflammatory Back Pain
NSAIDs, or nonsteroidal anti-inflammatory drugs, are the first choice of treatment for some types of arthritis that are not detected by standard tests, such as seronegative spondyloarthropathies. These drugs can be effective in relieving inflamed back pain (IBP) and can also help improve symptoms like morning stiffness and reduced chest expansion in related conditions. When combined with other proven treatments such as exercise and physical therapy, these medicines can greatly improve the patient’s overall quality of life.
While there isn’t a lot of direct evidence linking back pain to increased chances of premature death, certain types of arthritis that involve the spine, such as ankylosing spondylitis, are associated with a 36% to 76% increased risk of acute coronary syndrome (ACS), which is a sudden decrease in blood flow to the heart. They’re also associated with a 50% increased risk of venous thromboembolism, which is a blood clot that starts in a vein. Interestingly, female patients with PsA, a type of arthritis that affects some people who have psoriasis, have nearly double the risk of ACS compared to the general population. However, because these diseases and related back pain generally appear at a relatively young age, the absolute risks of ACS, venous thromboembolism, or stroke are still relatively small in these patient groups.
Possible Complications When Diagnosed with Inflammatory Back Pain
Inflamatory Back Pain (IBP) is associated with an immune response that disrupts the balance of bone remodeling, which can lead to osteoporosis noticeable within 10 years of diagnosis. Those with a condition known as ankylosing spondylitis are twice as likely to have vertebral fractures compared to the general population, especially in the neck region. Also, the risk of spinal cord injury is 11 times higher in these individuals. Patients with long-term ankylosing spondylitis have a higher risk of a condition known as cauda equine syndrome. Additionally, people with a disease called axial spondyloarthropathy are at a higher risk for kidney disease, showing an 8% increase in abnormal urine tests compared to the general population.
Common Risks:
- Osteoporosis
- Vertebral fractures
- Spinal cord injury
- Cauda equine syndrome
- Kidney disease
Chronic use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) by people with IBP has been linked with various complications. These drugs can worsen peptic ulcer disease, increase the risk of heart events in at-risk groups, trigger kidney injury or failure, and exacerbate existing reactive airway disease. When prescribing NSAIDs, the doctor has to consider the patient’s IBP-related health conditions, other illnesses, and other medications they are on, particularly glucocorticoids, blood thinners, water pills, and selective serotonin reuptake inhibitors (SSRIs).
Potential risks from NSAIDs:
- Worsening of peptic ulcer disease
- Increased risk of cardiovascular events
- Kidney injury or failure
- Exacerbation of reactive airway disease
Preventing Inflammatory Back Pain
The first step in treating Inflammatory Back Pain (IBP) is to educate patients about what they can expect as their condition progresses, and stress the importance of further tests to find out what’s causing the inflammation. Patients should be strongly advised to quit smoking, as it can make their symptoms worse, and should be pointed in the direction of helpful social and emotional support resources. One key aspect of treatment that really helps manage the condition is physical therapy, which includes exercise and training on how to hold your posture correctly. This can greatly help to manage the progress of the disease.
