What are the symptoms and treatment options for inflammation of the spine?

Symptoms and Treatment of Spinal Inflammation

The primary symptoms of spinal inflammation include inflammatory back pain characterized by morning stiffness, pain that improves with activity but not with rest, and fatigue, which should be treated with NSAIDs as first-line therapy, followed by TNF inhibitors or IL-17 inhibitors for refractory cases. 1

Common Symptoms of Spinal Inflammation

Cardinal Symptoms

• Inflammatory back pain with the following characteristics:
  • Morning stiffness lasting more than 30 minutes 2
  • Pain that improves with exercise but is not relieved by rest 2
  • Pain that awakens patient during the second half of the night 1
  • Alternating buttock pain 2
  • Insidious onset over months or years 1

Associated Symptoms

• Fatigue (often severe and persistent) 1
• Reduced spinal mobility in multiple planes 2
• Limited chest expansion due to costovertebral joint involvement 2
• Peripheral joint involvement (asymmetric, predominantly lower limbs) 2
• Enthesitis (inflammation at tendon/ligament insertion sites) 2, 1
• Extra-articular manifestations:
  • Acute anterior uveitis 1
  • Psoriasis 2
  • Inflammatory bowel disease 2, 1

Diagnostic Considerations

Clinical Assessment

• BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) to assess disease activity 2, 1
• ASDAS (Ankylosing Spondylitis Disease Activity Score) for monitoring 1
• Physical examination focusing on:
  • Spinal mobility measurements 2, 1
  • Chest expansion 2
  • Peripheral joint examination 2
  • Enthesitis sites 2

Laboratory Tests

• HLA-B27 testing (positive in 75-95% of patients with ankylosing spondylitis) 2, 1
• Inflammatory markers (ESR, CRP) - may be elevated but not always 1

Imaging

• Radiographs of sacroiliac joints and spine (may be normal in early disease) 2
• MRI of sacroiliac joints and spine (preferred for early diagnosis) 2
  • Can detect inflammation before radiographic changes 3
  • Recommended for persistent symptoms despite treatment 2

Treatment Algorithm

First-Line Treatment

1. NSAIDs (e.g., naproxen) 2, 1, 4

   • 75% of patients with ankylosing spondylitis show good response within 48 hours 2
   • Should be taken continuously rather than on-demand for better outcomes 1
   • Use lowest effective dose for shortest duration to minimize side effects 4

2. Physical therapy and exercise 1, 5

   • Regular exercise to maintain spinal mobility and posture
   • Home exercise programs to improve function

Second-Line Treatment (for NSAID-inadequate response)

1. TNF inhibitors (infliximab, adalimumab, etanercept, golimumab, certolizumab) 2, 1

   • Strongly recommended for active disease despite NSAID treatment
   • More effective in patients with disease duration <10 years 2
   • 50% improvement in about half of treated patients 2

2. IL-17 inhibitors (secukinumab, ixekizumab) 2, 1

   • Alternative for patients who fail TNF inhibitors
   • TNF inhibitors conditionally recommended over IL-17 inhibitors as first biologic 1

3. Sulfasalazine 2, 6

   • Limited efficacy for axial symptoms
   • More effective for peripheral joint involvement
   • Consider for patients with contraindications to biologics

Local Treatments

• Corticosteroid injections for peripheral joints or enthesitis 6
• Sacroiliac joint injections under fluoroscopic or CT guidance for persistent sacroiliitis 6

Surgical Interventions (for severe cases)

• Total hip arthroplasty for advanced hip arthritis 1
• Spinal surgery only in selected cases with severe kyphosis or neurological complications 1

Monitoring and Follow-up

• Regular assessment of disease activity using BASDAI or ASDAS 1
• Monitor inflammatory markers (ESR, CRP) 1
• Radiographic follow-up not necessary more frequently than every 2 years unless significant clinical changes occur 1
• Screen for extra-articular manifestations (uveitis, IBD, psoriasis) 1

Important Considerations and Pitfalls

• Delay in diagnosis is common (5-7 years from symptom onset to diagnosis) 2
• Differentiate from mechanical back pain - response to NSAIDs is a key distinguishing feature 2
• Early diagnosis and treatment are crucial to prevent structural deformities 1
• Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced osteoporosis 1
• Monitor for NSAID side effects including gastrointestinal, cardiovascular, and renal complications 4
• Screen for tuberculosis before starting TNF inhibitors 1

By recognizing the characteristic symptoms of spinal inflammation and implementing appropriate treatment early, disease progression can be slowed and quality of life significantly improved for patients with inflammatory spinal conditions.