What are the next steps for a patient with thoracic spine osteopenia, thoracic kyphosis, and suspected ankylosing spondylitis?

Management of Suspected Ankylosing Spondylitis with Thoracic Osteopenia and Kyphosis

Screen this patient immediately for osteoporosis with DXA scanning of both spine and hips, initiate physical therapy, avoid spinal manipulation, provide fall counseling, and confirm the diagnosis of ankylosing spondylitis before considering disease-modifying treatment. 1

Immediate Diagnostic and Safety Steps

Osteoporosis Screening

• Perform DXA scanning of both the spine AND hips (not just hips alone), as restricting scans to non-spine sites in patients with suspected syndesmophytes or spinal fusion could miss spinal osteoporosis 1
• This is conditionally recommended by the American College of Rheumatology specifically for patients with ankylosing spondylitis features 1
• The presence of marked osteopenia on plain films makes this urgent, as these patients are at high risk for devastating spinal fractures 1

Fall Prevention (Critical for Morbidity/Mortality)

• Implement fall evaluation and counseling immediately - falls can lead to spinal fractures with devastating neurologic consequences in patients with osteoporosis and spinal deformities 1
• This is strongly recommended even though evidence quality is very low, because the consequences of falls are catastrophic in this population 1

Absolute Contraindication

• Strongly avoid spinal manipulation with high-velocity thrusts - this is contraindicated in patients with advanced spinal osteoporosis or spinal fusion due to fracture risk 1, 2

Confirming the Diagnosis

Before initiating disease-modifying treatment, confirm ankylosing spondylitis diagnosis:

• Check HLA-B27 status (present in 75% of AS patients) 1
• Assess for inflammatory back pain characteristics (morning stiffness, improvement with exercise, nocturnal pain) 1
• Obtain inflammatory markers (CRP, ESR) for baseline and monitoring 1
• Consider MRI of sacroiliac joints if radiographic sacroiliitis not yet evident, as inflammation can be present years before radiographic changes 1
• Monitor disease activity using validated measures (BASDAI, ASDAS) at regular intervals 1

Non-Pharmacological Treatment (Start Immediately)

Physical Therapy - Highest Priority

• Initiate physical therapy immediately - this is strongly recommended over no treatment for both active and stable AS 1
• Prioritize land-based supervised exercise programs over aquatic therapy (moderate evidence) 1, 2
• Supervised group or individual exercise is superior to passive modalities like massage, ultrasound, or heat 1
• Advise regular unsupervised back exercises for home maintenance 1

Patient Education

• Enroll in formal self-management education programs (group or individual) - this shows moderate-quality evidence for improvement in disease activity and health status 1

Pharmacological Treatment

First-Line: NSAIDs

• Start full-dose NSAIDs as first-line treatment for pain and stiffness 1
• 75% of AS patients show good/very good response within 48 hours (versus only 15% with mechanical back pain) 1
• Consider continuous rather than on-demand NSAID use, as one study suggests this may retard radiographic progression 1
• Given the osteopenia, use a COX-2 selective NSAID or add gastroprotection to reduce GI bleeding risk 1

Escalation if NSAIDs Insufficient

• If peripheral arthritis is present, consider sulfasalazine (though no evidence for axial disease) 1
• For persistently high disease activity despite NSAIDs and physical therapy, consider TNF inhibitor therapy (infliximab, adalimumab, or etanercept) 1, 3
• TNF inhibitors show 50% improvement in approximately 50% of refractory patients, with 72% response rate in disease duration <10 years 1
• No need for mandatory DMARD trial before TNF inhibitors for axial disease 1

Surgical Considerations (Generally NOT Recommended)

Spinal Osteotomy

• Conditionally recommend AGAINST elective spinal osteotomy for severe kyphosis 1, 2
• This carries 4% perioperative mortality and 5% permanent neurologic sequelae risk 2
• Only consider in highly selected patients with severe kyphosis causing major physical and psychological impairments, and only at specialized centers 2, 4, 5, 6
• The main deformity location (hip, lumbar, thoracic, or cervical) must be precisely identified before any correction 7

Common Pitfalls to Avoid

• Do not restrict DXA to hips only - spine scanning is essential despite potential artifact from syndesmophytes 1
• Do not use methotrexate or other conventional DMARDs for axial disease - there is no evidence of efficacy 1
• Do not use systemic corticosteroids for axial disease - not supported by evidence (local injections for peripheral manifestations are acceptable) 1
• Do not delay physical therapy - it should begin immediately regardless of pharmacological treatment decisions 1