Ask the Expert: Focus on Ankylosing Spondylitis
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: 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.
Dr. Borenstein: Peripheral neuropathy and polyneuropathy are not usually associated with spondyloarthritis. On occasion, patients with ankylosing spondylitis have pseudosciatica. Pseudoscitastica mimics the nerve findings associated with a herniated disc. However, in AS, the pain down the leg is caused by irritation of the piriformis muscle that attaches to the sacroiliac joint that is inflamed with sacroiliitis. The irritated muscle contracts over the sciatic nerve that runs under the muscle. Patients experience pain that radiates down the leg in a line. Decrease in sacroiliitis usually resolves the leg pain. Peripheral neuropathy starts distally in the hands and feet and moves toward the central body. This is a different kind of problem.
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.
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.
Question: I have been prescribed Dilaudid for my neck and low back pain but it is not relieving my pain. I have also been diagnosed with a fracture of L5. What kind of medicine can be used as a replacement?
Dr. Borenstein: The answer to this question is complicated because the question involves two different problems. The first involves the use of chronic opioids for back pain and whether they remain effective. The second involves treatment of a fracture.
In general, opioids, like Dilaudid, have not proven to be as good at relieving pain as initially thought. These drugs are only partially effective and tend to lose their potency over time. Many patients experience no difference in pain intensity when opioids are tapered. Individuals who take opioids chronically are physically dependent on the agents independent of their analgesic effects. The amount of opioid needs to be gradually reduced to prevent withdrawal symptoms. Other general categories of drugs that may be helpful include nonsteroidal anti-inflammatory agents and anti-depressants.
A fracture of a L5 vertebral body may occur for a number of reasons, but osteoporosis is a prime candidate. If that is the case, a number of treatments are available that treat bone loss and can reverse the pain associated with a fracture. A rheumatologist or endocrinologist can help with the therapy of osteoporosis.
Dr. Borenstein: Surgical therapy for a fused spine is limited to those individuals who have severe curvature (kyphosis) such that they cannot look up. In those patients, an osteotomy, a procedure where a wedge of the fused spine is removed and the spine reattached so that the curve is reduced. Otherwise, no other procedure is available that reestablishes motion of the spine.
There are data to suggest that nonsteroidal anti-inflammatory drugs may be useful in preventing calcification of the spine in patients with spondyloarthritis. Two nonsteroidal drugs, ibuprofen and naproxen, are available in over the counter forms. These drugs have pain relieving properties and are anti-inflammatory. These drugs are less expensive than biologic agents.
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.