Loin and low back pain

A 50 year old male bricklayer presented to the emergency department with a five day history of pain in his left loin. He had a history of irritable bowel disease and low back pain. Acute renal colic was suspected and an intravenous urogram examination was performed (figure 1).

Thirty minute film from intravenous urogram

Questions

(1) What are the key findings from the intravenous urogram^{fig 1}?

(2) What is the most likely incidental diagnosis?

(3) How would this condition manifest clinically?

(4) State three extra-articular manifestations of this disease.

(5) How do the clinical features differ between men and women?

Answers

(1) Arrow A points to dye in the ureter, suggesting a left pelviureteric obstruction at the vesicoureteric junction. Arrow B points to the bridging of adjacent vertebral bodies by the formation of vertically orientated syndesmophytes, “bamboo spine.” These changes normally begin in the thoracolumbar and lumbosacral junctions.^w1-w5 The arrows C point to bilateral sacroiliitis, which begins with loss of definition of the cortical margin and is followed by erosions and joint widening then fusion and sclerosis. Abnormalities are initially asymmetric but become bilateral late in the disease process.^{w4 w5} The range of pathologies seen on this intravenous urogram show the importance of examining the whole radiograph, not simply focusing on one specific part of the film.

(2) Ankylosing spondylitis.

(3) Initially, the patient may complain of a dull ache, deep in the buttock or lower lumbar region. As the disease progresses he or she will experience morning stiffness that lasts several hours, improving with activity but returning after periods of immobility. Increased curvature of the thoracic and cervical spine is characteristic. In some cases this is so severe as to prevent the patient from being able to look straight ahead. This is accompanied by loss of expansion of the chest cavity. Arthritis can occur in peripheral joints, is asymmetrical, and predominantly affects large joints. Hip involvement will in time lead to fixed flexion deformity. Thirty per cent of patients with ankylosing spondylitis will develop an enthesis, inflammation at the junction of tendon or ligament to bone.^w1-w3

(4) Acute anterior uveitis; irritable bowel disease; IgA nephropathy; amyloidosis; pulmonary fibrosis of the upper lobes; and heart disease, especially aortic regurgitation.^{w2 w3}

(5) In men the spine and pelvis are most commonly affected with some involvement in the chest wall, shoulders, hips, and feet. In women ankylosing spondylitis tends to have less severe spinal involvement, with more symptoms in the hips, pelvis, knees, ankles, and wrists.^{w2 w3}

Discussion

Ankylosing spondylitis is the most common seronegative spondyloarthropathy. Seronegative spondyloarthropathies are a group of conditions that affect both the spine and peripheral joints and are linked to the type I human leukocyte antigen HLA-B27. They are called seronegative because no rheumatoid factors are produced. Other seronegative spondyloarthropathies include psoriatic arthritis, reactive arthritis, and enteropathic arthritis.

Patients with a definite diagnosis of ankylosing spondylitis face a lifetime of progressive structural deterioration associated with pain and functional disability, which contribute to substantial socioeconomic loss and reduced quality of life.

Epidemiology

Information about the incidence and prevalence of ankylosing spondylitis is sparse, but there seems to be wide geographic variation. It is commonly thought that in white populations the prevalence of ankylosing spondylitis is 0.1%-2%.^w6 Its frequency roughly parallels the prevalence of HLA-B27, with ankylosing spondylitis developing in 1%-2% of people with HLA-B27. It has been estimated that in the population of patients with ankylosing spondylitis, 65%-85% are men. Onset of symptoms normally occurs between the age of 15 and 35.^{w2 w3 w7}

Diagnosis

The principal clinical features are outlined in the answer to question 3. Examination of the lumbar spine shows restricted flexion in all three planes, most markedly in lateral flexion. Schober’s test is used to measure forward flexion. This test involves marking 10 cm above and 5 cm below the dimples of Venus while the patient is standing. In health the distance between these two marks increases from 15 cm to at least 22 cm on forward flexion. In ankylosing spondylitis, however, when the patient tries to bend forwards the distance between these two marks is less than 7 cm.^w4 Pain in the sacroiliac joints can be elicited with direct pressure or movement.

The characteristic posture of a patient with severe, untreated disease is that of loss of lumbar lordosis, buttock atrophy, and an exaggerated thoracic kyphosis with a stooped forward neck—the “question mark posture,” a common spot diagnosis in clinical exams.

Treatment

Treatment is most effective when a diagnosis has been made early, and a regimen of exercises started before syndesmophytes have the chance to form. Successful treatment options are intense early morning exercises and hydrotherapy, regular doses of non-steroidal anti-inflammatory drugs to reduce inflammation and pain and allow effective exercising; sulphasalazine or methotrexate for persistant peripheral joint disease; and intra-articular steroids for localised peripheral synovitis.^{w2 w3 w8 w9}

Cervical osteotomies are performed for patients who are unable to look straight ahead. It is also important to treat extra-articular manifestations—for example, uveitis—with topical corticosteroids. Antitumour necrosis factor shows promise for ankylosing spondylitis that resists conventional treatment.^{w8 w9}

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent: Obtained.

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2. Khan, M.A. Ankylosing spondylitis: introductory comments on its diagnosis and treatment. Ann Rheum Dis 2002; 61 (Suppl III):iii3-iii7.
3. Sieper, J., Braun, J., Rudwaleit, et al. Ankylosing spondylitis: an overview. Ann Rheum Dis 2002; 61 (Suppl III):iii8-iii18.
4. Orthopaedic Radiology: A Practical Approach. Third Ed. 1995. Adam Greenspan. Lippincott Williams and Wilkins.
5. Orthopaedic Radiology: Pattern recognition and differential diagnosis. Second Ed. 1998. Peter Renton. Martin Dunitz.
6. Alamanos, Y., Papadopoules, N.G., Voulgari, P.V., et al. Epidemiology of ankylosing spondylitis in Northwest Greece, 1983-2002. Rheum 2004;43:615-618.
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8. J Zochling, D van der Heijde, R Burgos-Vargas, et al. ASAS/EULAR recommendations for the management of ankylosing spondylitis, 2006. Ann Rheum Dis; 65: 442 - 452.
9. NHS review: http://www.nelm.nhs.uk/Record%20Viewing/viewRecord.aspx?id=584658

      

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