What Are the Treatments for Arthritis In the Spine?

Spinal arthritis (Spondyloarthritis, SpA), also known as seronegative spondyloarthropathies or spondyloarthropathies (SpAs), is a group of chronic inflammatory rheumatic diseases with specific pathophysiology, clinical, Radiological and genetic characteristics, inflammatory low back pain with or without peripheral arthritis, and certain features of extra-articular manifestations are unique symptoms and signs of this disease. The clinical manifestations of this type of disease vary greatly. Some patients have repeated and continuous progress, and some have been relatively static for a long time, and can work and live normally. Several spinal arthritis conditions gradually progress, and they may develop into typical ankylosing spondylitis, and after treatment, the condition may be controlled. Onset

Liang Dongfeng

(Deputy Chief Physician)

Department of Rheumatology, General Hospital of PLA (301 Hospital)

Western Medicine Name: Spinal arthritis
English name: spondyloarthritis, SpA

Other name: Sero-negative spondyloarthropathy, spinal arthropathy
Affiliated Department: Internal Medicine-Department of Immunology

Introduction to Spinal Arthritis Diseases

Spinal arthritis (Spondyloarthritis, SpA), also known as seronegative spondyloarthropathies or spondyloarthropathies (SpAs), is a group of chronic inflammatory rheumatic diseases with specific pathophysiology, clinical, Radiological and genetic characteristics, inflammatory low back pain with or without peripheral arthritis, and certain features of extra-articular manifestations are unique symptoms and signs of this disease. This type of disease includes: ankylosing spondylitis (AS), reactive arthritis (ReA), psoriatic arthritis (PsA), and inflammatory bowel disease arthritis (arthropathy of inflammatory bowel disease (IBD), undifferentiated spinal arthritis and juvenile chronic arthritis. Reiter's syndrome (RS) is synonymous with reactive arthritis and is now rarely used. This kind of disease often occurs in young and middle-aged people. Except that there is no gender difference in the incidence of psoriatic arthritis, there are more men than women in several other diseases.

There is a strong correlation between spinal arthritis and the HLA-B27 gene, which makes the concept well unified. The true concept of sero-negative spondyloarthropathy was clarified by Wright et al. More than ten years ago. The term "sero-negative spondyloarthropathy" is used to describe a related class of heterogeneous diseases that share many of the same clinical, radiological, and serological characteristics, as well as familial and genetic relationships. These diseases initially included ankylosing spondylitis, reactive arthritis, Wright syndrome, ulcerative colitis and Crohn's disease-related joint disease, Whipple disease, and Behcet's disease. These diseases have many differences and similarities, including rheumatoid factor negative, no subcutaneous nodules, radiographic sacroiliitis with or without inflammatory peripheral arthritis, and familial aggregation ^[2] .

Causes of spinal arthritis

B27 antigen is significantly increased in all diseases including spinal arthritis. Studies have confirmed that ankylosing spondylitis and reactive arthritis have similar B27 antigen frequencies. Periarthritis of inflammatory bowel disease is evidence of extraintestinal involvement, but B27 antigen expression does not increase. However, 75% of patients with inflammatory bowel disease with spondylitis are associated with the B27 antigen. These findings suggest that the pathogenesis of inflammatory bowel arthritis arthropathy is similar to that of ankylosing spondylitis. Patients with inflammatory bowel disease carrying HLA-B27 are at a higher risk of developing ankylosing spondylitis. The incidence of HLA-B27 did not increase in patients with psoriasis alone, and there was no evidence of increased B27 in patients with peripheral psoriatic arthritis, but 45% of psoriatic spondylitis has the B27 antigen, but it is associated with ankylosing spondylitis The correlation between arthritis and B27 antigen was significantly reduced. Nevertheless, these studies confirm that psoriatic arthritis should be included in spinal arthritis. These data suggest that other factors must play a role in inflammatory arthritis of the spine. Certain forms of juvenile-onset chronic arthritis should also be included in the category of spinal arthritis. Children with oligoarthropathy have a higher B27 frequency. However, Whipple's disease and Behcet's disease are no longer included in spinal arthritis due to lack of correlation with HLA-B27 and other characteristics.

HLA-B27 positive homozygous twins have different onsets and 10% of patients with ankylosing spondylitis do not carry HLA-B27, indicating that environmental factors are also important. Among non-genetic pathogenic factors, there are more infections. In the study of HLA-B27 transgenic mice, it was also found that transgenic mice live in a sterile environment and do not develop ankylosing spondylitis, suggesting that environmental factors are an indispensable condition for HLA-B27 related diseases. However, although many studies have shown that ankylosing spondylitis is associated with infection, so far, there is no conclusive evidence that the initiation of ankylosing spondylitis is related to pathogenic bacteria, and the role of microorganisms in ankylosing spondylitis is unknown. Tumor necrosis factor- (TNF-), a cytokine acting through two tumor necrosis factor receptors (TNFR1 and TNFR2), may be related to the pathogenesis of ankylosing spondylitis. Immunohistochemical analysis found that TNF- is an important cytokine that mediates inflammation in sacroiliac joints in patients with ankylosing spondylitis, which has also led to the first clinical trials of TNF inhibitors for ankylosing spondylitis ^[3] .

Pathological manifestations of spinal arthritis

The inflammatory process of spinal arthritis occurs at the starting and ending points where the ligaments attach to the bone, which is different from rheumatoid arthritis with much clinical and radiological evidence. The main targets of the initial inflammatory process of spinal arthritis appear at the starting and ending points, cartilage and a small range of synovium. With the formation of new bone on fibrous scar tissue, the inflammatory process has a tendency to heal itself, leading to joint stiffness and moderate Irreversible ossification of shafts and peripheral joints ^[4] .

Clinical manifestations of spinal arthritis

Axial involvement in spinal arthritis

In spinal arthritis, ankylosing spondylitis and psoriatic arthritis are mainly affected by the central axis. The broad range of the mid-axis should refer to the pelvis to the cervical spine, including the hip joint; the narrow-axis involvement mainly refers to the cervical, thoracic, lumbar, and sacroiliac joints. Axial spondylitis includes bone joints, ligament tendons, and attachment points.

Axial involvement includes early and late stages, with early manifestations of inflammatory low back pain, but no manifestations of sacroiliitis on the radiation. These patients are usually clinically easily missed or misdiagnosed. Advanced clinical manifestations are very obvious, including sacroiliitis, partial or full spine involvement, changes in patient's body shape, limited movement, and imaging changes, which are easily diagnosed clinically, but even if they are correctly diagnosed clinically, their treatment is often missed The optimal treatment period has been reached, or the patient has developed limited function or disability. Therefore, attention should be paid to the diagnosis and treatment of early axis involvement in ankylosing spondylitis, so as to control the disease as soon as possible ^[5] .

(1) Alternating hip pain

This is the most common early symptom in patients with ankylosing spondylitis. It is manifested as pain in one side of the hip or hip, which is more obvious. In severe cases, it can cause hip movements to be restricted and dare not walk. After a period of treatment, it can be improved, but it can be recurrent and bilateral attacks can occur. Because the sacroiliac joint is located deep in the buttocks, these symptoms are caused by sacroiliac joints or hip arthritis. Although hip pain may occur in patients with ankylosing spondylitis and patients with mechanical low back pain, patients with ankylosing spondylitis are more specific in that the onset of hip pain on one side first, and gradually alternating hip pain.

(2) Inflammatory low back pain

Low back pain in patients with spinal arthritis often develops insidiously, starting at the waist and hip area and gradually progressing to the back. It is usually noticeable in the middle of the night and is accompanied by a noticeable stiffness, which can cause difficulty turning over at night. When getting up, the waist and back are obviously stiff and need to be improved after exercise. The duration of this morning stiffness is related to the severity of the patient's condition, which can be relieved for several minutes, and the severe not only lasts for hours or even throughout the day. This inflammatory low back pain is an external manifestation of spinal minor arthritis and attachment point inflammation. Inflammatory low back pain is one of the most hallmark features of ankylosing spondylitis, and it is a powerful tool for screening and identifying those patients with chronic low back pain as spinal arthritis with axial involvement. The following 5 parameters can better explain inflammatory low back pain, including: improvement in symptoms after exercise; night pain; occult onset; onset before the age of 40; symptoms did not improve after rest. If the patient has chronic low back pain> 3 months and meets at least 4 of the 5 above, then it is considered inflammatory low back pain.

(3) Anterior chest wall pain

Patients with spinal arthritis often experience pain around the anterior chest wall. In severe cases, sternoclavicular joints may swell. This is due to the sternal joints, sternoclavicular joints, and costo-thoracic arthritis. The inflammation gradually develops, which can lead to a decrease in the thoracic activity of patients. Therefore, most of the diagnostic criteria for ankylosing spondylitis include limited chest expansion.

(4) Spinal rigidity

Ankylosing spondylitis and psoriatic arthritis spondylosis can occur in the late stages of the disease. Mainly due to the ossification of the vertebral ligaments, vertebra ribs, and thoracocostal joints, often resulting in impaired spinal mobility and increased risk of fractures. In the late stage of ankylosing spondylitis, extensive calcification of paravertebral soft tissues and sclerosis of ligaments or bands can be seen. Bone erosion of the vertebral body often leads to bone hyperplasia across the edge of the intervertebral disc. It is called ligament osteophyte and is a disc fibrous ring. The manifestation of ossification itself, after the formation of extensive ligament osteophytes, presents a typical "bamboo spine". Psoriatic arthritis and spondylosis often manifest as asymmetric ligament osteophyte formation and paravertebral ossification, which is characterized by ossification of the ligaments between the middle parts of adjacent vertebral bodies to form ossicle bridges, which are asymmetrically distributed.

Spinal arthritis peripheral joint involvement

Spinal arthritis affects the axial (spine) joints, and peripheral joint involvement is also common. Peripheral joints in the general sense, including all joints except the spine (axial axis joints), whether the shoulder and hip joints of patients with ankylosing spondylitis belong to peripheral or axial joints, there are still many disputes. Many patients with spinal arthritis first experience peripheral joint swelling and pain during the course of the disease, and back pain symptoms occur after several years. These patients are easily misdiagnosed as other types of arthritis and cannot be treated in a timely and correct manner, which delays the treatment of patients. And even cause disability for patients. The incidence of spinal arthritis peripheral joints is related to the age of the patient, showing that the younger the age of onset, the more obvious the peripheral joint involvement, and the higher the disability ^[6] .

The main features of peripheral joint involvement in ankylosing spondylitis are: lower extremity joints (knee, ankle joints) are more than upper extremity joints, single / oligo-joint involvement is more than multi-joint involvement, asymmetry is more than symmetry. Unlike rheumatoid arthritis, in addition to the hip joint, the symptoms of arthritis or joint pain in the knee and other joints are mostly intermittent and clinical symptoms are mild. X-ray examination is mainly based on swelling of the soft tissue around the joint, and rarely Radiographic evidence of bone destruction can be found. Arthroscopes can often see different degrees of synovial hyperplasia and inflammatory exudation, and there are few or rare serious consequences of bone erosion, destruction and joint destruction of affected joints.

Psoriatic arthritis can affect the interphalangeal joints of the distal hand, which is different from rheumatoid arthritis, which often involves the interphalangeal joints of the proximal hand. The joint involvement is sometimes heavier, and rheumatoid arthritis-like bone can appear. Erosion and destruction are different from other types of spinal arthritis ^[7] .

Spinal arthritis

Attachment inflammation is a characteristic lesion of spinal arthritis, and other diseases rarely occur. In the spine, attachment point inflammation can be seen in the attachment of the bursa and ligaments, but also in the intervertebral discs, costal joints, and transcostal process joints. The pain, stiffness, and limited mobility of the spinal joints are mostly from attachment points. Attachment inflammation also affects many external positions of the central axis, showing local swelling and pain at the corresponding site. Common sites are: heel (including the heel or Achilles tendon), local swelling and pain around the knee joint, ischial tuberosity, sacral Anterior epicondyle, pubic symphysis, and rib cartilage junction ^[8] .

Spinal arthritis skin and mucosa involvement

As a chronic systemic inflammatory disease, spinal arthritis is often accompanied by skin and mucosal involvement ^[9] .

(1) Psoriasis: Psoriasis rash occurs more often than psoriatic arthritis, and a few patients first develop arthritis and then rash. Skin psoriasis is common in the scalp and the extremities of the extremities, especially in the elbow and knee areas, with a sporadic or widespread distribution. Pay special attention to hidden areas such as hair, perineum, buttocks, and umbilical cords; rash manifestations are Pimples or plaques are round or irregular, with rich silvery white scales on the surface. After the scales are removed, there is a shiny film. The removal of the film can show spotted bleeding. This feature has diagnostic significance for psoriasis. The existence of psoriasis is an important difference from other inflammatory arthritis. There is no direct relationship between the severity of skin lesions and the severity of arthritis, only 35% are related. ^[10]

(2) Nail lesions : About 80% of patients with psoriatic arthritis have finger (toe) nail lesions, while those without arthritis have only 20% of finger (toe) nail lesions, so finger (toe) ) Nail lesions are characteristic of psoriatic arthritis. Common manifestations are thimble-like depressions, and multiple depressions in the nails of the distal interphalangeal joints that are inflammations are characteristic changes of psoriatic arthritis. Others have thickened decks, turbidity, black or white nails, uneven surfaces, horizontal grooves and mediastinums, and often horny hyperplasia of the nails. In severe cases, there may be nail stripping and sometimes spoon-shaped nails.

(3) Purulent skin keratosis: Purulent skin keratosis is excessive keratosis of the diseased skin. Skin lesions begin to appear as vesicles on the basis of erythema, and then develop into macular rash, pimples, and nodules. They are usually non-tender and can fuse into clusters. After ulceration, the skin keratinizes to form a thick palate. It is mainly distributed on the soles of the feet and can also occur in the palms and scrotum. The appearance of lesion rash is often difficult to distinguish from psoriasis rash. In addition, patients often have finger and toe deck lesions, such as thickened and turbid nails, malnutrition, hyperkeratosis under the nails, and even nails fall off.

(4) Nodular erythema: Nodular erythema is a kind of acute red or purplish painful inflammatory nodule that is easy to occur in the extensor side of the calf. The skin lesions suddenly occur, generally bilaterally symmetrical, from broad beans to walnuts. They range in size from 10 or more, with conscious pain or tenderness, and moderate hardness. After 3 to 4 weeks, the nodules gradually subsided, leaving temporary pigmentation. This skin lesion can also be seen in the thighs, the upper arm extension, etc. ^[11] .

(5) Conjunctivitis: Conjunctivitis is the most common ocular complication of reactive arthritis. It is rare in other types of spinal arthritis. Patients usually present with unilateral or bilateral involvement, congestion and tearing of the eyes, and papillary protrusions of mucopurulent secretions with conjunctival surface. This is easily related to other types of infectious conjunctivitis or "red eye disease". Confusion, symptoms usually resolve in 2-7 days.

(6) Whirl-shaped balanitis: usually refers to the painless superficial wet ulcers appearing near the glans and urethra. The surface is moist and starts to be small blisters. The symptoms of peripheral hyperemia are not obvious. Occasionally, superficial ulcers can fuse into The lameness is patchy, covering the entire glans, with obvious redness and insignificant tenderness. Sometimes the inside of the foreskin, the penis, and the scrotum can be affected. More common in patients with reactive arthritis.

(7) Oral ulcers: Superficial ulcers mainly appearing on the buccal mucosa and tongue. The initial stage is small blister. The divisions are in the upper jaw, gums, tongue and cheeks. The course is transient, and usually there is no discomfort such as pain. Symptoms are easily overlooked. It is more common in patients with reactive arthritis and spinal arthritis with intestinal disease.

(8) Enteritis: Arthritis associated with ulcerative colitis and Crohn's disease is called inflammatory bowel disease arthritis. And about 6% of patients with ankylosing spondylitis have intestinal mucosal inflammation visible to the naked eye or under the microscope. Inflammation sites are mainly distributed in the ileum, and occasionally microscopic colitis has been reported.

Other manifestations of spinal arthritis

(1) Systemic symptoms: Reactive arthritis often has moderate to high fever, while other types of spinal arthritis often have low to moderate fever when the disease is severe. Weight loss, anemia, and general weakness are more common in more severe conditions.

(2) Other organ involvement manifestations: uveitis is the most common eye damage associated with spinal arthritis. It is reported in the literature that uveitis can occur in about 25% of patients. Common manifestations of heart involvement in ankylosing spondylitis include heart valve dysfunction (aortic and mitral regurgitation), varying degrees of cardiac conduction system dysfunction, and left ventricular dysfunction. Due to rigidity of the thoracic spine, inflammation of the thoracic spine and thoracic rib joint, the expansion of the thorax is limited. The most common pulmonary pleural involvement of ankylosing spondylitis is fibrotic lesions in both upper lungs, with an incidence of 1.3% to 30%. Spinal fractures are not uncommon in advanced ankylosing spondylitis. The most common renal disease in ankylosing spondylitis is secondary amyloidosis. IgA nephropathy is uncommon in ankylosing spondylitis. Other common renal manifestations include mesangial proliferative glomerulonephritis ^[12] .

Spinal arthritis auxiliary examination

Spinal Arthritis Laboratory Examination

The rate of HLA-B27 gene positive in patients with ankylosing spondylitis is 90% to 95%, but only about 10% of people with HLA-B27 positive in the population have ankylosing spondylitis. Therefore, although the HLA-B27 test for ankylosing spondylitis It is highly specific and sensitive, but the HLA-B27 test results can neither be used as a diagnostic basis, nor can it predict the prognosis of patients, and can only increase the possibility of diagnosis.

Active patients can see rapid erythrocyte sedimentation (ESR), increased C-reactive protein (CRP), thrombocytosis, and mild anemia. Rheumatoid factor (RF) negative and mildly elevated immunoglobulins.

XCTMRI Spinal arthritis imaging examination: X-ray, CT, MRI

X-ray findings have diagnostic significance for ankylosing spondylitis. The earliest changes in ankylosing spondylitis occur in the sacroiliac joints. The X-ray film showed blur of the subchondral bone margin, bone erosion, blurred joint space, increased bone density and joint fusion. Usually based on the X-ray film, the severity of sacroiliitis is divided into 5 grades: 0 is normal; grade is suspicious; grade has mild sacroiliitis; grade has moderate sacroiliitis; grade is joints Fusion rigidity. Figure 1 shows sacroiliac joint III lesions.

For patients with clinical suspicious cases whose X-rays have not shown definite or grade or more changes in bilateral sacral arthritis, computed tomography (CT) should be used. The advantage of this technique is also that it has fewer false positives. However, because the upper part of the sacroiliac joint anatomy is a ligament, the imaging of the joint space is irregular and widened due to its attachment, which makes it difficult to judge. In addition, aging under the cartilage similar to the joint space stenosis and erosion of the sacroiliac joint is a natural phenomenon and should not be regarded as abnormal. See Figure 2.

Magnetic resonance imaging (MRI) is better than CT for judging sacral arthritis and spinal inflammation. Only MRI can show ankylosing spondylitis and sacral arthritis grade 0 lesions. The advantage of MRI is to observe ankylosing spondylitis. The morphology and signal of sacroiliac joint cartilage and articular surface bone change to achieve the purpose of early detection and diagnosis of ankylosing spondylitis. See Figure 3.

X-rays of the spine showed vertebral osteoporosis and square deformation, blurred vertebral facet joints, calcification of paravertebral ligaments, and formation of bone bridges. The extensive and severe ossification of the osteoporotic bridge in the late stage is called a "bamboo-like spine", as shown in Figure 4. Bone erosions of the pubic symphysis, ischial tuberosity, and tendon attachment points (such as the calcaneus), with reactive sclerosis and villous changes in adjacent bones, can cause new bone formation. These are mainly radiological manifestations of attachment point inflammation. Symptoms of sacral arthritis can (or do not) occur in patients with spinal arthritis.

The discovery of sacroiliitis has an important role in the imaging diagnosis of ankylosing spondylitis. Therefore, X-ray sacroiliac joint orthopedics and lumbar spine orthotopic radiographs should be the first choice in clinical practice; and chest orthopedics should be selected according to different clinical manifestations. X-ray examination of the bit film or other related parts. However, since sacroiliitis is often found months to years after the onset of ankylosing spondylitis, positive X-ray signs can be found. It may take up to 3 years after the onset of ossification of the ligaments. Therefore, X-rays should be used for suspicious cases. After the examination, a high-resolution CT scan or MRI of the sacroiliac joint can be selected, and a lumbar MRI can be performed at the same time. At present, for the detection of early sacroiliac joint lesions, high-resolution CT or MR scanning is usually used.

Spinal arthritis musculoskeletal ultrasound

Musculoskeletal ultrasound has gradually become a powerful imaging method for the evaluation of inflammatory arthritis, judging spondylitis, tendinitis, synovitis, bursitis and cysts, bone and cartilage lesions, and activity on spinal arthritis Sex, prognosis and treatment effects have their unique advantages.

Spinal Arthritis Diagnosis

(1) In 1991, the European Spine and Arthropathy Research Group (ESSG) proposed a set of classification criteria suitable for the entire group of spinal arthritis. Although these standards are not for clinical diagnosis, they are useful for identifying atypical or undifferentiated spinal joint There is indeed some clinical guiding significance on inflammation. The ESSG standard focuses on two main features of spinal arthritis: inflammatory low back pain and asymmetric oligoarthritis. If combined with another condition, it can be diagnosed as spinal arthritis ^[13] .

ESSG Spinal arthritis ESSG classification criteria

Inflammatory spinal pain or synovitis (asymmetric or predominantly lower extremity joints) plus at least one of the following:

Positive family history

psoriasis

Inflammatory bowel disease

Urethritis, cervicitis or acute diarrhea

Alternating gluteal pain

Tendon attachment

Sacroiliitis

(2) In 2004, the International Association for the Evaluation of Spinal Arthritis (ASAS) initiated an international collaboration to develop criteria for the classification of axial and peripheral spinal arthritis, and completed the criteria for axial spinal arthritis in 2009. The X-ray arthritis required by the revised New York standard in this standard is only a part of imaging arthritis and is not a necessary condition. Arthritis is also an important reference indicator. It also combines clinical manifestations (such as inflammatory low back pain, arthritis, Achilles tendinitis, etc.) and laboratory tests (HLA-B27 and CRP), which is even more beneficial. For the diagnosis of early diseases.

a) ASAS Classification Standard for Axial Spinal Arthritis (Applicable to patients with chronic low back pain, the age of onset is less than 45 years old)

Radiology of sacroiliitis with at least 1 feature of spinal arthritis or HLA-B27 positive plus at least 2 other features of spinal arthritis

Features of spinal arthritis : inflammatory low back pain; arthritis; Achilles tendinitis; uveitis; acrophysitis; psoriasis; Crohn's disease / colitis; effective treatment of NSAIDS; family history of spinal arthritis; HLA- B27 positive; CRP increased;

Radiographic sacroiliitis : Active (acute) inflammation revealed by MRI is highly suggestive of sacroiliitis associated with spinal arthritis; X-rays show clear sacroiliitis in compliance with revised New York standards.

Arthritis or tendinitis or finger (toe) inflammation
with
1 clinical features of spinal arthritis
Uveitis	arthritis
psoriasis	Tendonitis
Crohn's disease / colitis	Finger (toe) inflammation
Previous infection history	Inflammatory back pain (history)
HLA-B27	Family history of spinal arthritis
Sacroiliitis

Differential diagnosis of spinal arthritis

Spinal arthritis rheumatoid arthritis

In the early stage of ankylosing spondylitis, it is particularly necessary to distinguish from rheumatoid arthritis when only peripheral arthritis is the main manifestation. Ankylosing spondylitis occurs more frequently in men than in women with rheumatoid arthritis. Ankylosing spondylitis involves the sacroiliac joint without exception, and rheumatoid arthritis rarely has sacroiliac joint disease. Ankylosing spondylitis involves the entire spine from the bottom up, while rheumatoid arthritis only invades the cervical spine. Periarthritis is ankylosing spondylitis with a small number of joints, asymmetry, and the lower extremity joints are predominant, often accompanied by tendonitis; in rheumatoid arthritis, it is multi-joint, symmetrical, and limb size Onset. Ankylosing spondylitis has no rheumatoid nodules visible in rheumatoid arthritis. Ankylosing spondylitis is negative for rheumatoid factor, while the positive rate of rheumatoid arthritis accounts for 60% ~ 95%. Ankylosing spondylitis is mostly HLA-B27 positive, while rheumatoid arthritis is related to HLA-DR4 ^[14] .

Spinal arthritis gouty arthritis

Some patients with this disease have a longer duration of lower extremity arthritis, and sometimes the blood uric acid does not increase during the onset of disease. At this time, it is often necessary to distinguish it from peripheral arthritis caused by ankylosing spondylitis. At this time, the clinical characteristics of the two diseases need to be carefully identified.

Spinal arthritis non-specific low back pain

This kind of low back pain patients are the most common clinically. Such diseases include lumbar muscle strain, lumbar spasm, spinal osteoarthritis, cold irritating low back pain, etc. Such low back pain diseases do not have an inflammatory waist with ankylosing spondylitis. Back pain characteristics can be easily identified by sacroiliac joint X-ray or CT examination and related tests such as red blood cell sedimentation rate and C-reactive protein.

Spinal arthritis lumbar disc herniation

Intervertebral disc herniation is one of the common causes of inflammatory low back pain. The disease is confined to the spine and has no systemic manifestations such as fatigue, weight loss, and fever. All laboratory tests, including erythrocyte sedimentation, are normal. The main difference between it and ankylosing spondylitis can be confirmed by CT, MRI or spinal angiography ^[15] .

Spinal arthritis patella compact osteitis

More common in young women, the main manifestations of chronic lumbosacral pain and stiffness. There were no abnormalities in the clinical examination except for lumbar muscle tension. The diagnosis is mainly based on plain radiographs or CT of the sacroiliac joint. The typical manifestation is the obvious sclerosis area in the middle and lower two thirds of the sacroiliac joint along the sacroiliac joint. Invasion of the sacroiliac joint surface, no joint stenosis or erosion, so it is different from ankylosing spondylitis. The disease has no obvious characteristics of long sitting and lying pain, and it is not as effective as ankylosing spondylitis when receiving NSAIDs. Some female patients with early ankylosing spondylitis are difficult to distinguish from this disease. MRI of the sacroiliac joint may be helpful, but comprehensive clinical judgment is still needed. Follow-up observation is recommended for patients with difficult identification.

Spinal Arthritis Treatment

Non-drug treatment of spinal arthritis

Patients with ankylosing spondylitis and patients with spinal arthritis with peripheral joint disease should pay particular attention to rehabilitation exercises. Exercise with caution and uninterrupted exercise to achieve and maintain the best position of the spine joints, strengthen the paravertebral muscles and increase vital capacity. When standing, try to keep your chest, abdomen, and eyes straight ahead. The sitting position should also keep the chest upright. Should sleep on a relatively hard mattress, take a supine position to avoid the position of promoting deformity, pillows should not be too high. Reduce or avoid physical activity that causes persistent pain. Pain of inflammatory joints or other soft tissues is necessary for physical therapy.

Spinal arthritis general drug treatment

(1) Non -steroidal anti-inflammatory drugs ( NSAIDs ) ^[16]

NSAIDs can rapidly improve the pain and stiffness of the waist, hips and backs of patients, reduce joint swelling and pain, and increase the range of motion. The treatment of symptoms in patients with early or advanced spinal arthritis is the first choice. This class of drugs should not be simply understood as painkillers and their application ignored. This class of drugs has anti-inflammatory effects rather than simple pain relief. At present, patients with ankylosing spondylitis should not hesitate to full, as long as they have waist, hip and back pain The use of such drugs in the course of foot treatment should not endure pain in order to prevent side effects, otherwise long-term pain and stiffness can easily cause deformities such as spinal stiffness and kyphosis. The rapid onset of NSAIDs and the relief of symptoms are also a useful tool for the diagnosis of ankylosing spondylitis.

Because ankylosing spondylitis is mostly painful at night, the effect of applying such drugs before bed is most ideal. Among the adverse reactions of anti-inflammatory drugs are gastrointestinal upset, and a few can cause ulcers; others are headache, dizziness, liver and kidney damage, blood cell loss, edema, hypertension and allergic reactions. Physicians should choose an anti-inflammatory drug for each patient's specific situation. The simultaneous use of two or more anti-inflammatory drugs will not only increase the efficacy, but will also increase the adverse drug reactions and even bring serious consequences. Anti-inflammatory drugs usually need to be used for about 2 months. After the symptoms are completely controlled, reduce the dose and consolidate for a period of time with the minimum effective amount. Then consider stopping the drug. Stopping the drug too quickly may cause repeated symptoms. If the effect of a drug treatment is not obvious for 2 to 4 weeks, other different classes of anti-inflammatory drugs should be used instead. In the process of medication should always pay attention to monitoring adverse drug reactions and timely adjustments.

(2) glucocorticosteroid

Long-term oral treatment of glucocorticoids not only cannot prevent the development of the disease, but also brings more adverse reactions. Peripheral arthritis associated with this disease can be treated with long-acting corticosteroid injection. Repeat injections should be spaced 3 to 4 weeks apart, and generally not more than 2 to 3 times. For hip pain that cannot be controlled by other treatments, glucocorticoid sacroiliac joint injection under CT guidance can improve symptoms in some patients.

(3) sulfasalazine

The drug can improve joint pain, swelling and stiffness of spinal arthritis, and can reduce serum IgA levels and other laboratory activity indicators. It is particularly suitable for improving peripheral arthritis in patients with spinal arthritis and the pre-pigmentation of this disease Meningitis has the effect of preventing recurrence and reducing lesions. So far, there is no evidence for the therapeutic effect of the drug on the spinal arthritis's central axis joint disease and its effect on improving the prognosis of the disease. Usually the recommended dosage is 2.0 ~ 3.0g, which is taken orally in 2 ~ 3 times. This product has a slow onset of action, usually 4 to 6 weeks after administration. In order to increase the patient's tolerance, it usually starts with 0.25 g 3 times a day, and then increases by 0.25 g every week, or adjusts the dose and course of treatment according to the disease or the patient's response to the treatment, and maintains it for more than 1 year. In order to make up for the shortcomings of SSZ's slow onset and weak anti-inflammatory effect, a fast-acting non-steroidal anti-inflammatory drug is usually used in combination with it. Adverse reactions of this product include symptoms of digestive system, rash, decreased blood cells, headache, dizziness, and reduced sperm and morphological abnormalities in men (most of which can be recovered after withdrawal). Allergic to sulfa is prohibited.

(4) methotrexate (methotrexate, MTX)

MTX is widely used clinically to treat spinal arthritis. However, through comparative observation, this product has only an effect on peripheral arthritis, low back pain, stiffness and iritis, as well as the improvement of ESR and CRP levels, and there is no evidence of improvement in the radial joint disease. Usually 7.5mg ~ 15mg, individual severe patients can increase the dose, oral or injection, once a week as appropriate. At the same time, a non-steroidal anti-inflammatory drug can be used together. Although low-dose MTX has the advantage of fewer adverse reactions, its adverse effects are still a problem that must be paid attention to in treatment. These include gastrointestinal upset, liver damage, pulmonary interstitial inflammation and fibrosis, blood cell reduction, hair loss, headache, and dizziness. Therefore, regular blood tests, liver function, and other related items should be reviewed before and after administration.

(5) thalidomide

Domestic scutellaria and other observations observed that 30 patients with intractable male ankylosing spondylitis received thalidomide (200mg / d) for a one-year open trial. As a result, 26 patients completed the trial and found that the drug has a good effect on most patients. . At the same time, it was found that the transcription level of TNF-a in peripheral blood mononuclear cells was significantly reduced. However, this product has relatively many adverse reactions, such as drowsiness, dizziness, thirst, constipation, and increased dandruff. Rarely adverse reactions include decreased white blood cells, increased liver enzymes, microscopic hematuria, and numbness in the fingers. Those who choose this kind of treatment should be closely observed, blood and urine routine, liver and kidney function should be checked every 2 to 4 weeks in the initial period of medication. For long-term users, regular neurological examinations should be performed in order to detect possible peripheral neuritis in time. Taking this medicine in pregnant women can cause short limb deformities (seal fetuses) in the fetus. Therefore, this medicine should be contraindicated in pregnant women and patients who are planning to have children recently, including men. The initial dose is 50 mg / d, which is increased by 50 mg every 2 weeks, and maintained at 150 ~ 200 mg / d. It is useful to maintain 300 mg / d abroad . The medicine is prone to drowsiness and is suitable for taking at night.

(6) Leflunomide

This medicine has better curative effect on peripheral arthritis of ankylosing spondylitis. In addition, this medicine also has a better effect on other symptoms of ankylosing spondylitis, such as: irisitis, fever and so on. Treatment of extraspinal manifestations of ankylosing spondylitis. The drug is usually applied at a dose of 10 mg / d, and can be increased to 20 mg / d in severe cases. The most common side effect of the drug is liver damage. It is recommended to use liver protection drugs at the same time during the application of the drug, and liver function should be checked every 2 to 4 weeks at the beginning of the drug, and then every 3 to 6 months. Loss of appetite, pruritic rash (often seen after a long period of medication), weight loss, etc. can also occur during the treatment of this medicine.

Spinal Arthritis Biologics Treatment

(1) Overview ^[17]

The so-called biological agent is a monoclonal antibody or a recombinant product of a natural inhibitory molecule that selectively targets molecules or receptors involved in the immune response or inflammatory process. The biological agent targets the pathogenesis of rheumatism and is more effective than traditional immunosuppressive therapy. Specificity, the emergence of this class of drugs has brought spinal arthritis, rheumatoid arthritis and other rheumatic diseases into a new stage. More and more evidence and clinical practice have confirmed that anti-TNF- biologics have a good effect on spinal arthritis, and it has been found that the effect of this class of drugs on spinal arthritis is better than that of rheumatoid arthritis.

(2) Commonly used TNF- inhibitors

a) Etanercept is a fusion protein expressed in mammalian cell lines by connecting DNA encoding the soluble part of human TNF p75 receptor with DNA encoding human IgG1 Fc molecule. It can reversibly bind to TNF- and compete. Sexually inhibits the binding of TNF- to the TNF receptor site. The recommended usage is: 50 mg, subcutaneous injection, once a week or 25 mg, subcutaneous injection, twice a week. The two methods have similar effects on ankylosing spondylitis. There are three formulations of Yisaipu, Junker and Enbrel on the domestic market.

b) Adalimumab (Humira) is a fully humanized anti-TNF--specific IgG1 monoclonal antibody. It has been observed in vivo and in vitro that the drug binds to soluble TNF and inhibits TNF and cell surface. The TNF receptor binds to achieve its anti-TNF effect. The recommended usage is 40 mg subcutaneously, once every 2 weeks.

c) Infliximab (like g) is a human / mouse chimeric anti-TNF- specific IgG1 monoclonal antibody. The recommended usage for its treatment of ankylosing spondylitis is: 5 mg / kg, intravenous drip, the same dose is repeated in the second and sixth weeks after the first injection, and the same dose is injected every 6 weeks thereafter.

At present, the above three preparations have been approved by the US FDA and China SFDA for the treatment of ankylosing spondylitis. This kind of drugs has the characteristics of fast onset (several hours to 24 hours) and good curative effect. The condition of most patients can be quickly and significantly improved. After a period of application, the patient's physical function and health-related quality of life significantly improve, especially Can restore some of the newly appeared spinal disorders. However, its long-term efficacy and its effect on the X-ray changes of the central joint remain to be seen. After using this kind of preparation in sufficient amount for 2 to 3 months, the condition can be gradually extended, and NSAIDs and other anti-rheumatic drugs that improve the condition can be used at the same time. Many patients will not have a significant relapse.

(3) Adverse reactions of TNF- inhibitor

The use of such preparations can reduce the body's resistance to tuberculosis, so patients must be screened for tuberculosis infection before preparing for use, including asking if they have a history of tuberculosis, lung imaging, and pure tuberculin derivative Test (PPD test), TB-SPOT inspection can be performed by those with conditions. Close contact with patients with active tuberculosis should be avoided during the treatment with this class of drugs. If the patient has symptoms that indicate tuberculosis infection such as persistent cough, weight loss and fever, pay attention to whether there is a tuberculosis infection.

Such preparations may also cause other types of adverse reactions, including skin reactions at the injection site, increased risk of infection, exacerbation of disease activity or active hepatitis B in patients with recessive infection, exacerbation of congestive heart failure, and individual Patients with neuromyelinating lesions, etc. In addition, a small number of patients may have infusion reactions to infliximab, it is recommended that the drug should be closely observed when first using the drug.

Spinal arthritis arthroscopy

Entering the diseased joint through arthroscopy, using a rotary planer to remove the synovial tissue and aspirate it, can effectively alleviate the articular synovial inflammation of refractory spinal arthritis. The minimally invasive effect of arthroscopic operation significantly reduces the damage to the joints and surrounding tissues by traditional open surgery, which greatly shortens the postoperative recovery period for patients. Arthroscopy can also be used to examine articular cartilage and obtain synovial tissue.

Spinal Arthritis Surgical Treatment

For patients with ankylosing spondylitis with severe spinal forward flexion or scoliosis, which leads to obvious living disorders, such as walking can not see the road a few meters ahead, such patients can consider spine vertebral osteotomy to correct the deformity, but the risk of this type of surgery Larger, it may damage the spinal cord and cause paraplegia in the lower limbs. Therefore, it is not recommended to correct the deformity if the deformity is not very serious. Physical rehabilitation should be performed under active medical treatment, which can also slow down or inhibit the development of the deformity to a certain extent. For patients with apparently narrow hip joint space or necrotic deformation of the femoral head, in order to improve the joint function and quality of life of the patient, artificial total hip replacement can be considered. After replacement, the joint pain of most patients is controlled, and the function of some patients returns to normal or close to normal, and the life of the joint is 90% or more than 10 years.

Spinal arthritis psychotherapy

Patients with ankylosing spondylitis may experience anxiety, depression, and fear, and some patients may experience fatigue and alexithymia. A combination of physical therapy and psychological therapy should be used. Antidepressants may be used if necessary. .

Spinal arthritis prognosis

The clinical manifestations of this type of disease vary greatly. Some patients have repeated and continuous progress, and some have been relatively static for a long time, and can work and live normally. Several spinal arthritis conditions gradually progress, and they may develop into typical ankylosing spondylitis, and after treatment, the condition may be controlled. Younger onset, earlier hip involvement, recurrent iridocyclitis, delayed diagnosis, untimely and unreasonable treatment, and poor prognosis for those who do not adhere to long-term functional exercise. Although the prognosis of this disease has been greatly improved by the emergence of biological agents, this disease is still a chronic progressive disease and should be followed up for a long time under the guidance of a specialist ^[18] .