Inflammatory Back Pain

Most back pain is due to mechanical causes but a small number of people (between 1 and 2 in every 1000 people) will have inflammation of the spinal joints. This will always affect the sacroiliac joints, the joints that join the spine (sacrum) to the pelvis, but may also affect other parts of the spine. The most common cause of inflammation of the spine is Ankylosing Spondylitis but it can be associated with the skin rash psoriasis, inflammation of the bowel (Crohn's disease and ulcerative colitis) and as part of an arthritis that is a reaction to a recent infection.

Symptoms of Spinal Inflammation

  • Back pain associated with prolonged early morning spinal stiffness
  • Symptoms improved by exercise
  • Symptoms often starting in young people (20 - 30 years old)
  • Men significantly more frequently affected than women
  • Inflammation of the eye (uveitis) is a recognised complication
  • There may well be a family history as there is a strong genetic association with the gene HLAB27.

Investigations

X-rays of the spine and sacroiliac joints are usually normal unless patients have had symptoms for many years. An MRI scan is the investigation of choice for excluding or confirming the diagnosis in someone with suspicious symptoms.

Blood tests that measure inflammation (ESR and CRP) can be helpful but are not diagnostic.

Treatment

Patients with spinal inflammation should be referred to their local rheumatology department for specialist assessment and advice. Once the diagnosis is confirmed the priority is to maintain spinal function with daily exercise therapy, initially with a physiotherapist.

Pain control is usually best achieved with the use of anti-inflammatory drugs (often called non-steroidals or NSAIDs). The prolonged use of these drugs must be discussed with a patient's specialist or GP.

If patients fail to respond adequately to 2 different types of anti-inflammatory then they should be assessed for anti-TNF treatment as per NICE guidelines http://www.nice.org.uk/guidance/TA143

Further Reading & Resources

ARC - http://www.arc.org.uk/arthinfo/patpubs/6001/6001.asp

National AS Society (NASS) - http://www.nass.co.uk/

NHS Choice - http://www.nhs.uk/conditions/ankylosing-spondylitis/Pages/Introduction.aspx

NICE Guidance - http://www.nice.org.uk/guidance/TA143

Back Problems in Sport

Any condition affecting the spine may present in someone playing sport.

Regular exercise is an important part of the management of most if not all spinal problems and exercise and sport should be encouraged.

Certain sports may make some back conditions worse and if you are in any doubt you should seek expert advice from an experienced manual therapist (physiotherapist, osteopath, chiropractor) or sports medicine specialist.

If you need to have a back operation then you should discuss your sporting interests with your surgeon both before and after your operation.

If you are having problems returning to your sport because of back pain then it is frequently helpful to see a specialist who has a knowledge of back problems but also an appreciation and knowledge of sport e.g. specialist manual therapist or sports medicine specialist.

There are very few conditions that are usually only seen in sport but a stress fracture of the spine (referred to as a PARS fracture) is an example of a sporting problem.

PARS Fracture

The PARS is the bony arch of the vertebrae surrounding the spinal canal at the back of the spine.

A PARS fracture is caused by repetitive loading of the spine in extension and is therefore usually affects individuals who play sports that require spinal extension e.g. diving and gymnastics, tennis, cricket fast bowling, rowing, football.

Fractures may affect one side or both sides of the vertebrae.

Pain is at the site of the fracture and is made worse by extending the spine.

The lowest lumbar vertebrae (L5) is usually affected

If a PARS fracture is suspected you should be referred for specialist assessment by a sports medicine specialist who upon confirming the diagnosis will advise on appropriate treatment.