Arthritis back

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

The back is commonly affected by many forms of arthritis. Probably the most common form of arthritis that affects the back (spine) is osteoarthritis (OA). This is also known as degenerative arthritis or degenerative spondylosis.

Osteoarthritis typically begins to cause symptoms after the age of 30. The reason this happens can be understood better by briefly looking at the anatomy.

The spine consists of a stack of vertebrae that are separated from each other up front by pliable discs. These discs look like a jelly doughnut. They have a fibrous outer capsule with a gel inside that provides cushioning for the vertebrae.

Located in back of the discs are true joints- called facet joints- that allow the vertebrae to have flexibility and range of motion. When osteoarthritis develops, a few things occur.

First, the discs begin to dry out and harden. They become less pliable. They also begin to spread out. This results in what is known as a bulging disc. At the same time, the facet joints, which, like all joints, are lined by cartilage, begin to suffer from wear and tear and the facet joints form small spurs. The result is that nerve roots that exit the spinal cord between each set of vertebrae become irritated by either the disc bulge or by the facet spur, or both. This leads to localized inflammation of the nerve root which leads to muscle spasm and pain. If the nerve root is severely pinched, loss of function will occur.

Typically, osteoarthritis of the spine will cause most of its symptoms in the neck or low back. These are the parts of the spine that have the greatest mobility and which also are subjected to the greatest shearing forces. Patients will complain of stiffness and pain not only in the neck but also in areas where the nerve roots eventually terminate. For instance, in the neck, osteoarthritis in the neck can cause pain to radiate to the shoulder, and arm. The pain may also be accompanied by numbness, tingling, and weakness. Osteoarthritis affecting the low back can lead to compression of the nerve roots that go to the legs resulting in numbness, tingling, and weakness in the leg. This combination of referred pain and loss of function is called radiculopathy.

The treatment for osteoarthritis starts with a combination of anti-inflammatory medication and physical therapy. For patients with neck problems, soft cervical collars and neck support pillows are helpful. Occasionally topical treatments such as ice, heat, and arthritis creams might help with symptoms. Similar therapies also will help osteoarthritis affecting the low back.

Patients who don’t respond to conservative therapies might respond to different types of injections. Injections of steroid solution into the epidural space (the space between the spinal cord and the bony canal surrounding the spinal cord) are often effective in relieving pain and inflammation. Sometimes injecting steroid solutions into facet joints also can relieve pain.

Traction- distracting the vertebrae- is generally more helpful for neck disorders than low back disorders. A new type of distraction therapy called internal disc decompression (IDD) shows promise for people with low back pain.

Trancutaneous nerve stimulator (TENS) units sometimes help with pain relief as well.

Surgery is generally reserved for people with intractable pain- pain that doesn’t respond to any conservative measure- or people with a progressive neurologic deficit.

Another form of arthritis called diffuse idiopathic skeletal hyperostosis (DISH) also affects the spine. The treatment is similar to that for OA.

Inflammatory forms of arthritis that affect the back include the spondyloarthropathies (psoriatic arthritis, ankylosing spondylitis, and Reiter’s disease). These disorders cause significant inflammation in the facet joints as well as the joints that joint the spine to the pelvis (sacroiliac joints). Also like rheumatoid arthritis, the spondyloarthropathies can affect other organ systems. If not treated appropriately, the spine becomes fused. These conditions must be treated aggressively with anti-inflammatory medications, physical therapy, and disease- modifying drugs.

This latter group of medicines are designed to slow the progression of disease. Examples of DMARDs used include methotrexate, azathioprine (Imuran), sulfasalazine (Azulfidine). More recently, like rheumatoid arthritis, the spondyloarthopathies seem to be the result of excessive amounts of tumor necrosis factor. This is a special enzyme produced by cells of the immune system. Tumor necrosis factor is a substance that promotes inflammation and damage. Newer medicines called biologic therapies block the effects of tumor necrosis factor and are very effective in the spondyloarthropathies. Examples of these newer medicines are etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade, golimumab (Simponi), and certolizumab (Cimzia)).

Crystal-induced forms of arthritis such as gout and pseudogout may also affect the spine. The treatment for gout is to control the level of uric acid in the blood. For pseudogout, the treatment is similar to that for OA.

Rheumatoid arthritis rarely affects the low back but it can cause severe problems in the cervical spine. Because it is associated with severe inflammation, the ligaments and tendons that help to joint the vertebrae together become weakened. This leads to significant instability in the neck. In some cases, compression of the spinal cord occurs. This is called myelopathy and is a potentially life-threatening disorder.

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