Mystery Back Pain Can Signal a Hidden (and Serious) Problem

Why it's important to diagnose and treat it promptly
Mystery Back Pain Can Signal a Hidden (and Serious) Problem

You’ve heard of rheumatoid arthritis. But an equally common type of arthritis is probably not on your radar.

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Spondyloarthritis is a diagnosis doctors often miss. Yet it affects about 1 percent of the U.S. population (over 3 million people).

One reason spondyloarthritis is under-recognized is that its main symptom — chronic low back pain — affects 20 percent of adults at any given time.

“Sorting out spondyloarthritis from mechanical or benign back problems is a challenge. But we need to get better at recognizing it,” says rheumatologist Leonard Calabrese, DO.

“This formidable inflammatory disease causes pain, impairs function and significantly compromises quality of life. While we have good treatments for it, they work better in the early stages.”

What happens and who’s at risk

Spondyloarthritis inflames the small joints of the spine, as well as the places where ligaments and tendons attach to it.

If the process goes unchecked, the vertebrae begin to fuse, eroding the spinal column and the joint at its base, a condition called ankylosing spondylitis.

“It’s hard to undo these changes with treatment. That’s why early diagnosis is vital,” says Dr. Calabrese.

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Spondyloarthritis typically strikes before age 40 to 45. While it’s widely believed that women don’t get spondyloarthritis, “they certainly do,” says Dr. Calabrese. Men’s risk is only slightly higher.

Symptoms to watch for

“Spondyloarthritis is an insidious process. It doesn’t suddenly begin when you fall from the roof trying to clean gutters,” he says.

Other clues: Pain tends to be worse in the morning, gets better with exercise, and responds pretty well to non-steroid anti-inflammatory drugs (NSAIDs).

“If you’re under age 45, have back pain that began more than 12 weeks ago for no obvious reason, and have this symptom profile, you should be evaluated for spondyloarthritis,” says Dr. Calabrese.

Diagnosing spondylarthritis

It’s best to see a rheumatologist for evaluation. He or she will start by reviewing your symptoms, history and any X-rays.

“We now recognize that you don’t have to have advanced changes on X-rays or a rigid spine to have spondyloarthritis. In fact, your X-rays can be totally normal,” he says.

Magnetic resonance imaging (MRI), which reveals spine changes that may not be visible on X-ray, and blood tests, which show telltale inflammatory markers, can confirm the diagnosis.  

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Treatment options

Doctors start with NSAIDs such as naproxen, meloxicam or indomethacin to reduce the inflammation driving the disease.

The next step, if needed, may be prescribing biologic agents, some similar to those used in rheumatoid arthritis and psoriatic arthritis.

“These therapies may halt progression of spondyloarthritis. But they all work better when disease is of brief duration,” Dr. Calabrese stresses.

While biologics carry some risk, “If you’re not responding to NSAIDS and still have pain and functional disability, their benefits far outweigh any risks,” he says.

Spreading the word

A recent study suggests that as many as 25 percent of those under age 45 who see primary care doctors have hidden spondyloarthritis.

To improve early detection, Dr. Calabrese and other rheumatologists are developing educational tools to help primary care physicians and osteopathic doctors, who are the first to see patients with low back  pain.

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