RECOGNISING 

INFLAMMATORY
BACK PAIN

This programme is supported and funded

by Pfizer
Date of preparation: December 2011
Project code: ENB 248
 Contents

• Inflammatory back pain: overview
• Spondyloarthropathies
• Ankylosying spondylitis: overview
• Ankylosying spondylitis: diagnostic challenges
• Diagnostic and referral algorithm
• Summary
Inflammatory back pain: 
overview
 Back pain: scope of the problem
Back pain: scope of the issue
• Back pain is common; 60‐80% of UK population report back 
pain at some point in their life1

• One fifth to one quarter of all GP consultations are 
musculoskeletal related2

• Approximately 5% of patients with chronic back pain have 
ankylosing spondylitis3

• Differentiating chronic simple back pain from other more 
serious kinds of back pain is difficult, especially in a typical GP 
consultation period

1. Waddel, G et al. Occupational health guidelines for management of low back pain at work: evidence review. Occup. Med 2001;51(2):124-135
2. House of Commons. Early identification and diagnosis of rheumatoid arthritis. Available:
http://www.publications.parliament.uk/pa/cm200910/cmselect/cmpubacc/46/4605.htm. Last accessed February 2011.
3. McKenna, F. Spondyloarthritis. Reports on the Rheumatic Diseases 2010;6(5):1-6
 Common causes of low back pain (LBP)1 1
Common causes of low back pain (LBP)
• Mechanical
– Unknown cause, degenerative disc/joint disease, vertebral 
fracture, congenital deformity, spondylolysis
• Neurogenic
– Herniated disc, spinal stenosis, osteophytic nerve root 
compression, infection (e.g. herpes zoster)
• Non‐mechanical spinal conditions
– Neoplastic disease, inflammatory diseases (e.g. 
spondyloarthritis), infection (e.g. osteomyelitis), Paget’s disease
• Referred visceral pain
– GI disease (e.g. IBD, pancreatitis), renal disease
• Other
– Fibromyalgia, somatoform disorders

1. Cohen,S et al. Management of low back pain. BMJ 2008;337:a2718

 Inflammatory back pain (IBP)

• IBP is an inflammatory disease of unknown cause1A
• IBP primarily affects the lower back, buttocks, 
structures of the spine and large peripheral joints1B
• Inflammatory back pain may lead to ankylosis 2

1. Braun, J et al. Clinical significance of inflammatory back pain for diagnosis and screening of patients with axial spondyloarthritis. Ann Rheum Dis 2010;69:1264-1268
2. Lories, R et al. Inhibition of osteoclasts does not prevent joint ankylosis in a mouse model of spondyloarthritis. Rheum 2008;47:605–608
 IBP – relevant signs can include:1

– Age at onset of back pain  – Pain improves with 
<45 years (Peak age of  exercise
onset 15 – 35yrs) – Tenderness/inflammation 
– Back pain lasting > 3  over SI joint(s) (often seen 
months (possibly  as alternating buttock 
intermittent) pain)
– Night pain – Insidious onset (often 
– Early morning pain and  distinguishes from 
stiffness lasting more  mechanical back pain)
than one hour
Early diagnosis is key for IBP, as it is the main symptom of the
spondyloarthopathies

1. Sieper, J et al. New criteria for inflammatory back pain in patients with chronic pain: a real patient exercise by experts from the assessment of
spondylarthritis International Society (ASAS). Ann Rheum Dis 2009;68(6):784-8
 Overview: 
spondylarthropathies
 Spondyloarthropathies (SpA)
• A heterogenous group of immune‐mediated inflammatory 
diseases1A
• Can be divided into two subgroups according to the predominant 
symptoms (though may overlap):1B
– Axial SpA (spine)
– Peripheral SpA (peripheral joints)
• SpA can result in abnormal bone formation with eventual ankylosis 
of the spine, resulting in substantial disability2
• Diseases belonging to this group share clinical and genetic 
characteristics, which distinguish them from rheumatoid arthritis3

1. Braun, J et al. Clinical significance of inflammatory back pain for diagnosis and screening of patients with axial spondyloarthritis. Ann Rheum
Dis 2010;69:1264-1268
2. Colbert, RA. Classification of juvenile spondyloarthritis: enthesitis-related arthritis and beyond. Nat Rev Rheumatol 2010;6:477–485
3. Burgos-Vargas, R. From retrospective analysis of patients with undifferentiated spondyloarthritis (spa) to analysis of prospective cohorts and
detection of axial and peripheral spa. Rheum 2010;37:6
JG3

Ankylosing spondylitis is the prototype axial SpA1 

Inflammatory 
bowel disease
• Although each
condition has its
own
characteristics,
there is
Reiter’s  Reactive  Ankylosing  Undiff. significant
syndrome arthritis SpA
spondylitis
overlap
between them
and one can
evolve into
another2,3
Psoriatic 
arthritis

1. Sieper, J et al. The Assessment of SpondyloArthritis International Society (ASA) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 2009;68:ii1-ii44
2. Burgos-Vargas, R. From retrospective analysis of patients with undifferentiated spondyloarthritis (spa) to analysis of prospective cohorts and detection of axial and
peripheral spa. Rheum 2010;37:6
3. Nash, P et al. Seronegative spondyloarthropathies to lump or split?. Ann Rheum Dis 2005;64:ii9-ii13
Slide 10

JG3 Graphic taken from Wyeth AS training module

Jeyni Gnanapragasam, 08/03/2011
Ankylosing spondylitis
 Ankylosing spondylitis (AS)
• AS is the major subtype and a main outcome of SpAs1A
• Clinical features include:1B
– IBP
– Peripheral oligoarthritis (predominantly of lower limbs)
– Enthesitis  
– Specific organ involvement (including anterior uveitis, psoriasis, 
IBD)
• Pain generally felt deep in the buttock and/or lower lumbar 
regions1C
• Age of onset is usually from late teens and early adulthood1D
• Strong genetic association 
– 90‐95% of patients are positive for HLA B271E
• Family history in associated conditions has a strong effect on the 
risk of developing the disease1F
1. Braun J et al. Ankylosing spondylitis. Lancet 2007;369:1379-1390
 Epidemiology of AS

Gender differences Men more affected than women, with 2‐3:1 ratio1A
Symptom onset ~80% develop first symptoms <30 years, <5% present 
at >45 years1B
Prevalence 2‐5 per 1000 in UK2A
In 2006 an estimated 200,000 were diagnosed in UK2B
Incidence ~7 per 100,000 people per year3A
2,300 new diagnosis England and Wales per year3B
Prevalence amongst  Differs depending on ethnic background; AS is more 
populations prevalent in Caucasian population, and rare in black 
populations1C, 4
Mean age at diagnosis 335
Mean diagnostic delay 10 years2C
1. Braun ,J et al. Ankylosting spondylitis. Lancet 2007;369:1379-1390
2. National Ankylosing Spondylitis Society. Looking ahead : Best practice for the care of people with ankylosing spondylitis. Available: http://www.nass.co.uk/NASS/en/loose-leaf-
pages/resources-for-health-professionals-2/. Last accessed February 2011.
3. NICE. Ankylosing spondylitis - adalimumab, etanercept and infliximab: appraisal consultation document. Available:
http://www.nice.org.uk/guidance/index.jsp?action=article&r=true&o=34836 . Last accessed February 2011.
4. Brent, LH et al. Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy. eMed J 2001;2:1–23
5. Sieper, J et al. Ankylosing spondylitis: an overview. Ann Rheum Dis 2002;61(3):iii8–iii18
 Impact of AS
• Pain and disability of AS can be similar to that of rheumatoid arthritis1A

• UK data from 2001 shows 31% patients with AS unable to work2

• Standard mortality ratio (SMR) of 1.5 (similar to RA) – cardiac valve 
disease and fractures1B

• Quality of life studies indicate:1C
– Stiffness 90%
– Pain 83%
– Fatigue 62%
– Poor sleep 54%
– Concerns about appearance 51%
– Worry about the future 50%
– Medication side effects 41%

1. Keat, A.(2004). BSR guideline for prescribing TNFα blockers in adults with ankylosing spondylitis. Available:
http://www.rheumatology.org.uk/includes/documents/cm_docs/2009/p/prescribing_tnf_alpha_blockers_in_adults_with_ankylosing_spondylitis.pdf . Last accessed
February 2011.
2. Barlow, JH et al. Work Disability and family life; comparisons with US population Arthritis Rheumatism. Arthritis Care & Research 2001;45:424–429
 AS in women

• Historically, AS was considered a disease that overwhelmingly affects 
men1A
• Recent studies have shown a significant proportion are women, with a 
ratio of men:women approaching 2:1 as opposed to 3:11B

– Women have a significantly earlier age of disease onset and worse 
functional outcomes despite more radiographic severity in men1D
– There is suggestion that women have more peripheral arthritis1E
– A greater proportion of first degree relatives have a history of the 
disease1C

• The delay in diagnosis may be due to the lack of recognition of the disease 
in women1F
• As the phenotype of the disease tends to differ between the genders, this 
may influence the timing of diagnosis and initiation of treatments1G

1. Lee, K et al. Are there gender differences in severity of ankylosing spondylitis? Results from the PSOAS cohort. Ann Rheum Dis 2007;66(5):633-638
JG8

AS/SpA is associated with co‐morbidities1
And is closely linked to the genetic marker, HLA-B272

Articular Extra‐articular

Pauciarticular Eye 
asymmetric •Uveitis (acute anterior)
Spondylitis Heart

Sacroiliitis Lungs

Synovitis  Gut 
•Dactyilitis •IBD
Enthesitis Kidneys
•E.g. Achilles tendinitis
Skin
•Psoriasis
These impact on 
patient Quality of  Urinary tract
•Reactive arthritis
Life
1. Turkiewicz , A et al. Spondyloarthropathies and Associated Comorbidities: What Else Should We Be Looking For? Available:
http://www.medscape.com/viewarticle/567228). Last accessed February 2011.
2. www.spondylitis.org
Slide 16

JG8 Graphics taken from approved AS training module (Wyeth)

Jeyni Gnanapragasam, 02/03/2011
 AS and enthesitis1
STIR
• Enthesitis is an inflammation of 
the enthesis 
– Occurs in approximately one third of 
AS patients1A
Enthesitis
• Swelling of the tendon or ligament 
insertion results in painful and 
tender lesions 
– Reactive bone forms overgrowth or 
syndesmophyte1B T1

• Occurs in the spine and in 
peripheral sites
– e.g. the insertion of the Achilles  Enthesitis
tendon and the plantar fascia on the 
calcaneus1C (see image)

1. Brent, LH et al. Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy.

eMed J 2001;2:1–23
 AS – Classification Criteria

• The 1984 Modified New York criteria (mNYC) is used to classify and 
diagnose AS, and introduced the clinical parameter for IBP1A
Clinical criteria:
– Low back pain and stiffness for more than 3 months that improves with 
exercise, but is not relieved by rest
– Limitation of motion of the lumbar spine in the sagittal and frontal 
planes
– Limitation of chest expansion
Radiological: Sacroiliitis (Bilaterally Grade 2; Unilaterally 3‐4)1B

Definite AS if the radiological criterion is associated with at least one clinical 
criterion

1. Elyan, M et al. Diagnosing ankylosing spondylitis. Rheum 2006:33(78):12-23

Diagnostic challenge of 
ankylosing spondylitis
 AS – Diagnostic challenge

• Diagnosis of AS before occurrence of irreversible damage is 
a challenge1A
• The average time span for diagnosis is 8‐11 years from 
onset of symptoms and definite diagnosis2A
• AS can be difficult to diagnose, mainly due to:
– Symptoms can easily be confused with other causes of back 
pain1B
– Multiple tests are required to confirm a diagnosis2B
– More difficult to diagnose in females3A
• Earlier recognition of AS is becoming more important with 
the advent of more effective treatments1C

1. Elyan, M et al. Diagnosing ankylosing spondylitis. Rheum 2006; 33(78):12-23

2. O'Shea F et al. The challenge of early diagnosis in ankylosing spondylitis. J Rheumatol 2007;34:5-7
3. Lee, K et al. Are there gender differences in severity of ankylosing spondylitis? Results from the PSOAS cohort. Ann Rheum Dis 2007;66(5):633-638
 Red flag considerations
• Red flags1: 
– Progressive non‐mechanical pain
– Persistent severe restriction of lumbar flexion 

• The differential diagnosis of AS should exclude:1
– Cancer/Tumours (primary tumours are rare)
– Bacterial infections
– Metabolic bone disease (osteoporosis)
NOTE:
• X‐rays should be performed to examine vertebra is out of 
place2
• Onset of any new or different back pain warrants 
investigation
1. Butler, D et al (2000).The sensitive nervous system. Adelaide. Noigroup Publications.p169
2. PubMedHealth. Spondylolisthesis. Available: http://ncbi.nlm.nih.gov/pubmedhealth/PMH0002240. Last accessed February 2011.
Diagnostic and referral 
algorithm
 Development of a diagnostic algorithm
• There is an unacceptably long delay between the onset of 
symptoms and time of diagnosis for AS – an average of 8‐11 
years delay has been reported1A
• The longer the diagnosis is delayed, the worse the functional 
outcome may be2A
• 5% of patients presenting to the GP surgery with chronic back 
pain will have AS1B
• To optimize diagnostic accuracy of early AS, a comprehensive 
approach is crucial, with an understanding of the disease and 
its clinical picture2B

To offer an optimum quality of service to these patients, early diagnosis, and 
appropriate physical and medical therapies can lead to complete symptomatic 
remission in a significant number of cases

1. O'Shea, F et al. The challenge of early diagnosis in ankylosing spondylitis. J Rheum 2007;34:5-7
2. Elyan, M et al. Diagnosing ankylosing spondylitis. Rheum 2006:33(78):12-23
 How to make a diagnosis

• Elicit a history suggestive of IBP1A
• Ask about symptoms suggestive of HLA‐B27 
related diseases1B
• Examine the spine briefly to see if there is 
restriction of movement or tenderness1C
• If AS (or other SpA) is suspected, refer to 
rheumatologist1D
1. Elyan, M et al. Diagnosing ankylosing spondylitis. Rheum 2006:33(78):12-23
 Diagnostic algorithm
< 3 months
Back pain
> 3 months Acute onset
Onset
Insidious onset

Consider other cause
< 40 years
Age
> 40 years
< 30 minutes
Early morning stiffness
Yes  > 60 mins
Night pain
No
Intermittent Neurological symptoms
Refer to rheumatologist

Buttock/thigh pain
Yes  Improves with rest
Improvement
Improves with exercise No
In frontal plane
Loss of movement
In all planes
Yes 
Tender SI joint
No
Yes 
Enthesitis
No
Yes 
Associated problems
No
Yes 
Family/previous history
© Susan Gurden
 Secondary care pathway

Community 
programmes,
Physiotherapy  GP/ Shared 
self 
treatment,  care,
Multi‐ management,
exercise  regular 
disciplinary  programmes,  NASS, physiotherapy,
team, education,  access to work, monitoring and 
Physiotherapy  access to  hydrotherapy measurement,
health 
led AS clinics, treatment promotion, access to 
access to  psycho‐ appropriate 
rheumatology 
biologic clinic   social support advice line care pathway
if appropriate medication 
Rheumatology 
counselling
consultant for 
diagnosis individual 
care planning
GP  referral to 
assessment
other services
© Susan Gurden
Summary
 Key  messages
• Early diagnosis of inflammatory back pain has proved to be a challenge
as symptoms are similar to other causes of low back pain
• Presentation of AS can be subtle, particularly in the early stages
• AS can be a progressive condition over time so the earlier an accurate 
diagnosis in the disease course, the better the outcome for the patient
• Referral should be considered in all patients under 40 years who present 
with inflammatory back pain
• The main value of history and physical examination is to determine which 
patients should be referred for further evaluation and this may facilitate 
prognosis
• Rheumatology services could provide optimum care for AS patients by 
an expert multi‐disciplinary team
For further information

This programme is sponsored by Pfizer

Date of preparation: December 2011
Project code: ENB 248