Rheumatological Conditions That Affect The Spine

An Overview of Rheumatological Conditions that Affect the Spine

Spondyloarthopathies (spondylo=spine, arthros=joint, pathos= condition of)

Rheumatological conditions that affect the spine are due to autoimmune disorders that attack the musculoskeletal system. In a normal immune response, alien proteins such as those of bacterial or viral origin trigger the immune system to destroy the invading organism. In an autoimmune disorder, the immune system becomes confused and develops sensitivity to normal body proteins. When the immune response mistakenly identifies these normal host proteins as “foreign invaders”, inflammation, swelling, erosion of bone, joint and nerve destruction can occur. This is the basis of a spinal autoimmune disease.

Symptoms of Spinal Autoimmune Disease

With the exception of rheumatoid arthritis, many spinal autoimmune diseases start with sacroiliac joint (SI) involvement, the joints in the back of the pelvis. One of these diseases (ankylosing spondylitis) attacks the SI joint bilaterally (on both sides) but most of these disorders only cause unilateral (one-sided) SI joint injury.

The classic first symptoms are pain and stiffness in the morning that disappears with activity. Fatigue is also a common symptom of these rheumatologic conditions that affect the spine. Stiffness that disappears with exercise is very typical for spinal autoimmune diseases. Be forewarned that lumbar degenerative disc disease can also display similar symptoms.

Rheumatoid arthritis, psoriasis, ulcerative colitis, Crohns disease, Reiter’s syndrome, ankylosing spondylitis, lupus (SLE), myositis, polymyalgia rheumatica, and DISH (diffuse idiopathic skeletal hyperostosis) are some of the spondyloarthropathy diseases associated with spine pain and stiffness.

X-Ray Findings of Spondyloarthopathies

X-rays can demonstrate classic findings for these disorders. Syndesmophytes are bone spur formations that develop off the upper and lower edges of the vertebral bodies. They can be categorized as marginal or nonmarginal.

Marginal syndesmophytes are bone spurs that originate immediately out of the edge of the body and connect one vertebra to another thru the “margin” of the vertebra. Marginal syndesmophytes stay within the confines of the anterior and posterior longitudinal ligaments and are specific for ankylosing spondylitis. The spine develops the appearance of segmented bamboo so is called a “bamboo spine.” In the early stages, the normally “scooped” or curved front of the vertebra “fills in” with bone to become “square”.

Nonmarginal syndesmophytes appear as large spurs or “parrot beak” spurs and grow out of the corners of the vertebra. These spurs normally occur with spine involvement in psoriasis, ulcerative colitis, Crohns disease, Reiter’s Syndrome, and DISH.

Sacroiliac joints are the first joints to be involved with many of these disorders (except DISH). By using X-ray only, involvement of these joints can be difficult to diagnose. The edges of the joints may become blurred and occasionally the joint fuses and “disappears” on X-ray. Again, if the sacroiliac joint is involved, bilateral involvement characterizes ankylosing spondylitis and unilateral involvement covers most of the other inflammatory disorders. The MRI is the most sensitive scan to determine if the sacroiliac joint is inflamed.

Ankylosing spondylitis. Arrows point to marginal osteophytes. This is a bamboo spine

Non marginal syndesmophytes. Arrows point the these parrot beak spurs

Unilateral sacroiliac fusion. This CT scan notes the fusion (arrow).

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(Please keep reading below for more information on this condition.)

Rheumatoid Arthritis (RA)

It is estimated that 1–2% of the world’s population has rheumatoid arthritis. This disease attacks the synovium lining of diarthrodial joints. Diarthrodial joints are the common joints we all think of such as the shoulder or knee. The facets in the spine are diarthrodial joints and there are more of these joints in the spine than all the other joints in the body. The junction of C1 and C2 at the base of the neck is also a diarthrodial joint.

The basis of this disease is the immune attack of the synovium lining of the joint. The synovium is the thin layer of cells in every joint that produces the oily fluid that lubricates the joint, As noted before, the spine contains multiple diarthrodial joints (the facets and the atlanto-dens articulation of C1-2). Rheumatoid arthritis can affect all these joints.

Onset typically occurs symmetrically (on both sides) and the disease typically involves the hands at the early stage. Swelling and pain of the finger joints signals the onset. Painful nodules can form subcutaneously (under the skin), and the fingers will appear “windswept” (dislocated or subluxed all in one direction) in later stages.

The disease also affects other body systems such as the blood vessels (vasculitis) and nerves. The lungs can be affected as well as the pericardium (lining of the heart).

Nerve involvement can occur. Mononeuritis multiplex symptoms can develop. These are multiple occurrences of single unrelated nerve injury/involvement (ex: tibial nerve on the left leg and the median nerve on the right arm). The vascular supply to the nerve is damaged, starving the nerve of oxygen.

With a well-known disease process such as rheumatoid arthritis, you would assume that there should be one lab test to determine if the patient has the disease. That however is not the case. Some of the diagnostic tests positive in RA, such as the rheumatoid factor test, show up in 3% of the healthy population.

When RA affects the spine, the cervical spine is most commonly affected. Only rarely does the thoracic or lumbar spine become involved. With spinal involvement, the symptoms almost always start with stiffness and decreased range of motion of the neck.

Rheumatoid arthritis is a destructive disease that may have obvious X-ray findings in later stages. RA destroys the synovial joints so X-ray will reveal that the bone of the facets has become eroded. The vertebral bodies and discs will have no involvement.

A synovial joint exists between the dens (the top of C2) and the arch of C1. The disease can therefore produce C1-2 instability by eroding the dens or the transverse ligament. This creates an increase of the space between the two bone surfaces on the lateral cervical X-ray.

Commonly, degenerative spondylolysthesis (slip of one vertebra on the other) of the cervical vertebrae occurs with this disease process.

Seronegative Spondyloarthopathies

Seronegative spondyloarthopathies are called this due to the lack of the ability of any specific blood tests that can reveal the presence of these disorders (seronegative means no positive blood testing). The presence of these disorders is revealed by symptoms, findings on MRI and X-rays and non-specific blood testing. Non-specific blood testing means that certain blood test findings are present in these disorders that can also be present in any number of disorders. It is the combination of all these findings that reveal the presence of seronegative spondyloarthopathies.

The seronegative spondyloarthopathies are enteropathic arthritis, psoriatic arthritis, and Reiter’s syndrome. These diseases have many features in common, such as unilateral involvement of the sacroiliac joint, nonmarginal syndesmophytes (“parrot beak” bone spurs that grow on the side of the vertebral bodies), and fatigue/lethargy. Many patients with these disorders will have an HLA-B27 allele on one chromosome (a gene found on DNA strands). Just like in rheumatoid arthritis however, HLA-B27 is found in the normal population; so it is not by itself diagnostic if present.

Differential from Degenerative Disc Disease

Morning stiffness is the hallmark of spondyloarthopathies. Morning stiffness can also be associated with lumbar degenerative disc disease (DDD) and stenosis. Patients with all three diseases have reduction of lower-back pain with a hot shower and some stretching, but the patient with spondyloarthropathy will feel significantly better.

The DDD patient will have increased symptoms with exercise and the spondyloarthropathy patient will tolerate the increased activity without significant problems. The spondyloarthropathy patient may have symptomatic improvement with exercise. Sacral or central lumbar pain will be present in both. Spondyloarthropathy disorders are not normally associated with leg pain where DDD can have leg pain associated. Reiter’s patients may complain of heel pain.

Ankylosing Spondylitis

The prototype for autoimmune spinal disorders is ankylosing spondylitis (AS). This is a disease process that causes the spine to fuse together over time. Found generally in younger males, AS has classic prodromal symptoms. The diagnosis may not be identified for months after the onset of initial symptoms. The incidence of this disease is one in every thousand Caucasians. Females can also succumb to AS. The blood marker HLA-B27 is common with this disease, but its presence does not absolutely predict disease, and absence does not assure the lack of disease.

Young adult males will develop prodromal symptoms (symptoms that occur before full manifestation of the disease) such as morning stiffness and pain in the lower back (sacroiliac involvement). Sleep can be difficult. Some patients will develop iritis, an inflammation of the anterior chamber of the eye. This disease is cyclical. That is, ankylosing spondylitis is noted for exacerbations and remissions. Again, think of this disorder in a young adult male, if symptoms include morning stiffness that improves with activity.

Reiter’s Syndrome

Reiter’s syndrome is associated with either a sexually transmitted disease—chlamydia—or onset of a bacterial intestinal infection. After the infection ceases, the syndrome begins. The triad of symptoms consists of urethritis (inflammation of the urethra), conjunctivitis (inflammation of the white of the eye), and arthritis (pain in the joints). This syndrome includes the hallmark of the disorder, heel pain and swelling, most likely resulting from an inflammation of the insertion of the Achilles tendon or the planter fascia. Back pain from sacroiliac joint involvement (sacroillitis noted above) occurs in 70% of patients, and inflammation of the eye, conjunctivitis occurs in 40% of patients, Myalgias can occur, and sausage digits (highly swollen fingers) are also is seen with Reiter’s syndrome.

Psoriatic Arthritis

Psoriasis is primarily known as a skin disease. The skin on the extensor surfaces become reddened and develop a silvery flaky scale. A small percentage of patients develop arthritis. Psoriatic arthritis and spondyloarthropathy are associated with changes in the nail beds of the fingers. Sausage digit can be noted in some patients.

If a patient with psoriasis develops arthritis, 95% have peripheral joint involvement (elbows, knees, and hips); and 5% have spinal involvement, including sacroiliac involvement and the typical nonmarginal syndesmophytes.

Enteropathic Arthritis

These disorders are intestinal borne. The two most common diseases associated are Crohn’s disease and ulcerative colitis. Both involve intestinal debilitation, and both are known to involve the spine. Ten to twenty percent of patients will develop sacroiliac involvement, and 10% will develop spondylitis or spinal inflammation.

Myalgias and Fibromyalgia

Myositis and Myalgias

There are some unusual diseases that cause muscle-generated pain, such as polymyalgia rheumatica and myositis. These are systemic autoimmune diseases related to temporal arteritis. In these cases, the immune system attacks muscle proteins. Patients with this disorder have debilitating muscle aching. The common flu also causes temporary generalized muscle pain (myalgias) by a similar but temporary mechanism.

Fibromyalgia

Fibromyalgia is a controversial diagnosis as there are no lab tests, X-rays, or other concrete ways to prove this disorder exists. This diagnosis is made by excluding any other potential diagnoses and then inventorying the patient’s complaints to see if these fit with fibromyalgia guidelines.

The most common patient is a female of childbearing years. This syndrome tends to get somewhat better with activity but most patients will have not engaged in exercise as this causes soreness and fatigue. These patients complain of stiffness and lethargy. Headaches, irritable bowel syndrome, and sleep disturbances are quite common; and this disorder is regularly associated with depression. For diagnosis, pain should be noted in all four quadrants of the body: legs, arms, pelvis, and central core, with eleven of eighteen “tender points” present in specific areas. Treatment is similar to that of chronic pain syndromes but exercise is essential to treat fibromyalgia.

For additional resources on rheumatological conditions that affect the spine, or to learn more about spinal autoimmune diseases, please contact the office of Dr. Donald Corenman, spine specialist and back doctor in the Vail, Aspen, Denver and Grand Junction, Colorado area.

Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.