Department Of Rheumatology : Prevalence of LBA in a tertiary care Naval hospital Surg Cdr A Singhal, Brig R Ramasethu, Surg Cmde KI Mathai, Dr P Malviya

Introduction  Low backache is defined as pain and muscle tension or stiffness localised below the coastal margin and above the inferior gluteal folds with or without leg pain or sciatica.  A low back ache (LBA) is a common cause of outpatient referral and loss of man hours in service hospitals.  In this retrospective analysis we attempted to delineate the patterns of low back aches and their management at a tertiary care Naval Hospital.

Aim and Objective  To determine the patterns of low back ache and the disease burden in terms of LBA prevalence at a tertiary care hospital.  Inflammatory  Non inflammatory  Assessment for intervention requiring tertiary care health services  Spinal surgeries  Biological response modifiers

Materials and Methods  A retrospective cross-sectional study conducted in July 2014  Period of study : six months, 01 Jan to 30 Jun 14.  Data collected from OPD register, admission and discharge records and referral forms.  Participants were men and women aged between years, who had reported to Departments of Orthopaedics, Medicine, Rheumatology and Neurosurgery at INHS Asvini.  Patients were evaluated and classified based on the cause of LBA as either inflammatory or non inflammatory.

Materials and Methods (cont)  Inclusion criteria-  Patients with a history of LBA for at least 3 months duration.  The pain perception on a visual analogue scale (VAS) score of at least 3/10 in the previous week was included in this study.  Exclusion Criteria-  Age 70 yrs

Materials and Methods (cont)  Parameters used  History for Early Morning Stiffness  Restriction of range of movements (ROM) in more than one plane, and / or  Involvement of eye, Gastrointestinal tract, Genitourinary tract, or skin, nails, and peripheral joints.  Those having positive history were considered for evaluation of inflammatory LBA.

Materials and Methods (cont)  Metrology examinations were performed by using Bath Ankylosing Spondyloarthritis Metrology Index three (BASMI 3):  Tragus to wall distance  Intermalleolar distance  Modified Schoeber’s  Cervical spine rotation  Lateral lumbar flexion

Materials and Methods (cont)  Assessment of disease  Clinical  Visual Analogue Scale (VAS), peripheral joints, eyes, enthesial score, nails and skin changes were noted.  Radiological  Xray pelvis was done for all LBA cases.  MRI Sacroiliac joint or bone scan and Xray of peripheral joints was carried out on required basis.  ESR, CRP, ANA,and HLA B27 examination were carried out on required basis.

Results  Total 11,673 patients had reported to Departments of Orthopaedics, Neurosurgery and Rheumatology during study period of six months, out of them 6266 (53.7%) patients had LBA.  Total no. of patients having inflammatory LBA were 201 (3.2%).  Number of patients having significant mechanical backache requiring Neuro-surgical intervention was 73 (1.166%).  Total number of inflammatory backache who did not responded to NSAIDS requiring Biological Response Modifiers were 16(0.026%).

Results chart MONORTHO WARD ORTHO OPDRHEUMAT OPD NEUROSUR OPD MED1 WARDBRMs No of PIVD surg TotalLBATotalLBATotalLBATotalLBATotalLBA JAN FEB MAR APR MAY JUN TOTAL

ward/ opdNo of patientsLBA Inflammatory backacheBRMNo of PIVD surg Ortho Rheumat Neurosurgery Medical ward98912 total

Number of patients

Discussion  The high prevalence of low-back pain (LBP) has been highlighted for many years, but until recently, awareness of its influence on the population was inadequate.  LBA was a leading cause of disability as measured by years lived with disability worldwide  ( Global Burden of Disease (GBD) Projects 2010)

What is the magnitude of LBA?  Cost of back pain in US was $ 100 billion annually.  Back symptoms are the most common cause of disability in those <45 years.  Low back pain : second most common reason for doctor visit.  Lifetime risk of LBA= 80%, commonest musculoskeletal complaint  1% of population : chronically disabled because of back pain Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum 2008;58:26-35.

Which region comprises lower back?

Causes of low back pain?  Mechanical  Inflammatory  Visceral/ Referred

Inflammatory vs mechanical pain?

“Red Flags” of LBA  Cancer or infection :  Age >50yrs or <70 yrs  Past history of cancer  Unexplained weight loss  Immuno-suppression  UTI  IV drug abuse  Back pain not improved with rest  Spinal Fracture :  Age >70yrs  History of violent trauma  Prolonged use of steroids  Cauda equina syndrome/ severe neurologic compromise :  Acute urinary retention or overflow incontinence  Faecal incontinence  Saddle anaesthesia  Progressive weakness in lower limbs Greenberg MS: Handbook of Neurosurgery, 7 Edition, Page no. 432.

Bath Ankylosing Spondylitis Metrology Index (BASMI) 3-point answer scale 012 MildModerateSevere Lateral lumbar flexion ( cm )> < 5 Tragus to wall distance< > 30 Lumbar flexion (modified Schoeber's )> 42-4< 2 Maximal intermalleolar distance> < 70 Cervical rotation ( 0 )> < 20

Spine

Types of typical MRI lesions of sacroiliac joint Rudwaleit M, Jurik A-G, Hermann K-GA, Landewe´ R, van der Heijde D, Baraliakos X,et al. Defining active sacroiliitis on magnetic resonance imaging (MRI) forclassification of axial spondyloarthritis – a consensual approach by the ASAS/OMERACT MRI Group. Ann Rheum Dis  Active inflammatory lesions (STIR/post-gadolinium T1) :  Bone marrow oedema (osteitis)  Capsulitis  Synovitis  Enthesitis  Chronic inflammatory lesions (normally T1) :  Sclerosis  Erosions  Fat deposition  Bony bridges/ankylosis

Bone scan  Tc labelled methylene diphosphonates  Labelled WBC scan to identify area & source of infection.  Osteoid osteoma, sarcoma, metastasis, osteomyelitis, stress #  In excluding bone & joint disease  Diff b/w osteoarthritis & inflammatory arthritis

Sacroiliitis on imaging plus > 1 SpA feature SpA features 1 IBP 2 Arthritis 3 Enthesitis 4 Uveitis 5 Dactylitis 6 Psoriasis 7 Crohn’s /colitis 8 Good response to NSAIDs 9 Family history for SpA 10 HLA B Elevated CRP HLA B 27 plus > 2 SpA features Sacroliitis on imaging 1 Active ( acute inflammation ) on MRI highly suggestive of sacroiliitis associated with SpA 2 Definite radiographic sacroiliitis according to modified New York criteria OR ASAS classification criteria for Axial SpA in patients with >03 months back pain and age at onset < 45 yrs Rudwaleit M et al. Thedevelopment of Assessment of SpondyloArthritis international Society classificationcriteria for axial spondyloarthritis. Ann RheumDis 2009;68:777–83

ASDAS CRP and Disease activity Lukas C, Landewe´ R, Sieper J, Dougados M, Davis J, Braun J, et al. Development of an ASAS- endorsed disease activity score (ASDAS) in patients with ankylosing spondylitis. Ann Rheum Dis 2009;68:18–24.

Patients fulfilling the ASAS criteria for SpA. Treatment failure All patients should have had adequate therapeutic trials of at least two NSAIDs. (defined as for at least two NSAIDs over a period of 04 weeks at maximum recommended dose unless contraindicated )  Active disease for ≥4 weeks with very high disease activity (ASDAS CRP >3.5). When to use anti –TNF agents in SpA ? Current Opinion Rheumatol. 2010;22(4):388

Characteristics of approved BRM in inflammatory LBA Etanercept Enbrel Infliximab Remicade Adalimumab Humira Target TNF Half Life3-5 Days8-10 Days10-20 Days ConstructHumanChimericHuman Dosing Once Biweekly- weekly Once every 4-8 weeks Once every 1-2 weeks RouteSub-CutI.V.Sub-Cut COST, AVAILABILITY, EFFICACY AND SIDE EFFECT PROFILE…. ETC

Cost factor DrugCost/month (Rs) NSAIDS100 Methotrexate1000 Biological response modifiers100000

Conclusions  The prevalence of LBA in our clientele population is high.  Less than 1.3 % patients were considered for treatment with Biological Response Modifiers or underwent Neurosurgical intervention.  Therefore keeping variable cost of treatment in mind a high index of suspicion and utmost clinical acumen is required to prevent loss to exchequer.

Take home message  Despite high prevalence of LBA in our dependent clientele population, actual requirement of tertiary care treatment is relatively lesser.

Acknowledgement: Dept of Radio diagnosis and Imaging Dept of Pathology