Rheumatic

Juvenile Idiopathic Arthritis (JIA)

Adolescents with back pain related to JIA are most likely to have either enthesitis-related arthritis (ERA) or psoriatic arthritis. Back pain in these disorders results from inflammation of the spine and/or sacroiliac (SI) joints. In contrast to the pattern seen with mechanical back pain, inflammatory back pain is worsened by rest (i.e., morning stiffness), and improved by activity. ERA is more common in adolescent Caucasian boys and in those with a family history of HLA-B27-associated diseases (57,58,84,85). These adolescents often present with enthesitis of the heel or knee, peripheral arthritis, and less commonly acute anterior uveitis (57,83,84). Although adults with ankylosing spondylitis (AS) frequently have inflammatory spinal pain at onset, only a minority of children with ERA (12.8-24%) has been reported to have pain, stiffness, or limitation of movement of the lumbo-sacral or SI region during the first year of disease (57,83). Instead, most develop back symptoms after 5-10 years of disease (58). A minority of adolescents with inflammatory bowel disease (IBD) may develop spine and SI arthritis in a pattern similar to ERA. This can occur months to years before or after the onset of the gastrointestinal symptoms (82,83), and the arthritis in these patients appears to be independent of the bowel disease activity. Patients with psoriatic arthritis can have varying patterns of joint involvement, such as dactylitis, oligoarthritis or polyarthritis, and 11-47% will develop back pain due to sacroiliitis, again in a pattern similar to ERA

(58). The majority of children with psoriatic arthritis will develop joint inflammation before the onset of skin disease, often making the diagnosis a challenge (58,83). Typical skin findings include psoriasis vulgaris, nail pitting, and less commonly, onycholysis (58,85). Most children with psoriatic arthritis have a family history of psoriasis (58,85).

Direct palpation over the SI joint, compression of the pelvis, or distraction of the SI joint may elicit pain in the SI joint. (58). The development of sacroiliitis in ERA seems to be associated with disease duration and intensity

(59). Radiographs may show diffuse pelvic osteoporosis as well as changes in the bones surrounding the SI joint, such as blurring of the subchondral margins, erosions, joint space narrowing, reactive sclerosis, and fusion (57) (Fig. 2). Arthritis of the spine may be detected as a flattening of the lumbar curve on forward flexion, decreased lumbar expansion as measured by the Schober test, decrease in hyperextension, or restriction of chest wall expansion (58). Late radiographic changes of the spine include anterior vertebral squaring and anterior ligament calcification (57). MRI with gadolinium can detect signs of inflammation much earlier than radiographs (57,59), so should be done if suspected. Laboratory studies may show mild anemia, elevated inflammatory markers, thrombocytosis, and occasionally leukocytosis; the ANA and rheumatoid factor will be negative, while the HLA-B27 can be positive in 70% to 90% of patients (57,83,84). Patients presenting with back pain who have IBD may have anemia, high ESR, low albumin, a positive peripheral staining anti-neutrophil cytoplasmic antibody (P-ANCA), or anti-Saccharomyces cerevisiae antibody (ASCA), and/or occult or frank hema-tochezia (57). (For further discussion of JIA, see Chapter 7.)

Other Autoimmune Disorders

Adolescents with systemic lupus erythematosus (SLE), mixed connective tissue disease, chronic vasculitis, or dermatomyositis may also develop back pain. SLE and MCTD are most common in the adolescent female, while dermatomyositis is more common from mid childhood through early adolescence (86-89). Back pain in these patients may be secondary to arthritis, infection, osteoporosis, osteonecrosis, referred from pathology in the chest or abdomen, or transverse myelitis, but these patients can also develop other more common causes of back pain in adolescents such as mechanical problems, nonspecific back pain, or fibromyalgia. Arthritis as a cause of back pain is unusual in these patients who are more likely to have peripheral small joint arthritis rather than axial arthritis (86-89).

Jia Patterns Rheumatology

Figure 2 This 16-year-old girl had a 3-week history of progressive daily arthralgias involving her knees, neck, back, and upper extremity joints. She had morning stiffness, fatigue, and limping. Her laboratory studies showed a Hg of 11.2gm/dl, platelet count of 414K/mcl, ESR 82, negative ANA, and a positive HLA-B27. (A) An X-ray of her SI joints shows bilateral sclerosis on both sides of her SI joint, with widening of the left side (arrow) suggestive of erosion, and irregularity on the right side. (B) An MRI at this time (T1 TSE coronal with fat saturation after gadolinium) shows moderate erosive changes bilaterally, with large erosion on the left side (arrow), and enhancement along both the sacral and iliac sides.

Figure 2 This 16-year-old girl had a 3-week history of progressive daily arthralgias involving her knees, neck, back, and upper extremity joints. She had morning stiffness, fatigue, and limping. Her laboratory studies showed a Hg of 11.2gm/dl, platelet count of 414K/mcl, ESR 82, negative ANA, and a positive HLA-B27. (A) An X-ray of her SI joints shows bilateral sclerosis on both sides of her SI joint, with widening of the left side (arrow) suggestive of erosion, and irregularity on the right side. (B) An MRI at this time (T1 TSE coronal with fat saturation after gadolinium) shows moderate erosive changes bilaterally, with large erosion on the left side (arrow), and enhancement along both the sacral and iliac sides.

Dealing With Back Pain

Dealing With Back Pain

Deal With Your Pain, Lead A Wonderful Life An Live Like A 'Normal' Person. Before I really start telling you anything about me or finding out anything about you, I want you to know that I sympathize with you. Not only is it one of the most painful experiences to have backpain. Not only is it the number one excuse for employees not coming into work. But perhaps just as significantly, it is something that I suffered from for years.

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