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Inflammatory arthritis vs degenerative? #280961
08/08/18 01:39 PM
08/08/18 01:39 PM
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DadCue Offline OP
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I had a visit with my rheum regarding starting a biologic. Briefly, she stated that I have severe degenerative arthritis and a biologic probably would not be helpful. I asked how is it possible to tell what caused it the arthritis. She just said that inflammatory arthritis "looks different" than degenerative arthriitis and wrote in her note, "Back pain c/w degenerative disease seen on imaging. No signs of enthesopathy". I should have asked why I have had the diagnosis of reactive arthritis for 35 years?

Question, I googled the term enthesopathy and reread the MRI. The interpretation of the MRI states, "Mild broad-based disc bulge and severe bilateral facet and ligamentum flavum hypertrophy causing severe canal stenosis and neuroforaminal narrowing. I'm not sure what causes "ligamentum flavum hypertrophy" but it seems to be a form of enthesopathy.

Another question, The MRI that was done was a standard MRI without contrast. Isn't some kind of dye needed to detect inflammation and to visualize enthesitis.

Thanks



Re: Inflammatory arthritis vs degenerative? [Re: DadCue] #280963
08/08/18 02:36 PM
08/08/18 02:36 PM
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seymour Online
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Taking a wild guess here but it might mean that you didn’t have enthesitis visible on MRI so she thinks your pain is mechanical as she didn’t see active inflammation?

Re: Inflammatory arthritis vs degenerative? [Re: DadCue] #280967
08/09/18 05:35 PM
08/09/18 05:35 PM
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Thanks Seymour, other people must be on vacation or just as confused as I am about this stuff. I told my rheum there was nothing mechanical about the pain because it would happen for absolutely no reason. I'm irritated. I'm going to celebrate that my inflammation markers were normal for a change. I plan on watching the movie "Forest Gump" which seems kind of random but it is humorous and sad at the same time. It is a good all weather movie!



Re: Inflammatory arthritis vs degenerative? [Re: DadCue] #280969
08/09/18 05:37 PM
08/09/18 05:37 PM
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Recently, I started having tail bone pain which I never had previously in my life. If you ask me it's probably from damage of the spine. Did your ReA start spine pain?

Re: Inflammatory arthritis vs degenerative? [Re: DadCue] #280970
08/09/18 08:20 PM
08/09/18 08:20 PM
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Originally Posted by DadCue
Thanks Seymour, other people must be on vacation or just as confused as I am about this stuff. I told my rheum there was nothing mechanical about the pain because it would happen for absolutely no reason. I'm irritated. I'm going to celebrate that my inflammation markers were normal for a change. I plan on watching the movie "Forest Gump" which seems kind of random but it is humorous and sad at the same time. It is a good all weather movie!


I’m in your exact situation. My rheumy thinks my pain is mechanical but it makes no sense at all. It happens even when I don’t move and it affects pretty much my entire body. It’s very irritating when they say stuff like this that make no sense.

Re: Inflammatory arthritis vs degenerative? [Re: DadCue] #280971
08/09/18 08:41 PM
08/09/18 08:41 PM
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DadCue, I'm not sure any of us are qualified to interpret MRI results, which is probably why you haven't had much response. I did google "ligamentum flavum hypertrophy" and found the following:

"Ligamentum flavum hypertrophy means that the ligamenta flava (the plural of ligamentum flavum) is inflamed due to stress on the spine. This generally occurs in people over the age of 50 due to the natural degeneration process of the spine."
from https://www.laserspineinstitute.com/articles/ligamentum_flavum_articles/hypertrophy/283/

It's obvious that this rheumy is not the one who originally diagnosed you. How long have you been seeing her? I would ask her (nicely) about the reactive arthritis diagnosis and why she has moved away from that diagnosis.

You might consider getting a second opinion from another rheumy since your current rheumy's diagnosis differs from the original.

On your MRI question, there are several types of MRI's: T1, T2, STIR, with and without contrast. Again, I don't have enough knowledge to talk intelligently about them and when a certain type is appropriate. SAA sponsored a webinar on using MRI to diagnose spondyloarthritis. I need to go back and watch it again.
https://www.youtube.com/watch?v=Tucj4XpYR0o




Ginny - 58 year old female
Dx with USpA in March 2013; changed to AS in July 2015
Iritis and Scleritis
unicompartmental knee replacements: right-June 2014, left-Aug 2018
MTX, Humira, Cyclobenzaprine, plus Celebrex as needed
Supplements: Folic Acid, Vitamin A, Vitamin D, Calcium, Fish Oil, Culturelle probiotic, Melatonin (as needed)
Re: Inflammatory arthritis vs degenerative? [Re: DadCue] #280977
08/10/18 01:52 AM
08/10/18 01:52 AM
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DadCue Offline OP
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SouthernMoss: You are correct, she did not make the original diagnosis---that was 30 years ago. She entered the picture 15 years ago and was the 3rd opinion -- none of which I requested except for the 1st. She has never disputed the original diagnosis. At our recent visit, she agreed that a biologic would likely be beneficial for reactive arthritis and never said that I didn't have reactive arthritis. We talked about the damage to my spine and I nicely asked if a biologic might prevent more damage. She didn't really answer and proceeded with the exam.

During the exam I said that I had back pain but it was nothing to complain about. As she completed the exam she said that I had severe degenerative disease and a biologic would not likely help. I said that I have NEVER complained about mechanical back pain. She just looked at me and suggested we check the inflammation markers again. (these are always elevated). I never guess what the CRP and ESR will be but for some reason I predicted they would be normal -- they were.

Another part of our conversation was about a new study involving a biologic for PMR (google it). Prednisone is the only treatment for PMR and the same doctor reluctantly diagnosed it long ago and prescribed prednisone. She was never comfortable with this diagnosis because I was too young at the time and PMR isn't associated with uveitis. She still thinks I have reactive arthritis with underlying PMR.

I never really cared about the diagnosis so long as the pain was controlled and prednisone did that extremely well. I never have had much in the way of imaging except for occasional x-rays. The last couple years has revealed severe arthritis and I'm trying to understand why.



Re: Inflammatory arthritis vs degenerative? [Re: DadCue] #280994
08/10/18 05:57 PM
08/10/18 05:57 PM
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I was diagnosed with A.S. about 20 years and was able to control it with NSAIDs until 6 years ago. I sometimes doubted I had A.S. at all, although being HLA B27 positive made it likely. When everything started to get bad I also got a severe case of poison ivy and they put me on prednisone. Of course all my arthritis symptoms went away! So the rheumatologist thought that was very interesting and adequate empirical evidence that I had a spondyloarthropathy. We started biologics treatment not long afterward. I never had blood work demonstrating inflammation and any MRI and x-rays were relatively unremarkable. A recent x-ray of the lower back also showed degenerative changes like yours, but there was never any doubt of A.S. After all, having A.S. will not protect you from osteoarthritis and age related degenerations (although my guess is it makes it worse)!

At any rate, I am suggesting a course of prednisone, and if it makes your symptoms get better there is at least empirical evidence that there is something inflammatory going on. That might convince your rheumatologist to test biologics.

Re: Inflammatory arthritis vs degenerative? [Re: DadCue] #281011
08/11/18 10:04 PM
08/11/18 10:04 PM
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I concur with southernMoss, a second opinion may help shed more light on your situation. Did she mention wether the disc bulges were compressing the nerves?
From what I know they can be very hesitant to start biologics due to side effects and they tend to outweigh risks V benefit.
Has she booked a review for u?

Re: Inflammatory arthritis vs degenerative? [Re: FM2018] #281012
08/12/18 12:26 AM
08/12/18 12:26 AM
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Originally Posted by FM2018
I concur with southernMoss, a second opinion may help shed more light on your situation. Did she mention whether the disc bulges were compressing the nerves?


My Rheum didn't comment about nerves damage. An orthopedic surgeon was consulted and said, "the nerves were being crushed". He proposed a complicated surgery which would have surgically fused my lumbar spine. The disc bulge didn't seem to be a preoblem, The facet joints were severely arthritic and ligaments surrounding the spine were enlarge because of chronic inflammation. A neurosurgeon was also consulted and he was more conservative and wouldn't do anything unless the pain became unbearable. My primary care doctor told me not to rush into surgery.

The pain was unbearable when the MRI was ordered. It was my first MRI of the spine and I was off prednisone at the time. When prednisone was restarted the pain went away. My right leg is still weak and I have a permanent limp.



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