Patient doubts the value of treatment

Dear Dr. Roach: My significant other and I are debating whether I should pursue follow-up testing with a rheumatologist for the possibility of ankylosing spondylitis. I say no, and she says yes, because things could be worse down the road if do have AS and don’t deal with it starting now.

I am in my mid-60s, 45 years with iritis and in the past year was positive on an HLA-B27 test. My lumbar spine X-ray impression was “mild lumbar spondylosis,” but not fusion. My lowerback and hip pain and stiffness generally are worse in the morning and get better with activity and as-needed Advil. My primary care physician gave me an option to refer out to a rheumatologist for follow-up.

My feeling is that it would be an unnecessary expense and time. My significant other disagrees. What would you recommend?

B.B.

Answer: I agree with your significant other, without hesitation.

Ankylosing spondylitis is an inflammatory type of arthritis whose major symptom is lower-back pain, but one which can affect other joints and other parts of the body, including skin, gut and eye. The abnormalities usually show up on X-ray but sometimes do not.

Making the diagnosis of ankylosing spondylitis isn’t always straightforward. A careful interpretation of the spine film results is necessary by an experienced radiologist who can grade the sacroiliac joint; this is critical in helping to support or reject a diagnosis of AS.

Iritis, inflammation of the iris, is more consistent with a different inflammatory joint disease called reactive arthritis. With AS, the eye disease is typically uveitis. Although it’s possible the eye doctor used the term imprecisely.

The reason I think a rheumatologist is essential in this disease is that the condition should be recognized as early as possible so that proper treatment may be begun. You may be right that no more than ibuprofen is necessary.

However, AS can progress despite medication, and a more aggressive regimen may be necessary.

You deserve an expert opinion.