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Posts Tagged ‘bone erosion’

I’m still in the midst of recovering from cervical fusion surgery on May 15 and am currently completing physical therapy. The process seems to be going well, pain and numbness is almost completely gone, and I’m slowly regaining muscle strength. After dealing with it for over 8 months, the neck and associated parts finally feels much better. But RA is never silent and has a way of rearing its ugly head just when you think things are calm. Sure, there is always the ongoing “background noise” of RA – fatigue, joint and muscle pain, finger swelling and pain, joint locking, and the persistent ankle pain after having three surgeries. But now the left hip is begging – no screaming – for attention.

Hip problems became apparent almost two years ago when I began getting steroid injections for trochanteric bursitis from my rheumatologist. Bursae are sac-like structures that are found in some joints and aid in providing friction reduction.[1] I had a bursa removed as part of an ankle surgery. The trochanteric bursa is on the outside of the hip and is commonly involved in RA.[2]

While my neck was healing, the left hip progressively grew worse. Sitting for any length of time was impossible, getting in and out of a chair and car was difficult, sleeping on the left side was not feasible, and the left side was favored while walking. At a recent rheumatology appointment, a fourth cortisone steroid injection was given into the trochanteric bursa. But the injection brought no relief. My rheumatologist referred me to an orthopedic specialist.

The orthopedic surgeon examined x-rays and noted that the space in the ball and socket joint, while somewhat reduced, looked fine. There was no bone erosion perceived. We spent some time discussing my earlier problems with the trochanteric bursa, the multiple steroid injections, and my current symptoms of groin and buttock pain. He then laid me down on my back and began to examine my hip movement through a series of tests. I couldn’t lift my leg off the table and extreme pain was felt when he manipulated it in various ways. After the physical exam his entire line of inquiry changed from the more external trochanteric bursa to focusing on tissues around the joint itself. He immediately began to suspect a labral tear. The labrum is cartilage that surrounds the hip joint.[3] But a physical exam and x-ray cannot directly pinpoint what’s really going on so an MRI is needed. A traditional MRI can’t always detect soft tissue in the complex hip joint so an arthrogram is added. Before the MRI, a radiologist injects a combination of fluid, steroid, and a contrast into the hip joint under the guidance of an x-ray. After the injection, you go directly to the MRI machine. The steroid can also provide a therapeutic purpose in reducing inflammation and pain. I am scheduled for an MR arthrogram tomorrow and hopefully it will help solve the mystery.

In addition to the more traditional bone erosion, I have a history of developing soft tissue damage to the musculoskeletal system from RA. This episode with the hip seems to be following that story.

[1] http://orthoinfo.aaos.org/topic.cfm?topic=a00409

[2] https://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Tendinitis_and_Bursitis/

[3] http://www.hss.edu/condition-list_labral-tears-hip.asp#.U_zH9WRDvA4

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In an earlier post, I outlined how RA can impact much more than bones including many organs and soft tissues. One group of soft tissues that can be damaged by RA includes those involved with the musculoskeletal system. The musculoskeletal system involves a complex interaction between muscles, bones, joints, and various connective soft tissues – all which can be the target of RA.

Erosion of bone tissues in joints is on of the trademark symptoms of rheumatoid arthritis. Through complex autoimmune biochemical processes, the body’s immune system attacks it’s own tissues like it was a foreign invader. A cascade of signaling chemicals promotes the production of bone cells called osteoclasts that erode bone tissue and surrounding cartilage. This kind of gross damage…

Read more at http://rheumatoidarthritis.net/living/attack-on-connective-tissues/

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Multi-Level: involving more than one.

Anterior: nearer the front, especially situated in the front of the body or nearer to the head.

Cervical: of or relating to the neck.

Discectomy: surgical removal of the whole or a part of an intervertebral disc.

Fusion: the process or result of joining two or more things together to form a single entity.

Osteophytes: bone spurs

Excision: Surgical removal by cutting.

I received an epidural steroid injection into my neck and no relief was felt. Pain levels in my neck, shoulders, and arms got out of hand to the point where sleep was not being had. My fingers were numb, tingling, with small motor function suffering. Work, both professional and at home, was not getting done. Leaving the house was mostly out of the question. Because of these issues, my physical therapist refused to treat me and based on a discussion about various other symptoms, he said that he was running next door to the neurosurgeon’s office to determine if they could see me immediately. He came back shortly and said that they were getting me in 30 minutes. After a long exam and discussion, the doctor indicated that surgery would be the only route that would provide long term relief. After thinking about it and reading the variety of literature provided by the doctor’s office, I finally agree to proceed and it is scheduled for May 15.

The procedure will be a multi-level anterior cervical discectomy, fusion and osteophyte excision. Going in from the front of the neck, two herniated discs between vertebrae C5-C6 and C6-C7 will be removed, bone spurs impinging on nerves and spinal cord cut away, a plastic mesh containing parts of my own bone material inserted into the disc space, and titanium screws will be used to connect the three vertebrae. The entire procedure will take about 3-4 hours and I will stay in the hospital overnight. Recovery is at least 6 weeks. Here’s a nice post from Sandy who described her experiences with a similar procedure.

I’ve had three ankle surgeries and a sinus surgery. Even though the sinus surgery was very close to my brain, this one seems a little more intense. Maybe that’s because they will be putting titanium screws into my neck. Or that a hospital stay is required. Or that there’s so many life necessary parts in that area. But I trust the surgeon as he’s well qualified and trained, board certified, part of a large hospital spine center, and done many of these procedures in the past. The decision to have surgery is never to be taken lightly. But given the long term and increasingly intense pain, coupled with disability of function, it’s clearly time to proceed.

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Rheumatoid_arthritis_jointBone erosion is one of the hallmark symptoms of RA and the biological processes involved in RA often result in the breakdown of bony tissue primarily in joints which are surrounded by a sac called the synovium (see diagram). I have this telltale bone erosion in my fingers documented via x-ray and a dime-sized erosion was found in my heel bone several years ago which caused a sharp bone spur. A surgeon removed the damaged tissue and a pathology report confirmed that it was caused by the erosive processes associated with RA.

But RA can impact other parts of the joint including the surrounding soft tissue – tendons, ligaments, and cartilage. Chronic tenosynovitis, inflammation of the sheath of a tendon is common in rheumatoid arthritis and can result in the permanent damage and tearing of the involved tendons. Such tendon problems caused by RA are well known by the scientific community and are linked to joint deformities (see Sivakumar, et al, 2008; Wakefield, et al, 2007). Tendon problems have even been posited as being one of the most powerful predictors of early RA (Eshed, et al, 2009). Sophisticated imaging techniques developed in the last few decades, such as MRIs and ultrasound, can reveal connective tissue damage in joints caused from RA including tenosynovitis and bursitis (Boutry, et al, 2007). Bursitis, inflammation of the fluid-filled sacs that protect joints (see NIH site), often accompanies tenosynovitis. RA is also implicated as a cause of cartilage damage in knees (see the AAOS site). An MRI taken at the onset of my RA diagnosis revealed cartilage damage in one knee.

Soft tissue damage became apparent after dealing with a persistently cranky elbow that was only getting worse to the point that major pain killers were needed one evening. I learned from an orthopedic doctor this week that I now have tendon tears in my elbow. The good news is that the bones and joint spaces are in good shape and appear to be undamaged from RA. While in non-RA patients the tendons commonly tear due to overuse, the doctor was unsure about the relative contributions of RA and overuse to the tearing. But since I don’t tend to overuse my elbow, except when fishing a couple of times this summer, I can’t help but think that RA is the major contributor – especially in light of previous history. Tendon problems have been a hallmark of my struggles with RA. One of the first symptoms I experienced, even before official diagnosis, was Achilles tendon tearing in both ankles which resulted in two surgeries. This bilateral problem, coupled with other symptoms, ultimately led to seeing a rheumatologist and receiving a diagnosis of RA. Several years later the tendon tearing continued and a third surgery was needed on the right ankle to repair the tendon, remove a bursa sac, and remove damaged bone tissue. Even after those procedures, my Achilles tendons continue to speak rather loudly everyday.

At this point, conservative treatments to the elbow will begin and include use of braces, topical NSAIDs (Voltaren gel), and physical therapy. Cortisone injections may be used if conservative treatments don’t work with surgical repair being the last line of treatment. So we wait and see if the most recent RA treatment (Rituxan) and the newly prescribed elbow treatments can slow down soft tissue damage enough to allow the tendons to heal on their own.

Photo attribution: By Wouterstomp at en.wikipedia [Public domain], from Wikimedia Commons

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450px-Walking_ManThe other day I walked into the kitchen and my wife laughingly said to me, “You’re walking like Frankenstein”. I laughed back because I knew that I was like the “living dead” for many reasons but mostly because of changes in my joints. I have bursitis in both hips which radiates pain down the thigh and in the buttocks (I got two cortisone shots recently and they did nothing – but that’s another story), cartilage damage in both knees, and three surgeries on my ankles. Add to that, I could barely get out of bed and walk around this morning due to sharp pain in the same area of the right ankle that’s had two surgeries. I’ve felt that pain before which was from erosion in the heel bone causing spurs to dig into the Achilles tendon. Yep, I was walking stiffly and probably looked like a monster from a movie.

It’s a natural tendency to make adjustments due to pain or joints that aren’t working as designed. Joint changes from rheumatoid arthritis seem to be inevitable As bone and soft tissues are attacked, damaged, and eroded, the joints can no longer work as they should. Fortunately, disease modifying medications can slow down the damaging biochemical processes. In spite of being on medications, changes are still affecting my movement and activity.

When the term arthritis is mentioned, the first thing that comes to most people’s mind is probably bone damage. With the more common osteoarthritis (OA), there may be damaged cartilage causing bone to rub together. But with rheumatoid arthritis (RA), the immune system attacks the body’s own tissue. The capsule surrounding the joint, called the synovium, becomes enlarged due to an increase of immune cells. Eventually an overproduction of bone eroding cells and enzymes begins to erode bone tissue and soft tissues.[i] The soft tissues that hold the joint together including tendons, ligaments, and cartilage are also damaged.[ii] [iii] When all of these tissues become affected, the entire skeletal structure designed for movement cannot work properly. Add to that stiffness caused by RA, and the result is walking like Frankenstein!

My joints used for walking are changing and the effects are becoming noticeable not just to me, but to those around me. Add to that the fact that any hope for strenuous physical activity is pretty much gone for now. My daughter wants to go snow skiing but the best I could do is drive her there and sit in the lodge drinking cocoa. The hope is that treatments can keep the process at bay long enough so I can avoid more surgeries and using assistive devices just to carry out that common, everyday task we take for granted – walking.

Photo Credit: By Stefan Eggert (User:Berreu) (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons

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 Definition of TWINGE
transitive verb
1 dialect : pluck, tweak
2: to affect with a sharp pain or pang[i]

A typical day with RA includes gentle reminders such as stiff and tender fingers while typing, difficulty getting up out of a chair if sitting more than 30 minutes, a knee that pops loudly while flexing, elbows that ache, and then there’s the ubiquitous fight with fatigue. After three ankle surgeries on torn Achilles tendons, tendon insertion tears, and bone erosion in the heel, these areas are omnipresent reminders of RA. Most days it’s tolerable and doesn’t impact walking – although strenuous exercise is out of the question. But every once in a while when going up or down stairs a sharp pain comes out of nowhere to scream a very loud reminder. This twinge catches me by surprise. Many times the pain is so bad that I must stop on the stairs and change the way I walk. Many have seen me limp away from the stairs. The sharp pain usually lasts for a few hours before subsiding. Once the major pain is gone, I usually forget it and move on. But the little voice in my head always asks if there is more RA-induced damage that will result in another surgical procedure someday. Ignoring that voice is helpful as there’s nothing to do about it now.

Recovery from sinus surgery seems to be going well. It’s been 10 days and the bleeding is almost gone, breathing is better, headaches are less intense, and energy levels are slowly returning yet with peaks and valleys. The best news is that today was the last dose of the antibiotic Cephalexin. This is the last of four antibiotics taken over the past 3 months. These strong antibiotics impact the GI system in very uncomfortable ways which won’t be missed. Arava will be added back to the RA treatment regimen tomorrow. Of course, Arava brings its own set of GI side effects which aren’t too bad at the 10mg per day level. The next Orencia infusion is Tuesday and I’m glad that I didn’t have to miss a dose during this entire sinus situation. Hopefully sinus infections will be a thing of the past.

Early next week I plan to write a post about the role of cell death in rheumatoid arthritis, genetic links, possible treatments, and how this is connected to cancer. Have a good weekend!


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I’ve been absent from this blog for almost 1 ½ years, I decided to jump back and start writing again. And much has transpired since the last post. After stringing it out as long as possible, I had my third ankle surgery in late November 2011. The orthopedic surgeon cleaned up bone erosion on the top side of the heel bone, removed a bone spur poking into my Achilles tendon, removed a bursa sac, and repaired mores tears in the Achilles tendon. Tissues samples were sent to pathology and the lab results noted bone erosion and inflammation caused by rheumatoid arthritis.

Stopping Humira injections in early November 2011 was necessitated by the pending ankle surgery but also by the fact that it just wasn’t helping that much anymore. In addition, a 3 cm swollen lymph node in my armpit needed to be checked out. Short story – saw a great oncologist and after many blood tests, an ultrasound, and a CT scan with iodine contrast, everything came back negative with no lymphoma! One interesting blood test result was that I had a positive Rheumatoid Factor test for the first time. I was finally seropositive and felt like I was no longer the seronegative stepchild of RA. Although I know that upwards of 30% of folk don’t have positive RA blood tests.

I was started on Orcenia infusions in January 2012. I was done with TNF blockers after using Enbrel, Cimzia, and Humira. After insurance approval, I had three loading doses every two weeks before moving to a regular schedule of once a month. Having a nurse administered infusion at a clinic was a new experience compared to self-injections of Enbrel and Humira. It was a rough few months but I began to get back some energy and have less joint pain and stiffness.

By this point, I decided to pursue a new rheumatologist. I had been with my original rheumatologist from the beginning and he made the initial diagnosis. But over time I began to realize that it was time for a change. I sought out a new rheumy by asking around, checking out published lists of top doctors in the region, and looking at patient reviews online. A choice was made and an appointment with a new rheumy scheduled. As an added advantage, her clinic just relocated to a brand new, clean, and cheery building. I had all medical records sent to her.

The first appointment was a pleasant experience from the beginning with smiling staff, caring nurses, and the fact that I didn’t have to wait. The first thing the doctor told me was that she spent considerable time reading all of my medical records. That was a refreshing to know – she already had an idea about my case before I arrived. She then asked me to tell my story in my own words. Given my history, my new rheumy suspects that I may have a combination of RA and ankylosing spondylitis – an autoimmune condition which commonly affects ankles, hips, and backs. She joked that I would be a good subject for genetic testing! We discussed how Orencia was working and she felt like I would benefit from the addition of a disease modifying drug (DMARD). Since methotrexate and I didn’t have a good relationship a few years ago, she wanted to try leflunomide (Arava). In fact, she suspects that one reason that TNF blockers stopped working was that I wasn’t on combination therapy resulting in the building up of antibodies to Enbrel and Humira. I appreciated her optimism about being able to help and compassion about my experiences.

New adventures lie ahead with a new doctor, new medicines, and new possible side effects. But hope springs eternal just like the sun finally coming out in Seattle.

Photo taken by my daughter on a sunny day in Puget Sound.

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