Back Pain and The Covid-19 Pandemic
By: Dr. David Borenstein M.D. 5/2020
Coronavirus 19 infection is a novel disease that has spread across the world. Since it is a new infection, all of the world’s population is at risk. Although the characteristics of this infection continue to be discovered, some factors have become clear. Individuals who are 50 years old or greater have increased susceptibility. In addition, individuals with co-morbidities have an increased mortality. Do these factors have an impact on the members of The Spine Community?
The most common disorders that affect members of the Spine Community are mechanical disorders like a herniated intervertebral disc or spinal stenosis. These problems have no impact on the immune system. The threat to an individual with mechanical disorders has to do more with their age. Spinal stenosis patients tend to be older and would be at risk because of an age factor.
Other disorders, like ankylosing spondylitis, do damage because of abnormalities of the immune system. The immune system has multiple functions. One function involves wound repair that is mediated through inflammation. Immune function also protects against a variety of infections that are recognized as “non-self.” These foreign invaders may be bacteria, viruses, or fungi, for example. The transport of blood factors (immunoglobulins) and immune cells (neutrophils, lymphocytes, monocytes, macrophages) to the locations of infections is an intricate process that requires an organized series of events that result in the elimination of these infections.
When all these factors are working appropriately, an individual can expect their immune system to get it just right, not to little or too much. In individuals who have an impaired immune system, they may be immunocompromised because of a disorganization of the immune process. For example, diabetes with increased glucose levels can impair blood vessel function that allows for the free flow of immunoglobulins and immune cells to an area of infection. In this circumstance, organisms can grow unchecked causing increasing severity of infection. Improving glucose levels is one way of improving immune function.
In individuals who have an overactive immune system, damage may appear in different areas of the body including the joints. Individuals who have overactive immune systems include those with ankylosing spondylitis and rheumatoid arthritis. In these disorders, the immune system mistakes parts of the body as”non-self” and tries to destroy it. In these individuals, the immune system needs to be suppressed so that damage to one’s self is limited. In these patients, immunosuppression is important to the degree that it controls the disease but does not go so far to immunocompromise the individual.
Both of these groups are at increased risk from the Covid-19 virus. It is potentially easier to reverse immunosuppression than to reverse an immunocompromised individual. I have suggested to my patients who have exposed to Covid-19 to skip a dose of their biologic therapy until they know whether they have been infected or not. A simple intervention like this does not exist for those immunocompromised individuals. Immunoglobulin levels may be improved by the infusion of gammaglobulins. Currently, therapy does not exist that improves the function of the immune cells significantly to reverse these abnormalities.
The CDC and NIH are offering the best advice available in regard to avoiding the Covid-19 infection. Testing is essential in identifying people who have the infection. Once those individuals are identified, they can be isolated to decrease the risk of spreading the infection. That is the most efficient way of decreasing numbers until a vaccine is developed and distributed. At this time, one of the drugs that is used in the treatment of rheumatoid arthritis, tocilizumab, an anti-interleukin -6 antibody, may have an inhibiting effect on the extent of pulmonary disease associated with the infection. If this turns out to be true, this could be a means of saving individuals with compromised lung function.
Immunocompromised and immunosuppressed individuals should take the Covid-19 infection very seriously. The recommendations of washing hands frequently, refraining from touching your face, and avoiding large crowds makes sense. We all need to be vigilant to reduce the risk to ourselves and others until this infection is controlled.