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Inflammatory Back Pain and the Diagnosis of Axial Spondyloarthritis

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Inflammatory Back Pain and the Diagnosis of Axial Spondyloarthritis T o p i c s i n R h e u m a T o l o g y Inflammatory Back Pain and the Diagnosis of Axial Spondyloarthritis Michael P. Keith, MD, FACP, FACR ack pain is one of the expect to see no more than 1 or 2 patients with SpA out most common muscu- of 100 referrals for chronic back pain based on a recent loskeletal problems in estimate of prevalence.4 Therefore, SpA may not be the United States. In considered in a busy clinical environment. Furthermore, B2008, Lawrence and colleagues1 radiographic changes such as sacroiliitis may take years reported that about half of to develop and typically are not present when clinical adults included in a national symptoms begin.5 To facilitate consideration of SpA in survey reported back pain in the patients with chronic back pain by orthopedic surgeons, preceding year. Though the vast inflammatory back pain and other clinical features sug- majority of patients will have gestive of these disorders will be discussed in the con- resolution of their symptoms with conservative manage- text of classification schemes employed in the current ment, patients with acute back pain are frequently evalu- approach to SpA. ated with unnecessary tests, contributing to increased healthcare costs.2 Inflammatory Back PaIn A small portion of the population develops chronic Back pain reported by patients can be conceptually back pain. The National Arthritis Data Workgroup divided into mechanical lower back pain (MLBP) or reported 14% of adults experienced an episode of low inflammatory back pain (IBP). The etiology of MLBP back pain that lasted more than 2 weeks at some point usually cannot be precisely defined but involves muscles, in their lives; pains lasting more than 3 to 6 months ligaments, and degenerative changes of the interver- AJO1 1 occurred in 5% to 10% of patients with low back pain. tebral discs or facet joints of the spine. Back pain in These patients are often referred to musculoskeletal spe- axial spondyloarthritis is referred to as IBP with several cialists for evaluation of potential underlying conditions. criteria sets available in the medical literature.6,7 Though In patients with chronic back pain, seronegative spon- sensitivity and specificity of IBP with respect to the dyloarthropathy (SNSA) should be considered. Over diagnosis of axial SpA are only about 80%,7 it remains the last several years, the rheumatology community has an important component of screening tools proposed to movedDO toward using the termNOT axial spondyloarthritis guide referralsCOPY for back pain.5,8 (SpA) to describe the inflammatory disorders charac- Calin and colleagues9 proposed the first set of inflam- teristically involving the spine previously grouped under matory back pain criteria in 1977. Five components were SNSA: ankylosing spondylitis, psoriatic arthritis, inflam- included: matory bowel disease related (enteropathic) arthritis, and 1) Insidious onset of back pain, reactive arthritis following specific enteric and genitouri- 2) Age at onset of less than 40 years, nary infections.3 The availability of a handbook serves as 3) Improvement with exercise, an important resource when approaching patients with 4) Morning stiffness, and symptoms suggestive of SpA.3 5) Back pain present for 3 or more months. Despite improvement in nomenclature, delay in diag- A 2006 study by Rudalweit and colleagues6 demon- nosis of axial spondyloarthritis occurs and results from strated a 4 component criteria for the diagnosis of IBP epidemiologic and clinical factors. Back pain is a ubiq- performed similarly to the original Calin criteria. These uitous problem and the majority of patients have a non- criteria included: specific cause of their symptoms; most providers can 1) Morning stiffness > 30 minutes, 2) Alternating buttock pain, Dr. Keith is Chief, Rheumatology Service, Walter Reed National 3) Awakening during the second half of the night due Military Medical Center, Bethesda, MD, and Associate Professor to back pain, and of Medicine, Uniformed Services University of the Health 4) Improvement of back pain with exercise but not Sciences, Bethesda, MD with rest. Address correspondence to: Dr. Keith, Rheumatology Service, In 2009, experts from the Assessment of Spondylo- WRNMMC, 8901 Wisconsin Ave, Bethesda, MD 20889 (tel, 301-295- Arthritis International Society (ASAS) developed IBP 4512; fax, 301-295-5218; e-mail, [email protected]). criteria based on the evaluation of 20 patients with Am J Orthop. 2012;41(12):E166-168. Copyright Frontline Medical undifferentiated back pain felt by referring rheuma- Communications Inc. 2012. All rights reserved. tologists to have possible axial SpA.7 The panel of 13 E166 The American Journal of Orthopedics® www.amjorthopedics.com M. P. Keith rheumatologists developed a 5 component criteria with fascia, is common in SpA.12 Finally, dactylitis, so-called the presence of 4 criteria yielding a sensitivity of 77.0% sausage digit, also occurs in SpA, particularly in psoriatic and a specificity of 91.7% for the presence of IBP; results arthritis.12 were similar but with a lower specificity in a validation Spondyloarthritis is a systemic inflammatory disease cohort (n = 648) in which 4 of 5 criteria gave a sensitivity and extra-articular inflammatory disease can occur in of 79.6% and a specificity of 72.4% for IBP. The “IBP several organ systems. Skin involvement prior to joint according to experts” criteria include age at onset less involvement is typical in the majority of cases of psori- than 40 years, improvement with exercise, no improve- atic arthritis. Keratoderma blenorragicum and circinate ment with rest, insidious onset, and pain at night with balanitis are psoriasis-like skin lesions present in some improvement upon getting up. patients with reactive arthritis. Abdominal symptoms Clinicians caring for patients with chronic back pain of pain, diarrhea, and hematochezia may occur in SpA should seek elements of inflammatory back pain as a patients with underlying inflammatory bowel disease. routine part of their evaluation. According to the ASAS, Acute anterior uveitis (iridocyclitis) is the most common each of the IBP criteria performs similarly in clinic prac- inflammatory eye lesion in SpA and results in severe eye tice.3 Regardless of the criteria employed, the finding pain, redness, and photophobia. of IBP is the entry point of published screening strate- gies and should trigger additional evaluation for axial ancIllary testIng SpA.3,5,8 Laboratory and radiographic studies are important adjuncts in the evaluation of IBP when SpA is suspected. classIfIcatIon of axIal sPondyloarthrItIs Elevated C-reactive protein (CRP) indicates systemic Multiple classification schemes have been developed to inflammation and is included in the ASAS criteria for facilitate the study of axial SpA. Though not specifically SpA.12 Human leukocyte antigen B27 (HLA-B27) is a intended for diagnostic use, classification criteria provide cellular marker associated with SpA, especially ankylos- a useful framework for the diagnosis of axial SpA in ing spondylitis.13 Radiographic sacroiliitis is a character- clinical practice. Currently available classification sets istic finding of SpA and is included in all the aforemen- include the European Spondyloarthritis Study Group tioned classification criteria.10-12 (ESSG) criteria,10 the Amor criteria,11 and most recently, HLA-B27 is present in the majority of cases of anky- 12 AJO the ASAS criteria. See Table. losing spondylitis and in 42-75% of undifferentiated spondyloarthrtitis.14 HLA-B*2705 is the most common clInIcal features of sPa subtype worldwide.13 Difficulty in the application of a Each criteria set describes clinical features contributing positive test results from the fact that this marker occurs to the diagnosis of axial SpA. Despite some variability in unaffected populations. HLA-B27 is estimated to be between the sets, they all capture clinical features that present in approximately 8% of Caucasians and 2% to mayDO indicate SpA in patients NOT younger than 45 years 4% of AfricanCOPY Americans.15 Its presence alone is not suf- old who have chronic (>3 months) back pain. Clinical ficient for diagnosis; however its presence in a patient with features that aid in the diagnosis of SpA can be divided inflammatory back pain increases the likelihood of SpA into history, articular manifestations other than IBP, and by a factor of 9.5 In general, HLA-B27 testing should extra-articular manifestations. be reserved for those patients with IBP and therefore a Historical features that should be elicited when reasonable pre-test probability of SpA rather than as a approaching back pain include response to non-steroidal screening tool in all patients with chronic back pain. anti-inflammatory drugs (NSAIDs) and family history. Judicious use of radiographs in patients with IBP can An excellent response to NSAIDs is a marker for spondy- aid in making the diagnosis of SpA. Spinal changes of loarthritis and helps to differentiate IBP from MLBP.12 Familial forms 3 of spondyloarthritis have been Table. ASAS Classification Criteria for Axial Spondyloarthritis described and indicate a higher like- Patients with ≥3 months back pain and age at onset < 45 years lihood of disease in patients with a • Sacroiliitis on imaging (radiograph or MRI) • Positive HLA-B27 positive family history.12 Peripheral skeletal manifestations • Plus 1 or more spondyloarthritis feature • Plus 2 or more spondyloarthritis features should be sought in patients with Spondyloarthritis features IBP.
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