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Prevalence of Spondyloarthritis Among Patients Who Underwent Lumbar Disc Herniation Surgery

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Prevalence of Spondyloarthritis Among Patients Who Underwent Lumbar Disc Herniation Surgery Arch Rheumatol 2020;35(2):189-195 doi: 10.46497/ArchRheumatol.2020.7323 ORIGINAL ARTICLE Prevalence of Spondyloarthritis Among Patients Who Underwent Lumbar Disc Herniation Surgery Özgül SOYSAL GÜNDÜZ1, Servet AKAR2, Dilek SOLMAZ2, Gerçek CAN3, Fatoş ÖNEN3, Nurullah AKKOÇ1 1Department of Internal Medicine, Division of Rheumatology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey 2Department of Internal Medicine, Division of Rheumatology, Katip Çelebi University, Faculty of Medicine, İzmir, Turkey 3Department of Internal Medicine, Division of Rheumatology, Dokuz Eylul University, Faculty of Medicine, İzmir, Turkey ABSTRACT Objectives: This study aims to estimate the prevalence of spondyloarthritis (SpA) among patients who had been surgically treated for lumbar disc herniation (LDH), according to the modified New York (mNY) criteria for the diagnosis of ankylosing spondylitis and Amor, the European Spondyloarthropathy Study Group (ESSG), the Assessment of Spondyloarthritis International Society (ASAS) classification criteria for SpA. Patients and methods: The study included 321 patients (142 males, 179 females; mean age 49±10.8 years; range, 18 to 79 years) who underwent LDH surgery between April 2008 and May 2012 in the neurosurgery clinic of our hospital. Patients were contacted by phone on at least two attempts. Totally, 123 patients accepted to come to the outpatient clinic, while the remaining 198 agreed to be interviewed on the phone. Patients who agreed to come to the outpatient rheumatology clinic underwent clinical examination, and pelvic X-ray and magnetic resonance imaging (MRI) scan of the sacroiliac joints when indicated. Results: Inflammatory back pain was diagnosed in 108 patients (34%) and 40 patients (13%) according to Calin criteria and the ASAS criteria, respectively. Prevalence of SpA among all patients was estimated as 17.7% according to the ESSG criteria, and 8.7% according to Amor criteria. Five of the 308 pelvic radiographs had definite radiographic sacroiliitis as required by the mNY criteria. Four patients had a characteristic pattern of bone marrow edema on MRI examination in accordance with the ASAS definitions. The overall prevalence of sacroiliitis (MRI sacroiliitis+X-ray sacroiliitis) among the patients who came to the clinic was 7.3% ([4+5]/123). Conclusion: The relatively increased prevalence of SpA among patients who underwent LDH surgery indicates the necessity of increasing awareness on the new concept of axial SpA for specialists treating patients with low back pain. Keywords: Inflammatory back pain, lumbar disc herniation, spondyloarthritis. Spondyloarthritis (SpA), being a group of symptoms and diagnosis.2-5 Inability to diagnose diseases carrying common pathophysiological, AS early decreases the quality of life due to pain, clinical, radiological and genetic characteristics, stiffness and limitations and moreover, it causes a is one of the most commonly encountered critical labor loss because of beginning in the early rheumatological diseases in society with an twenties, the most active phase of life. estimated standardized prevalence of 1.7%.1 The most prominent clinical feature of AS Ankylosing spondylitis (AS), the prototype of is chronic back pain (CBP), mostly in the form this group, has the longest diagnostic delay with of inflammatory back pain (IBP). Inability of the a period of 5 to 10 years between the onset of first level health-care providers and the other Received: November 28, 2018 Accepted: June 28, 2019 Published online: February 07, 2020 Correspondence: Özgül Soysal Gündüz, MD. Celal Bayar Üniversitesi Tıp Fakültesi İç Hastalıkları Anabilim Dalı, Romatoloji Bilim Dalı, 45030 Yunusemre, Manisa, Turkey. Tel: +90 505 - 228 29 30 e-mail: [email protected] Citation: Soysal Gündüz Ö, Akar S, Solmaz D, Can G, Önen F, Akkoç N. Prevalence of Spondyloarthritis Among Patients Who Underwent Lumbar Disc Herniation Surgery. Arch Rheumatol 2020;35(2):189-195. ©2020 Turkish League Against Rheumatism. All rights reserved. 190 Arch Rheumatol specialists like orthopedists and neurosurgeons 179 females; mean age 49±10.8 years; range, in recognizing IBP and other SpA symptoms is 18 to 79 years) either accepted to come to our one of the main reasons accounting for the delay clinic (n=123) or to have a telephone interview in the diagnosis of AS.2,6 In clinical practices, (n=198). The study protocol was approved by the disc disease is a common inaccurate alternative Dokuz Eylül University Hospital Ethics Committee diagnosis determined for AS patients suffering (approval number: 137-IOC/2009). A written from chronic low back pain.7-9 Inappropriate informed consent was obtained from each patient. overuse of lumbar spinal magnetic resonance The study was conducted in accordance with the imaging (MRI) examinations in these patients principles of the Declaration of Helsinki. leads to an overdiagnosis of lumbar disc herniation Patients were identified for contact by phone (LDH) due to incidental findings on MRI, and it on at least two attempts, with one week apart also infrequently results in unnecessary surgical (Figure 1). All contacted patients with or without interventions. Therefore, in this study, we aimed current back pain were invited to the outpatient to estimate the prevalence of SpA among patients rheumatology clinic for clinical examination. who had been surgically treated for LDH, according Patients were evaluated using a standard to the modified New York (mNY) criteria10 for questionnaire that provided detailed information the diagnosis of AS and Amor,11 the European on demographics and features of IBP according Spondyloarthropathy Study Group (ESSG),12 the to the ASAS13 criteria, the Calin criteria,14 Berlin Assessment of Spondyloarthritis International criteria,15 and also all the features of SpA listed in Society (ASAS)13 classification criteria for SpA. the mN Y,10 Amor,11 ESSG12 and ASAS13 criteria. For patients who were unwilling to come to the clinic but who accepted the phone interview, PATIENTS AND METHODS an appointment was set to administer the same questionnaire on the phone. There were 789 patients who underwent LDH surgery between April 2008 and May 2012 in Information on demographics, signs and the neurosurgery clinic of Dokuz Eylül University symptoms at presentation, clinical course and Hospital. We were unable to reach 468 patients treatment data were obtained from patients and (59.3%) despite at least two attempts of contact. hospital records. The frequency of nonsteroidal All contacted and not-contacted patients had anti-inflammatory drug (NSAID) usage before similar age (mean age 49±10.8 years and 48±11.5 and after LDH surgery, and rates of NSAID years; p=0.344) and similar sex distribution responses were recorded. Patients who came to (male: 44.2% and female: 39.3%; p=0.244). the clinic underwent all spinal measurements and Patients we have contacted (n=321) (142 males, a neurological examination. Functional status Patients who underwent lumbar disc herniation surgery between 2008 and 2012 (n=789) Contacted patients Not-contacted patients (n=321) (n=468) Patients who came to Patients interviewed on the clinic (n=123) the phone (n=198) 116 pelvic X-ray were 192 pelvic X-ray were evaluated evaluated 12 magnetic resonance imaging of sacroiliac joints evaluated Figure 1. Flowchart summarizing the evaluation of patients with prior lumbar disc herniation surgery for fulfilling the various spondyloarthritis classification criteria. Spondyloarthritis and Lumbar Disc Herniation 191 was assessed by the Bath Ankylosing Spondylitis of continuous variables, while Chi-square test was Functional Index,16 and the activity of disease used to examine the differences with categorical was assessed by the Bath Ankylosing Spondylitis variables. A p value <0.05 was considered to be Disease Activity Index.17 Spinal mobility statistically significant. measurements were detected by using the Bath Ankylosing Spondylitis Metrology Index.18 The imaging scans of all patients obtained RESULTS before and after LDH operation were examined The group of patients who came to the from hospital image databank. Standard pelvic clinic and the group of patients interviewed on X-rays were performed to assess sacroiliac joints the phone had similar age, sex distribution and (SIJs) if the patients accepted face-to-face interview. symptom duration. However, education level was We used the pelvic X-rays still available on the significantly higher in patients who came to the hospital image database for patients who were clinic (9±4.4 years vs. 7±4.1 years; p<0.001), and interviewed on the phone, or who came to the they reported higher residual low back pain after clinic but refused to undergo a new X-ray. MRI was surgery (68% vs. 51.7%; p<0.001). The mean performed on SIJs in patients with IBP according age of all patients at the onset of low back pain to the IBP criteria without radiographic sacroiliitis. was 34±12.5 years and it was 41±12.4 years at Acute and chronic lesions on SIJs MRI were scored LDH diagnosis. Some of the demographic and according to ASAS/The Outcome Measures in clinical characteristics of the study groups are Rheumatology (OMERACT) MRI working group.19 summarized in Table 1. The pelvic X-rays and MRI scans were scored by Inflammatory back pain was found in 108 one rheumatologist and one radiologist who were patients (33.6%) according to Calin criteria,14 in 51 blinded for clinical information. patients (16.4%) according to Berlin criteria,15 and Statistical analysis in 40 patients (13%) according to ASAS criteria.13 The statistical analysis was carried out using A total of 308 pelvic radiographs were the SPSS version 13.0 software (SPSS Inc., obtained. Totally, 116 of the 123 attending Chicago, IL, USA). Values are presented as patients had new pelvic X-rays, and 192 of the mean±standard deviation for continuous variables, 198 non-attending patients had a standard pelvic and as percentage values for categorical variables. X-ray archived in the hospital’s image database Student’s t-test was used to compare the groups (Figure 1).
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