Could that back pain be caused by ankylosing spondylitis?

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Applied Evidence

Could that back pain be caused by ankylosing spondylitis?

J Fam Pract. 2019 May;68(4):E1-E6

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References

1. Sieper J, Poddubnyy D. Axial spondyloarthritis. Lancet. 2017;390:73-84.

2. Lawrence R, Helmick C, Arnett F, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41:778-799.

3. Rudwaleit M, van der Heijde D, Landewe R, et al. The development of assessment of spondyloarthritis international society classification criteria for axial spondyloarthritis (part II); validation and final selection. Ann Rheum Dis. 2009;68:777-783.

4. Seo MR, Baek HL, Yoon HH, et al. Delayed diagnosis is linked to worse outcomes and unfavorable treatment responses in patients with axial spondyloarthritis. Clin Rheumatol. 2015;34:1397-1405.

5. van der Linden SM, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984;27:361-68.

6. National Institute for Health and Care Excellence. NICE Guideline, No. 65. Spondyloarthritis in over 16s: diagnosis and management. February 2017. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0091652/. Accessed April 24, 2019.

7. Dincer U, Cakar E, Kiralp MZ, et al. Diagnosis delay in patients with ankylosing spondylitis: possible reasons and proposals for new diagnostic criteria. Clin Rheumatol. 2008:27:457-462.

8. Underwood MR, Dawes P. Inflammatory back pain in primary care. Br J Rheumatol. 1995;34:1074-1077.

9. Strand V, Singh J. Evaluation and management of the patient with suspected inflammatory spine disease. Mayo Clin Proc. 2017;92:555-564.

10. Sieper J, van der Heijde D, Landewe R, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Ann Rheum Dis. 2009;68:784-788.

11. Poddubnyy D, van Tubergen A, Landewe R, et al. Development of ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis. Ann Rheum Dis. 2015;74:1483-1487.

12. Rostom S, Dougados M, Gossec L. New tools for diagnosing spondyloarthropathy. Joint Bone Spine. 2010;77:108-114.

13. Bernard SA, Kransdorf MJ, Beaman FD, et al. ACR appropriateness criteria chronic back pain suspected sacroiliitis-spondyloarthropathy. J Am Coll Radiol. 2017;14:S62-S70.

14. Dougados M, Demattei C, van den Berg R, et al. Rate and predisposing factors for sacroiliac joint radiographic progression after a two-year follow-up period in recent-onset spondyloarthritis. Arthritis Rheumatol. 2016;68:1904-1913.

15. Regel A, Sepriano A, Baraliakos X, et al. Efficacy and safety of non-pharmacological treatment: a systematic literature review informing the 2016 update of the ASAS/EULAR recommendations for the management of axial spondyloarthritis. RMD Open. 2017;3:e000397.

16. Kroon FPB, van der Burg LRA, Ramiro S, et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for axial spondyloarthritis (ankylosing spondylitis and non-radiographic axial spondyloarthritis). Cochrane Database Syst Rev. 2015;7:CD010952.

17. Radner H, Ramiro S, Buchbinder R, et al. Pain management for inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and other spondyloarthritis) and gastrointestinal or liver comorbidity. Cochrane Database Syst Rev. 2012;1:CD008951.

18. van der Heijde D, Ramiro S, Landewe R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76:978-991.

19. Maxwell LJ, Zochling J, Boonen A, et al. TNF-alpha inhibitors for ankylosing spondylitis. Cochrane Database Syst Rev. 2015;4:CN005468.

20. Sieper J, Poddubnyy D. New evidence on the management of spondyloarthritis. Nat Rev Rheumatol. 2016;12:282-295.

21. Zochling J. Measures of symptoms and disease status in ankylosing spondylitis. Arthritis Care Res. 2011;63:S47-S58.

In addition, AS predominantly affects people in the third and fourth decades of life, but as many as 5% of patients of all ages with chronic back pain (> 3 months) can be classified as having AS.⁸ In patients who have IBP features, 14% can be classified as having axSpA.⁹ Therefore, it is important to recognize the features of IBP (TABLE 1¹⁰). The presence of 4 of the 5 of IBP features has a sensitivity of 77% and a specificity of 91.7% for IBP.¹⁰

A different kind of back pain. The vast majority of patients presenting with low back pain will have features of mechanical back pain, which include improvement with rest, mild and short-lived morning stiffness and/or pain upon waking, and the absence of inflammatory markers. Those with axSpA, on the other hand, are more likely to report improvement of pain with exercise, no improvement with rest, and pain at night with improvement upon rising. While the presence of IBP features alone isn’t diagnostic for nr-axSpA or AS, such features should increase your suspicion, especially when such features are present in younger patients.

Physical exam findings

Physical exam findings are neither sensitive nor specific for the diagnosis of an axSpA disorder, but can help build a case for one. The physical exam can also assist in identifying comorbid conditions including uveitis, psoriasis, dactylitis, and enthesitis. Experts do not recommend using serial measurements of axial range of motion because they are time-consuming, and normative values are highly variable.

On examination of the peripheral joints and feet, note any swollen, tender, or deformed joints, as well as any dactylitis. Although any enthesis can be affected in axSpA, the insertional points of the Achilles and the plantar fascia are the most typical,¹ so pay particular attention to these areas. On skin exam, note any evidence of psoriatic manifestations. Refer all patients with suspected uveitis to an ophthalmologist for confirmation of the diagnosis.

Lab studies: Not definitive, but helpful

No laboratory studies confirm a diagnosis of nr-axSpA or AS; however, 2 studies—C-reactive protein (CRP) and HLA-B27—are important, as levels are listed as part of ASAS’s axSpA features (TABLE 2³) and are factors that should be considered when deciding whether a referral is needed (TABLE 3¹¹). As such, HLA-B27 and CRP testing should be performed in all patients suspected of having an axSpA spectrum disorder.

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