How to diagnose axial spondyloarthritis early

BACKGROUND Chronic low back pain (LBP), the leading symptom of ankylosing spondylitis (AS) and undifferentiated axial spondyloarthritis (SpA), precedes the development of radiographic sacroiliitis, sometimes by many years. OBJECTIVE To assign disease probabilities and to develop an algorithm to help in the early diagnosis of axial SpA. METHODS Axial SpA comprises AS and undifferentiated SpA with predominant axial involvement. Clinical features include inflammatory back pain (IBP), alternating buttock pain, enthesitis, arthritis, dactylitis, acute anterior uveitis, a positive family history, psoriasis, inflammatory bowel disease, and good response to NSAIDs. Associated laboratory findings include raised acute phase reactions, HLA-B27 association, and abnormalities on skeletal imaging. Sensitivities, specificities, and likelihood ratios (LRs) of these parameters were determined from published studies. A 5% prevalence of axial SpA among patients with chronic LBP was used. The probability of the presence of axial SpA, depending on the presence or absence of the above clinical features of SpA, was determined. A probability of > or = 90% was used to make a diagnosis of axial SpA. RESULTS The presence of inflammatory back pain features increased the probability of axial SpA from the background 5% prevalence to 14%. The presence of 2-3 SpA features was necessary to increase the probability of axial SpA to 90%. The highest LRs were obtained for HLA-B27 and MRI. Diagnostic algorithms to be used in daily practice were suggested. CONCLUSIONS This approach can help clinicians to diagnose with a high degree of confidence axial SpA at an early stage in patients with IBP who lack radiographic sacroiliitis.

[1]  J. Hanly,et al.  Early recognition of sacroiliitis by magnetic resonance imaging and single photon emission computed tomography. , 1994, The Journal of rheumatology.

[2]  K. Puhakka,et al.  Imaging of sacroiliitis in early seronegative spondylarthropathy , 2003 .

[3]  A. Calin,et al.  Clinical history as a screening test for ankylosing spondylitis. , 1977, JAMA.

[4]  H. Zeidler,et al.  Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial , 2002, The Lancet.

[5]  K. Wolf,et al.  Early sacroiliitis in patients with spondyloarthropathy: evaluation with dynamic gadolinium-enhanced MR imaging. , 1995, Radiology.

[6]  M. Baron,et al.  HLA-B27 testing in ankylosing spondylitis: an analysis of the pretesting assumptions. , 1989, The Journal of rheumatology.

[7]  G. Hunder.  The Use and Misuse of Classification and Diagnostic Criteria for Complex Diseases , 1998, Annals of Internal Medicine.

[8]  M. Khan.  Clinical application of the HLA-B27 test in rheumatic diseases. A current perspective. , 1980, Archives of internal medicine.

[9]  G. Boyer,et al.  Evaluation of the European Spondylarthropathy Study Group preliminary classification criteria in Alaskan Eskimo populations. , 1993, Arthritis and rheumatism.

[10]  C. Bombardier,et al.  Criteria for rheumatic disease. Different types and different functions. The American College of Rheumatology Diagnostic and Therapeutic Criteria Committee. , 1994, Arthritis and rheumatism.

[11]  F. Guillemin,et al.  Prevalence of rheumatoid arthritis and spondyloarthropathy in Brittany, France. Société de Rhumatologie de l'Ouest. , 1999, The Journal of rheumatology.

[12]  A. Cats,et al.  Evaluation of diagnostic criteria for ankylosing spondylitis: a comparison of the Rome, New York and modified New York criteria in patients with a positive clinical history screening test for ankylosing spondylitis. , 1985, British journal of rheumatology.

[13]  John C. Davis,et al.  Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor alpha. , 2002, The New England journal of medicine.

[14]  M. Underwood,et al.  Inflammatory back pain in primary care. , 1995, British journal of rheumatology.

[15]  A. Cats,et al.  Radiological and scintigraphic findings in patients with a clinical history of chronic inflammatory back pain , 2004, Skeletal Radiology.

[16]  M. Khan,et al.  HLA-B27 polymorphism and association with disease. , 2000, The Journal of rheumatology.

[17]  John A. Davis,et al.  Anti-tumour necrosis factor α therapy for ankylosing spondylitis: international experience , 2002 .

[18]  D. Baeten,et al.  Randomized double-blind comparison of chimeric monoclonal antibody to tumor necrosis factor alpha (infliximab) versus placebo in active spondylarthropathy. , 2002, Arthritis and rheumatism.

[19]  P I Terasaki,et al.  High association of an HL-A antigen, W27, with ankylosing spondylitis. , 1973, The New England journal of medicine.

[20]  M. Dougados,et al.  Clinical relevance of C-reactive protein in axial involvement of ankylosing spondylitis. , 1999, The Journal of rheumatology.

[21]  J. Gran,et al.  Prevalence of ankylosing spondylitis in males and females in a young middle-aged population of Tromsø, northern Norway. , 1985, Annals of the rheumatic diseases.

[22]  S. D. Miron,et al.  The value of quantitative sacroiliac scintigraphy in detection of sacroiliitis , 1983, Clinical Rheumatology.

[23]  K. Puhakka,et al.  Imaging of sacroiliitis in early seronegative spondylarthropathy: Assement of abnormalities by MR in comparison with radiography and CT , 2003, Acta radiologica.

[24]  Jürgen Braun,et al.  Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis , 2003, Rheumatology International.

[25]  M. Dougados,et al.  Relative value of erythrocyte sedimentation rate and C-reactive protein in assessment of disease activity in ankylosing spondylitis. , 1999, The Journal of rheumatology.

[26]  J. Häberle,et al.  Studying patients with inflammatory back pain and arthritis of the lower limbs clinically and by magnetic resonance imaging: many, but not all patients with sacroiliitis have spondyloarthropathy. , 1999, Rheumatology.

[27]  F. Christiansen,et al.  Use of the B27 test in the diagnosis of ankylosing spondylitis: a statistical evaluation. , 1981, Arthritis and rheumatism.

[28]  H. Brachinger,et al.  Decision analysis , 1997 .

[29]  P. Greenland,et al.  Selection and interpretation of diagnostic tests and procedures. Principles and applications. , 1981, Annals of internal medicine.

[30]  H. Zeidler,et al.  Evaluation of early diagnostic criteria for ankylosing spondylitis in a 10 year follow-up. , 1990, Zeitschrift fur Rheumatologie.

[31]  M. Langer,et al.  Magnetic resonance imaging (MRI) for detection of active sacroiliitis--a prospective study comparing conventional radiography, scintigraphy, and contrast enhanced MRI. , 1996, The Journal of rheumatology.

[32]  M. Khan,et al.  Ankylosing spondylitis: introductory comments on its diagnosis and treatment , 2002, Annals of the rheumatic diseases.

[33]  D. Sackett,et al.  The Ends of Human Life: Medical Ethics in a Liberal Polity , 1992, Annals of Internal Medicine.

[34]  N. Zvaifler,et al.  Mesenchymal precursor cells , 2002, Annals of the rheumatic diseases.

[35]  H. Zeidler,et al.  Clinical features and prognosis of patients with possible ankylosing spondylitis. Results of a 10-year followup. , 1988, The Journal of rheumatology.

[36]  S. M. van der Linden,et al.  Occurrence of spinal pain syndromes in a group of apparently healthy and physically fit sportsmen (orienteers). , 1988, Scandinavian journal of rheumatology.

[37]  R. Himstedt.  On the diagnosis of ankylosing spondylitis. , 1952, Rheumatism.

[38]  M. Ferraz,et al.  Evaluation of the European Spondylarthropathy Study Group (ESSG) preliminary classification criteria in Brazilian patients. , 1997, Clinical and experimental rheumatology.

[39]  J. Gran.  An epidemiological survey of the signs and symptoms of ankylosing spondylitis , 1985, Clinical rheumatology.

[40]  J. Gran,et al.  HLA-B27 and spondyloarthropathy: value for early diagnosis? , 1995, Journal of medical genetics.

[41]  M. Dougados,et al.  The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. , 1991, Arthritis and rheumatism.

[42]  M. Dougados,et al.  Are classification criteria for spondylarthropathy useful as diagnostic criteria? , 1995, Revue du rhumatisme.

[43]  J. Braun,et al.  Diagnosing reactive arthritis: role of clinical setting in the value of serologic and microbiologic assays. , 2002, Arthritis and rheumatism.

[44]  M. Minami,et al.  Spondyloarthropathies in Japan: nationwide questionnaire survey performed by the Japan Ankylosing Spondylitis Society. , 2001, The Journal of rheumatology.

[45]  James Neil Weinstein,et al.  Low back pain [5] (multiple letters) , 2001 .

[46]  E. Collantes-Estévez,et al.  Assessment of 2 systems of spondyloarthropathy diagnostic and classification criteria (Amor and ESSG) by a Spanish multicenter study. European Spondyloarthropathy Study Group. , 1995, The Journal of rheumatology.

[47]  M. Dougados,et al.  [Evaluation of the Amor criteria for spondylarthropathies and European Spondylarthropathy Study Group (ESSG). A cross-sectional analysis of 2,228 patients]. , 1991, Annales de medecine interne.

[48]  B. Amor.  Usefulness of criteria for spondyloarthropathies. , 2000, Joint, bone, spine : revue du rhumatisme.

[49]  Muhammad Asim Khan,et al.  Update on Spondyloarthropathies , 2002, Annals of Internal Medicine.

[50]  M. Dougados,et al.  [Criteria of the classification of spondylarthropathies]. , 1990, Revue du rhumatisme et des maladies osteo-articulaires.

[51]  C. Ritchlin.  Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor-alpha. , 2002, Current rheumatology reports.

[52]  R D Sturrock,et al.  Ankylosing spondylitis and HL-A 27. , 1973, Lancet.

[53]  J. Braun,et al.  Prevalence of spondylarthropathies in HLA-B27 positive and negative blood donors. , 1998, Arthritis and rheumatism.

[54]  A. Escudero,et al.  Can some cases of 'possible' spondyloarthropathy be classified as 'definite' or 'undifferentiated' spondyloarthropathy? Value of criteria for spondyloarthropathies. Spanish Spondyloarthropathy Study Group. , 2000, Joint, bone, spine : revue du rhumatisme.

[55]  J. Sieper,et al.  Use of dynamic magnetic resonance imaging with fast imaging in the detection of early and advanced sacroiliitis in spondylarthropathy patients. , 1994, Arthritis and rheumatism.

[56]  J. Gran,et al.  Referrals from General Practice to an Outpatient Rheumatology Clinic: Disease Spectrum and Analysis of Referral Letters , 2000, Clinical Rheumatology.

[57]  H. Awada,et al.  Validation of the European Spondylarthropathy Study Group and B. Amor criteria for spondylarthropathies in Lebanon. , 1997, Revue du rhumatisme.

[58]  K. Puhakka,et al.  Assessment of abnormalities by MR in comparison with radiography and CT , 2003 .

[59]  A. Cats,et al.  Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. , 1984, Arthritis and rheumatism.

[60]  E. L. Persons,et al.  Ankylosing Spondylitis , 1955, GP.

[61]  M. Chan,et al.  The Prevalence and Nature of Back Pain in an Industrial Complex: A Questionnaire and Radiographic and HLA Analysis , 1980, Spine.

[62]  M. Khan,et al.  Diagnostic value of HLA-B27 testing ankylosing spondylitis and Reiter's syndrome. , 1982, Annals of internal medicine.

[63]  A. Calin,et al.  Ankylosing spondylitis: interaction between genes, joints, age at onset, and disease expression. , 2001, The Journal of rheumatology.

[64]  M. Sadowska-Wroblewska,et al.  Clinical symptoms and signs useful in the early diagnosis of ankylosing spondylitis , 1983, Clinical Rheumatology.