scholarly journals MRI compared with low-dose CT scanning in the diagnosis of axial spondyloarthritis

2019 ◽  
Vol 39 (4) ◽  
pp. 1295-1303 ◽  
Author(s):  
Lusi Ye ◽  
Yuncai Liu ◽  
Qinqin Xiao ◽  
Ledan Dong ◽  
Caiyun Wen ◽  
...  
Keyword(s):  
Back Pain ◽  
Sacroiliac Joint ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Significant Proportion ◽  
High Specificity ◽  
Ct Scanning ◽  
Conventional Radiography ◽  
Plain Radiography ◽  
Inflammatory Back Pain

Abstract Objectives To compare the performance of conventional radiography, ldCT, and MRI in the diagnosis of sacroiliitis in suspected axial spondyloarthritis (axSpA). Methods Patients presenting with > 3 months chronic back pain were assessed by axSpA-experienced rheumatologists and diagnosed as axSpA or not; axSpA patients were then considered nr-axSpA or AS using plain radiography. Non-axSpA patients were recruited as controls, and divided into non-inflammatory and inflammatory groups on the basis of inflammatory back pain and/or CRP/ESR elevation. Clinical variables, pelvic radiography, sacroiliac joint (SIJ) ldCT, and SIJ MRI were obtained. Results A total of 121 patients were included and had SIJ radiography and ldCT, of whom 71 additionally had an SIJ MRI. These included 23 non-inflammatory controls, 21 inflammatory controls, 32 nr-axSpA cases, and 45 AS cases. Fourteen of 32 (44%) nr-axSpA patients had positive ldCT scans, 21/24 (88%) had MRI-BMO, and 11/24 (46%) had MRI-structural lesions. ldCT had high specificity with only 1/23 (4%) non-inflammatory controls being positive. MRI-BMO had the highest sensitivity for nr-axSpA, but compared with ldCT lower specificity, with 5/15 (33%) of non-inflammatory controls being positive, and similar sensitivity for AS (20/22 (91%) vs 44/44 for ldCT). Conclusions ldCT identifies evidence of radiographic change in a significant proportion of nr-axSpA cases and is highly specific for axSpA. MRI-BMO lesions are more sensitive than either conventional radiography or MRI-structural assessment for axSpA. The relative position of these imaging modalities in screening for axSpA needs to be reconsidered, also taking into account the costs involved.Key Points• ldCT is more sensitive for erosions or sclerosis in axSpA than plain radiography, with 44% of patients with nr-axSpA having evidence of AS-related sacroiliac joint changes on ldCT.• MRI-structural lesions are no more sensitive but are less specific for AS than ldCT.• MRI-BMO is the most sensitive test for nr-axSpA of the modalities tested but is less specific for axSpA than for ldCT.

scholarly journals SAT0380 ENHANCING RHEUMATOLOGY REFERRALS AMONG INFLAMMATORY BOWEL DISEASE PATIENTS WITH SUSPECTED AXIAL SPONDYLOARTHRITIS

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1138.2-1138
Author(s):  
C. S. E. Lim ◽  
M. Tremelling ◽  
L. Hamilton ◽  
A. Macgregor ◽  
K. Gaffney
Keyword(s):  
Back Pain ◽  
Musculoskeletal Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Inflammatory Back Pain ◽  
Aminosalicylic Acid ◽  
Research Support ◽  
Clinical Probability ◽  
Asas Criteria ◽  
History Of

Background:Axial spondyloarthritis (axSpA) is associated with inflammatory bowel disease (IBD). In IBD patients, the clinical probability of axSpA increases in those with chronic back pain (CBP) whose symptoms started before the age of forty-five years old. In practice, this should trigger a rheumatology review especially if accompanied by other symptoms suspicious of inflammatory disease. However, in any health system, the goal of identifying all possible cases need to be balanced with the practical realisation of the finite resources available.Objectives:The study aimed to define the clinical characteristics of a subgroup of IBD patients who are routinely managed in secondary care who have an increased clinical probability for axSpA. Identification of these characteristics may help improve the quality and specificity of referrals to Rheumatology from Gastroenterology clinics.Methods:An analytical cross-sectional study was undertaken. Consecutive IBD patients attending routine Gastroenterology clinics were sent a modified validated back pain questionnaire. The questionnaire included the presence or absence of a previous diagnosis of axSpA; components of validated inflammatory back pain criteria; diagrams to indicate the location of back pain and other musculoskeletal pain; personal and family history of known axSpA manifestations; and details of their IBD course, activity and treatment.IBD patients, with back pain duration > 3 months with onset before 45 years were considered to have a medium diagnostic probability (MDP) for axSpA. MDP-positive IBD patients were compared with MDP-negative IBD patients and logistic regression was used to model the association with clinical features.Results:Four hundred and seventy consecutive IBD patients (mean age 54 years; 46% male) were surveyed. Two hundred and nine patients (59%) replied, of whom 191 patients (69%) consented to participate. One hundred and seventy-three (91%) of those who consented had a valid completed questionnaire and were included for data analysis. Of these, 74% had Ulcerative Colitis and 26% had Crohn’s disease. Their mean age was 58 years, 39% male. Mean age at IBD diagnosis was 39 years, mean IBD disease duration 19 yrs. CBP (back pain greater than three months) was reported by 76%. Inflammatory back pain fulfilling Calin, Berlin, ASAS criteria was seen in 23%, 29%, and 15% respectively. In addition, 80% reported peripheral musculoskeletal pain. Self-reported personal history of enthesitis, reactive arthritis (ReA), acute anterior uveitis (AAU), skin psoriasis (PSO) and dactylitis were 50%, 30%, 24%, 15% and 0% respectively. Self-reported family history of IBD, ReA, PSO, axSpA and AAU were 60%, 36%, 22%, 11%, and 1% respectively.Ninety-one (53%) patients were MDP-positive and 82 (47%) patients were MDP-negative. The clinical characteristics associated with MDP (adjusted for age at invitation) were: the presence of inflammatory back pain using ASAS criteria [OR 8.84 (1.61,48.67); p=0.01], longer interval between symptom onset and gastroenterologist diagnosis of IBD [OR 1.09 (1.03,1.16); p=0.005], and use of rectal topical 5-aminosalicylic acid [OR 3.27 (1.11,9.68); p=0.03].Conclusion:Chronic back pain and peripheral musculoskeletal pain are common in a secondary care IBD population. In IBD patients, with back pain duration > 3 months and onset before 45 years, the presence of inflammatory back pain, longer diagnostic delay of IBD and the use of rectal topical 5-aminosalicylic acid were associated with a higher clinical probability of axSpA. The identification of these clinical features may not only improve the quality and specificity of Rheumatology referrals from Gastroenterology in this subgroup of patients but also lends real world evidence to current ASAS-endorsed recommendations for early referral of patients with a suspicion of axial spondyloarthritis.Disclosure of Interests:Chong Seng Edwin Lim Grant/research support from: AbbVie - Research support/grant but NOT for this study., Mark Tremelling: None declared, Louise Hamilton: None declared, Alexander Macgregor: None declared, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma

scholarly journals Identifying patients with axial spondyloarthritis in primary care: how useful are items indicative of inflammatory back pain?

2011 ◽  
Vol 70 (10) ◽  
pp. 1782-1787 ◽  
Author(s):  
A Braun ◽  
E Saracbasi ◽  
J Grifka ◽  
J Schnitker ◽  
J Braun
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Age At Onset ◽  
Inflammatory Back Pain ◽  
Single Item ◽  
Inflammatory Drugs ◽  
Waking Up ◽  
Key Questions

BackgroundThe value of clinical items defining inflammatory back pain to identify patients with axial spondyloarthritis (SpA) in primary care is unclear.ObjectiveTo identify predictive clinical parameters for a diagnosis of axial SpA in patients with chronic back pain presenting in primary care.MethodsConsecutive patients aged <45 years (n=950) with back pain for >2 months who presented to orthopaedic surgeons (n=143) were randomised based on four key questions for referral to rheumatologists (n=36) for diagnosis.ResultsThe rheumatologists saw 322 representative patients (mean age 36 years, 50% female, median duration of back pain 30 months). 113 patients (35%) were diagnosed as axial SpA (62% HLA B27+), 47 (15%) as ankylosing spondylitis (AS) and 66 (21%) as axial non-radiographic SpA (nrSpA). Age at onset ≤35 years, improvement by exercise, improvement with non-steroidal anti-inflammatory drugs, waking up in the second half of the night and alternating buttock pain were identified as most relevant for diagnosing axial SpA by multiple regression analysis. Differences between AS and nrSpA were detected. No single item was predictive, but ≥3 items proved useful for good sensitivity and specificity by receiver operating characteristic modelling.ConclusionThis study shows that a preselection in primary care of patients with back pain based on a combination of clinical items is useful to facilitate the diagnosis of axial SpA.

General Practitioners’ Perceptions of Their Ability to Identify and Refer Patients with Suspected Axial Spondyloarthritis: A Qualitative Study

2014 ◽  
Vol 41 (5) ◽  
pp. 897-901 ◽  
Author(s):  
Marloes van Onna ◽  
Simone Gorter ◽  
Aniek van Meerendonk ◽  
Astrid van Tubergen
Keyword(s):  
Back Pain ◽  
Qualitative Study ◽  
General Practitioners ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Inflammatory Back Pain ◽  
Coding System ◽  
Disease Spectrum ◽  
Insidious Onset ◽  
Mechanical Back Pain

Objective.To explore the knowledge, beliefs, and experiences of general practitioners (GP) about inflammatory back pain (IBP) and axial spondyloarthritis (axSpA) and potential barriers for referral of patients suspected of having axSpA.Methods.A qualitative study involving semistructured interviews with GP was conducted. Transcripts of the interviews were independently read and annotated by 2 readers. Illustrative themes were identified and a coding system to categorize the data was developed.Results.Ten GP (all men; mean age 49 yrs) were interviewed. All could adequately describe “classic” ankylosing spondylitis (AS) and mentioned chronic back pain and/or stiffness as key features. All GP thought that AS is almost exclusively diagnosed in men. Six GP knew that there is a difference between mechanical back pain and IBP, but could recall only a limited number of variables indicative of IBP, such as awakening night pain (4 GP), insidious onset of back pain (1 GP), improvement with movement (1 GP), and (morning) stiffness (2 GP). Two GP mentioned peripheral arthritis as other SpA features, none mentioned dactylitis or enthesitis. GP awareness of associated extraarticular manifestations was low. Most GP expressed that (practical) referral measures would be useful.Conclusion.GP are aware of “classic”, but longterm features of axSpA. Knowledge about the disease spectrum and early detection is, however, limited. Addressing these issues in training programs may improve recognition of axSpA in primary care. This may ultimately contribute to earlier referral, diagnosis, and initiation of effective treatment in patients with axSpA.

scholarly journals Diagnostic accuracy of inflammatory back pain for axial spondyloarthritis in rheumatological care

RMD Open ◽  
2018 ◽  
Vol 4 (2) ◽  
pp. e000825 ◽  
Author(s):  
Denis Poddubnyy ◽  
Johanna Callhoff ◽  
Inge Spiller ◽  
Joachim Listing ◽  
Juergen Braun ◽  
...  
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Diagnostic Accuracy ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Final Diagnosis ◽  
Inflammatory Back Pain ◽  
Likelihood Ratios ◽  
High Prevalence ◽  
Selection Parameter

ObjectiveInflammatory back pain (IBP), the key symptom of axial spondyloarthritis (axSpA), including ankylosing spondylitis, has been proposed as a screening test for patients presenting with chronic back pain in primary care. The diagnostic accuracy of IBP in the rheumatology setting is unknown.MethodsSix rheumatology centres, representing secondary and tertiary rheumatology care, included routinely referred patients with consecutive chronic back pain with suspicion of axSpA. IBP (diagnostic test) was assessed in each centre by an independent (blinded) rheumatologist; a second (unblinded) rheumatologist made the diagnosis (axSpA or no-axSpA), which served as reference standard.ResultsOf 461 routinely referred patients, 403 received a final diagnosis. IBP was present in 67.3%, and 44.6% (180/403) were diagnosed as axSpA. The sensitivity of IBP according to various definitions (global judgement, Calin, Berlin, Assessment of SpondyloArthritis international Society criteria for IBP) was 74.4%–81.1 % and comparable to published figures, whereas the specificity was unexpectedly low (25.1%–43.9%). The resulting positive likelihood ratios (LR+) were 1.1–1.4 and without major differences between sets of IBP criteria. The presence of IBP according to various definitions increased the probability of axSpA by 2.5%–8.4% only (from 44.6% to 47.1%–53.0%).ConclusionsThe diagnostic utility of IBP in the rheumatology setting was smaller than expected. However, this was counterbalanced by a high prevalence of IBP among referred patients, demonstrating the effective usage of IBP in primary care as selection parameter for referral to rheumatology. Notably, this study illustrates potential shifts in specificity and LR+ of diagnostic tests if these tests are used to select patients for referral.

Evaluation of 2 Screening Strategies for Early Identification of Patients with Axial Spondyloarthritis in Primary Care

2011 ◽  
Vol 38 (11) ◽  
pp. 2452-2460 ◽  
Author(s):  
DENIS PODDUBNYY ◽  
JANIS VAHLDIEK ◽  
INGE SPILLER ◽  
BEATE BUSS ◽  
JOACHIM LISTING ◽  
...  
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Age At Onset ◽  
Positive Family History ◽  
Screening Method ◽  
Inflammatory Back Pain ◽  
Care Level ◽  
Primary Care Level

Objective.To evaluate 2 referral strategies for axial spondyloarthritis (SpA) in patients with chronic low back pain at the primary care level.Methods.Referral physicians (n = 259) were randomly assigned to either Strategy 1 or Strategy 2 in order to refer patients with chronic back pain (duration > 3 months), age at onset of back pain < 45 years, and no diagnosis of axial SpA, to a cooperating rheumatologist (n = 43). According to Strategy 1, suitable patients were referred if at least 1 of the following screening criteria was present: inflammatory back pain, HLA-B27, or sacroiliitis detected by imaging. According to Strategy 2, patients were referred if 2 out of 5 criteria were positive: the same 3 criteria from Strategy 1 and additionally a positive family history of ankylosing spondylitis (AS) or a good treatment response to nonsteroidal antiinflammatory drugs. The final diagnosis of the rheumatologist was used as the “gold standard.”Results.In total, 560 consecutively referred patients were included in the analysis. Among 318 patients referred by Strategy 1, 41.8% (95% CI 36.5%–47.3%) were diagnosed with definite axial SpA. Among 242 patients referred by the second strategy, definite axial SpA was diagnosed in 36.8% (95% CI 31.0%–43.0%) of the cases.Conclusion.Both referral strategies demonstrated comparable performance in identification of patients with axial SpA. Strategy 1 might be preferred as an easy and reliable screening method for axial SpA at the primary care level.

Alternative diagnoses in patients with chronic back pain not diagnosed with axial spondyloarthritis: data from the SPACE cohort

2017 ◽  
pp. annrheumdis-2017-212175
Author(s):  
Zineb Ez-Zaitouni ◽  
Robert B M Landewé ◽  
Désirée van der Heijde ◽  
Floris A van Gaalen
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis

scholarly journals Frequency of Impaired Spinal Mobility in Patients with Chronic Back Pain Compared to Patients with Early Axial Spondyloarthritis

2018 ◽  
Vol 45 (12) ◽  
pp. 1643-1650 ◽  
Author(s):  
Camilla Fongen ◽  
Hanne Dagfinrud ◽  
Inger Jorid Berg ◽  
Sofia Ramiro ◽  
Floris van Gaalen ◽  
...  
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Spinal Mobility ◽  
Chest Expansion ◽  
Wall Distance ◽  
Intermalleolar Distance ◽  
Cervical Rotation ◽  
Mobility Measure ◽  
Spinal Flexion

Objective.To examine the frequency of impaired spinal mobility in patients with chronic back pain of short duration and to compare it with the frequency of impaired spinal mobility in patients with axial spondyloarthritis (axSpA), possible SpA, and no SpA.Methods.The SpondyloArthritis Caught Early (SPACE) cohort includes patients with chronic back pain (≥ 3 mos, ≤ 2 yrs, onset < 45 yrs). Spinal mobility was assessed with lateral spinal flexion, chest expansion, cervical rotation, occiput-to-wall distance, and lumbar flexion. Hip mobility was assessed with intermalleolar distance. Mobility measures were defined as impaired if below the 5th percentile reference curve from general population, adjusted for age and height when appropriate. Proportions of patients categorized with impaired mobility were examined with chi square.Results.In total, 393 patients with chronic back pain were included: 142 axSpA, 140 possible SpA, and 111 no SpA. Impairment in ≥ 1 mobility measure was present in 66% of all patients. The most frequently impaired mobility measure was lateral spinal flexion (40%), followed by chest expansion (22%), cervical rotation (18%), intermalleolar distance (17%), lumbar flexion (15%), and occiput-to-wall distance (11%). No statistically significant differences in proportion of patients with impaired spinal mobility were found between patients with axSpA and the other subgroups in any of the tests.Conclusion.Two out of 3 patients with chronic back pain of short duration had impaired spinal mobility compared to the general population. Impaired spinal mobility occurs as often in patients with early axSpA as in other forms of chronic back pain.

scholarly journals Comorbid pain in axial spondyloarthritis, including fibromyalgia

2020 ◽  
Vol 12 ◽  
pp. 1759720X2096612
Author(s):  
Clementina López-Medina ◽  
Anna Moltó
Keyword(s):  
Back Pain ◽  
Vertebral Fractures ◽  
Structural Damage ◽  
Axial Spondyloarthritis ◽  
Inflammatory Diseases ◽  
Correct Diagnosis ◽  
Degenerative Changes ◽  
Inflammatory Back Pain ◽  
Management Options ◽  
Biomechanical Stress

The main symptom in patients with axial spondyloarthritis (axSpA) is inflammatory back pain, caused principally by inflammation of the sacroiliac joints and the spine. However, not all back pain in patients with axSpA is related to active inflammation: other types of pain can occur in these patients, and may be related to structural damage (e.g. ankylosis), degenerative changes, vertebral fractures or comorbid fibromyalgia, which are not uncommon in these patients. Structural damage and ankylosis may lead to a biomechanical stress, which can lead to chronic mechanical pain; and degenerative changes of the spine may also exist in patients with axSpA also leading to mechanical pain. Osteoporosis is more prevalent in axSpA patients than in the general population, and vertebral fractures may result in acute bone pain, which can persist for several months. Fibromyalgia, which is also more prevalent in patients with chronic inflammatory diseases (including axSpA), presents with widespread pain which can mimic entheseal pain. A correct diagnosis of the origin of the pain is crucial, since treatments and management may differ considerably. Recognizing these causes of pain may be a challenge in clinical practice, especially for fibromyalgia, which can coexist with axSpA and may have a significant impact on biologic drug response. In this review, we provide an update of the most common causes of pain other than inflammatory back pain in axSpA patients, and we discuss the latest management options for such causes.

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