Could that back pain be caused by ankylosing spondylitis?

,; ,

Applied Evidence

Could that back pain be caused by ankylosing spondylitis?

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

By

Carlton J. Covey, MD, FAAFP

Lee T. Church, MD, FAWM

It can often take years for patients with this condition to learn the true cause of their pain. But this guide to the work-up can help speed the diagnostic process.

PDF Download

PRACTICE RECOMMENDATIONS

› Evaluate all patients with back pain lasting > 3 months for inflammatory back pain features. C

› Treat all patients with confirmed or suspected axial spondyloarthritis with a trial of nonsteroidal anti-inflammatory drugs. A

› Recommend that all patients with back pain—including those with suspected axial spondyloarthritis—start an exercise program that includes both strength and aerobic activities. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

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.

CASE

A 38-year-old man presents to your primary care clinic with chronic low back stiffness and pain. You have evaluated and treated this patient for this complaint for more than a year. His symptoms are worse in the morning upon wakening and improve with activity and anti-inflammatory medications. He denies any trauma or change in his activity level. His medical history includes chronic insertional Achilles pain and plantar fasciopathy, both for approximately 2 years. The patient reports no systemic or constitutional symptoms, and no pertinent family history.

How would you proceed with his work-up?

Ankylosing spondylitis (AS) is a form of arthritis that primarily affects the spine and sacroiliac joints. It is the most common spondyloarthropathy (SpA)—a family of disorders that also includes psoriatic arthritis; arthritis associated with inflammatory bowel disease; reactive arthritis; and juvenile SpA.¹ AS is most prevalent in Caucasians and may affect 0.1% to 1.4% of the population.²

Historically, a diagnosis of AS required radiographic evidence of inflammation of the axial spine or sacrum that manifested as chronic stiffness and back pain. However, the disease can also be mild or take time for radiographic evidence to appear. So an umbrella term emerged—axial spondyloarthritis (axSpA)—that includes both AS and the less severe form, called nonradiographic axSpA (nr-axSpA). While patients with AS exhibit radiographic abnormalities consistent with sacroiliitis, patients with early, or nr-axSpA, do not have radiographic abnormalities of the sacroiliac (SI) joint or axial spine.

In clinical practice, the distinction between AS and nr-axSpA has limited impact on the management of individual patients. However, early recognition, intervention, and treatment in patients who do not meet radiographic criteria for AS can improve patient-oriented outcomes.

The family physician (FP)’s role. It is not necessary that FPs be able to make a definitive diagnosis, but FPs should:

be able to recognize the symptoms of inflammatory back pain (IBP);
know which radiographic and laboratory studies to obtain and when;
know the Assessment of SpondyloArthritis international Society (ASAS) criteria³that assist in identifying patients at risk for axSpA; and
know when to refer moderate- to high-risk patients to rheumatologists for assistance with the diagnosis.

FPs should have a high index of suspicion in any patient who has chronic back pain (> 3 months) with other features of SpA, and should pay special attention to young adult patients (< 45 years) who have IBP features.

Continue to: Definitive data to show...