Evaluation and Management of the Patient With Suspected Inflammatory Spine Disease

Abstract

Axial spondyloarthritis (AxSpA) is a chronic inflammatory rheumatic disease characterized by inflammatory back pain (IBP) that manifests in childhood, late adolescence, or early adulthood. Ankylosing spondylitis (AS) and nonradiographic AxSpA represent 2 ends of the AxSpA spectrum. Diagnosis can be challenging because patients develop IBP that may not be associated with radiographic changes in the sacroiliac joints. Patients early in the course of disease are estimated to have at least the same level of disease activity and pain as patients with established disease; thus, they could benefit substantially from earlier diagnosis. Although the recent use of magnetic resonance imaging and its inclusion in diagnostic criteria has enhanced the identification of early AxSpA, improvement in early diagnosis has not been consistently reported across all studies. Limited knowledge of the continuum of AxSpA disease manifestations and lack of recognition of IBP in primary practice may contribute to this. Implementing a referral strategy that identifies patients with IBP for additional testing and assessment may lead to better recognition of early signs and symptoms of AxSpA, thereby offering the potential for improved patient outcomes. This review presents an overview of the epidemiology, clinical characteristics, and burdens of AxSpA, followed by a case presentation outlining approaches to the evaluation and management of a patient with suspected inflammatory spine disease.

Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review

“…However, there is often a substantial delay between symptom onset and axSpA diagnosis, with recent reports suggesting an average diagnostic delay of 5-14 years [6][7][8][9][10][11]. One factor contributing to the delay in diagnosis of axSpA is the difficulty in distinguishing inflammatory back pain (IBP), a key symptom of axSpA that affects the spine and sacroiliac joints [12,13], from other highly prevalent forms of low back pain in the general population-the overall global prevalence of low back pain is approximately 9% [14], and up to 80% of adults will experience low back pain in their lifetime [15,16]. Additionally, chronic ([ 3 months) back pain is a common symptom among several conditions seen in primary care [17,18]; prevalence estimates of chronic low back pain vary by country and range from 4 to 24% [19].…”

Axial spondyloarthritis in the USA: diagnostic challenges and missed opportunities

“…Axial spondyloarthritis (axSpA), a chronic inflammatory rheumatic disease primarily affecting the sacroiliac joints (SIJs) and spine, commonly presents in patients aged < 40 years, with inflammatory back pain (IBP) as a presenting symptom [1][2][3][4]. The term axSpA encompasses both ankylosing spondylitis (AS) and non-radiographic axSpA (nr-axSpA), which are distinguished by the presence or absence of definitive sacroiliitis on plain radiographs [5].…”

“…These factors cause underrecognition of axSpA that can result in a missed or late diagnosis, which, in turn, leads patients to have prolonged pain, stiffness, fatigue, and decreased mobility. Additional poor long-term outcomes include irreversible new bone formation in the axial skeleton, loss of spinal function, and reduced QOL [1,15,16].…”

Psoriatic arthritis for dermatologists

“…Axial inflammatory articular disease (part of the stem criteria of CASPAR) is typically characterized by slow-developing back pain persisting for >3 months before age 40 years, alternating buttock pain (caused by sacroiliitis), pain causing waking from sleep during the second half of the night and prolonged morning stiffness or stiffness upon immobility (57,58). Additionally, treatments that are effective for other PsA domains may not improve axial disease.…”