Online first
Review paper
Published online: 2024-03-22

open access

Page views 109
Article views/downloads 77
Get Citation

Connect on Social Media

Connect on Social Media

Delayed diagnosis of axial spondyloarthritis

Katarzyna Wiąk-Walerowicz1, Ewa Wielosz1

Abstract

Axial spondyloarthritis (axSpA) is an inflammatory joint disease whose predominant symptom is inflammatory pain in the spine. It occurs in approximately 1% of the population, with a higher incidence in men. Spinal pain in the course of spondyloarthritis is called inflammatory back pain. In addition to inflammatory back pain, other symptoms of axSpA include enthesitis, peripheral arthritis and extra-articular symptoms. A patient's family history and human leukocyte antigen B27 (HLA-B27) should also be considered, as these correlate closely with a higher incidence of spondyloarthritis. AxSpA is often underdiagnosed, and no specific serological test or physical examination can determine the diagnosis of spondyloarthritis. Despite good knowledge of the disease, the time between the first symptoms and diagnosis is still too long, which adversely affects the subsequent treatment options, as well as the mental and economic condition of patients. Patients are not referred to a rheumatologist quickly enough. Therefore, the features of inflammatory back pain, the symptoms associated with axial spondyloarthritis and the diagnostic tests should be well known by general practitioners and other specialists to whom patients with pain are first referred. This would accelerate accurate diagnosis and prompt implementation of appropriate treatment. This paper discusses symptoms of axSpA and emphasises the importance of prompt diagnosis in patients with complaints typical of spondyloarthritis.

 

Article available in PDF format

View PDF Download PDF file

References

  1. Sieper J, Poddubnyy D. Axial spondyloarthritis. Lancet. 2017; 390(10089): 73–84.
  2. Reveille JD, Weisman MH. The epidemiology of back pain, axial spondyloarthritis and HLA-B27 in the United States. Am J Med Sci. 2013; 345(6): 431–436.
  3. Rudwaleit M, Haibel H, Baraliakos X, et al. The early disease stage in axial spondylarthritis: results from the German Spondyloarthritis Inception Cohort. Arthritis Rheum. 2009; 60(3): 717–727.
  4. Poddubnyy D, Vahldiek J, Spiller I, et al. Evaluation of 2 screening strategies for early identification of patients with axial spondyloarthritis in primary care. J Rheumatol. 2011; 38(11): 2452–2460.
  5. Kataria RK, Brent LH. Spondyloarthropathies. Am Fam Physician. 2004; 69(12): 2853–2860.
  6. Erol K, Gok K, Cengiz G, et al. Extra-articular manifestations and burden of disease in patients with radiographic and non-radiographic axial spondyloarthritis. Acta Reumatol Port. 2018; 43(1): 32–39.
  7. Kiltz U, Heldmann F, Baraliakos X, et al. Treatment of ankylosing spondylitis in patients refractory to TNF-inhibition: are there alternatives? Curr Opin Rheumatol. 2012; 24(3): 252–260.
  8. Stolwijk C, Boonen A, van Tubergen A, et al. Epidemiology of spondyloarthritis. Rheum Dis Clin North Am. 2012; 38(3): 441–476.
  9. Reveille JD. Biomarkers for diagnosis, monitoring of progression, and treatment responses in ankylosing spondylitis and axial spondyloarthritis. Clin Rheumatol. 2015; 34(6): 1009–1018.
  10. Braun J, Sieper J. Ankylosing spondylitis. Lancet. 2007; 369(9570): 1379–1390.
  11. Poddubnyy D, Rudwaleit M, Haibel H, et al. Rates and predictors of radiographic sacroiliitis progression over 2 years in patients with axial spondyloarthritis. Ann Rheum Dis. 2011; 70(8): 1369–1374.
  12. Kiltz U, Heldmann F, Baraliakos X, et al. Treatment of ankylosing spondylitis in patients refractory to TNF-inhibition: are there alternatives? Curr Opin Rheumatol. 2012; 24(3): 252–260.
  13. Boel A, Molto A, van der Heijde D, et al. Do patients with axial spondyloarthritis with radiographic sacroiliitis fulfil both the modified New York criteria and the ASAS axial spondyloarthritis criteria? Results from eight cohorts. Ann Rheum Dis. 2019; 78(11): 1545–1549.
  14. Strand V, Singh JA. Evaluation and Management of the Patient With Suspected Inflammatory Spine Disease. Mayo Clin Proc. 2017; 92(4): 555–564.
  15. Dillon CF, Hirsch R. The United States National Health and Nutrition Examination Survey and the epidemiology of ankylosing spondylitis. Am J Med Sci. 2011; 341(4): 281–283.
  16. Poddubnyy D, Sieper J. Radiographic progression in ankylosing spondylitis/axial spondyloarthritis: how fast and how clinically meaningful? Curr Opin Rheumatol. 2012; 24(4): 363–369.
  17. Weisman MH, Witter JP, Reveille JD. The prevalence of inflammatory back pain: population-based estimates from the US National Health and Nutrition Examination Survey, 2009-10. Ann Rheum Dis. 2013; 72(3): 369–373.
  18. Walsh JA, Pei S, Penmetsa GK, et al. Cohort identification of axial spondyloarthritis in a large healthcare dataset: current and future methods. BMC Musculoskelet Disord. 2018; 19(1): 317.
  19. Khan MA. Ankylosing spondylitis: introductory comments on its diagnosis and treatment. Ann Rheum Dis. 2002; 61 Suppl 3(Suppl 3): iii3–iii7.
  20. Deodhar A, Mease PJ, Reveille JD, et al. THU0065 Prevalence of Axial Spondyloarthritis among Undiagnosed Chronic Back Pain Patients in the United States: Table 1. Ann Rheum Dis. 2014; 73(Suppl 2): 198.3–199.
  21. Garrido-Cumbrera M, Navarro-Compán V, Bundy C, et al. EMAS Working Group. Identifying parameters associated with delayed diagnosis in axial spondyloarthritis: data from the European map of axial spondyloarthritis. Rheumatology (Oxford). 2022; 61(2): 705–712.
  22. Jones A, Harrison N, Jones T, et al. Time to diagnosis of axial spondylarthritis in clinical practice: signs of improving awareness? Rheumatology (Oxford). 2014; 53(11): 2126–2127.
  23. Roussou E, Sultana S. Spondyloarthritis in women: differences in disease onset, clinical presentation, and Bath Ankylosing Spondylitis Disease Activity and Functional indices (BASDAI and BASFI) between men and women with spondyloarthritides. Clin Rheumatol. 2011; 30(1): 121–127.
  24. Slobodin G, Reyhan I, Avshovich N, et al. Recently diagnosed axial spondyloarthritis: gender differences and factors related to delay in diagnosis. Clin Rheumatol. 2011; 30(8): 1075–1080.
  25. Rudwaleit M, Sieper J. Referral strategies for early diagnosis of axial spondyloarthritis. Nat Rev Rheumatol. 2012; 8(5): 262–268.
  26. Kouvari M, Yannakoulia M, Souliotis K, et al. Challenges in Sex- and Gender-Centered Prevention and Management of Cardiovascular Disease: Implications of Genetic, Metabolic, and Environmental Paths. Angiology. 2018; 69(10): 843–853.
  27. Ulutaş F, Çobankara V, Şenol H, et al. A single center experience: physician related diagnostic delay and demographic and clinical differences between patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis. Rom J Intern Med. 2021; 59(3): 278–285.
  28. Braun J, van den Berg R, Baraliakos X, et al. 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis. 2011; 70(6): 896–904.
  29. Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa 1976). 1987; 12(3): 264–268.
  30. Deodhar A, Mittal M, Reilly P, et al. Ankylosing spondylitis diagnosis in US patients with back pain: identifying providers involved and factors associated with rheumatology referral delay. Clin Rheumatol. 2016; 35(7): 1769–1776.
  31. Sieper J, van der Heijde D. Review: Nonradiographic axial spondyloarthritis: new definition of an old disease? Arthritis Rheum. 2013; 65(3): 543–551.
  32. Poddubnyy D, Sieper J. Radiographic progression in ankylosing spondylitis/axial spondyloarthritis: how fast and how clinically meaningful? Curr Opin Rheumatol. 2012; 24(4): 363–369.
  33. Lukas C, Cyteval C, Dougados M, et al. MRI for diagnosis of axial spondyloarthritis: major advance with critical limitations 'Not everything that glisters is gold (standard)'. RMD Open. 2018; 4(1): e000586.
  34. Rudwaleit M, van der Heijde D, Landewé 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(6): 777–783.
  35. Landewé R, Nurminen T, Davies O, et al. A single determination of C-reactive protein does not suffice to declare a patient with a diagnosis of axial spondyloarthritis 'CRP-negative'. Arthritis Res Ther. 2018; 20(1): 209.
  36. Ez-Zaitouni Z, Bakker PAC, van Lunteren M, et al. Presence of multiple spondyloarthritis (SpA) features is important but not sufficient for a diagnosis of axial spondyloarthritis: data from the SPondyloArthritis Caught Early (SPACE) cohort. Ann Rheum Dis. 2017; 76(6): 1086–1092.
  37. Fallahi S, Jamshidi AR. Diagnostic Delay in Ankylosing Spondylitis: Related Factors and Prognostic Outcomes. Arch Rheumatol. 2016; 31(1): 24–30.
  38. Feldtkeller E, Braun J. Impact of sex on inheritance of ankylosing spondylitis. Lancet. 2000; 355(9209): 1096–7; author reply 1098.
  39. Hamilton L, Gilbert A, Skerrett J, et al. Services for people with ankylosing spondylitis in the UK--a survey of rheumatologists and patients. Rheumatology (Oxford). 2011; 50(11): 1991–1998.
  40. Sieper J, Srinivasan S, Zamani O, et al. Comparison of two referral strategies for diagnosis of axial spondyloarthritis: the Recognising and Diagnosing Ankylosing Spondylitis Reliably (RADAR) study. Ann Rheum Dis. 2013; 72(10): 1621–1627.
  41. van der Heijde D, Sieper J, Elewaut D, et al. Referral patterns, diagnosis, and disease management of patients with axial spondyloarthritis: results of an international survey. J Clin Rheumatol. 2014; 20(8): 411–417.
  42. Magrey MN, Danve AS, Ermann J, et al. Recognizing Axial Spondyloarthritis: A Guide for Primary Care. Mayo Clin Proc. 2020; 95(11): 2499–2508.