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The diagnosis of nr-axSpA may be challenging due to limited awareness and experience among non-rheumatologists. Rheumatologists may consider a complex set of factors to make a diagnosis of nr-axSpA, including patient history, lab results, features of spondyloarthritis (SpA), and imaging. 1
The first step to evaluating a patient with chronic back pain for nr-axSpA is to determine whether they are experiencing inflammatory back pain (IBP).2 Features of IBP include age at onset less than 40 years, insidious onset, improvement with exercise, no improvement with rest, and pain at night with improvement upon getting up (Figure 4).3 Click here to download an IBP screening tool.
Clinicians should next evaluate the patient for the presence of SpA features, including arthritis, enthesitis, dactylitis, psoriasis, uveitis, a family history of SpA, or inflammatory bowel disease. Patients with nr-axSpA often respond well to non-steroidal anti-inflammatory drugs (NSAIDs) and may have an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP). Human leukocyte antigen B27 (HLA-B27) testing may also be performed, as a positive HLA-B27 test is associated with an increased likelihood that the patient has nr-axSpA.1
Imaging is also important to the recognition and diagnosis of nr-axSpA. Patients with nr-axSpA will not have definitive structural damage of the sacroiliac joints (SIJs) that is evident on x-ray but may have evidence of sacroiliitis by magnetic resonance imaging (MRI).3
For those with chronic IBP with an age of onset of less than 45 years and features of SpA, the presence of objective signs of inflammation (such as elevated CRP and evidence of sacroiliitis by MRI) can help improve the confidence of an nr-axSpA diagnosis (Figure 5).1,3,4
Figure 4. Inflammation in the Sacroiliac Joint Can Manifest as Pain at Night or Alternating Buttock Pain, Which May Prompt A Workup for axSpA3,5
Figure 5. Probability of nr-axSpA Diagnosis Based on Features of SpA and Imaging1
AS, ankylosing spondylitis; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; GP, general practitioner; HLA-B27, human leukocyte antigen B27; IBP, inflammatory back pain; MRI, magnetic resonance imaging; nr-axSpA, non-radiographic axial spondyloarthritis; NSAIDs, non-steroidal anti-inflammatory drugs; PCP, primary care physician; SIJ, sacroiliac joint; SpA, spondyloarthritis.
*≥3 axSpA features will increase the probability to 80% to 95%. †The probability depends on the presence of 1 or 2 features of SpA.
Anthony M. Turkiewicz, MD
Anthony M. Turkiewicz, MD
1. Rudwaleit M, van der Heijde D, Khan MA, et al. How to diagnose axial spondyloarthritis early. Ann Rheum Dis. 2004;63(5):535-543.
2. Braun J, Sieper J. Classification, diagnosis, and referral of patients with axial spondyloarthritis. Rheum Dis Clin North Am. 2012;38(3):477-485.
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(6):777-783.
4. Sieper J, Rudwaleit M, Baraliakos X, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009;68(suppl 2):ii1-ii44.
5. Rudwaleit M, Metter A, Listing J, et al. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum. 2006;54(2):569-578.
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Version: August 2019
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