Med Palace | Blog | Spondyloarthritis, without back pain?

With the development of diagnostic procedures and therapeutic facilities, early diagnosis and early therapy of diseases have been realized. Early treatment starts in the early phase of a disease, before structural damage and functional impairment may occur. In order to diagnose diseases early, new classification criteria have been developed.

Inflammatory diseases of the spine are called spondyloarthritides (SpA). Early classification criteria of SpA were introduced by the International Spondylarthritis Society in 2009 (ASAS criteria).

Before the introduction of these criteria, spondyloarthritis could only be diagnosed if inflammatory back pain - characterized by sacroileitis - was present. Clinical symptoms of inflammatory back pain were not enough, x-ray detection of sacroileitis was obligatory. According to the new ASAS criteria, early detection of sacroileitis by MRI is sufficient and moreover, SpA can be classified on the basis of clinical signs even without detecting sacroileitis.

Thus, the new ASAS classification criteria can be fulfilled if the typical SpA features are present, current inflammatory back pain is not necessary.

Spondyloarthritis subtypes are axial (spinal involvement) and peripheral (predominant involvement of the lower limbs) SpA according to their clinical manifestation. Axial SpA is diagnosed if a patient is younger than 45 years, and inflammatory back pain lasting for more than 3 months can be explained by sacroileitis detected by any of the imaging methods (either conventional x-ray or MRI). At the same time, axial SpA can also be defined if a patient is positive for HLA B27, a highly specific genetic marker of the disease.

Without current back pain, peripheral SpA is the diagnosis, typical clinical presentations of which are asymmetrical lower limb oligoarthritis (arthritis), sausage like fingers of the hands and feet (dactylitis) and inflammation at the sites of the tendon and ligament attachments (enthesitis).

One or two typical extraarticular features must be added to the axial and peripheral major criteria to diagnose SpA. Extraarticular SpA signs are uveitis (eye involvement), psoriasis and inflammatory bowel diseases (M.Crohn and colitis ulcerosa). Genitourinary or gastrointestinal infections might precede SpA by 2-6 weeks. Family history of SpA and cumulation of HLA B27 positivity can also be observed. Inflammatory back pain can be detected as sacroileitis by imaging (either x-ray or MRI). Systemic inflammation is confirmed by laboratory parameters, raised ESR and CRP. Current back pain has a very good response to NSAIDs.

Ankylosing spondyloarthritis (SPA) is the prototype of axial SpA. The disease course of SPA is characterised by ongoing axial inflammation and radiographic progression associated with restricted mobility of the spine and decreased function, finally leading to complete ossification of the spine (bamboo spine) and the sacroiliac joints.

Other forms of SpA, either predominantly axial or peripheral, are the enteropathic and psoriatic SpA, and reactive arthritis that occurs after a primary infection. It might happen that SpA cannot be differentiated for a while.

Biological agents (anti-TNF inhibitors and anti-IL17 antibodies) have made a breakthrough in the treatment of SpA. Early diagnosis and modern biologicals are highly effective, resulting in early recovery, and bamboo spine is no longer an unfavourable outcome.