UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Diagnosis and differential diagnosis of ankylosing spondylitis and non-radiographic axial spondyloarthritis in adults

Authors
David T Yu, MD
Astrid van Tubergen, MD, PhD
Section Editor
Joachim Sieper, MD
Deputy Editor
Paul L Romain, MD

INTRODUCTION

Ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) are potentially disabling chronic inflammatory conditions affecting the axial skeleton that are manifested by chronic back pain. The onset is typically before 45 years of age. The diagnosis of AS depends upon the presence of plain radiographic abnormalities consistent with sacroiliitis [1], while such findings are not evident on plain radiography in nr-axSpA, where the diagnosis is supported by evidence of active inflammation of the sacroiliac (SI) joints on magnetic resonance imaging (MRI) and/or a combination of other findings [2]. AS and nr-axSpA can also involve the hips, shoulders, and peripheral joints; extraarticular manifestations, including uveitis, may also be seen. (See "Clinical manifestations of ankylosing spondylitis in adults".)

The name “ankylosing spondylitis” is derived from the Greek root “ankylosis,” meaning stiffening of a joint, and “spondylos,” which refers to a vertebra. “Ankylosing spondylitis” thus refers to the inflammatory disorder associated with fibrous or bony bridging of joints in the spine, including the bridging of one or more intervertebral discs. Other terms used historically for AS include Bechterew’s disease, Marie-Strümpell disease, and rheumatoid spondylitis.

The diagnostic evaluation, diagnosis, and differential diagnosis of AS and nr-axSpA will be reviewed here together. The clinical manifestations, treatment, and pathogenesis of this disorder are discussed separately. (See "Clinical manifestations of ankylosing spondylitis in adults" and "Assessment and treatment of ankylosing spondylitis in adults" and "Pathogenesis of spondyloarthritis".)

NOMENCLATURE AND CLASSIFICATION

Ankylosing spondylitis (AS) is the prototypic form of spondyloarthritis (SpA, formerly termed spondyloarthritides or spondyloarthropathies), a family of disorders characterized by sacroiliitis and spondylitis, inflammation and new bone formation around the entheses (the sites of ligament and tendon insertion into bone), and an association with human leukocyte antigen (HLA)-B27. (See "Clinical manifestations of ankylosing spondylitis in adults".)

Other conditions included historically in the SpA family are undifferentiated SpA; reactive arthritis; psoriatic arthritis; juvenile SpA; and arthritis and spondylitis associated with inflammatory bowel diseases, including Crohn’s disease and ulcerative colitis [1]. (See "Clinical manifestations and diagnosis of peripheral spondyloarthritis in adults" and "Reactive arthritis" and "Clinical manifestations and diagnosis of psoriatic arthritis" and "Spondyloarthropathy in children" and "Arthritis associated with gastrointestinal disease".)

                

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Wed Oct 19 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. 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.
  2. Rudwaleit M, Khan MA, Sieper J. The challenge of diagnosis and classification in early ankylosing spondylitis: do we need new criteria? Arthritis Rheum 2005; 52:1000.
  3. Rudwaleit M, van der Heijde D, Landewé R, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 2011; 70:25.
  4. 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; 68:777.
  5. Kiltz U, Baraliakos X, Karakostas P, et al. Do patients with non-radiographic axial spondylarthritis differ from patients with ankylosing spondylitis? Arthritis Care Res (Hoboken) 2012; 64:1415.
  6. van Tubergen A, Weber U. Diagnosis and classification in spondyloarthritis: identifying a chameleon. Nat Rev Rheumatol 2012; 8:253.
  7. 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; 72:1621.
  8. Rudwaleit M, Sieper J. Referral strategies for early diagnosis of axial spondyloarthritis. Nat Rev Rheumatol 2012; 8:262.
  9. Rudwaleit M, van der Heijde D, Khan MA, et al. How to diagnose axial spondyloarthritis early. Ann Rheum Dis 2004; 63:535.
  10. Calin A, Garrett S, Whitelock H, et al. A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. J Rheumatol 1994; 21:2281.
  11. Sieper J, van der Heijde D, Landewé 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.
  12. Feldtkeller E, Bruckel J, Khan MA. Scientific contributions of ankylosing spondylitis patient advocacy groups. Curr Opin Rheumatol 2000; 12:239.
  13. Cidem M, Karacan I, Uludag M. Normal range of spinal mobility for healthy young adult Turkish men. Rheumatol Int 2012; 32:2265.
  14. Almodóvar R, Zarco P, Collantes E, et al. Relationship between spinal mobility and disease activity, function, quality of life and radiology. A cross-sectional Spanish registry of spondyloarthropathies (REGISPONSER). Clin Exp Rheumatol 2009; 27:439.
  15. Ramiro S, van Tubergen A, Stolwijk C, et al. Reference intervals of spinal mobility measures in normal individuals: the MOBILITY study. Ann Rheum Dis 2015; 74:1218.
  16. Assassi S, Weisman MH, Lee M, et al. New population-based reference values for spinal mobility measures based on the 2009-2010 National Health and Nutrition Examination Survey. Arthritis Rheumatol 2014; 66:2628.
  17. Sieper J, van der Heijde D. Review: Nonradiographic axial spondyloarthritis: new definition of an old disease? Arthritis Rheum 2013; 65:543.
  18. Khan MA. Thoughts concerning the early diagnosis of ankylosing spondylitis and related diseases. Clin Exp Rheumatol 2002; 20:S6.
  19. Stolwijk C, van Onna M, Boonen A, van Tubergen A. Global Prevalence of Spondyloarthritis: A Systematic Review and Meta-Regression Analysis. Arthritis Care Res (Hoboken) 2016; 68:1320.
  20. Sieper J, Rudwaleit M. Early referral recommendations for ankylosing spondylitis (including pre-radiographic and radiographic forms) in primary care. Ann Rheum Dis 2005; 64:659.
  21. 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; 38:2452.
  22. Braun A, Gnann H, Saracbasi E, et al. Optimizing the identification of patients with axial spondyloarthritis in primary care--the case for a two-step strategy combining the most relevant clinical items with HLA B27. Rheumatology (Oxford) 2013; 52:1418.
  23. Poddubnyy D, van Tubergen A, Landewé R, et al. Defining an optimal referral strategy for patients with a suspicion of axial spondyloarthritis: what is really important? Response to: 'Evaluating the ASAS recommendations for early referral of axial spondyloarthritis in patients with chronic low back pain; is one parameter present sufficient for primary care practice?' by van Hoeven et al. Ann Rheum Dis 2015; 74:e69.
  24. Devauchelle-Pensec V, D'Agostino MA, Marion J, et al. Computed tomography scanning facilitates the diagnosis of sacroiliitis in patients with suspected spondylarthritis: results of a prospective multicenter French cohort study. Arthritis Rheum 2012; 64:1412.
  25. Song IH, Carrasco-Fernández J, Rudwaleit M, Sieper J. The diagnostic value of scintigraphy in assessing sacroiliitis in ankylosing spondylitis: a systematic literature research. Ann Rheum Dis 2008; 67:1535.
  26. van den Berg R, de Hooge M, Rudwaleit M, et al. ASAS modification of the Berlin algorithm for diagnosing axial spondyloarthritis: results from the SPondyloArthritis Caught Early (SPACE)-cohort and from the Assessment of SpondyloArthritis international Society (ASAS)-cohort. Ann Rheum Dis 2013; 72:1646.
  27. van der Linden S, 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.
  28. Bennett PH, Burch TA. Population Studies of the Rheumatic Diseases, Excerpta Medica Foundation, Amsterdam 1968. p.456-457.
  29. van den Berg R, Lenczner G, Feydy A, et al. Agreement between clinical practice and trained central reading in reading of sacroiliac joints on plain pelvic radiographs. Results from the DESIR cohort. Arthritis Rheumatol 2014; 66:2403.
  30. Jang JH, Ward MM, Rucker AN, et al. Ankylosing spondylitis: patterns of radiographic involvement--a re-examination of accepted principles in a cohort of 769 patients. Radiology 2011; 258:192.
  31. Baraliakos X, Braun J. Hip involvement in ankylosing spondylitis: what is the verdict? Rheumatology (Oxford) 2010; 49:3.
  32. Rudwaleit M, Jurik AG, Hermann KG, et al. Defining active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI group. Ann Rheum Dis 2009; 68:1520.
  33. Lambert RG, Bakker PA, van der Heijde D, et al. Defining active sacroiliitis on MRI for classification of axial spondyloarthritis: update by the ASAS MRI working group. Ann Rheum Dis 2016; 75:1958.
  34. Weber U, Lambert RG, Østergaard M, et al. The diagnostic utility of magnetic resonance imaging in spondylarthritis: an international multicenter evaluation of one hundred eighty-seven subjects. Arthritis Rheum 2010; 62:3048.
  35. Arnbak B, Grethe Jurik A, Hørslev-Petersen K, et al. Associations Between Spondyloarthritis Features and Magnetic Resonance Imaging Findings: A Cross-Sectional Analysis of 1,020 Patients With Persistent Low Back Pain. Arthritis Rheumatol 2016; 68:892.
  36. de Hooge M, van den Berg R, Navarro-Compán V, et al. Patients with chronic back pain of short duration from the SPACE cohort: which MRI structural lesions in the sacroiliac joints and inflammatory and structural lesions in the spine are most specific for axial spondyloarthritis? Ann Rheum Dis 2016; 75:1308.
  37. Weber U, Pedersen SJ, Østergaard M, et al. Can erosions on MRI of the sacroiliac joints be reliably detected in patients with ankylosing spondylitis? - A cross-sectional study. Arthritis Res Ther 2012; 14:R124.
  38. Deodhar A. Sacroiliac Joint Magnetic Resonance Imaging in the Diagnosis of Axial Spondyloarthritis: "A Tiny Bit of White on Two Consecutive Slices" May Be Objective, but Not Specific. Arthritis Rheumatol 2016; 68:775.
  39. Weber U, Zubler V, Zhao Z, et al. Does spinal MRI add incremental diagnostic value to MRI of the sacroiliac joints alone in patients with non-radiographic axial spondyloarthritis? Ann Rheum Dis 2015; 74:985.
  40. Hermann KG, Baraliakos X, van der Heijde DM, et al. Descriptions of spinal MRI lesions and definition of a positive MRI of the spine in axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI study group. Ann Rheum Dis 2012; 71:1278.
  41. Mandl P, Navarro-Compan V, Terslev L, et al. EULAR recommendations for the use of imaging in spondyloarthritis in clinical practice. Ann Rheum Dis 2014; 73 (Suppl 2):abstract FRI0127.
  42. Terslev L, Naredo E, Iagnocco A, et al. Defining enthesitis in spondyloarthritis by ultrasound: results of a Delphi process and of a reliability reading exercise. Arthritis Care Res (Hoboken) 2014; 66:741.
  43. D'Agostino MA, Aegerter P, Bechara K, et al. How to diagnose spondyloarthritis early? Accuracy of peripheral enthesitis detection by power Doppler ultrasonography. Ann Rheum Dis 2011; 70:1433.
  44. Deodhar A, Reveille JD, van den Bosch F, et al. The concept of axial spondyloarthritis: joint statement of the spondyloarthritis research and treatment network and the Assessment of SpondyloArthritis international Society in response to the US Food and Drug Administration's comments and concerns. Arthritis Rheumatol 2014; 66:2649.
  45. Olivieri I, D'Angelo S, Padula A, et al. Spondyloarthritis with onset after age 45. Curr Rheumatol Rep 2013; 15:374.
  46. Salaffi F, De Angelis R, Carotti M, et al. Fibromyalgia in patients with axial spondyloarthritis: epidemiological profile and effect on measures of disease activity. Rheumatol Int 2014; 34:1103.
  47. Tuite MJ. Sacroiliac joint imaging. Semin Musculoskelet Radiol 2008; 12:72.
  48. Mitra R. Osteitis Condensans Ilii. Rheumatol Int 2010; 30:293.
  49. Mattei TA, Rehman AA. Schmorl's nodes: current pathophysiological, diagnostic, and therapeutic paradigms. Neurosurg Rev 2014; 37:39.
  50. Balaban B, Yasar E, Ozgul A, et al. Sacroiliitis in familial Mediterranean fever and seronegative spondyloarthropathy: importance of differential diagnosis. Rheumatol Int 2005; 25:641.
  51. Langevitz P, Livneh A, Zemer D, et al. Seronegative spondyloarthropathy in familial Mediterranean fever. Semin Arthritis Rheum 1997; 27:67.
  52. Eshed I, Rosman Y, Livneh A, et al. Exertional leg pain in familial Mediterranean fever: a manifestation of an underlying enthesopathy and a marker of more severe disease. Arthritis Rheumatol 2014; 66:3221.
  53. Kaşifoğlu T, Calişir C, Cansu DU, Korkmaz C. The frequency of sacroiliitis in familial Mediterranean fever and the role of HLA-B27 and MEFV mutations in the development of sacroiliitis. Clin Rheumatol 2009; 28:41.