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Classification criteria for spondyloarthropathies

  • Istinye University Medicalpark Gaziosmanpasa Hospital, Istanbul, Turkey


Spondyloarthropathies (SpA) are a group of inflammatory arthritis which consist of ankylosing spondylitis (AS), reactive arthritis, arthritis/spondylitis associated with psoriasis (PsA), and arthritis/spondylitis associated with inflammatory bowel diseases. It is now more important than ever to diagnose and treat SpA early. New therapeutic agents including blockers of tumor necrosis factor have yielded tremendous responses not only in advanced disease but also in the early stages of the disease. Sacroiliitis on conventional radiography is the result of structural changes which may appear late in the disease process. However, magnetic resonance imaging (MRI) can visualize active inflammation at sacroiliac joints and spine in recent onset disease. The modified New York criteria, the European Spondyloarthropathy Study Group criteria and the Amor criteria do not include advanced imaging techniques like MRI which is very sensitive to the early Inflammatory changes. Assessment of SpondyloArthritis international Society has defined MRI methods for the assessment of sacroiliac joints and spine, criteria for inflammatory back pain and developed new criteria for classification of axial and peripheral spondyloarthritis. These new criteria are intended to be used for patients with SpA at the very early stage of their disease. Also, classification of psoriatic arthritis study group developed criteria for the classification of PsA. The widespread use of these criteria in clinical trials will provide evidence for a better definition of early disease and recognize many patients who may further develop classical AS or PsA. These efforts will guide therapeutic trials of potent drugs like biological agents in the early stage of these diseases.
Classication criteria for spondyloarthropathies
Ozgur Akgul, Salih Ozgocmen
Ozgur Akgul, Salih Ozgocmen,
Division of Rheumatology,
Department of Physical Medicine and Rehabilitation, Erciyes
University, Gevher Nesibe Hospital, 38039 Kayseri, Turkey
Author contributions:
Akgul O and Ozgocmen S collectively
reviewed the literature and drafted the manuscript.
Correspondence to: Salih Ozgocmen, Professor,
Division of
Rheumatology, Department of Physical Medicine and Rehabilita-
tion, Erciyes University, Gevher Nesibe Hospital, FTR AD, Ro-
matoloji BD, 38039 Kayseri, Turkey.
July 29, 2011
October 20, 2011
November 29, 2011
Published online:
December 18, 2011
Spondyloarthropathies (SpA) are a group of inamma-
tory arthritis which consist of ankylosing spondylitis
(AS), reactive arthritis, arthritis/spondylitis associated
with psoriasis (PsA), and arthritis/spondylitis associ-
ated with inammatory bowel diseases. It is now more
important than ever to diagnose and treat SpA early.
New therapeutic agents including blockers of tumor
necrosis factor have yielded tremendous responses not
only in advanced disease but also in the early stages
of the disease. Sacroiliitis on conventional radiography
is the result of structural changes which may appear
late in the disease process. However, magnetic reso-
nance imaging (MRI) can visualize active inammation
at sacroiliac joints and spine in recent onset disease.
The modied New York criteria, the European Spondy-
loarthropathy Study Group criteria and the Amor cri-
teria do not include advanced imaging techniques like
MRI which is very sensitive to the early Inammatory
changes. Assessment of SpondyloArthritis international
Society has defined MRI methods for the assessment
of sacroiliac joints and spine, criteria for inammatory
back pain and developed new criteria for classication
of axial and peripheral spondyloarthritis. These new
criteria are intended to be used for patients with SpA at
the very early stage of their disease. Also, classication
of psoriatic arthritis study group developed criteria for
the classication of PsA. The widespread use of these
criteria in clinical trials will provide evidence for a better
denition of early disease and recognize many patients
who may further develop classical AS or PsA. These
efforts will guide therapeutic trials of potent drugs like
biological agents in the early stage of these diseases.
© 2011 Baishideng. All rights reserved.
Key words:
Classification criteria; Spondyloarthritis;
Psoriatic arthritis; Ankylosing spondylitis
Peer reviewers:
Thomas J Kishen, Dr., Spine Service,
Sparsh-Hospital for Advanced Surgeries 146, Infantry Road,
Bangalore 560001, Karnataka, India; Kanji Mori, MD, PhD,
Assistant Professor, Department of Orthopaedics Surgery, Shiga
University of Medical Science, Tsukinowa-cho, Seta, Otsu
520-2192, Japan; Wen-Bao Wang, MD, Department of Surgery,
Harlem Hospital, 106 Fort Washington Avenue, Apt 3H, New
York, NY 10032, United States
Akgul O, Ozgocmen S. Classication criteria for spondyloarthrop-
athies. World J Orthop 2011; 2(12): 107-115 Available from:
Spondyloarthropathies (SpA) are a group of inamma-
tory arthritis that consist of ankylosing spondylitis (AS),
reactive arthritis, arthritis/spondylitis associated with
psoriasis (PsA) and arthritis/spondylitis associated with
inflammatory bowel diseases (IBD). The association
with human leukocyte antigen (HLA)-B27, peripheral
joint involvement predominantly of the lower extremi-
ties, sacroiliitis, spondylitis, enthesitis, dactylitis, uveitis,
enteric mucosal lesions and skin lesions are the shared
manifestations of the diseases
. Categorization of an
individual patient into a subset of SpA can be difcult
Online Submissions:ce
World J Orthop 2011 December 18; 2(12): 107-115
ISSN 2218-5836 (online)
© 2011 Baishideng. All rights reserved.
107 December 18, 2011
Volume 2
Issue 12
Akgul O
et al
. Classication criteria for spondyloarthropathies
due to the lack of well-defined criteria for the diagno-
. The newly developed Assessment of SpondyloAr-
thritis International Society (ASAS) classication criteria
proposes to classify the SpA according to leading clinical
manifestations; predominantly axial or predominantly
peripheral, with or without associated psoriasis, IBD or
preceding infection
The new developments in the clinical and scientific
aspects of SpA were pursued by the need for new strate-
gies for denition of early diagnosis and outcome criteria
for clinical studies. There is a long delay, approximately 5-6
years, between the rst occurrence of the SpA symptoms
and the diagnosis of the disease especially for female,
juvenile onset or HLA-B27 negative patients
. The
major reason for this delay may be the low awareness of
AS among the physicians as well as a lack of well dened
criteria for identifying patients with inflammatory back
pain (IBP) from chronic low back pain of mechanical
origin. Relatively late appearance of sacroiliitis on plain
radiographs, due to insidious nature of AS, is another
reason for delay. Recent developments demonstrated that
inammation of sacroiliac joints could be well visualized
by magnetic resonance imaging (MRI) long before than
radiographic changes take place
Classication criteria serve to dene disease groups for
clinical and epidemiological studies
. These sets of clas-
sication criteria combine different types of information
like symptoms, signs, laboratory findings, imaging, ge-
netic factors and etiological agents.
Classification criteria should not contain too many
false positives and should have high specicity. Because
of the inverse relationship, it has low sensitivity. In clini-
cal studies, classification criteria provide homogeneous
patient groups which thus enable comparisons. On the
other hand, diagnostic criteria should have high sensitiv-
ity in order to make a correct diagnosis; this means that
it may contain false positives and may have low specic-
ity. Most of the rheumatic diseases do not have unique
or specific diagnostic tests and classification criteria
have been developed to identify homogeneous patient
populations for clinical trials. It should be noted that
most of the criteria sets in rheumatology have been de-
veloped as classication criteria for clinical research but
unfortunately are widely used as diagnostic tools in daily
practice. This is, for example, the case with the formerly
the American Rheumatism Association criteria (for the
classication of rheumatoid arthritis) and the European
Spondylarthropathy Study Group (ESSG) preliminary
criteria for the classication of spondyloarthropathies
Inammatory back pain
Inflammatory back pain is the leading symptom of the
SpA and mirrors inammation of sacroiliac joints, spine
and spinal entheses. However its value for the diagnosis,
classification and screening in primary care settings is
not well recognized. Clinical history has been proposed
as a screening test to identify patients with SpA among
those who have chronic back pain
In general, criteria
for IBP were derived from studies comparing patients
with AS and patients with back pain of other etiologies
and from studies based on expert opinion. Although IBP
is considered as the foremost clinical symptom for axial
SpA, its sensitivity and specicity with respect to diagno-
sis of axial SpA does not exceed 80%
et al
examined 42 patients with AS and 24
patients with other origin of back pain for 5 features of
back pain: (1) insidious onset; (2) age at onset < 40 years;
(3) duration of back pain
3 mo; (4) associated with
morning stiffness; and (5) improvement with exercise. IBP
was considered in the presence of 4 of 5 features, and
these were the first criteria for IBP
(Table 1). However,
Calins criteria had some limitations. Duration of morn-
ing stiffness was later reported by Gran; a duration more
than 30 min is associated with AS, and has 64% sensitivity
and 58% specicity
In the original study, Calins criteria
have 95% specificity and 76% sensitivity but the subse-
quent studies showed low sensitivity and specificity
Adding a single criterion “getting out of the bed at night
improved the sensitivity of these criteria
Modied New York Criteria (mNY) for AS integrated
features of the Calin’s criteria made the definition of
back pain in patients with AS: low back pain and stiff-
ness more than 3 mo, improving with exercise but is not
relieved by rest
. Various combinations of IBP features
were evaluated in 101 patients with AS and 112 patients
with mechanical low back pain by Rudwaleit
et al
. Clini-
cal features of back pain were: (1) morning stiffness >
30 min; (2) age of onset; (3) no improvement by rest; (4)
awakening because of the pain in the second half of the
night only; (5) alternating buttock pain; and (6) duration
December 18, 2011
Volume 2
Issue 12
Calin’s criteria
for IBP
Berlin criteria for IBP ASAS IBP criteria mnemonic
for criteria “iPAIN”
Age at onset
< 40 yr
Morning stiffness of
> 30 min duration
Insidious onset
Duration of back
pain > 3 mo
Improvement in back
pain with exercise but
not with rest
Pain at night
(with improvement upon
getting up)
Insidious onset
Nocturnal awakening
(second half of the night
Age at onset < 40 yr
with exercise
Alternating buttock pain Improvement with exercise
No improvement with rest
Requires the
presence of four
of ve criteria
The sensitivity is 70%
specicity 81% if two
of the four criteria are
The sensitivity is 77.0% and
specicity 91.7% if at least
four out of ve criteria are
Table 1 Inammatory back pain criteria sets and mnemonic
for assessment of spondyloarthritis international society
IBP: Inflammatory back pain; ASAS: Assessment of spondyloarthritis
international society; iPAIN: Inammatory PAIN.
of back pain. None of the single parameters differenti-
ated AS from MLBP. Based on a good balance between
sensitivity, specificity and feasibility the Berlin criteria
were proposed with 70% sensitivity and 81% specicity
(Table 1).
In 2009, thirteen internationally well-known rheuma-
tologists, considered as experts in AS/SpA and members
of ASAS, participated in the development of new clas-
sification criteria for IBP. They presented new ASAS
IBP criteria without major differences from formerly
established IBP criteria (Table 1). ASAS IBP criteria have
77.0% sensitivity and 91.7% specicity when at least four
out of five parameters are present. Calin criteria had a
higher sensitivity but a lower specificity. Berlin criteria
had a lower sensitivity and a higher specificity with re-
spect to newly developed criteria
. Mnemonic for ASAS
IBP criteria (iPAIN: Inflammatory PAIN) has been re-
cently published
(Table 1).
Imaging of the sacroiliac joints and the spine has an
important role in the diagnosis, classication and moni-
toring for patients with SpA. Sacroiliitis on conventional
radiography became an important diagnosis in AS and
was given an outstanding role in the development of
classication criteria in 1961 and mNY criteria in 1984
(Table 2) Usually bilateral grade
2 or unilateral grade
3 sacroiliitis are considered critical for the diagno-
sis of AS
However, radiographic sacroiliitis reflects
structural changes which may appear late in the disease
process at least in a subset of patients
. Thus, it has
low specicity especially for patients at the early stages
of the disease.
Magnetic resonance imaging can visualize active in-
flammation at sacroiliac joints and spine in established
or in early pre-radiological axial disease, regardless of
disease stage
. The mNY, ESSG criteria and the Amor
criteria do not contain MRI as an imaging tool. Actually,
MRI of the sacroiliac joints was dened however it was
not well established or standardized, when these criteria
were developed.
ASAS classication criteria for axial SpA have imag-
ing and clinical arms. The imaging arm includes either
sacroiliitis on conventional radiography or sacroiliitis on
MRI, which is highly important for recognition of pre-
radiographic changes in early SpA
Regarding spondylitis, which may also occur before
sacroiliitis, a denition of a “positive MRI” for the spinal
inammation is also needed
. However, there is insuf-
ficient data for the use of spinal MRI and little is yet
known about the specicity of spinal features in the axial
Active inflammatory lesions such as bone marrow
edema/osteitis, synovitis, enthesitis and capsulitis associ-
ated with SpA can be detected by MRI. Also structural
damage such as sclerosis, erosions, fat deposition and an-
kylosis can be detected by MRI. ASAS/OMERACT im-
aging group dened minimum amount of bone marrow
edema (one lesion at least two adjacent slices or more
than one lesion at least one slice) which is required for
the denitive diagnosis sacroiliitis
. Figure 1A-D repre-
sents a normal radiograph of the pelvis and early changes
on sacroiliac MRI of a male patient at the early stages of
the disease (pre-radiographic stage). Figure 2A-C repre-
sents inflammatory changes and structural damage on
spinal MRI.
HLA B-27
HLA B-27 positivity is extremely relevant to the early di-
agnosis of SpA. Five to 10% of the population are HLA
B-27 positive and in patients with AS and SpA the posi-
tivity of HLA B-27 changes to 70% to 95% and nearly
70%, respectively
Ankylosing spondylitis
Ankylosing spondylitis is the most common and most
typical form of SpA. It is two to three times more com-
mon in men than women. Ankylosing spondylitis usu-
ally begins with back pain and stiffness at a young age
but various presentations, such as peripheral arthritis
and enthesopathy may antedate back symptoms in some
patients. Late onset after the age of 45 is uncommon in
AS however some patients may reasonably be diagnosed
late. Inammatory low back pain is one of the presenting
features but not solely specic to AS. History of uveitis,
positive family history for AS, impaired spinal mobility or
chest expansion supports the diagnosis
Axial involvement is one of the characteristics of the
disease and 90% of patients have radiographic sacroiliitis
during the course of the disease. The rst classication
criteria for AS were proposed in 1963 at the European
Congress of Rheumatology in Rome, based on the clini-
cal experience of rheumatologists. Later in 1966, thoracic
pain and uveitis were removed from the criteria set be-
cause of low specicity and low sensitivity. This preceded
the framework of New York criteria which was modied
in 1984 by using inammatory back pain components re-
ported by Calin
et al
. A patient can be classied as hav-
ing denite AS if at least one clinical criterion (IBP, limi-
tation of lumbar spine or limitation of chest expansion)
plus radiologic criterion (bilaterally grade 2 or unilateral
109 December 18, 2011
Volume 2
Issue 12
Low back pain for at least 3 mo duration improved by exercise and not
relieved by rest
Limitation of lumbar spine motion in sagittal and frontal planes
Chest expansion decreased relative to normal values for age and sex
Unilateral sacroiliitis grade 3–4
Bilateral sacroiliitis grade 2–4
Denite ankylosing spondylitis if (4a or 4b) and any clinical criterion
Table 2 Modified New York criteria for ankylosing
Akgul O
et al
. Classication criteria for spondyloarthropathies
grade 3-4 sacroiliitis) are fullled
. These classication
criteria are inevitably used for the diagnosis of AS by
most clinicians (Table 2).
All these criteria included presence of spinal/thoracic
pain, restriction of spinal mobility and radiological sacroi-
liitis. Restriction of spinal mobility and radiological sac-
roiliitis may reect structural damage and spinal/thoracic
pain may reect active inammation and structural dam-
age as well. It is obvious that these criteria do not perform
well in patients with early/pre-radiographic phase of AS.
Axial spondyloarthritis
As mentioned above, sacroiliitis on plain radiographs
takes years from the onset IBP and the symptoms of IBP
alone are not diagnostic in many patients.
Berlin criteria were developed to assist physicians for
early diagnosis of SpA. In this criterion set, the clini-
110 December 18, 2011
Volume 2
Issue 12
Figure 1 Normal radiograph of the pelvis and early changes on sacroiliac
magnetic resonance imaging of a male patient at the early stages of the
disease at the pre-radiographic stage. A: Thirty-ve year old male, normal
anterior posterior pelvis radiograph; B: T1-weighted Fast Spin Echo semi-
oblique coronal scans of the sacroiliac joints; C: T2-weighted fat suppressed
images shows bone edema at both sacral and iliac bones; D: T1-weighted
post-contrast image shows enhancement of the contrast media revealing acute
Figure 2 Inflammatory changes and structural damage on spinal mag-
netic resonance imaging. A: T1-weighted fast spin echo sagittal magnetic
resonance scan of the lumbar spine shows hypointense lesion on end plates
of thoracic 11 and 12 vertebrae; B: T2-weighted fat suppressed sagittal image
shows hyperintense signals at the lesion and also at the upper anterior of the
L3 and lower anterior of L2 vertebra; C: T1-weighted post-contrast images
shows enhancement of the contrast media at the borders of the lesion revealing
acute spondylodisciitis.
Akgul O
et al
. Classication criteria for spondyloarthropathies
111 December 18, 2011
Volume 2
Issue 12
cal, laboratory (HLA B-27) and imaging (MRI of sac-
roiliac joints) features were included. The diagnosis of
recent-onset axial SpA (pre-radiographic SpA) can be
established in patients who have clinical features without
radiographic changes but sacroiliitis on MRI. This study
also analyzed the role of MRI as a diagnostic tool
The performance of Berlin criteria has been tested and
showed that the diagnostic capacity in patients with axial
undifferentiated SpA in the Chinese population was simi-
lar to ESSG and Amor criteria
In 2004, ASAS decided to improve current SpA cri-
teria particularly to apply to patients in the early disease
stages. It was proposed that SpA patients with predomi-
nantly axial symptoms but without radiographic sacroili-
itis could be considered as patients with pre-radiographic
phase of AS. The need for an early diagnosis in all pa-
tients with AS and axial SpA is put forward
In 2009, ASAS developed two candidate criteria sets
for classication of axial SpA that include patients with-
out denite radiographic sacroiliitis
. The candidate sets
were tested in the entire cohort of 649 patients from 25
centers in 16 countries. The new criteria consisted of a
‘clinical arm’ and ‘imaging arm’ (Figure 3).
The entire set
had 82.9% sensitivity and 84.4% specificity and for the
‘imaging arm’ alone sensitivity was 66.2% and specicity
was 97.3%. The specicity of the new criteria was much
better than ESSG criteria modied by adding MRI and
slightly better than Amor criteria modified by adding
. The sensitivity is almost the same for the three
criteria set. ASAS criteria are quite simple and easily ap-
plicable in daily clinical practice and a mnemonic is pro-
posed to facilitate its use
(Figure 3).
Peripheral spondyloarthritis
After the development of ASAS criteria for axial SpA,
ASAS experts developed criteria for patients with SpA
with predominant peripheral manifestations and com-
pared these with ESSG and Amor criteria which were
generated for the entire SpA group including peripheral
. Patients with peripheral manifestations including
peripheral arthritis, dactylitis and enthesitis and without
back pain were included. The sensitivity of the criteria was
77.8% and the specicity was 82.2% (Figure 4). The new
ASAS classication criteria for peripheral arthritis would
seem to perform better than ESSG and Amor criteria.
Spondyloarthritis in general
Spondyloarthropathies were formally classied in Amor
criteria in 1990. Amor’s criteria are a list of signs based
on a scoring system of laboratory, radiologic and clini-
cal features and do not require an entry criterion
The signs in the criteria contribute 1 point, 2 points or 3
points; a score of 6 or more classies a patient as having
SpA. Although sacroiliitis is not mandatory for the diag-
nosis of SpA, it had the highest score (3 points) and is
considered to be very specic for SpA
(Table 3).
ESSG criteria were proposed in 1991. In ESSG crite-
ria IBP and/or peripheral arthritis are required as entry
criteria. Patients with at least one entry criterion and one
minor criterion are classified as having SpA
5). The aim of ESSG criteria is to include undifferenti-
ated SpA which was not been proposed in Amor criteria.
Both of these criteria were considered to be helpful for
the diagnosis of SpA and had a broader denition of the
spectrum however, they have low sensitivity particularly
for the early diagnosis of SpA. For example, some of the
leading symptoms like uveitis may be omitted by ESSG
criteria but captured by Amor criteria.
Both sets of criteria were evaluated in a multicenter
cross-sectional study including 124 patients with SpA
and 1964 controls. Overall performance of both sets was
similar and the performance was better in patients with
a denite diagnosis
. These criteria were evaluated for a
Turkish population in 157 patients with SpA and in 127
patients with various rheumatic diseases. Results showed
that both criteria had a similar value for classication of
Arthritis or enthesitis or dactylitis
Patient with peripheral manifestations only
(if back pain is actually present the axial SpA criteria should be applied)
2 of the remaining
IBP in the past
Positive family history for SpA
1 of
Inammatory bowel disease
Preceding infection
Sacroiliitis on imaging
Figure 4 Assessment in spondyloarthritis international society classica-
tion criteria for peripheral spondyloarthritis or spondyloarthritis in gen-
. SpA: Spondyloarthropathies; IBP: Inammatory back pain; HLA: Human
leukocyte antigen.
Sacroiliitis on
1 SpA feature
HLA-B27 plus
2 other SpA
SpA features SPINEACHE
Sausage digit (dactylitis)
Psoriasis- Positive family history of SpA
Inammatory back pain
NSAID good response
Enthesitis (heel)
Crohn’s/Colitis disease-elevated CRP
Eye (uveitis)
Figure 3 Assessment in SpondyloArthritis international Society
classification criteria for axial spondyloarthritis and mnemonic for
assessment of spondyloarthritis international society classification
Sacroiliitis on imaging active (acute) inflammation on magnetic
resonance imaging highly suggestive of sacroiliitis associated with SpA or
definitive radiographic sacroiliitis according to modified New York criteria;
Elevated CRP is considered a SpA feature in the context of chronic back pain.
SpA: Spondyloarthropathies; CRP: C-reactive protein; NSAID: Nonsteroidal
antiinammatory drugs; HLA: Human leukocyte antigen.
Akgul O
et al
. Classication criteria for spondyloarthropathies
112 December 18, 2011
Volume 2
Issue 12
SpA and were comparable in terms of specificity and
In a newly published study, performance of ESSG
criteria, ASAS criteria and mNY criteria were compared
in patients with SpA. The ASAS criteria had the highest
sensitivity compared to ESSG criteria and mNY criteria
98.4%, 83.6% and 71.9%, respectively
. In other stud-
ies of different ethnicities, lower sensitivity for mNY but
similar sensitivity for ESSG was reported
Recently, the French Society of Rheumatology pre-
sented the DESIR cohort. Patients were recruited if they
had IBP more than 3 mo and less than 3 years. A total of
708 patients were recruited and the mNY criteria, Amor
criteria, ESSG criteria and axial ASAS criteria were ful-
lled by 26%,77%, 76% and 67% at entry, respectively
The diagnostic accuracy of the ESSG criteria, Amor
criteria and the combination of them was analyzed in 24
patients who were misdiagnosed as SpA. The ratio of the
misdiagnosed patients who fullled ESSG criteria, Amor
criteria and combination were 45.8%, 16.7%, 16.7%, re-
spectively. This study suggests that ESSG criteria may not
be absolutely secure for the diagnosis of SpA
Performance of mNY criteria, ESSG criteria, Amor
criteria and Berlin criteria in patients with IBP of a maxi-
mum of 2 years duration was evaluated. Fourteen of the
68 patients had AS according to mNY and all fulfilled
three of SpA criteria sets. The highest classication rate
was found with the ESSG criteria (84%), followed by the
Amor criteria (71%) and the Berlin criteria (65%). The
ESSG criteria were the most sensitive and the mNY crite-
ria for AS appeared to be most specic sets of criteria
Psoriatic arthritis
Psoriatic arthritis (PsA) is defined as an inflammatory
arthritis associated with cutaneous psoriasis. Patients may
have peripheral arthritis (oligoarthritis or polyarthritis),
enthesitis, dactylitis or sacroiliitis/spondylitis
At the be-
ginning of the century PsA was thought to coincidentally
occur with rheumatoid arthritis (RA) and psoriasis. Psori-
atic arthritis was adopted as a distinct disease for the rst
time in 1964. The distinction between RA and PsA was
made based on the clinical and radiological features
In 1973 Moll and Wright
reported a proposal for
the classication of PsA. When a patient with psoriasis
has inammatory arthritis and is negative for rheumatoid
factor (RF) PsA can be classied in ve distinct clinical
subsets as: (1)
oligoarticular asymmetric arthritis (< 5
tender and swollen joints); (2)
polyarticular arthritis; (3)
distal interphalangeal joint predominant; (4) spondylitis
predominant; and (5) arthritis mutilans predominant.
Over the passing years minor modications have been
made on these criteria. Gladman
et al
suggested that
there is no need to insist on seronegativity for RF, since
it can be positive in healthy subjects and in their series,
12% of cases were RF (+) even when the patients who
had a characteristic sign of RA, like rheumatoid nodules
and extra-articular manifestations were excluded. It is
also possible to differentiate seronegative RA from PsA
by using other antibodies, anti-cyclic citrullinated peptide
which has much higher specicity than RF for the diag-
nosis of RA.
Psoriasis is a common disease affecting nearly 1%-2%
of the population. In some forms of arthritis coinciden-
tal psoriasis may also occur. Psoriasis may precede, si-
Amor criteria
Clinical symptoms or history of scoring Points
Lumbar or dorsal pain at night or morning stiffness of
lumbar or dorsal pain
Asymmetrical oligoarthritis 2
Buttock pain 1
If alternate buttock pain 2
Sausage like toe or digit 2
Heel pain or other well-dened enthesopathy 2
Iritis 1
Nongonococcal urethritis or cervicitis within 1 mo before
the onset of arthritis
Acute diarrhea within one month before the 1 mo onset
of arthritis
Psoriasis, balanitis, or inammatory bowel disease
(ulcerative colitis or Crohn’s disease)
Radiological ndings
Sacroiliitis (bilateral grade 2 or unilateral grade 3) 3
Genetic background
Presence of HLA-B27 and/or family history of ankylosing
spondylitis, reactive arthritis, uveitis, psoriasis, or
inammatory bowel disease
Response to treatment
Clear-cut improvement within 48 h after NSAIDs intake or
rapid relapse of the pain after their discontinuation
A patient is considered as suffering from a pondyloarthropathy
if the sum is
Table 3 Amor criteria for the classication of spondyloarthro
NSAID: Nonsterodial anti-inflammatory drug; HLA: Human leukocyte
Inammatory spinal pain or synovitis
(asymmetric, predominantly in lower extremities)
Plus one of the following
Family history: rst- or second-degree relatives with ankylosing spondylitis,
psoriasis, acute iritis, reactive arthritis, or inammatory bowel disease
Past or present psoriasis, diagnosed by a physician
Past or present ulcerative colitis or Crohn’s disease, diagnosed by a
physician and conrmed by radiography or endoscopy
Past or present pain alternating between the two buttocks
Past or present spontaneous pain or tenderness at examination of the site
of the insertion—the Achilles tendon or plantar fascia (enthesitis)
Episode of diarrhea occurring within 1 mo before onset of arthritis
Nongonococcal urethritis or cervicitis occurring within 1 mo before onset
of arthritis
Bilateral grade 2–4 sacroiliitis or unilateral grade 3 or 4 sacroiliitis [grades
are 0: normal; 1: possible; 2: minimal; 3: moderate; 4: completely fused.
Figure 5 European Spondyloarthropathy Study Group Criteria for the
classication of spondyloarthropathies
Akgul O
et al
. Classication criteria for spondyloarthropathies
113 December 18, 2011
Volume 2
Issue 12
multaneously occur or appear many years after the onset
of arthritis. In latter cases patients may be misdiagnosed
with other types of arthritis like seronegative RA or reac-
tive arthritis; however, positive family history for psoria-
sis may be helpful in these cases. Patients with arthritis
should be carefully examined for existence of “hidden”
psoriatic lesions which may be located under the breasts,
around the umbilicus or anus, over the hairline, nasal cleft
or nails
Patients with PsA tend to have inflammatory axial
involvement similar to AS. There are several differences
from the classical AS
(1) asymmetrical sacroiliitis; (2)
non-marginal syndesmophytes; (3) asymmetrical syndes-
mophytes; and (4) more frequent involvement of the cer-
vical spine.
Bennett thought that Moll and Wright criteria tend to
over diagnosing PsA and suggested new criteria in 1979.
In these new set of criteria, clinical and radiological fea-
tures were combined with synovial uid analysis and his-
tology. These criteria have not been widely used in pro-
spective studies since synovial uid analysis and histology
are not practical. Psoriatic skin or nail involvement plus
either peripheral joint or axial disease were required
Simplification of Bennetts criteria has been made by
Vasey and Espinoza
ESSG criteria were also valid for PsA. For the first
time skin or nail involvement was not mandatory in these
criteria. Cases in which arthritis precedes psoriasis are
well recognized and family history of psoriasis can help
the diagnosis
A denition of PsA based on enthesopathy has been
proposed by McGonagle
et al
There is a significant
problem with these criteria because of MRI require-
ments. It is not practical to use MRI in epidemiological
research. MRI appearance shows both features of enthe-
sopathy and synovitis and so the discrimination capac-
ity would be markedly attenuated in established disease.
et al
proposed criteria from actual patient data
to diagnose PsA which requires a score of 11 points for
There are few studies that compare different crite-
ria for the diagnosis of PsA. A study which compared
performance of the criteria revealed that the sensitivity
of Vasey and Espinoza, McGonagle and Gladman were
99% whereas Bennett and ESSG criteria were signicant-
ly less sensitive. The specicity of the criteria was as high
as 93% and 99%, and there were no statistically signi-
cant difference between criteria. Fournie criteria were the
most difcult to use and Vasey and Espinoza, and Moll
and Wright were the easiest. Vasey and Espinoza, Glad-
man or McGonagle are the most accurate and feasible in
distinguishing RA from PsA
The classification of psoriatic arthritis (CASPAR)
study group is an international group of investigators,
all of whom have records of research in PsA. They pro-
posed new data-driven classication criteria for PsA and
collected prospective clinical and radiological data of 588
patients with PsA and 536 patients with other inamma-
tory arthritis, at least half of them with RA (Figure 6).
The performance of the new criteria were also compared
to other existing data
. The sensitivity and specicity of
the CASPAR criteria in the original study were 91.4% and
98.7%, respectively. These criteria were more specic but
less sensitive than Vasey and Espinoza criteria.
The main limitation of the CASPAR criteria is the ap-
plicability to recent-onset disease. Very high sensitivity of
CASPAR criteria in early and late PsA was also demon-
strated in a study
. This study analyzed patients referred
to a special tertiary referral clinic and did not have a
control population. It seems likely that only patients with
secure clinical diagnoses are referred and enrolled into
this clinic, possibly leading to an overestimation of the
sensitivity of the criteria
Family history of psoriasis is the advantage of CAS-
PAR criteria over Vasey and Espinoza as well as Moll and
Wright criteria. It is also possible to make a diagnosis of
PsA for patients who are RF positive and have polyar-
ticular symmetric arthritis. The CASPAR, as a simple and
user-friendly criteria set, has high potential to be intro-
duced as the universal classication criteria for PsA
Chronic low back pain is a common and important prob-
lem and patients with this disorder are seen by a variety
of specialists including rheumatologists, orthopedic sur-
geons, physiatrists, family physicians etc. Inflammatory
Inammatory articular disease (joint, spine or enthesal) and 3 points of fol-
lowing criteria)
Evidence of current psoriasis
, a personal history of psoriasis, or a family
history of psoriasis
Current psoriasis is dened as psoriatic skin or scalp disease present to
day as judged by a rheumatologist or dermatologist
A personal history of psoriasis is dened as a history of psoriasis that
may be obtained from a patient, family physician, dermatologist,
rheumatologist, or other qualied health care provider
A family history of psoriasis is dened as a history of psoriasis in a
rst- or second-degree relative according to patient report)
Typical psoriatic nail dystrophy including onycholysis, pitting, and
hyper keratosis observed on current physical examination
A negative test result for the presence of rheumatoid factor by any
method except latex but preferably by enzyme-linked immunosorbent
assay or nephelometry, according to the local laboratory reference range
Either current dactylitis, dened as swelling of an entire digit, or a history
of dactylitis recorded by a rheumatologist
Radiographic evidence of juxtaarticular new bone formation, appearing
as ill-dened ossication near joint margins (but excluding osteophyte
formation) on plain radiographs of the hand or foot
Figure 6 Classication of psoriatic arthritis study group criteria for the
classication of psoriatic arthritis
Current psoriasis is assigned a score
of 2; all other features are assigned a score of 1.
Akgul O
et al
. Classication criteria for spondyloarthropathies
114 December 18, 2011
Volume 2
Issue 12
low back pain is usually the leading symptom of spondy-
loarthropathies and physicians should always be aware.
For a correct diagnosis IBP should be differentiated from
mechanical back pain. A detailed screening of signs and
symptoms in terms of insidious onset, morning stiffness,
pain at night, improvement with exercise and favorable
response to NSAIDs may ease the discrimination. Other
common features of SpA like dactylitis, enthesitis, ar-
thritis and history of preceding infections should also
be checked. Imaging has an important role in the early
diagnosis of SpA and the very early phase of sacroiliitis
or spondylitis could be detected by documenting active
inammatory lesions like bone marrow edema, enthesitis,
capsulitis or synovitis on MRI. HLA B-27 positivity is ex-
tremely relevant to the early diagnosis of SpA.
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S- Editor
Yang XC
L- Editor
Roemmele A
E- Editor
Yang XC
Akgul O
et al
. Classication criteria for spondyloarthropathies
... However, the panel suggests that in such cases, the ASDAS be used. 49,50 Considering the paucity of information on the diagnostic instruments for the screening of patients with PsA, severity assessment of PsA should be performed on a case-to-case basis 26 ...
Full-text available
Objective: Psoriatic arthritis (PsA), a chronic inflammatory disease characterized by heterogeneous clinical manifestations, substantially impacts the quality of life of affected individuals. This article aims at developing consensus recommendations for the management of PsA and associated comorbidities and screening and monitoring requirements of PsA therapies in the United Arab Emirates (UAE) population. Methods: An extensive review of present international and regional guidelines and publications on the pharmacological management, monitoring of therapies in the context of PsA was performed. Key findings from guidelines and literature were reviewed by a panel of experts from the UAE at several meetings to align with current clinical practices. Consensus statements were formulated based on collective agreement of the experts and members of Emirates Society for Rheumatology. Results: The consensus recommendations were developed to aid practitioners in clinical decision-making with respect to dosage recommendations for pharmacological therapies for PsA, including conventional drugs, non-biologic, and biologic therapies. Consensus recommendations for therapeutic options for the treatment of PsA domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease, were developed. The panel emphasized the importance of monitoring PsA therapies and arrived at a consensus on monitoring requirements for PsA therapies. The expert panel proposed recommendations for the management of common comorbidities associated with PsA. Conclusion: These consensus recommendations can guide physicians and healthcare professionals in the UAE in making proper treatment decisions, as well as efficiently managing comorbidities and monitoring therapies in patients with PsA.
... According to the Assessment of Spondyloarthritis International Society (ASAS) criteria for axial spondyloarthritis (axSpA), patients who suffered from back pain for more than 3 months and the age at onset was less than 45 years old were considered as suspected AS. The diagnosis was confirmed with one image finding of sacroiliitis plus at least one SpA symptom, or human leukocyte antigen (HLA)-B27 positivity plus at least 2 SpA features (13,14). In addition, the diagnosis of PsA was based on Classification Criteria for Psoriatic Arthritis (CASPAR). ...
Full-text available
Objectives Optic neuritis is (ON) is believed to be an immune-mediated disease; however, the association between optic neuritis and autoimmune diseases remains unclear. This study aimed to identify the incidence rate and adjusted hazard ratio (aHR) of autoimmune diseases in patients with optic neuritis. Methods This nationwide, population-based, retrospective cohort study collected patients’ data between 1999 and 2013 from the National Health Insurance Research Database in Taiwan. A total of 9,235 patients were included. Using 1:4 propensity scoring, 1,847 patients were enrolled in the optic neuritis group and 7,388 in the non-optic neuritis group according to age, sex, comorbidities, and corticosteroid use. Follow-up was started from the index date and the endpoint was a diagnosis of new-onset autoimmune diseases including, myasthenia gravis (MG), psoriatic arthritis (PsA), systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and ankylosing spondylitis (AS). Results The Kaplan-Meier curves depicted that patients with optic neuritis had a higher cumulative incidence of autoimmune diseases than patients without optic neuritis. Cox proportional hazard regression showed that patients with optic neuritis were at a high risk of autoimmune diseases (aHR: 1.40; 95% C.I., 1.05–1.87), including MG (aHR: 4.16, 95% C.I.: 1.33–12.94), SLE (aHR: 3.33, 95% C.I.: 1.24–8.97), and AS (aHR: 2.86, 95% C.I.: 1.54–5.31). Subgroup analysis provided that patients with optic neuritis aged below 65 years (aHR: 1.42, 95% C.I.: 1.03–1.96) or who were females (aHR: 1.59, 95% C.I.: 1.11–2.27) had a significantly increased risk of autoimmune diseases compared to respective controls. The use of corticosteroids reduced the risk of autoimmune diseases in patients with optic neuritis (aHR for corticosteroids non-users: 1.46, 95% C.I.: 1.03–2.07). Conclusion Patients with optic neuritis presented with a high risk of autoimmune diseases such as MG, SLE, and AS, especially patients with optic neuritis who were young or females. Corticosteroids attenuated the link between optic neuritis and subsequent autoimmune diseases.
... However, the panel suggests that in such cases, the ASDAS be used. 49,50 Considering the paucity of information on the diagnostic instruments for the screening of patients with PsA, severity assessment of PsA should be performed on a case-to-case basis 26 ...
Full-text available
Objective: Psoriatic arthritis (PsA), a chronic inflammatory arthropathy, is often underdiagnosed in Middle Eastern countries, substantially impacting the treatment of affected individuals. This article aims to highlight current unmet clinical needs and provide consensus recommendations for region-specific evaluation methods and nonpharmacological therapies in the United Arab Emirates (UAE). Method: An extensive literature review was conducted, focusing especially on global and regional guidelines for the evaluation and treatment of PsA. These form the basis of the consensus statements formulated. Additionally, an expert panel of key opinion leaders from the UAE reviewed these guidelines and available literature at an advisory board meeting to identify unmet needs, bridge clinical gaps in the UAE, and develop consensus statements for the evaluation and treatment of PsA. Result: The consensus statements were developed based on overarching principles for the management of PsA, evaluation of patients with PsA, and nonpharmacological approaches for the management of PsA. The overarching principles included adopting a targeted, multidisciplinary approach, along with collaboration between rheumatologists and dermatologists in cases of clinically significant skin involvement. The panel also highlighted the value of composite disease severity measures for characterizing clinical manifestations of PsA. In terms of nonpharmacological management approaches, lifestyle modification (comprising dietary change, exercise, and cessation of smoking) and psychotherapy were recommended. Conclusion: The consensus statements will aid healthcare professionals in clinical decision-making in the context of PsA.
... The two arms altogether have 82.9% sensitivity and 84.4% specificity and, for the 'imaging arm' alone, the reported sensitivity was 66.2% and specificity 97.3% (143,144). Of note, imaging cannot be assessed in isolation and needs to be interpreted in the light of clinical presentation and results of laboratory investigations. ...
Full-text available
Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.
... The prevalence of HLA-B27 in AS ranges from 88 to 90% in patients compared to 4-8% among general population. [13][14][15][16][17] The association of HLA-B27 varies from 19-94% in sero-negative spondyloarthritis (SSpA) patients and ranges from 1.4-8% in general population in India. [18][19][20] A patient with clinical manifestations similar to rheumatoid arthritis who is tested negative for Rheumatoid Factor (RF) and Anti Cyclic Citrullinated Peptide (Anti-CCP), tested positive for HLA-B27 or scan proved on diagnosing sacroiliitis will be defined as Seronegative Spondyloarthritis. ...
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Human leukocyte antigens (HLA) are gene products found in the major histocompatibility complex, aiding in differentiation of “self” from “non-self” antigens, and is crucial for the communication between immune cells of the human body. HLA-B27, in specific, has a strong interrelation with different types of Spondyloarthritis (SpA). The aim of this study is to study the frequency of HLA-B27 in suspected Spondyloarthritis patients presenting with axial and peripheral joint involvement, who attended our tertiary care centre from August-2017 to January-2021. Patients fulfilling Assessment of Spondyloarthritis International Society (ASAS) criteria for Spondyloarthritis were included in the study, and were further classified into Spondyloarthritis sub-groups. Blood samples were collected for CRP and ESR tests along with HLA-B27 detection by RT-PCR method. Magnetic resonance imaging was done for sacroiliac joints in patients with lower back pain. Analysis of 289 samples of SpA patients revealed 156 (54%) to be HLA-B27 positive and 133 (46%) to be HLA-B27 negative. There were 98 patients (63%) with Ankylosing spondylitis, 33 (21%) had Reactive arthritis, 19 (12%) had Psoriatic arthritis, 6 (4%) had Undifferentiated Spondyloarthritis, and inflammatory bowel disease was diagnosed in 0% in HLA-B27 positive Spondyloarthritis patients. The frequency of HLA-B27 among the Spondyloarthritis (SpA) patients in our study was found to be 54% (156), more common clinical manifestation in men belonging to the age group of 16-25 years positive patients. Ankylosing spondylitis (AS) was found to be the most common sub-groups observed among the SpA patients.
... The term "spondyloarthritis" (SpA) refers to a group of inflammatory diseases with overlapping clinical and imaging features and pathogenic mechanisms but with differences in clinical outcome or response to treatment (1). Although pathogenesis is still not fully understood, SpA is considered to be induced mainly by genetic and environmental triggers (2). ...
Objective. The spondyloarthritis group comprises chronic inflammatory conditions that share clinical, genetic and radiographic features. The impact of comorbidities on disease activity is not entirely known. The aim of this study is to identify the frequency and management of comorbidities in SpA patients. Materials and methods. A six-month retrospective study included 235 SpA patients for whom demographic, disease data and associated comorbidities were collected, according to EULAR’s designated categories. Statistical analysis was performed using Microsoft Excel. Results. 71% were males, with a mean age of 42.3, suffering from SpA for more than 15 years. 60% patients were overweight or obese, 25% had been diagnosed with hypertension, 28% were smokers. 18% suffered from dyslipidemia and 9% had type II diabetes. 16% had hepatitis B while 2% had C viral infection, 14% had previous mild to moderate urinary or pulmonary infections. Osteoporosis was confirmed in 6% and malignancies in 2.5% cases. Conclusions. The most frequently encountered comorbidities were cardio-vascular events, followed by gastro-intestinal disorders. SpA patients require early comorbidity detection with the aid of their rheumatologist and a multidisciplinary care to avoid additional disease burden.
... S pondyloarthritis (SpA) describes a group of interrelated rheumatic conditions comprising ankylosing spondylitis (AS), psoriatic arthritis (PsA), arthritis/spondylitis with inflammatory bowel disease (IBD), and reactive arthritis. At present, anti-tumor necrosis factors (TNF) agents are the most promising therapy option when it comes to disease remission and outcome rates [1]. The concept of blocking a single pro-inflammatory cytokine such as TNF-α could restore homeostasis of a complex network and ameliorate signs and symptoms of chronic inflammatory diseases was a real breakthrough in medical practice. ...
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Therapeutic options for patients with Spondyloarthritis (SpA) are limited. The present-day pharmacotherapy for Spondyloarthritis comprises immunomodulator/suppressive drugs. In this case report, we describe a 29-year old Postgraduate resident in Medicine who was diagnosed with spondyloarthritis and was managed by a combination of various disease-modifying drugs like methotrexate and sulfasalazine and immunomodulators such as systemic corticosteroids as well as Tumor Necrosis Factor-alfa inhibitors. After a series of therapeutic trials with them, the chimeric TNF blocker Infliximab led to significant clinical improvement in symptoms and reduction in disease activity.
Background Whole body MRI has been used to evaluate inflammatory lesions associated with axial spondyloarthritis (SpA). These sequences are extensive, time consuming and add to the cost of the investigation. We aimed to determine the utility of selected sequence MRI imaging of the axial skeleton including spine, pelvis and sacroiliac (SI) joints to identify features of (SpA). Methods A retrospective study was conducted on 76 patients diagnosed with SpA that underwent a selective sequence MRI imaging of the axial skeleton. The MRI were reported by two musculoskeletal trained radiologists were reviewed. The MRI sequences included whole spine sequences of sagittal STIR (short tau inversion recovery), T1 weighted and T2 weighted sequences. Coronal STIR and T1 weighted images were studied for SI joints and pelvis. The MRI were assessed based on the guidelines outlined by the Assessment of SpondyloArthritis International Society (ASAS) for features of spondylitis, spondylodiscitis, enthesitis, synovitis, capsulitis, bone marrow edema, fatty marrow replacement, erosions and bony ankylosis. Inflammatory lesions were documented in the spine, sacroiliac, facet, hip and costovertebral joints. Results The mean scan duration was 28 min. SI joint involvement was noted in 74 (97.3%) of patients. The other most prevalent findings were spondylitis in 44 (57.8%) patients, costovertebral joint involvement in 31 (40.7%), facet joint lesions in 32 (42.1%), spondylodiscitis in 21 (27.6%), enthesitis in 13 (17.1%), hip lesions in 16 (21%) and ankylosis in 10 (13.1%). Conclusions This selective sequence imaging of the pelvis and spine was able to identify typical lesions of SpA in a shorter time period. Fifty-five percent patients had lesions in the posterior elements including facet joints and costovertbral joints that would be missed on traditional SI joint imaging.
Aim: To test the diagnostic efficacy of a multiparametric rheumatology lumbosacral magnetic resonance (MR) imaging protocol in detection and characterization of axial spondylarthritis (SpA) and compare it with serology and clinical findings. Methods: A consecutive series of multiparametric rheumatology lumbosacral MR imaging examinations performed on 3T MR scanner. Three-dimensional inversion recovery turbo spin echo, precontrast and postcontrast fat-suppressed T1-weighted images, as well as diffusion-weighted images were used to detect active erosions and enthesitis using established criteria. Pearson χ2 was used for categorical variables. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were measured for magnetic resonance imaging (MRI) and serology, based on the final diagnosis from rheumatologists. An alpha error below 0.05 was considered statistically significant. Results: The final study sample included 130 consecutive patients (80 women and 50 men; mean ± SD 44 ± 13 and 45 ± 14 years, respectively). Seventy-eight subjects were diagnosed with axial SpA and 52 with non-SpA arthropathy. In the non-SpA group, 27 patients were diagnosed with osteoarthritis, 6 had unremarkable imaging, whereas 19 were considered as clinically undetermined. There was positive correlation between positive MRI results and SpA diagnosis (P < 0.00001). No correlation existed between positive serology alone and SpA diagnosis (P = 0.0634). Although MRI and serology proved equally sensitive in detecting SpA, the specificity and overall accuracy of MRI were significantly higher. Inflammatory activity was detected in 45 (57.7%) cases, in the pelvic enthesis in 29 (37.2%) cases, in the lumbosacral spine in 16 (20.5%) cases, in the hip joints in 15 (19.2%) cases, and in the pubic symphysis in 5 (6.4%). Inactive sacral disease was seen in 7 of 35 enthesitis patients (20.0%), and in 2 SpA cases, there were no sacral lesions. Conclusions: The results suggest that in patients with suspected SpA, MRI should not be limited to the sacroiliac joints, but also include enthesitis sites and other joints of the axial skeleton. The multiparametric rheumatology protocol increases the efficacy of MRI in detecting enthesitis and joint inflammatory disease, thereby offering additional information to the clinician and assisting in the early diagnosis/detecting disease activity.
Axial spondyloarthritis is a chronic inflammatory disorder that primarily involves the axial skeleton (sacroiliac joints and spine), causing stiffness, severe pain and fatigue. In some patients, definitive structural damage of sacroiliac joints is visible on imaging and is known as radiographic axial spondyloarthritis. Some patients do not have a clear radiographic damage of the sacroiliac joints, and this subtype is known as non-radiographic axial spondyloarthritis. Early diagnosis is important for reducing the risk of irreversible structural damage and disability. Management of axial spondyloarthritis is challenging in Saudi Arabia because of inadequate disease knowledge and the unavailability of local guidelines. Therefore, this expert consensus is intended to provide recommendations, including the referral pathway, the definition of remission and the treat-to-target approach, to all healthcare professionals for the management of patients with axial spondyloarthritis. A Delphi technique of consensus was developed by involving an expert panel of 10 rheumatologists, 1 dermatologist and 1 general physician. The experts offered consensus-based recommendations based on a review of available scientific evidence and clinical experience for the referral, screening and management of patients with axial spondyloarthritis.
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Early diagnosis of spondyloarthritis (SpA) is essential as anti-tumor necrosis factor therapy can achieve significant symptomatic relief and control of disease activity. This study aims to compare the clinical characteristics, disease activity, and functional status of a Chinese cohort of SpA patients who were re-classified into ankylosing spondylitis (AS) patients fulfilling the modified New York (MNY) criteria, those with undifferentiated SpA (USpA) fulfilling the European Spondyloarthropathy Study Group (ESSG) classification criteria only (USpA/ESSG) and those who fulfill Assessment of SpondyloArthritis International Society (ASAS) only (USpA/ASAS). Disease activity was evaluated by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), severity of morning stiffness, patient global assessment, and C-reactive protein. Functional status was evaluated by Bath Ankylosing Spondylitis Functional Index (BASFI), modified Schober index, and dimension of chest expansion. One hundred and twenty-eight patients with disease duration of 16.3 ± 10.4 years were recruited. Patients in USpA/ESSG and USpA/ASAS were significantly younger (p = 0.01), had shorter disease duration (p < 0.01), and lower BASFI (p = 0.03) than established AS patients. All three groups have active disease with comparable BASDAI >3. BASFI correlated inversely with dimension of chest expansion and negatively modified Schober index in AS patients (p < 0.01) and modestly with BASDAI (r = 0.25, p < 0.01). BASFI correlated moderately with BASDAI in USpA/ESSG (r = 0.61, p < 0.01) but not with chest expansion or modified Schober index. Compared with established AS patients recognized by MNY criteria, patients fulfilling USpA defined by ESSG or ASAS criteria had earlier disease, as active disease and less irreversible functional deficit.
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Psoriatic arthritis is an inflammatory rheumatic disorder of unknown etiology occurring in patients with psoriasis. The Classification Criteria for Psoriatic Arthritis study group has recently developed a validated set of classification criteria for psoriatic arthritis with a sensitivity of 91.4% and a specificity of 98.7%. Three main clinical patterns have been identified: oligoarticular (≤ 4 involved joints) or polyarticular (≥ 5 involved joints) peripheral disease and axial disease with or without associated peripheral arthritis. In this context distal interphalangeal arthritis and arthritis mutilans may occur. According to other reports, also in our centre, asymmetric oligoarthritis is the most frequent pattern at onset. Axial disease has been estimated between 5% and 36% of patients. It is characterized by an irregular involvement of the axial skeleton with a predilection for the cervical spine. Recurrent episodes of enthesitis and dactylitis represent a hallmark of psoriatic arthritis. In around 20% of cases distal extremity swelling with pitting edema of the hands or feet is observed. Unilateral acute iridocyclitis, usually recurrent in alternate fashion, is the most frequent extra-articular manifestation, and accelerated atherosclerosis is the prominent comorbidity. The clinical course of peripheral and axial psoriatic arthritis is usually less severe than rheumatoid arthritis and ankylosing spondylitis, respectively. Local corticosteroid injections and non-steroidal anti-inflammatory drugs are recommended in milder forms. Sulphasalazine and methotrexate are effective in peripheral psoriatic arthritis. Recent studies have provided evidence on the efficacy of anti-tumor necrosis factor-α drugs to control symptoms and to slow or arrest radiological disease progression.
Spondyloarthropathies are a cluster of Interrelated and overlapping chronic Inflammatory rheumatic diseases that primarily include ankylosing spondylitis, reactive arthritis, and the arthritis associated with psoriasis and inflammatory bowel diseases. The primary pathologic sites are the entheses (the sites of bony insertion of ligaments and tendons); the axial skeleton, including the sacroiliac joints; the limb joints; and some nonarticular structures, such as the gut skin, eye, and aortic valve. Although spondyloarthropathles are not associated with rheumatoid factor, they show a strong association with HLA-1327; however, this association varies markedly among various spondyloarthropathles and among ethnic groups. The most widely used classification criterion, from the European Spondyloarthropathy Study Group, encompasses the currently recognized wider disease spectrum, with a sensitivity and specificity that generally exceed 85%. Spondyloarthropathies occur in genetically predisposed persons and are triggered by environmental factors, but the cellular and molecular mechanisms of Inflammation are not yet fully understood. Chlamyclial and many enterobacterial infections can trigger reactive arthritis, but an infectious trigger for ankylosing spondylitis has not yet been established. HLA-1327 Itself is involved In enhancing genetic susceptibility, but the underlying molecular basis Is still unknown; additional genes include the putative susceptibility genes for Crohn disease, ulcerative colitis, and psoriasis. A specific susceptibility gene for Crohn disease, NOD2, Is located on chromosome 16q12, and one of the candidate genes for psoriasis, PSORS1, has been mapped to a 60-kb fragment on chromosome 6p, which Is telomeric to the HLA-C locus. This paper reviews the efficacy of anti-tumor necrosis factor-a therapy and other therapeutic advances.
A controlled study of 138 subjects demonstrated that the clinical history may be sensitive (95%) and specific (85%) in the differential diagnosis of ankylosing spondylitis when reliance on five specific historic features is made. Back pain that is insidious in onset, in a patient younger than 40 years, persisting for at least three months, associated with morning stiffness and improving with exercise is characteristic of inflammatory spinal disease. (JAMA 237:2613-2614, 1977)
Classification criteria for most of the disorders belonging to the spondylarthropathy group already exist. However, the spectrum of spondylarthropathy is wider than the sum of these disorders suggests. Sero-negative oligoarthritis, dactylitis or polyarthritis of the lower extremities, heel pain due to enthesitis, and other undifferentiated cases of spondylarthropathy have been ignored in epidemiologic studies because of the inadequacy of existing criteria. In order to define classification criteria that also encompass patients with undifferentiated spondylarthropathy, we studied 403 patients with all forms of spondylarthropathy and 674 control patients with other rheumatic diseases. The diagnoses were based on the local clinical expert's opinion. The 403 patients included 168 with ankylosing spondylitis, 68 with psoriatic arthritis, 41 with reactive arthritis, 17 with inflammatory bowel disease and arthritis, and 109 with unclassified spondylarthropathy. Based on statiscal analysis and clinical reasoning, we propose the following classification criteria for spondylarthropathy inflammatory spinal pain or synovitis (asymmetric or predominantly in the lower limbs), together with at least 1 of the following: positive family history, psoriasis inflammatory bowel disease, urethritis, or acute diarrhea, alternating buttock pain, enthesopathy, or sacroiliitis as determined from radiography of the pelvic region. These criteria resulted in a sensitivity of 87% and a specificity of 87%. The proposed classification criteria are easy to apply in clinical practice and performed well in all 7 participating centers. However, we regard them as preliminary until they have been further evaluated in other settings.
For over 30 years, investigators have used the simple but non-validated classification criteria suggested by Moll and Wright. Several authors have suggested modifications to these but most remain unvalidated or require human leukocyte antigen analysis. Now, a worldwide initiative has developed new criteria which include both clinical and radiological features. These will require further study before they are fully adopted but their improved performance should result in less variation between study cohorts. The recurring question of disease heterogeneity continues to occupy researchers in this field. Despite recent pleas to abandon the original five sub-groups, a case can be made for retaining at least the two sub-groups of peripheral and axial disease and, possibly, splitting the peripheral disease into oligo- and poly-arthritis.
The French Society of Rheumatology has initiated a large national multicenter, longitudinal, prospective follow-up of patients presenting with early inflammatory back pain in order to set up a database to facilitate several investigations on diagnosis, prognosis, epidemiology, pathogenesis and medico-economics in the field of early inflammatory back pain and spondyloarthritis. Patients were recruited if they had inflammatory back pain of more than 3 months and less than 3 years. Patients will be followed every 6 months during the first 2 years then every year during at least 5years. Apart from information collected on a Case Report Form (demographics, disease activity, severity, co-morbidities, socio-economics, treatments, radiological and MRI evaluation of the spine and the pelvis according to the local investigators, and for some centers bone densitometry and ultrasonography of entheses), the digital X-rays and MRI of the spine and pelvis are stored using a specific software (Carestream) and the biological samples (DNA, RNA, sera, urines) are centralized at the Biological Resources Center (Bichat Hospital). The recruitment period of the 708 patients (mean age: 34±9years, female 54%, HLA-B27 positive: 57%) in the 25 centers was 26 months (from December 2007 to April 2010). The modified New York criteria, Amor criteria, ESSG criteria and axial ASAS criteria were fulfilled by 26%, 77%, 76% and 67% of the patients at entry, respectively. A history or current symptoms suggestive of peripheral arthritis, acute anterior uveitis and inflammatory bowel disease were observed in 21%, 9% and 4% of the patients, respectively. The disease was active (BASDAI: 45±20) despite an NSAID intake in 66% of the patients. This large cohort should facilitate the conduct of researches in different areas (clinical, medico-economics, translational) in order to improve our knowledge on the pathogenesis and natural history of axial spondyloarthritis.
New bone formation of the vertebral column is pathognomonic for ankylosing spondylitis (AS), while acute and/or chronic changes in the sacroiliac joints are relevant for diagnosis. The 'gold standard' for assessment of structural changes in AS are conventional radiographs, while MRI is useful to assess inflammation. Recent MRI studies have shown that the lower half of the thoracic spine is most commonly affected in AS. Scoring tools for spinal inflammation such as the ASspiMRI-a have been proposed, successfully used in large clinical trials and compared in a multireader experiment; none was finally preferred by OMERACT. Quantification of structural spinal AS changes is performed by the modified Stokes AS Spine Score (mSASSS), which evaluates lateral cervical and lumbar radiographs. Two years was identified as the shortest possible follow-up time based on the reliability and sensitivity to change of the mSASSS. A potential disadvantage of the mSASSS is that the thoracic spine is not included. Recent data based on the mSASSS have suggested that tumour necrosis factor blockers do not inhibit radiographic progression in AS. Since the mean radiographic change is reported to be less than 1 syndesmophyte over 2 years, the sensitivity to change of the mSASSS has been questioned. However, in one study where continuous non-steroidal anti-inflammatory drugs use was compared with on-demand use, a difference between these two methods of drug intake was reported. The face and construct validity of the mSASSS has been criticised because a score of ´1´ contains a mixture of osteodestructive (erosions) and osteoproliferative changes (squaring and sclerosis). A new scoring system, the RASSS, which concentrates only on bone formation and which includes the lower part of the thoracic spine is currently being evaluated. The relationship between inflammation and new bone formation in AS has recently been investigated. Low sclerostin and DKK-1 serum levels, both inhibitors of bone formation, were found to be associated with syndesmophyte formation in patients with AS.