The complicated concept of Axial SpA explained
By Dr Irwin Lim, Rheumatologist
Up to 5% of patients with chronic back pain have an Inflammatory cause for the spinal symptoms rather than or in addition to, mechanical/degenerative reasons.
The prototype cause of inflammatory spinal disease is Ankylosing Spondylitis (for a description of this, follow link).
The problem is that the diagnosis of Ankylosing Spondylitis (AS) depends on seeing damage on Xrays of a particular area of the lower back/buttock region, called the Sacroiliac joints. These changes are called sacroiliitis.
When severe, and typically late in the disease, sacroiliitis is easy to diagnose (animation link).
However, it is true that the Xray diagnosis can be very difficult earlier in the disease.
It’s well understood that it may take years for these changes to be apparent, and therefore, the diagnosis is not made for years. It’s delayed.
To try to address this, the concept of Axial Spondyloarthritis was developed by the Assessment of SpondyloArthritis international Society (ASAS group).
Axial Spondyloarthritis (axial SpA) refers to inflammatory disease in which the predominant symptom is back pain, and where radiological changes of sacroiliitis may or may not be present.
Now, this relatively new term confuses many, including many rheumatologists who may not be used to it. It’s however a concept that is here to stay. Current medical literature, both textbooks and scientific journals, will refer to this term so I thought it would be good to give you some handle on this.
Within this axial SpA group, you then have 2 subgroups:
- Ankylosing Spondylitis (AS) – this is the diagnosis when the Xray changes for sacroiliitis are clearly present
- Non-radiographic axial spondyloarthritis – this is the type of axial SpA in which the Xray changes are not present. This term is a mouthful, usually abbreviated to non-radiographic axial SpA or nr-axSpA.
Non-radiographic axial SpA is diagnosed when there is a typical story for inflammatory back pain, with other clinical criteria pointing to it or by typical changes on MRI showing active inflammation of the bone.
So think of the term Axial SpA as an attempt to encompass both patients with late stage disease, Ankylosing Spondylitis, and those with earlier stage disease, non-radiographic axial SpA.
BJC Health established the Sydney Spondyloarthritis Centre in 2011. We raise the profile of these diseases, we provide a better pathway to diagnosis, provide education as well as world-class treatment. Most importantly, we care & we want to improve the lives of people suffering from these diseases. Read about it here.
Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here. Arthritis requires an integrated approach. We call this, Connected Care. Contact us.Not All Back Pain is The Same
This guest post is by Philip Robinson. Philip is a rheumatologist working in the Ankylosing Spondylitis clinic at the Princess Alexandra Hospital in Brisbane. He is also completing a PhD in the genetics of Ankylosing Spondylitis at the Diamantina Institute of the University of Queensland.
By Dr Philip Robinson, Rheumatologist
So, firstly I would like to thank Irwin for giving me this opportunity to write on a subject I feel very passionately about. Irwin is fantastic for all the work he puts into patient education and teaching.
I have seen a number of patients recently who haven’t been diagnosed with their Ankylosing Spondylitis (AS) for many, many years, the most recent was about 25 years.
Now this is an extreme example, but the average time from when a person gets their symptoms to when they are diagnosed is about 8-10 years, depending on what study you look at and whether you are a man or a woman.
There are a number of factors which influence this.
Firstly, back pain is really common in the community, and so people hear about back pain all around them. This tends to “normalise” this in their mind, and they also see people complaining of back pain and not getting help. This will tend to make people not seek help for their back pain.
Often, people also don’t understand that all back pain isn’t the same.
A lot of back pain is mechanical. A lot may be caused by wear-and-tear.
There are other types of back pain that aren’t as common. One example is Ankylosing Spondylitis.
There are effective treatments for AS, and not only expensive ones (such as the TNF inhibitors). Appropriate exercise can make a big difference. And, about 1 in 3 people with AS go into remission (yes, almost all of their symptoms go away) with just non-steroidal anti-inflammatory drugs (NSAIDs).
(Please note you shouldn’t use non-steroidal anti-inflammatories for ankylosing spondylitis, or any other type of chronic back pain, without a doctor supervising the treatment. All medicines have risk and benefits which need to be individualised to the patient.)
One of the other reasons why it takes a long time to be diagnosed is that family doctors see a lot of back pain too and sorting out the early AS from the wear and tear back pain can be very difficult.
The chance of having early AS increases if you are young (what does that mean? – well in this context it means before the age of 45 years), and have had back pain for longer than 3 months.
If this is the case then talking to your family doctor about it is a good idea.
So my question to you is, how do we make sure people who may have early ankylosing spondylitis know about this important topic and get the help they need early?
Philip Robinson uses social media to help improve awareness of rheumatic disease.
Please follow Philip on twitter @philipcrobinson
What do you mean? My back pain is INFLAMMATORY?
By Dr Irwin Lim, Rheumatologist
Lots of folks have back pain. Most back pain is blamed on lifting something heavy or some sporting injury or degeneration due to the passage of time.
But, there is an often forgotten cause. Inflammation of the spine.
It’s important to be able to differentiate back pain which is Inflammatory, as it may mean the underlying diagnosis is Spondyloarthritis or Ankylosing Spondylitis.
This video explains the main features associated with Inflammatory Back Pain.
Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here. Arthritis requires an integrated approach. We call this, Connected Care. Contact us.Spondyloarthritis: Demonstrating Lumbar Lateral Flexion
By Dr Irwin Lim, Rheumatologist
The response to our Modified Schober Test demonstration was great, with over 700 views so far!
Our patients with inflammatory back pain have Spondyloarthritis or the prototype condition, Ankylosing Spondylitis.
While the Modified Schober Test is a well known examination used for these diseases, the restriction measured with forward flexion can be a late event.
Often, the loss of lumbar spinal movement is seen earlier and more markedly in lateral flexion. This video demonstrates this examination.
Rachael Butterworth, our Spondyloarthritis physiotherapist demonstrates on our model, Errol while Dr Roberto Russo facilitates.
We’ve created a range of videos highlighting some of the examination techniques used to help make a diagnosis in spondyloarthritis. You can find these on our Youtube channel.
Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here. Arthritis requires an integrated approach. We call this, Connected Care. Contact us.Demonstrating the Modified Schober Test
By Dr Irwin Lim, Rheumatologist
We see a lot of patients with inflammatory back pain in our clinics. Some of these patients have Spondyloarthritis or the prototype condition, Ankylosing Spondylitis.
Given our expertise in this area, we’ve decided to create a range of videos highlighting some of the examination techniques used to help make a diagnosis. You can find these on our Youtube channel.
Rachael Butterworth, our Spondyloarthritis physiotherapist demonstrates on our model, Errol while Dr Roberto Russo facilitates.
This video is an example, and highlights the Modified Schober Test, a test commonly used to help measure the lumbar spine flexibility (or lack of).
BJC Health established the Sydney Spondyloarthritis Centre in 2011. We raise the profile of these diseases, we provide a better pathway to diagnosis, provide education as well as world-class treatment. Most importantly, we care & we want to improve the lives of people suffering from these diseases. Read about it here.
Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here. Arthritis requires an integrated approach. We call this, Connected Care. Contact us.Follow Us!
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