This document discusses the diagnosis of axial spondyloarthritis (SpA), including ankylosing spondylitis (AS). It outlines that inflammatory back pain is a key feature of axial SpA. Diagnostic clues for SpA include inflammatory back pain, enthesitis, asymmetric peripheral arthritis, association with HLA-B27 gene, and extra-articular manifestations like psoriasis, inflammatory bowel disease, uveitis. The document also discusses classification criteria for AS and SpA from ESSG in 1991 and ASAS in 2009, as well as diagnostic imaging findings. The take home message is that diagnosis of SpA requires considering clinical manifestations, family history and/or HLA-B27 status, and

1. Outlines
 發炎性背痛(inflammatory back pain,
發炎性背痛之診斷新進展 IBP)
 脊椎關節炎(spondyloarthritis, SpA)
 Diagnostic clues
魏 正 宗 MD., PhD.
 Classification criteria for AS and SpA
中山醫學大學附設醫院過敏免疫風濕科主任
中藥臨床試驗中心主任
醫學研究所副教授
Diagnosis of AS / SpA
下背痛
 1960: seronegative arthritis
•80% 一生至少痛一次
 1970: Seronegative spondyloarthropathy
 1984: Modified New York Criteria for AS •50% 在一週內痊癒
 1991: ESSG criteria for Spondyloarthritis
•90% 在二個月內痊癒
 2009: ASAS criteria for axial SpA
下背痛的臨床診斷
• Mechanical disorders
• Metabolic disorders
Strain Osteoporosis
Disk herniation Osteomalacia
Spinal stenosis/ Osteoarthritis
stenosis/ PTH, GH
Spondylolithesis • Infection
Fracture Vertebral osteomyelitis
Transitional segment Disc infection
Scoliosis Pyogenic sacroiliitis
• Inflammatory disorders Herpes zoster
Spondyloarthropathy • Visceral referred pain
Myofascial pain/ Fibromyalgia Aneurysm
Diffuse idiopathic skeletal GI/ GU/ Gyn conditions
hyperostosis • Neoplasm
Osteitis condensans ilii Primary or metastatic
Polymyalgia rheumatica • Psychogenic
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2. 指導教授Andrei Calin是僵直性脊椎炎臨床研究的權威，
Royal National Hospital for Rheumatic Diseases, Bath, UK.
已出版兩百多篇論文及數本教科書。
Inflammatory back pain is key feature
of axial SpA
AS
SpA
IBP
Back pain
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3. 脊椎關節炎Spondyloarthritis Diagnostic clues for SpA
1. 僵直性脊椎炎(Ankylosing Spondylitis) 1. 發炎性下背痛：薦腸關節炎(sacroiliitis)
2. 反應性關節炎(Reactive arthritis, 過去 及脊椎炎(spondylitis) 。
稱為萊特氏症候群Reiter syndrome) 2. 接骨點炎 (enthesitis) 。
3. 乾癬性關節炎（Psoriatic arthritis） 3. 不對稱性的下肢關節炎。
4. 發炎性大腸疾病（Enteropathic
4. 與HLA-B27基因有關聯。
arthropathy）
5. 未分化型脊椎關節炎 5. 有關節外的表徵：如乾癬、腸炎、尿道
（Undifferentiated spondyloarthritis） 炎、葡萄膜炎。
Finger to floor test
Enthesopathy, dactylitis
Enthesopathy,
Posterior SI
compression test
Patrick test
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4. European Spondyloarthropathy Study Group
Classification Criteria for Spondyloarthropathy
Extra-articular
Extra- (ESSG, 1991)
manifestations of SpA
Inflammatory spinal pain OR Peripheral
synovitis (asymmetrical or lower limb)
PLUS any one of the following:
•
alternate buttock pain
•
psoriasis
•
sacroiliitis
•
inflammatory bowel disease
•
enthesopathy
•
urethritis or cervicitis or acute diarrhea
Psoriasis Uveitis •
positive family history
Dougadous, 1991
International Congress on Spondyloarthropathy
Gent,
Belgium
X ray finding of spondylitis
Anterior
Squaring of
vetebral bodies
Corner enthesitis
Lt: AS with bamboo spine
Rt: Diffuse idiopathic skeletal
Syndesmophyte Hyperostosis(DISH)
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5. Three Problems of the MNY criteria
1. Ignore the other features
associated with SpA, e.g.
SpA,
enthesitis, psoriasis and uveitis
enthesitis,
2. Ignore the role of HLA-B27 in
HLA-
diagnosis
3. Too much reliance on plain X-ray
X-
changes of sacroiliiac joints
HLA-B27, when to test?
HLA-
When you are not so sure
about the diagnosis of SpA.
SpA.
Genetic counseling
薦腸關節炎sacroiliitis
薦腸關節炎sacroiliitis
Rt side grade 3 sacroiliitis
Lt side grade 2 sacroiliitis
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6. Sacroiliitis Osteiitis condensans ilii
A breakthrough in diagnosis
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7. Chronic low back pain (5% probability of axial SpA)
Inflammatory back pain
yes (14% probability) no (<2% probability)
Presence of other SpA-features:
heel pain (enthesitis), dactylitis, uveitis,
positive family history, Crohn‘disease,
s
alternating buttock pain, psoriasis, asymmetrical
arthritis, positive response to NSAIDs, No further testing unless SpA is strongly suspected
acute phase reactants (elevated ESR/CRP) because of the presence of other features.
 SpA features
3 1-2 SpA feature(s) no SpA feature
(80-95%) (35-70%)* (14%)
X-rays
pos neg HLA-27 HLA-27
pos neg pos neg
(80-90%) (<10%) (59%) (<2%)
MRI
Consider other pos neg
diagnosis (80-95%) (<15%) Consider other
diagnosis
AS Axial SpA**
Axial SpA**
Take home message
Diagnosis of SpA Thank you
 Clinical manifestations
–Articular: axial, peripheral
Articular:
–Extra-articular
Extra- 魏正宗 MD,PhD.
MD,PhD.
 Familyhistory and/or HLA-B27
HLA-
 Image studies
中山醫學大學附設醫院過敏免疫風濕科
– -ray
X
Tel: 0975128095
–CT Email: wei3228@gmail.com
–MRI
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