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Ann Rheum Dis 66:1479-1484 doi:10.1136/ard.2006.068734
  • Extended report

Performance of referral recommendations in patients with chronic back pain and suspected axial spondyloarthritis

  1. Henning Christian Brandt1,
  2. Inge Spiller1,
  3. In-Ho Song1,
  4. Janis L Vahldiek1,
  5. Martin Rudwaleit1,
  6. Joachim Sieper1
  1. 1
    Rheumatology, Department of Medicine I, Charité Campus Benjamin Franklin, Berlin, Germany
  1. Joachim Sieper, MD, Professor in Rheumatology, Consultant in Rheumatology, Rheumatology, Medical Department I, Charité – Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany; joachim.sieper{at}charite.de
  • Accepted 14 April 2007
  • Published Online First 24 April 2007

Abstract

Background: Ankylosing spondylitis (AS) and its early form account for up to 5% of all patients with chronic back pain. Interest has recently focused on shortening the delay of 5–10 years between the appearance of first symptoms and the diagnosis of AS, particularly because effective treatments have now become available. Referral parameters that are easy for doctors in primary care to apply to patients presenting with possible AS could contribute to earlier diagnosis.

Methods: Orthopaedists and primary-care doctors were requested to refer patients with (1) chronic low back pain (duration >3 months) and (2) onset of back pain before <45 years of age to a specialist rheumatology outpatient clinic for further diagnostic investigation if at least one of the following screening parameters was present: (1) inflammatory back pain, (2) positive human leucocyte antigen B27, and (3) sacroiliitis detected by imaging. The final diagnosis was made according to expert opinion.

Results: In total, 350 referred cases were analysed. A diagnosis of definite axial spondyloarthritis (axial SpA), comprising established AS and pre-radiographic axial SpA, could be made in 45.4% of all referred patients (of which 50.3% were classified as AS and 49.7% as preradiographic axial SpA), whereas 45.4% were classified as non-SpA and 9.1% as possible SpA. A diagnosis of definite axial SpA could be made in 34.2% if only one referral parameter was positive, and in 62.6% if there was >1 positive referral parameter.

Conclusions: The proposed referral parameters have proven useful when applied in primary care in identifying patients with AS/pre-radiographic axial SpA among young to middle-aged patients with chronic low back pain.

Footnotes

  • The study was partly supported by unrestricted grants from Essex Pharma GmbH, Germany and Wyeth Pharma GmbH, Germany.

  • Abbreviations:
    AS
    ankylosing spondylitis
    BASDAI
    Bath Ankylosing Spondylitis Disease Activity Index
    BASFI
    Bath Ankylosing Spondylitis Functional Index
    CRP
    C-reactive protein
    HLA
    human leucocyte antigen
    IBP
    inflammatory back pain
    NSAIDs
    non-steroidal anti-inflammatory drugs
    SIJ
    sacroiliac joints
    SpA
    spondyloarthritis
    TNF
    tumour necrosis factor