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Extended report
Presence of multiple spondyloarthritis (SpA) features is important but not sufficient for a diagnosis of axial spondyloarthritis: data from the SPondyloArthritis Caught Early (SPACE) cohort
  1. Z Ez-Zaitouni1,
  2. P A C Bakker1,
  3. M van Lunteren1,
  4. I J Berg2,
  5. R Landewé3,
  6. M van Oosterhout4,
  7. M Lorenzin5,
  8. D van der Heijde1,
  9. F A van Gaalen1
  1. 1Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  2. 2Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  3. 3Department of Clinical Immunology and Rheumatology, Amsterdam Medical Center, Amsterdam, The Netherlands
  4. 4Department of Rheumatology, Groene Hart Ziekenhuis, Gouda, The Netherlands
  5. 5Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
  1. Correspondence to Z Ez-Zaitouni, Department of Rheumatology, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, The Netherlands; z.ez-zaitouni{at}


Objectives Concerns have been raised about overdiagnosis of axial spondyloarthritis (axSpA). We investigated whether patients with chronic back pain (CBP) of short duration and multiple SpA features are always diagnosed with axSpA by the rheumatologist, and to what extent fulfilment of the Assessment of SpondyloArthritis International Society (ASAS) axSpA criteria is associated with an axSpA diagnosis.

Methods Baseline data from 500 patients from the SPondyloArthritis Caught Early cohort which includes patients with CBP (≥3 months, ≤2 years, onset <45 years) were analysed. All patients underwent full diagnostic workup including MRI of the sacroiliac joints (MRI-SI) and radiograph of sacroiliac joints (X-SI). For each patient, the total number of SpA features excluding sacroiliac imaging and human leucocyte antigen B27 (HLA-B27) status was calculated.

Results Before sacroiliac imaging and HLA-B27 testing, 32% of patients had ≤1 SpA feature, 29% had 2 SpA features, 16% had 3 SpA features and 24% had ≥4 SpA features. A diagnosis of axSpA was made in 250 (50%) of the patients: 24% with ≤1 SpA feature, 43% with 2 SpA features, 62% with 3 SpA features and 85% with ≥4 SpA features. Of the 230 patients with a positive ASAS classification 40 (17.4%) did not have a diagnosis of axSpA. HLA-B27 positivity (OR 5.6; 95% CI 3.7 to 8.3) and any (MRI-SI and/or X-SI) positive imaging (OR 34.3; 95% CI 17.3 to 67.7) were strong determinants of an axSpA diagnosis.

Conclusions In this cohort of patients with CBP, neither the presence of numerous SpA features nor fulfilment of the ASAS classification criteria did automatically lead to a diagnosis axSpA. Positive imaging was considered particularly important in making a diagnosis of axSpA.

  • Spondyloarthritis
  • Low Back Pain
  • Outcomes research

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  • Handling editor Gerd R Burmester

  • Contributors ZEZ designed the study, performed the statistical analyses, interpreted findings, and drafted and revised the manuscript. FvG and DvdH designed the study, interpreted the data, and drafted the manuscript. All authors contributed to the acquisition and interpretation of data, and read and approved the final manuscript.

  • Competing interests : None declared.

  • Patient consent Obtained.

  • Ethics approval Local Medical Ethical Committees of all involved centres.

  • Provenance and peer review Not commissioned: externally peer reviewed.