Non-radiographic Axial Spondyloarthropathy—Often Not Recognized and Commonly Misdiagnosed

Non-radiographic Axial Spondyloarthropathy—Often Not Recognized and Commonly Misdiagnosed Posted By:
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Non-radiographic axial spondyloarthropathy (nr-axSpA) is an autoimmune, inflammatory disease affecting the spine, sacroiliac joints, and hips. Unlike its more well-known counterpart, ankylosing spondylitis (AS), nr-axSpA has been studied less and can have less concrete objective findings, making it harder to diagnose in many patients. The condition seems to be on a continuum with AS (also termed radiographic axial spondylitis) and some have described nr-axSpA as an "early" AS. However, some with nr-axSpA will never have sacroiliitis, the classic hallmark of AS, detectable on x-ray or MRI. Despite having similar characteristics to AS, there have been some distinct differences found between patients with nr-axSpA and patients with AS—though both conditions can cause significant symptoms and disability.

Why is nr-axSpA still underrecognized and often misdiagnosed? As noted above, patients with nr-axSpA may not have radiographic or MRI findings suggesting an inflammatory process. Secondly, back pain and neck pain are very common complaints in the general population and often symptoms are attributed to mechanical issues or fibromyalgia. Lastly, women in particular do not often have classical symptoms of an axial spondyloarthropathy: Women with nr-axSpA have been shown to have more cervical involvement and more extra-articular manifestations than males.

How can you increase the detection of nr-axSpA?

  1. Monitor for inflammatory back pain. A helpful acronym is IPAIN:
    • Insidious onset
    • Pain worse at night
    • Age of onset <40 years
    • Improvement with exercise
    • No improvement with rest
  2. Monitor for other symptoms and signs of spondyloarthropathy in those with inflammatory back pain >3 months including dactylitis, uveitis, psoriasis, and inflammatory bowel disease—especially in those with a positive human leukocyte antigen (HLA)-B27 and those who are younger
  3. Refer to a rheumatologist if axial spondyloarthropathy is suspected

Consequences of delayed diagnosis or misdiagnosis of nr-axSpA include worse functional impairment, higher healthcare cost, and worse quality of life. With help from non-rheumatology healthcare providers, patients with nr-axSpA can have expedited referral to a rheumatologist for faster diagnosis and treatment.

References
  • Rusman T, et al. Gender differences in axial spondyloarthritis: Women are not so lucky. Curr Rheumatol Rep. 2018;20:35.

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Filed under: Rheumatology

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