Ankylosing spondylosis (AS) is a lifelong disease requiring medication, the cause of which is unknown. Diagnosis is challenging and there are no definitive criteria for early diagnosis; it is largely based on patient symptoms and physician experience, and misdiagnosis and underdiagnosis often occur. Misdiagnosis will bring unnecessary loss and suffering to the patient, and omission will delay the patient’s condition.
The following concepts need to be known before exploring early early diagnosis.
1. Inflammatory back pain
Inflammatory back pain needs to be separated from mechanical back injury (lumbar strain). Inflammatory back pain (mainly lower back pain) is the primary and important diagnostic cue for ankylosing spondylitis. The diagnosis is made if 4 of the 5 diagnostic criteria are met: 1. IBP: <40 years old. 2. duration of disease >3 months; 3. insidious onset (no history of trauma); 4. pain causing awakening in the second half of the night, relieved by activity and not relieved by rest; 5. morning stiffness >30 minutes.
2.Spinal arthritis
Divided into medial spondyloarthritis and peripheral spondyloarthritis, AS is the prototype of medial spondyloarthritis, but not all spondyloarthritis develops into AS. The International Spondyloarthritis Assessment Society (ASAS) 2010 proposed the following diagnostic criteria for medial spondyloarthritis.
Inclusion criteria: 1. back pain > 3 months; 2. age < 45 years. (In the author's opinion: back pain should qualify as non-traumatic injury back pain. Here, special attention should be paid to the fact that the author has encountered cases in which 1 month of back pain was diagnosed as ankylosing spondylitis)
Further diagnostic conditions: 1. One of the features of axial spondyloarthritis* is satisfied in the case of sacroiliac arthritis detected by X-ray or MRI. 2. Two of the features of axial spondyloarthritis* are satisfied in the case of HLA-B27 positivity.
* Characteristic entries of spondyloarthritis: 1. inflammatory back pain. 2. arthritis. 3. inflammatory iritis of the attachment point of the Achilles tendon. 4. finger (toe) inflammation. 5. psoriasis. 6. Crohn’s disease or ulcerative colitis. 7. significant effect of NSAIDS-like drugs within 48 hours. 8. family history of spondyloarthritis. 9. positive for HLA-B27. 10. increased CRP.
In the author’s opinion, low back pain symptoms are the top priority for diagnosis, and understanding the cause of the characteristics of low back pain is key and must be separated from strain-related low back pain and injury-related low back pain. It must be emphasized that a positive HLA-B27 cannot be used as a strong diagnostic basis, but this indicator is often misused. Foreign studies have shown that a positive HLA-B27 has a sensitivity of about 35% and a specificity of about 91% in the diagnosis of AS and medial spondyloarthritis. it is correctly understood that if HLA-B27 is positive, there is only a 35% chance that it is AS, but if HLA-B27 is negative, there is a 91% chance that it is not AS. so a negative HLA-B27 has outstanding clinical significance when it is negative, but positivity is not diagnostic.
AS is the prototype, subtype and outcome of SpA, especially mid-axis SpA. Axial SpA includes AS (presence of permanent damage on x-ray of the sacroiliac joint) and early or healing spondyloarthritis (sacroiliac arthritis on MRI or consistent with the diagnosis of spondyloarthritis mentioned above). Foreign studies have favored SpA over AS treatment.
Therefore, the diagnosis of AS is mainly formed on the basis of symptomatology with reference to ancillary diagnoses, and immune inflammatory changes in other systemic organs provide reference. The author believes that the diagnosis of AS needs to take into account the criteria of inflammatory back pain and spondyloarthritis, and more importantly, long-term follow-up of patients for judgment and re-judgment.
Regarding the treatment of AS/SpA, we need to keep in mind: 1) the purpose of treatment: symptom control and prevention of spondyloarthritis; 2) the duration of treatment: lifelong; 3) the side effects of drugs may cause more damage than AS/SpA; and 4) the timing and intensity of the drugs in question are still unclear.
In 2010 the European Rheumatoid Alliance and the International Ankylosing Spondylitis Society (ASAS/EULAR) published updated recommendations regarding the treatment of ankylosing spondylitis.
First, the recommendations are based on an analysis of clinical literature reports and have an evidence-based medical foundation. Those who developed the recommendations included two individuals who completed a systematic literature analysis. The expert panel included 21 rheumatoid physicians, 2 orthopedic surgeons, and 2 patients.
The following excerpts are presented.
1. Objective of treatment: To maintain the patient’s functional and social activities and maximize the quality of healthy life by controlling symptoms and inflammation and preventing progressive structural destruction. The treatment of AS should be decided jointly by the rheumatoid physician and the patient. The best treatment requires a combination of non-pharmacological and pharmacological treatments. If other systems such as digestive and cardiovascular diseases are also present, please be seen by the relevant department.
2.Exercise therapy, especially family-oriented exercise therapy is very effective.
3.NSAID drugs are the first-line drugs to relieve pain and stiffness, and can be used for a long time, but be aware of the drug side effects.
4.Analgesics such as paracetamol and opiates can be used to assist in pain relief.
5.Hormone local injection can be considered, but systemic use is not recommended.
6.DMARD drugs are not effective for axial diseases, and can be considered for peripheral arthritis.
7.Anti-TNF agents are used when conventional treatment cannot control and the disease is in high activity. It is not required to use DMARD before using TNF agents.
8.Surgical orthopaedics.
When AS causes severe hunchback deformity or hip ankylosis, spinal orthopedic or joint replacement surgery should be performed regardless of whether it is in the active stage.
In the author’s opinion, the protocol emphasizes the importance of comprehensive treatment and the concept of evaluation and re-evaluation; however, since the above recommendations are mainly made by rheumatologists and are based on foreign experience, they have certain specialty limitations. In fact, in China and other countries (e.g., Germany in Europe), orthopedics is the first department for patients, so it is important to respond to the opinions of orthopedic surgeons and to increase the training of orthopedic surgeons.