Undifferentiated spondyloarthropathies (uSpA), also known as undifferentiated spondyloarthropathies, were first described by Burns in 1982. As the name implies, undifferentiated spondyloarthropathies are a group of diseases that have some of the clinical and/or radiological features of spondyloarthropathies (spa), but have an atypical presentation and do not yet meet any of the established diagnostic criteria for spondyloarthropathies. Meaning may refer to.
(1) An early manifestation of an SpA that will later develop into a classic SpA;
(2) An “abortive” form of a definite SpA that will not develop into a typical SpA later;
(3) An overlapping syndrome that cannot be differentiated into a definite SpA;
(4) SpA that cannot be defined now but may be clearly classified in the future.
For such patients we use Chinese medicine injections for treatment with few side effects. The following information is selected for reference.
The clinical manifestations of uSPA have the following characteristics compared with AS patients:
(1) Mild and atypical symptoms;
(2) No limitation of spinal movement;
(3) No psoriatic arthritis, no enteropathic arthritis;
(4) Sacroiliac arthritis is not necessarily present;
(5) Not necessarily positive for HLA-B27;
(6) The proportion of females was significantly higher than that of AS patients.
The premise of undifferentiated spondyloarthropathy is that the patient must have spondyloarthropathy. Spondyloarthropathies are a group of diseases that have some common features as follows:
(1) HLA-B27 is the main genetic susceptibility factor;
(2) Inflammation of the tendon-bone attachment points and synovitis are the basic pathological changes;
(3) It often involves the sacroiliac joint, spine and major joints;
(4) negative rheumatoid factor;
(5) If the disease is not controlled, it can progress to spinal ankylosis, joint ankylosis, and even disability.
Undifferentiated spondyloarthropathy is not a disease, but is considered undifferentiated spondyloarthropathy if a specific disease diagnosis is not met in seronegative spondyloarthropathies. It can be an early or mild manifestation of a disease, and many patients are diagnosed with ankylosing spondylitis or other spondyloarthropathies after a number of years of follow-up. There are also patients who have difficulty meeting the diagnostic criteria for a particular spondyloarthropathy throughout their lives and have to be diagnosed with undifferentiated spondyloarthropathy for a long time.
USPA accounts for a large proportion of seronegative spondyloarthropathies and is not uncommon clinically, and the majority of patients with seronegative spondyloarthropathies can be diagnosed with this disease. Ankylosing spondylitis or other spondyloarthropathies in children may be diagnosed as undifferentiated spondyloarthropathy in children before a definitive diagnosis is made, with the exception of other diseases.
The prevalence of undifferentiated spondyloarthropathy is 3-10 times higher than that of ankylosing spondylitis in the same population. Seronegative spondyloarthropathies are a large group of diseases, including ankylosing spondylitis (AS), Rett syndrome, psoriatic arthritis, enteropathic arthritis, and reactive arthritis.
The misdiagnosis rate of uSPA is high, and it is easily misdiagnosed as disc herniation, rheumatoid arthritis, sciatica, and so on. It is often due to undifferentiated spondyloarthropathies that recurrent episodes of joint swelling and pain, such as swelling and pain in the right knee for a few months this year and in the left ankle for a few months next year, are mistaken for “wandering arthritis”, and swelling and pain in the knee and ankle for a few months with no radiological damage to the joint, are considered as “non-erosive” arthritis. Some patients have arthralgia that responds to weather changes, which is considered to be characteristic of “rheumatoid arthritis”. This is a common mistake in the management of undifferentiated spondyloarthropathies and should be noted.
Because of the variety of symptoms and the atypical nature of the disease, it is important to be vigilant about the disease. For example, hip pain often indicates sacroiliac arthritis, inner thigh pain and hip pain indicate hip involvement, and many patients complain of heel, foot, chest, and knee pain, which should be carefully examined not for synovitis but for adhesionitis. Although uSPA patients do not have significant back pain or even absence, it is still important to examine the sacroiliac joint when this disease is suspected. In addition to the “4” test and the presence of local pressure pain, more methods should be used, such as downward and outward pressure on both sides of the iliac crest in the horizontal position and downward and outward pressure on one side of the iliac crest in the lateral position, to see if sacroiliac joint pain can be induced.
The following tests should be done when the disease is clinically suspected: HLA-B27, sacroiliac joint imaging. If a patient has a 50% chance of being diagnosed with AS, if the patient is B27 positive, the probability of diagnosing AS increases to about 95%, and if the patient is B27 negative, the probability of having AS decreases to about 3%. For this reason, the HLA-B27 antigen, which detects the expression of the HLA-B27 gene, is used to help diagnose atypical spondyloarthropathies. If plain radiographs are normal or suspicious, CT examinations should be performed. The mechanism of the disease is not yet understood and is thought to be the result of a combination of infection, environmental factors, autoimmune function, and genetic background.
Diagnostic criteria: Amor et al. 1990 diagnostic criteria for spondyloarthropathies (numbers after each parenthesis are points).
I. Clinical symptoms or past history.
1. Nocturnal low back pain or back pain or morning stiffness (1 point);
2. Asymmetric arthritis (2 points);
3. Hip pain: one or both sides (1 or 2 points);
4.Toe or finger salami-like swelling (2 points);
5, heel pain or pain in other parts of the attachment point (2 points);
6.Iriditis (2 points);
7. Non-gonococcal urethritis coexisting with or occurring within 1 month before the onset of arthritis (1 point);
8, acute diarrhea as above (1 point);
9, history of psoriasis or glomerulonephritis or enteropathy (ulcerative colitis, clonorchiasis) (2 points).
Second, radiological examination: sacroiliac arthritis (bilateral ≥ grade II, unilateral ≥ grade III) (3 points).
III. Genetic background: HLAB27 positive or first-degree relative with positive AS or Rett syndrome, uveitis, psoriasis or chronic colonic disease (2 points).
IV. Response to treatment: effective with non-steroidal anti-inflammatory drugs (NSAIDS) for 48 hours and relapsed 48 hours after discontinuation (2 points).
Diagnosis: 12 points ≥ 6 can be diagnosed as spondyloarthropathy SpA. If the previous diagnostic criteria are met, but certainly not including 7.8.9 in the table and radiological changes, less than 6 points, can be diagnosed as undifferentiated spondyloarthropathy. Radiological sacroiliac joint grading refers to the five-level classification of the AS New York diagnostic criteria.Grade 0.
Normal sacroiliac joints.
Grade 1: Suspected or very mild sacroiliac arthritis.
Grade 2: Mild sacroiliac arthritis with blurring of the joint margins, sclerosis of the proximal joint area, narrowing of the joint space, and bone destruction.
Grade 3: Moderate sacroiliac arthritis with blurred joint margins, sclerosis of the proximal joint area, narrowing of the joint space, and bone destruction.
Grade 4: sacroiliac joint ankylosis, fusion with or without sclerosis.
The joint vacuum sign is the presence of air in the joint cavity and its occurrence can be attributed to cartilage degeneration. In general, cartilage enjoys immune immunity, but when inflammation occurs on the cartilage surface due to certain circumstances (trauma, infection, etc.), the cartilage matrix is degraded, the cartilage antigenic components are exposed, causing an immune response and local production of cytokines, which further causes destruction of cartilage, and this process is repeated and intensified, resulting in the expansion of the joint space, which was originally tightly jointed, forming a low-pressure space, and the gas in the surrounding tissues is mainly The gas in the surrounding tissues, mainly nitrogen, penetrates into the space, forming a vacuum.
Most of the sacroiliac joint vacuum signs are located in the anterior half of the central sacroiliac joint, which may be related to the large anterior-posterior diameter of the joint at this location being susceptible to mechanical factors. Sacroiliac arthritis is an important indicator for the diagnosis of seronegative spondyloarthropathies (including Uspa), but Uspa sacroiliac arthritis is often not obvious, and CT can detect its early lesions. In addition, the sacroiliac joint vacuum sign is significantly higher in undifferentiated spondyloarthropathies, and the extent of the vacuum sign correlates with lower back pain, which may be due to inflammatory damage and erosion of the subchondral bone of the sacroiliac joint at an early stage. This result is helpful for the rational explanation of the clinical symptoms (especially pain) of Uspa. The extent of the sacroiliac joint vacuum sign may indirectly reflect the extent of degeneration and disintegration of the sacroiliac joint cartilage.
The clinical diagnosis of undifferentiated spondyloarthropathy requires the start of drug therapy, not the excessive pursuit of “diagnosis” before starting medication, so as not to delay treatment.
First, Western drug therapy: more than half of the patients on the NSAIDs is not obvious, need to be combined with slow-acting anti-rheumatic drugs such as salazosulfapyridine treatment. Oral administration: 1 line of NSAIDs, according to the patient’s individual situation, choose a drug for oral administration. Use when the pain is present and stop when it disappears. For example: anti-inflammatory pain, naproxen, furosemide, ibuprofen, etc. Line 2 is immunosuppressive drugs: methotrexate, low-dose shock therapy: 1-2 tablets once a week for the first week, then increase 1 tablet per week to 10-15 mg per week for maintenance. Line 3 is slow-acting drugs: lorazepam 1 g orally three times a day, leflunomide 20 mg orally once a day, and in March leflunomide is changed to 10 mg daily. Once a day. After one year of treatment, salazosulfapyridine and leflunomide were discontinued, and methotrexate was used to maintain the fruit thereafter. Clinically, uSpA patients are younger, with shorter onset, undetermined disease progression, and poor compliance with oral medications for longer periods of time, so patients who are not sensitive to oral NSAIDs are treated with SIJ injections.
Second, the current intra-sacroiliac joint drug treatment method is more effective and more general. The commonly used puncture methods are.
1.Sacroiliac joint puncture method with bony marker positioning: 10-20ml of drug solution can be injected. The advantage is that it is simple and easy to perform, but the disadvantage is that the success rate of unskilled operators is not high, the accuracy rate is also low, and the relative treatment effect may be affected.
2.CT-guided sacroiliac joint puncture method: under the guidance of CT to confirm the puncture needle is in the sacroiliac joint cavity, dial out the needle core, inject the liquid 2% lidocaine 1ml and prednisolone acetate (50~100) mg/betamethasone acetate 1.5mg. The advantages are accurate positioning, high success rate of puncture and reliable effect, but the cost is higher.
Third, Chinese medicine has a long history and unique advantages in the treatment of this disease.
Qin Xizhang pain, compound summer without tablets, Leigongteng, Bai Shao total glucoside tablets, etc. can relieve the disease and improve the quality of life of patients, for the treatment of uSPA safer and more effective drugs. Acupuncture treatment can also achieve good results.
Follow-up results. Results 127 uSpA patients.
(1) The ratio of men to women was 1.8:1, and female patients had a late onset, mild disease, and a better prognosis;
(2) Low back pain (93.7%) and peripheral joint swelling and pain (96.0%) were most common during the course of the disease;
(3) The prevalence of low back pain was significantly higher in women than in men, and the prevalence of pain in the hip, hip area or heel and other attachment points was higher in men than in women;
(4) All 7 cases with hand and joint involvement as the first symptom were female;
(5) The positive rate of family history was 42.5% and the positive rate of HLA-B27 was 52.8%;
(6) First diagnostic imaging features, CT was more sensitive than X-ray for the diagnosis of uSpA, and the positive rates of sacroiliac arthritis in both were 75.0% (78/104) and 60.0% (51/85), respectively. The positive rate of sacroiliac joint destruction was higher in men than in women (P<0.05);
(7) At 5-year follow-up, 18 cases developed ankylosing spondylitis, 1 case of inflammatory bowel disease arthritis, 1 case of psoriatic arthritis, 20 cases remained uSpA, and 16 cases had disappeared symptoms. 13 of the 18 patients with confirmed AS were male, accounting for 72.2%. 5-year CT of the sacroiliac joint showed significant progression of sacroiliac joint destruction above grade II, and the positive rates were 3.6% and 48.2% after the initial diagnosis and 5 years, respectively. percent.
Conclusion uSpA is a group of common spondyloarthropathies with diverse clinical symptoms and a genetic predisposition; the involvement of the sacroiliac joint is more severe in men than in women; some patients may progress to other spondyloarthropathies such as AS, PsA and inflammatory bowel disease arthritis. Patients with uSpA should be closely followed up, and regular CT examination of the sacroiliac joint can help early diagnosis.