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發炎性背痛之診斷新進展

魏 正 宗 MD., PhD.

中山醫學大學附設醫院過敏免疫風濕科主任中藥臨床試驗中心主任醫學研究所副教授

Outlines

發炎性背痛(inflammatory back pain,IBP)

脊椎關節炎(spondyloarthritis, SpA)Diagnostic cluesClassification criteria for AS and SpA

Diagnosis of AS /Diagnosis of AS / SpASpA

1960:1960: seronegativeseronegative arthritisarthritis

1970:1970: SeronegativeSeronegative spondyloarthropathyspondyloarthropathy

1984: Modified New York Criteria for AS1984: Modified New York Criteria for AS

1991: ESSG criteria for Spondyloarthritis1991: ESSG criteria for Spondyloarthritis

2009:2009: ASAS criteria for axialASAS criteria for axial SpASpA

下背痛下背痛••80%80% 一生至少痛一次一生至少痛一次

••50%50% 在一週內痊癒在一週內痊癒

••90%90% 在二個月內痊癒在二個月內痊癒

下背痛的臨床診斷下背痛的臨床診斷•• Mechanical disordersMechanical disorders

StrainStrainDiskDisk herniationherniationSpinalSpinal stenosisstenosis/ Osteoarthritis/ OsteoarthritisSpondylolithesisSpondylolithesisFractureFractureTransitional segmentTransitional segmentScoliosisScoliosis

•• Inflammatory disordersInflammatory disordersSpondyloarthropathySpondyloarthropathyMyofascialMyofascial pain/ Fibromyalgiapain/ FibromyalgiaDiffuse idiopathic skeletalDiffuse idiopathic skeletal

hyperostosishyperostosisOsteitisOsteitis condensanscondensans iliiiliiPolymyalgiaPolymyalgia rheumaticarheumatica

••Metabolic disordersMetabolic disordersOsteoporosisOsteoporosisOsteomalaciaOsteomalaciaPTH, GHPTH, GH

•• InfectionInfectionVertebralVertebral osteomyelitisosteomyelitisDisc infectionDisc infectionPyogenicPyogenic sacroiliitissacroiliitisHerpes zosterHerpes zoster

••Visceral referred painVisceral referred painAneurysmAneurysmGI/ GU/GI/ GU/ GynGyn conditionsconditions

••NeoplasmNeoplasmPrimary or metastaticPrimary or metastatic

••PsychogenicPsychogenic

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Royal National Hospital for Rheumatic Diseases, Bath, UK.Royal National Hospital for Rheumatic Diseases, Bath, UK. 指導教授Andrei Calin是僵直性脊椎炎臨床研究的權威，已出版兩百多篇論文及數本教科書。

Inflammatory back pain is key featureof axial SpA

Back painBack pain

IBPIBP

SpASpA

ASAS

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脊椎關節炎SpondyloarthritisSpondyloarthritis

1. 僵直性脊椎炎(Ankylosing Spondylitis)2. 反應性關節炎(Reactive arthritis, 過去

稱為萊特氏症候群Reiter syndrome)3. 乾癬性關節炎（Psoriatic arthritis）4. 發炎性大腸疾病（Enteropathic

arthropathy）5. 未分化型脊椎關節炎

（Undifferentiated spondyloarthritis）

Diagnostic clues for SpA

1. 發炎性下背痛：薦腸關節炎(sacroiliitis)及脊椎炎(spondylitis) 。

2. 接骨點炎 (enthesitis) 。3. 不對稱性的下肢關節炎。4. 與HLA-B27基因有關聯。5. 有關節外的表徵：如乾癬、腸炎、尿道

炎、葡萄膜炎。

Finger to floor test

Posterior SIcompression test

Patrick test

EnthesopathyEnthesopathy,, dactylitisdactylitis

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UveitisPsoriasis

ExtraExtra--articulararticularmanifestations ofmanifestations of SpASpA

EuropeanEuropean SpondyloarthropathySpondyloarthropathy Study GroupStudy GroupClassification Criteria forClassification Criteria for SpondyloarthropathySpondyloarthropathy(ESSG, 1991)(ESSG, 1991)

Inflammatory spinal painInflammatory spinal pain OR PeripheralPeripheralsynovitissynovitis (asymmetrical or lower limb)(asymmetrical or lower limb)

PLUS any one of the following:••alternate buttock painalternate buttock pain••psoriasispsoriasis••sacroiliitissacroiliitis••inflammatory bowel diseaseinflammatory bowel disease••enthesopathyenthesopathy••urethritisurethritis oror cervicitiscervicitis or acute diarrheaor acute diarrhea••positive family historypositive family history

Dougadous, 1991

International Congress on Spondyloarthropathy

Gent,

Belgium

AnteriorAnteriorSquaring ofSquaring ofvetebralvetebral bodiesbodies

SyndesmophyteSyndesmophyte

Corner enthesitis

X ray finding of spondylitisX ray finding of spondylitis

Lt: AS with bamboo spineRt: Diffuse idiopathic skeletalHyperostosis(DISH)

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Three Problems of the MNY criteriaThree Problems of the MNY criteria

1.1. Ignore the other featuresIgnore the other featuresassociated withassociated with SpASpA, e.g., e.g.enthesitisenthesitis, psoriasis and, psoriasis and uveitisuveitis

2.2. Ignore the role of HLAIgnore the role of HLA--B27 inB27 indiagnosisdiagnosis

3.3. Too much reliance on plain XToo much reliance on plain X--rayraychanges ofchanges of sacroiliiacsacroiliiac jointsjoints

HLAHLA--B27, when to test?B27, when to test?

When you are not so sureWhen you are not so sureabout the diagnosis ofabout the diagnosis of SpASpA..

Genetic counselingGenetic counseling

薦腸關節炎薦腸關節炎sacroiliitissacroiliitis

Rt side grade 3 sacroiliitisLt side grade 2 sacroiliitis

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SacroiliitisSacroiliitis OsteiitisOsteiitis condensanscondensans iliiilii

A breakthrough in diagnosis

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Chronic low back pain (5% probability of axial SpA)

Inflammatory back pain

yes (14% probability) no (<2% probability)

HLA-27

No further testing unless SpA is strongly suspectedbecause of the presence of other features.

Presence of other SpA-features:heel pain (enthesitis), dactylitis, uveitis,positive family history, Crohn‘s disease,alternating buttock pain, psoriasis, asymmetricalarthritis, positive response to NSAIDs,acute phase reactants (elevated ESR/CRP)

MRI

Axial SpA**

pos(80-90%)

neg(<10%)

Consider otherdiagnosis

X-rays

pos neg

AS

HLA-27

3 SpA features(80-95%)

1-2 SpA feature(s)(35-70%)*

no SpA feature(14%)

pos(59%)

neg(<2%)

pos(80-95%)

neg(<15%) Consider other

diagnosis

Axial SpA**

Take home messageTake home messageDiagnosis ofDiagnosis of SpASpA

Clinical manifestationsClinical manifestations––ArticularArticular: axial, peripheral: axial, peripheral––ExtraExtra--articulararticular

Family history and/orFamily history and/or HLAHLA--B27B27 Image studiesImage studies

––XX--rayray––CTCT––MRIMRI

Thank youThank you

魏正宗魏正宗 MD,PhDMD,PhD..

中山醫學大學附設醫院過敏免疫風濕科中山醫學大學附設醫院過敏免疫風濕科

Tel: 0975128095Tel: 0975128095Email: wei3228@gmail.comEmail: wei3228@gmail.com