Axial Spondyloarthritis (including ank spond)

Overview

Spondyloarthritis is a group of inflammatory conditions that have a range of manifestations. Spondyloarthritis may be predominantly:

Axial

• Radiographic axial spondyloarthritis (ankylosing spondylitis)
• Non- radiographic axial spondyloarthritis

Peripheral

• Psoriatic arthritis
• Reactive arthritis
• Enteropathic spondyloarthritis

People with predominantly axial spondyloarthritis may have additional peripheral symptoms, and vice versa.

Axial presentations of spondyloarthritis are often misdiagnosed as mechanical low back pain, leading to delays in access to effective treatments.

Peripheral presentations are often seen as unrelated joint or tendon problems, and can be misdiagnosed because problems can move around between joints.

Before Referral

SPADE Tool

The SPADE tool has been designed to assist medical professionals define the probability of axial spondyloarthritis in a patient with chronic back pain, below the age of 45 with no definitive changes on X-ray. 

It is recommended that this tool is used when assessing patients in primary care.

Referral Criteria (as listed on the BNSSG ICB Inflammatory Back Pain Referral Form)

Please note there is no absolute score cut off for referrals to be accepted as each referral will be triaged individually, but a score of 3/5 of the criteria below suggests increased likelihood of axSpA.

• Back pain (+/- stiffness) starting before age 35.
• Waking in 2nd half of night due to back pain +/- stiffness
• Alternating buttock pain +/- stiffness
• Pain/ stiffness improves with movement (not rest)
• Pain/ stiffness improves with NSAIDs within 48 hours.

Investigations

Investigations in primary care should be guided by the diagnostic criteria listed above and the SPADE tool.

• HLA B27 -  consider requesting if exactly 3 of the referral criteria are present. Otherwise not required. A negative result does not exclude axial spondyloarthritis. Consider requesting advice and guidance if there is still diagnostic uncertainty.
• Other bloods - FBC, UE, LFT, bone profile, CRP should be included with a referral. (The SPADE tool suggests ESR is required but this is not necessary).
• Autoantibodies - such as RF, ANA, ANCA are not necessary for diagnosis of AxSpA and can lead to confusion so should be avoided. 
• Imaging: is not necessary, as many rheumatologists prefer to arrange this themselves. However, you might consider X-ray of the spine for differential diagnosis. Axial spondyloarthritis may be present despite no evidence of sacroiliitis on a plain film X‑ray . Please do NOT arrange a spinal MRI, as rheumatology do specialist scans as deemed necessary. 

Additional Information

Please include the following additional information if a referral is being made:

• Is there a 1st degree relative with SpA
• Is there a history of current or past inflammatory arthritis
• Is there a history of difficult to treat enthesities (e.g achilles tendinitis/plantar fasciitis)
• Is there a history of current or past psoriasis
• Is there a  history of current or past iritis or uveitis (diagnosed by an ophthalmologist)
• Is there is history of inflammatory bowel disease (diagnosed by a gastroenterologist)

If Referral criteria are not met but inflammatory back pain is still suspected then consider requesting Advice & Guidance.

Please also refer to the Back pain / spinal pathway page of Remedy for further advice on investigation of back pain.

Referral

Suspected inflammatory back pain / axial spondyloarthritis / ankylosing spondylitis

Referrals for patients with suspected axial spondyloarthritis (e.g ankylosing spondylitis) should be referred to a general rheumatology clinic via eRS (not via EIA pathway unless they have significant peripheral symptoms).

For these patients please use the BNSSG ICB Inflammatory Back Pain Referral Form - available as EMIS document.

Suspected peripheral spondyloarthrits / psoriatic arthritis

Referrals for patients with significant polyarticular symptoms (peripheral spondyloarthritis or psoriatic arthritis)  would normally be submitted to the EIA service via eRS if criteria are met (the EIA proforma should be used to access this service - available in EMIS).

Advice and Guidance

If there is ongoing uncertainty about a patient's suitability for referral then please consider using a Rheumatology Advice and Guidance Service (via eRS). The box can also be ticked to permit the secondary care team to be convert to a referral if necessary.

Greater Bristol NASS therapy session

Greater Bristol NASS is a service for patients with confirmed axial spondyloarthritis. It has been running for over 20 years at Southmead Hospital, and each Wednesday provide gym (1 x 40 minute session) and hydrotherapy sessions (2x 40 minute sessions).

Patients need to have a confirmed diagnosis of axial spondyloarthritis and live in the BNSSG area. Anyone that comes along for the first time gets in for free but there is a fee after that and it is mentioned in the link above.

GP's can either contact NASS on behalf of the patient (the GP can then confirm the patient's axial spondyloarthritis diagnosis) or the patient can refer themselves. In any event, they would prefer if either the GP or patient contacted them so they are aware that they are coming, as the patient needs to fill out medical questionnaire, when they arrive. If the GP is referring them (and if allowed through confidentiality) the GP can also give a brief medical history.

Email: Bristol@nass.co.uk (not secure so do not send patient details)

Telephone: 0117 9397982 (from 4pm onwards)

Times: Wednesdays evenings from 6:30pm - 8:30pm. One session of gym, which last 40 minutes and starts at 6:30pm. Followed by 2 hydrotherapy sessions 7:10 & 7:50.

Based at: Gate 24, Outpatient Therapies, Brunel Building, Southmead Hospital.

Resources

NICE guidlelines

There are also NICE guidelines which include advice about the diagnosis of Spondyloarthritis and when to refer.

National Axial Spondyloarthritis Society

The NASS website has information and resources for patients and professionals:

Homepage | National Axial Spondyloarthritis Society (nass.co.uk)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.