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*For medical professionals only, don’t equate low back pain with ankylosing spondylitis Ankylosing spondylitis (AS) is a chronic Autoimmune diseases characterized by involvement of peripheral joints and tendon attachments are classic representatives of such diseases as spondyloarthritis (Sp.
AS has obvious familial aggregation phenomenon and is closely related to HLA-B2AS eventually leads to joint deformity and loss of function, which seriously affects the patient's ability to live and wo.
The disease has the characteristics of high prevalence, long course, and high disability ra.
It not only affects the sacroiliac joints, spine and other axial joints and peripheral joints, but also can involve a variety of tissues and orga.
Because its pathogenesis is still unknown, there is no cu.
Diseases and disabilities not only bring physical and psychological pain to the patients themselves, but also bring heavy economic and social burdens to their families and socie.
Early diagnosis is very important for AS patien.
Today, let us follow the footsteps of .
Kong Xiangyan of Beijing Military Region General Hospital, walk into two cases of AS clinical misdiagnosis, and have a deeper understanding of AS ~ remember the diagnostic criteria, and help you practice "eye-catching eyes" "To clearly distinguish AS among a wide range of diseases, we first need to understand how AS is diagnos.
At present, the New York standard in 1984 is still widely used in clinical practice, namely: low back pain: at least 3 months, relieved after activity, not relieved after rest; lumbar spine mobility limitation; reduced chest expansion; bilateral sacroiliitis Grade 2-4, unilateral grade 3-4 (X-ray) affirmative AS: sacroiliitis plus one of 3 clinical criter.
However, this standard has strong specificity and poor sensitivity (AS patients may only have symptoms of low back pain in the early stage of the disease, and no radiological change.
Therefore, patients without radiological changes may not be able to receive timely diagnosis and treatment, resulting in patients There is a delay of 5 to 10 years from symptom onset to diagnos.
Since then, new diagnostic criteria have been introduced one after another, but they have not been widely used in clinical practice due to their insufficient sensitivity and specifici.
In 2009, ASAS proposed a new classification standard for axial spondyloarthritis, focusing on the early classification and diagnosis of S.
Axial SpA including AS is a classification of a class of diseases, not a definitive diagnosis of a single disea.
This standard applies to patients under the age of 45 with low back pain ≥3 mont.
Figure 1: The classification criteria of axial spondyloarthritis proposed by ASAS in 2009 Among them, the most characteristic manifestations of AS are inflammatory low back pain, sacroiliitis, and spinal rigidi.
Other manifestations include the following: enthesitis; ocular involvement: conjunctivitis, uveitis; peripheral arthritis; anterior chest wall inflammation: manubrium joint, sternoclavicular joint, costothoracic arthritis; morning stiffness: after waking up in the morning Stiffness and discomfort in the lower back, which can be relieved after activities, and the duration is related to the severity of the conditi.
In mild cases, it can be relieved in a few minutes, and in severe cases, it can be relieved for several hours or all day; alternating hip pain; heel pa.
Misdiagnosed Case 1 - Is Inflammatory Back Pain AS? CASE INTRODUCTION Young female, 31 years old, was admitted to hospital with "lumbosacral pain for 7 month.
The main manifestations were sacroiliac pain, no morning stiffness, and no relief after exerci.
He had been treated in many local hospitals and received massage and other treatments, but the above symptoms did not impro.
Self-administration of non-steroidal anti-inflammatory drugs, the symptoms were slightly reliev.
Past history of recurrent pelvic inflammatory disease and pelvic effusi.
Physical examination: clear speech, no skin rash and superficial lymph node enlargement, regular rhythm, no murmur in the auscultation area of each valve, clear breath sounds in both lungs, no dry and wet rales, mild tenderness and reflex in the right lower quadra.
throbbing pa.
The tenderness of the lumbar 1 sacral 1 vertebra was obvious, and the bilateral "4" test was positi.
Refers to the distance from the ground to 3cm, the distance from the pillow to the wall is 0cm, and the schober test is negati.
Laboratory tests: ESR 27mm/h, C-reactive protein 27mg/L, HLA-B27 negati.
Immunoglobulin IgG, IgA, IgM, complement C3, complement C4, rheumatoid factor, anti-chain "O", autoantibody test, antinuclear antibody (ANA) 2 items, antikeratin antibody, antiphospholipid antibody were all negati.
Urine routine: urine specific gravity (SG) 012, urine bacterial culture was positi.
No obvious abnormality was found in blood routine, stool routine and blood biochemist.
Ultrasound: fatty liver, gallbladder, pancreas, spleen, and kidneys showed no obvious abnormality; uterus, ovary and double appendages showed no obvious abnormali.
MRI of the hip joint showed no obvious abnormality, and MRI of the lumbar spine showed: lumbar 5-sacral 1 intervertebral disc herniati.
Whole body bone scan:The bone salt metabolism of the pyramidal body and limb joint area is not uniform, and the concentration is slightly increas.
It is recommended to combine the clinical practice and follow up;No obvious abnormality in the bone salt metabolism of the rest of the bo.
CT of the sacroiliac joint showed that the sacroiliac joint was sclerotic in the proximal joint area, with clear joint edges and no joint space narrowi.
Figure 2: Patients with sacroiliac joint CT patients with elevated inflammatory markers and persistent lumbosacral pain, which is really confusing, and people can't help but associate it with .
But as soon as the CT results come out, AS can be ruled out instant.
Why is this? This is to understand the CT manifestations of the sacroiliac joint in AS patients! Table 1: Classification of CT manifestations of the sacroiliac joint in AS patients From this point of view, the CT joint edge of this patient is clear and there is no joint space narrowing, which obviously does not conform to the characteristic changes of the sacroiliac joint of .
In the end, the patient was diagnosed with osteitis dense, which was significantly relieved after receiving celecoxib, topical physiotherapy and other treatmen.
Tips: Osteitis Dense is a benign low back pain of unknown cause that women are prone to after pregnancy and childbir.
Some scholars consider that it is related to the ischemia of the lower iliac bone caused by the compression of the abdominal aorta by the pregnant uter.
Features: Radiology mainly shows increased bone density in the ear-shaped part of the ilium near the sacroiliac joint surface, which is a uniform, thick white, and triangular bone dense band with a clear ed.
The sacroiliac joint space is clear and tidy, and there is no bone destructi.
In most cases, inflammatory indexes such as erythrocyte sedimentation rate were not elevated, and bone scintigraphy was norm.
Most scholars believe that osteitis dense is a non-inflammatory chan.
Misdiagnosed Case 2 - This "senile disease" also touches porcelain AS? Case introduction A 62-year-old male was referred for "low back pain for 1 mont.
One month ago, the patient had low back pain without obvious incentives, which was obvious in the morning and relieved after exerci.
The X-ray examination of the lumbar spine in the other hospital showed the formation of a hypertrophic bone bridge on the right side of the lumbar 2-3 pyram.
Considering AS, it is recommended to consult a rheumatology departme.
Laboratory tests: blood routine, liver and kidney function, erythrocyte sedimentation rate, and C-reactive protein were norm.
Urine routine was norm.
The CT examination of the sacroiliac joint showed no obvious abnormali.
Thoracic X-ray examination: In many thoracic vertebrae, only the right edge hypertrophic osteophyte bridge was form.
Figure 3: Lateral X-ray Figure 4: Frontal X-ray Relatively speaking, this case is much more "sincere" than the form.
Although the patient has symptoms of low back pain, there is no increase in inflammatory indicators in the examination resul.
There was no obvious abnormality in the iliac joint, and the only special thing was the X-ray changes of the patient's thoracic spi.
However, the diagnosis is actually not that difficu.
From the lateral X-ray of the patient, it can be seen that it is not the characteristic bone bridge formation of AS (that is, it is close to the vertical state), and it can also be seen from the frontal X-ray that it is not symmetric.
Bamboo-like changes, multiple thoracic vertebrae in this patient were only formed by the right-sided hypertrophic osteophyte brid.
Finally, the patient was diagnosed with diffuse idiopathic hyperostosis (DIS.
Tips: DISH is a disease formed by calcification and ossification of soft tissues, especially tendons and tendon attachmen.
The characteristic lesion is the calcification and ossification of the anterior longitudinal ligament, which is most common in the thoracic spi.
On the lateral radiograph of the thoracic spine, it is similar to the bamboo-like changes of AS, which is difficult to distinguish from .
However, the osteophyte hyperplasia in this disease is generally thicker, more common in the right side of the thoracic spine, and rare in the left side, which is its characteristic manifestati.
The disease mostly occurs in elderly patients, the etiology is unclear, and may be related to hyperinsulinemia, hyperlipidemia, obesity, gout,e.
The disease generally develops slowly and mainly presents with lower back pain and stiffne.
Osteophytes increase significantly, and compression symptoms may appear in the corresponding par.
There is no special treatment, mainly symptomatic treatme.
I believe that through the sharing of the above two misdiagnosed cases, everyone has a deeper understanding of .
In clinical work, we must always be vigilant, in order to reduce the misdiagnosis rate of AS, shorten the diagnosis time of AS, and let the majority of AS patients have a more "upright" life! Click to read the original text to learn more about the details of the cases immediate.
It is full of dry goods, not to be missed! More exciting cases, where to find? Corey sent a patient, but the symptoms are simple, but no cure is good, and the worse the treatment is, the worse it is? Disease A is diagnosed as disease B, how can confusing diseases avoid misdiagnosis? The main points of diagnosis and treatment in various departments, want to quickly get through a classic case? What is the cause behind this symptom? What's at fault? The wonderful cases you want to see are all available in the "Rheumatology Cases" column of the Doctor Station 👇 Scan the QR code below the codeClick "Download Now"Open the Doctor Station App and click the columnFind the "corresponding department" in the case sharing Pay attention to the column and subscribe to the column, and read a good case every day! Download the Doctor Station App and subscribe anytime, anywhere~
AS has obvious familial aggregation phenomenon and is closely related to HLA-B2AS eventually leads to joint deformity and loss of function, which seriously affects the patient's ability to live and wo.
The disease has the characteristics of high prevalence, long course, and high disability ra.
It not only affects the sacroiliac joints, spine and other axial joints and peripheral joints, but also can involve a variety of tissues and orga.
Because its pathogenesis is still unknown, there is no cu.
Diseases and disabilities not only bring physical and psychological pain to the patients themselves, but also bring heavy economic and social burdens to their families and socie.
Early diagnosis is very important for AS patien.
Today, let us follow the footsteps of .
Kong Xiangyan of Beijing Military Region General Hospital, walk into two cases of AS clinical misdiagnosis, and have a deeper understanding of AS ~ remember the diagnostic criteria, and help you practice "eye-catching eyes" "To clearly distinguish AS among a wide range of diseases, we first need to understand how AS is diagnos.
At present, the New York standard in 1984 is still widely used in clinical practice, namely: low back pain: at least 3 months, relieved after activity, not relieved after rest; lumbar spine mobility limitation; reduced chest expansion; bilateral sacroiliitis Grade 2-4, unilateral grade 3-4 (X-ray) affirmative AS: sacroiliitis plus one of 3 clinical criter.
However, this standard has strong specificity and poor sensitivity (AS patients may only have symptoms of low back pain in the early stage of the disease, and no radiological change.
Therefore, patients without radiological changes may not be able to receive timely diagnosis and treatment, resulting in patients There is a delay of 5 to 10 years from symptom onset to diagnos.
Since then, new diagnostic criteria have been introduced one after another, but they have not been widely used in clinical practice due to their insufficient sensitivity and specifici.
In 2009, ASAS proposed a new classification standard for axial spondyloarthritis, focusing on the early classification and diagnosis of S.
Axial SpA including AS is a classification of a class of diseases, not a definitive diagnosis of a single disea.
This standard applies to patients under the age of 45 with low back pain ≥3 mont.
Figure 1: The classification criteria of axial spondyloarthritis proposed by ASAS in 2009 Among them, the most characteristic manifestations of AS are inflammatory low back pain, sacroiliitis, and spinal rigidi.
Other manifestations include the following: enthesitis; ocular involvement: conjunctivitis, uveitis; peripheral arthritis; anterior chest wall inflammation: manubrium joint, sternoclavicular joint, costothoracic arthritis; morning stiffness: after waking up in the morning Stiffness and discomfort in the lower back, which can be relieved after activities, and the duration is related to the severity of the conditi.
In mild cases, it can be relieved in a few minutes, and in severe cases, it can be relieved for several hours or all day; alternating hip pain; heel pa.
Misdiagnosed Case 1 - Is Inflammatory Back Pain AS? CASE INTRODUCTION Young female, 31 years old, was admitted to hospital with "lumbosacral pain for 7 month.
The main manifestations were sacroiliac pain, no morning stiffness, and no relief after exerci.
He had been treated in many local hospitals and received massage and other treatments, but the above symptoms did not impro.
Self-administration of non-steroidal anti-inflammatory drugs, the symptoms were slightly reliev.
Past history of recurrent pelvic inflammatory disease and pelvic effusi.
Physical examination: clear speech, no skin rash and superficial lymph node enlargement, regular rhythm, no murmur in the auscultation area of each valve, clear breath sounds in both lungs, no dry and wet rales, mild tenderness and reflex in the right lower quadra.
throbbing pa.
The tenderness of the lumbar 1 sacral 1 vertebra was obvious, and the bilateral "4" test was positi.
Refers to the distance from the ground to 3cm, the distance from the pillow to the wall is 0cm, and the schober test is negati.
Laboratory tests: ESR 27mm/h, C-reactive protein 27mg/L, HLA-B27 negati.
Immunoglobulin IgG, IgA, IgM, complement C3, complement C4, rheumatoid factor, anti-chain "O", autoantibody test, antinuclear antibody (ANA) 2 items, antikeratin antibody, antiphospholipid antibody were all negati.
Urine routine: urine specific gravity (SG) 012, urine bacterial culture was positi.
No obvious abnormality was found in blood routine, stool routine and blood biochemist.
Ultrasound: fatty liver, gallbladder, pancreas, spleen, and kidneys showed no obvious abnormality; uterus, ovary and double appendages showed no obvious abnormali.
MRI of the hip joint showed no obvious abnormality, and MRI of the lumbar spine showed: lumbar 5-sacral 1 intervertebral disc herniati.
Whole body bone scan:The bone salt metabolism of the pyramidal body and limb joint area is not uniform, and the concentration is slightly increas.
It is recommended to combine the clinical practice and follow up;No obvious abnormality in the bone salt metabolism of the rest of the bo.
CT of the sacroiliac joint showed that the sacroiliac joint was sclerotic in the proximal joint area, with clear joint edges and no joint space narrowi.
Figure 2: Patients with sacroiliac joint CT patients with elevated inflammatory markers and persistent lumbosacral pain, which is really confusing, and people can't help but associate it with .
But as soon as the CT results come out, AS can be ruled out instant.
Why is this? This is to understand the CT manifestations of the sacroiliac joint in AS patients! Table 1: Classification of CT manifestations of the sacroiliac joint in AS patients From this point of view, the CT joint edge of this patient is clear and there is no joint space narrowing, which obviously does not conform to the characteristic changes of the sacroiliac joint of .
In the end, the patient was diagnosed with osteitis dense, which was significantly relieved after receiving celecoxib, topical physiotherapy and other treatmen.
Tips: Osteitis Dense is a benign low back pain of unknown cause that women are prone to after pregnancy and childbir.
Some scholars consider that it is related to the ischemia of the lower iliac bone caused by the compression of the abdominal aorta by the pregnant uter.
Features: Radiology mainly shows increased bone density in the ear-shaped part of the ilium near the sacroiliac joint surface, which is a uniform, thick white, and triangular bone dense band with a clear ed.
The sacroiliac joint space is clear and tidy, and there is no bone destructi.
In most cases, inflammatory indexes such as erythrocyte sedimentation rate were not elevated, and bone scintigraphy was norm.
Most scholars believe that osteitis dense is a non-inflammatory chan.
Misdiagnosed Case 2 - This "senile disease" also touches porcelain AS? Case introduction A 62-year-old male was referred for "low back pain for 1 mont.
One month ago, the patient had low back pain without obvious incentives, which was obvious in the morning and relieved after exerci.
The X-ray examination of the lumbar spine in the other hospital showed the formation of a hypertrophic bone bridge on the right side of the lumbar 2-3 pyram.
Considering AS, it is recommended to consult a rheumatology departme.
Laboratory tests: blood routine, liver and kidney function, erythrocyte sedimentation rate, and C-reactive protein were norm.
Urine routine was norm.
The CT examination of the sacroiliac joint showed no obvious abnormali.
Thoracic X-ray examination: In many thoracic vertebrae, only the right edge hypertrophic osteophyte bridge was form.
Figure 3: Lateral X-ray Figure 4: Frontal X-ray Relatively speaking, this case is much more "sincere" than the form.
Although the patient has symptoms of low back pain, there is no increase in inflammatory indicators in the examination resul.
There was no obvious abnormality in the iliac joint, and the only special thing was the X-ray changes of the patient's thoracic spi.
However, the diagnosis is actually not that difficu.
From the lateral X-ray of the patient, it can be seen that it is not the characteristic bone bridge formation of AS (that is, it is close to the vertical state), and it can also be seen from the frontal X-ray that it is not symmetric.
Bamboo-like changes, multiple thoracic vertebrae in this patient were only formed by the right-sided hypertrophic osteophyte brid.
Finally, the patient was diagnosed with diffuse idiopathic hyperostosis (DIS.
Tips: DISH is a disease formed by calcification and ossification of soft tissues, especially tendons and tendon attachmen.
The characteristic lesion is the calcification and ossification of the anterior longitudinal ligament, which is most common in the thoracic spi.
On the lateral radiograph of the thoracic spine, it is similar to the bamboo-like changes of AS, which is difficult to distinguish from .
However, the osteophyte hyperplasia in this disease is generally thicker, more common in the right side of the thoracic spine, and rare in the left side, which is its characteristic manifestati.
The disease mostly occurs in elderly patients, the etiology is unclear, and may be related to hyperinsulinemia, hyperlipidemia, obesity, gout,e.
The disease generally develops slowly and mainly presents with lower back pain and stiffne.
Osteophytes increase significantly, and compression symptoms may appear in the corresponding par.
There is no special treatment, mainly symptomatic treatme.
I believe that through the sharing of the above two misdiagnosed cases, everyone has a deeper understanding of .
In clinical work, we must always be vigilant, in order to reduce the misdiagnosis rate of AS, shorten the diagnosis time of AS, and let the majority of AS patients have a more "upright" life! Click to read the original text to learn more about the details of the cases immediate.
It is full of dry goods, not to be missed! More exciting cases, where to find? Corey sent a patient, but the symptoms are simple, but no cure is good, and the worse the treatment is, the worse it is? Disease A is diagnosed as disease B, how can confusing diseases avoid misdiagnosis? The main points of diagnosis and treatment in various departments, want to quickly get through a classic case? What is the cause behind this symptom? What's at fault? The wonderful cases you want to see are all available in the "Rheumatology Cases" column of the Doctor Station 👇 Scan the QR code below the codeClick "Download Now"Open the Doctor Station App and click the columnFind the "corresponding department" in the case sharing Pay attention to the column and subscribe to the column, and read a good case every day! Download the Doctor Station App and subscribe anytime, anywhere~
