View Sops Annals of the Rheumatic Diseases BMJ Journals

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					List of procedures at the Early SpA clinic
   1) Confirmation of referral criteria
   2) Detailed medical history
   3) Examination
   4) Collection of measures:
              numerical rating scale of global patient assessment
              BASDAI
              BASFI
              SF12 (optional)
              ASQoL
              BASMI
              chest expansion
              number of painful and swollen joints
              enthesis index
   5) Laboratory and X-ray studies performed were:
              cell blood counts
              biochemistry
              C-RP
              ESR
              HLA-B27
   6) Data about pharmacological or non pharmacological treatment used was also introduced.
   7) Report and diagnosis:
              After every visit, a clinical report was prepared automatically with this information, and provided to
               the patient. In this report, the patients could be clinically judged, or classified, into one of the
               following group of diagnosis:
                      i. mechanical low back pain
                     ii. inflammatory low back pain unrelated to SpA
                     iii. peripheral arthritis unrelated to SpA
                     iv. other diagnosis unrelated to SpA
                     v. or confirmed SpA.
              Despite the clinical diagnosis, the data collected permitted the classification of the patients
               according to the following criteria:
                      i. Amor [1],
                     ii. ESSG [2]
                     iii. Berlin criteria [3]
                     iv. Additionally, the program encouraged the use of the following criteria:
                              1. For classification of AS, the New York modified criteria for AS [4]
                              2. for psoriatic and reactive arthritis, international established criteria [5, 6].
              Diagnosis was assessed as of the second visit, after all tests had been revised.
The procedures of the program were approved by the Ethic Committee of the Hospital Reina Sofía, Córdoba.

Discussion on referral and diagnostic criteria in Esperanza
Over the last few years, groups of rheumatologists have been trying to accelerate the diagnosis and treatment of
patients with SpA. This argument supported the development of new criteria [3] because the established criteria for
AS rely on the combination of clinical symptoms plus unequivocal radiographic sacroiliitis, while X-rays are often
normal when symptoms first arise. Recommendations for early referral of AS in primary care and criteria for
classification for pre-radiographic stages of axial SpA have been proposed [7-9]. In Berlin, Sieper and Rudwaleit
proposed, as referral criteria, the presence of low back pain for more than 3 months in patients under 45 plus a)
inflammatory back pain or b) HLA-B27 or c) presence of sacroiliitis (by x-ray or MRI)[9]. The results of the application
of these referral recommendations in patients with chronic back pain has been proven to be useful, when applied in
primary care, for identifying new patients with AS or pre-radiographic axial SpA with long standing disease of several
years of duration [7]. However, laboratory or imaging parameters may be costly or difficult to use in the primary care
setting. This is the reason why we chose excluding any imaging or laboratory techniques from the referral criteria.
Our results confirm that clinical referral criteria without laboratory tests or imaging procedures may be as efficient,
as a more comprehensive referral criterion. A large experience in early SpA has been published from the Maastricht
SpA clinic [8]. In this clinic, patients referred have inflammatory back pain of less than 2 years duration (n=68). The
source of patients’ referral could either be rheumatologists, or orthopedic surgeons, or dermatologists, or
gastroenterologists, or ophthalmologists. The study compared three different criteria set for the diagnosis of SpA,
being the ESSG criteria the most sensitive, then followed by Amor’s, and Berlin’s criteria. Out of the 68 patients with
IBP, 56 fulfilled ESSG criteria, 48 Amor’s criteria and 43 Berlin’s criteria. Only 4 patients did not fulfil any criteria set
and 36 (53%) fulfilled all criteria sets. In this cohort, the contribution of MRI—performed in all patients as per
protocol—, and of HLA-B27, was limited for making a diagnosis of axial SpA.

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proposal for modification of the New York criteria. Arthritis Rheum 1984; 27(4):361-368.
5.       Taylor W, Gladman D, Helliwell P, et al. Classification criteria for psoriatic arthritis: development of new
criteria from a large international study. Arthritis Rheum 2006; 54(8):2665-2673.
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Suppl 1:suppl 29-31.
7.     Brandt HC, Spiller I, Song IH, et al. Performance of referral recommendations in patients with chronic back
pain and suspected axial spondyloarthritis. Ann Rheum Dis 2007; 66(11):1479-1484.
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and radiographic forms) in primary care. Ann Rheum Dis 2005; 64(5):659-663.

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