Rheumazentrum Ruhrgebiet Herne, Ruhr-University, Bochum.
German Rheumatism Research Center, Berlin.
Rheumatology (Oxford). 2020 Dec 1;59(12):3845-3852. doi: 10.1093/rheumatology/keaa212.
Chronic inflammatory back pain (IBP) is frequently reported in axial SpA (axSpA) but also in the general population. We evaluated a recently proposed two-step referral system for early recognition of axSpA in primary care and compare it with other combinations of symptoms and SpA-related items.
Consecutive chronic back pain patients ≤45 years of age answered a questionnaire and were seen by a primary care physician who decided whether HLA-B27 needed to be determined. They were then referred to a rheumatologist who made the diagnosis. Generally sticking to the two-step system with HLA-B27 as an additional option, combinations with a sensitivity ≥90% and a likelihood ratio >4 were compared.
A total of 326 patients were included, 46 of whom were diagnosed with axSpA (14.1%). The sensitivity of the strategy was 87%, the specificity was 56.8% and the positive and negative predictive values were 24.8% and 96.4%, respectively. A 'good response to NSAIDs', 'morning stiffness >30 min' and 'elevated C-reactive protein' performed best, with a sensitivity of 91%, specificity of 67%, positive predictive value of 31% and negative predictive value of 98%. On that basis, only three patients had to be seen by a rheumatologist to diagnose one.
The earlier proposed referral system worked well but was outperformed by other combinations with high sensitivity and better specificity, which deserve to be prospectively studied.
慢性炎症性背痛（IBP）在中轴型脊柱关节炎（axSpA）中经常被报道，也存在于普通人群中。我们评估了一种新提出的两步转诊系统，用于在初级保健中早期识别 axSpA，并将其与其他症状和与 SpA 相关项目的组合进行比较。
连续的≤45 岁的慢性背痛患者回答了一份问卷，并由初级保健医生进行了检查，该医生决定是否需要确定 HLA-B27。然后，他们被转诊给风湿病医生进行诊断。通常坚持两步系统，将 HLA-B27 作为额外选择，比较具有≥90%敏感性和>4 的似然比的组合。
共纳入 326 名患者，其中 46 名被诊断为 axSpA（14.1%）。该策略的敏感性为 87%，特异性为 56.8%，阳性预测值和阴性预测值分别为 24.8%和 96.4%。“对 NSAIDs 的良好反应”、“晨僵>30 分钟”和“C 反应蛋白升高”表现最佳，敏感性为 91%，特异性为 67%，阳性预测值为 31%，阴性预测值为 98%。在此基础上，只需要看三个风湿病医生就能诊断出一个病例。
早期提出的转诊系统效果良好，但其他具有高敏感性和更好特异性的组合表现更优，值得前瞻性研究。
