Axial spondyloarthritis (axial SpA) is a condition that affects millions, yet its complexities and subtleties often lead to underdiagnosis and delayed treatment. A recent presentation at the Rheumatology Nurses Society annual conference highlighted how important it is for healthcare providers to recognize the dynamic nature of this disease to ensure better patient outcomes.

According to J. Nicholas Manwarung, MSN, APRN, a nurse practitioner in rheumatology at the Alaska Native Tribal Health Consortium, chronic back pain is a widespread issue that often masks more severe underlying conditions such as axial SpA. Manwarung explained that differentiating between inflammatory and mechanical back pain is crucial for early diagnosis and effective treatment.

Non-Radiographic Axial Spondyloarthritis Often Overlooked

One of the biggest challenges in diagnosing axial SpA is the difficulty in recognizing non-radiographic forms of the disease. Manwarung pointed out that between 10% and 40% of patients with non-radiographic axial SpA will develop radiographic signs later, making it vital to monitor patients over time. Many patients are underdiagnosed, largely due to a lack of awareness and insufficient research in this area.

Axial SpA manifests not only in the spine but also in the cervical spine and peripheral areas. Key signs such as enthesitis, syndesmophytes, and sacroiliitis are often missed, especially by non-rheumatology providers. Manwarung emphasized the importance of clinicians recognizing these signs to make an accurate diagnosis.

Fluid Nature of Axial Spondyloarthritis

The disease is described as ‘fluid,’ meaning that its symptoms and progression can vary widely from patient to patient. Some individuals may experience remission, while others might develop more severe forms, such as non-radiographic axial SpA. Genetic predispositions, particularly mutations in HLA-B27, can also play a role, but these mutations are not present in all cases. This variability makes it essential not to put patients into rigid diagnostic categories.

Manwarung also stressed that certain patients may not fit neatly into any established diagnostic criteria, yet they may still benefit from treatment. Clinicians must stay vigilant, even with patients who have undifferentiated or previously unrecognized axial SpA.

Optimizing Imaging and Early Intervention

Accurate imaging is another critical component of early diagnosis and management. Manwarung recommends starting with an X-ray of the AP pelvis and obtaining a bilateral view of the sacroiliac joints to better assess the condition. By diagnosing and treating axial SpA early, clinicians can prevent debilitating progression, such as the complete fusion of the spine, which can severely impact a patient’s quality of life.

Genetic and Environmental Factors

While genetic factors like HLA-B27 mutations are common in many axial SpA patients, the presence of this mutation varies depending on ethnic background. Moreover, the disease may be influenced by environmental factors, further underscoring its complex and fluid nature.