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The assessment of the spondyloarthritis international society concept and criteria for the classification of axial spondyloarthritis and peripheral spondyloarthritis: A critical appraisal for the pediatric rheumatologist.

Burgos-Vargas R - Pediatr Rheumatol Online J (2012)

Bottom Line: The ASAS criteria evolved from the idea that the earlier the recognition of patients with ankylosing spondylitis, the better the efficacy of tumor necrosis factor blockers.The application of those specific strategies in children and adolescents with SpA seems limited because the most important manifestation in the early stage of disease is not IBP, but peripheral arthritis and enthesitis.In this instance, the logical approach to juvenile onset SpA according to ASAS criteria should not be through the axial criteria but rather the peripheral set of criteria.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Rheumatology, Hospital General de México, Faculty of Medicine, Universidad Nacional Autónoma de México, Dr, Balmis 148, Colonia Doctores, México, DF 06720, Mexico. burgosv@prodigy.net.mx.

ABSTRACT
This review refers to the origin and current state of the assessment of the SpondyloArthritis International Society (ASAS) criteria for the classification of axial and peripheral spondyloarthritis (SpA) and the possible implications in the pediatric population. The ASAS criteria evolved from the idea that the earlier the recognition of patients with ankylosing spondylitis, the better the efficacy of tumor necrosis factor blockers. Strategies included the development of new concepts, definitions, and techniques for the study of clinical signs and symptoms. Of relevance, the new definition of inflammatory back pain (IBP) and the introduction of sacroiliitis by magnetic resonance imaging represented the most important advance in the early identification of AS in the "pre-radiographic stage" of the disease. AS is considered in this paper as a disease continuum with symptoms depending on age at onset. The application of those specific strategies in children and adolescents with SpA seems limited because the most important manifestation in the early stage of disease is not IBP, but peripheral arthritis and enthesitis. In this instance, the logical approach to juvenile onset SpA according to ASAS criteria should not be through the axial criteria but rather the peripheral set of criteria.

No MeSH data available.


Related in: MedlinePlus

Grade 3 bilateral sacroiliitis in a 14-year-old boy with 6 years disease duration. There is subchondral sclerosis of the iliac bone, joint surface irregularities, which include some erosions on both sides, and joint space narrowing of the hips (From Burgos-Vargas, R. 2006, The juvenile-onset spondyloarthritides. In: Weisman MH, van der Heijde D, Reveille JD. Ankylosing spondylitis and the Spondyloarthropathies. Mosby. Philadelphia. pp 94–106).
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Figure 4: Grade 3 bilateral sacroiliitis in a 14-year-old boy with 6 years disease duration. There is subchondral sclerosis of the iliac bone, joint surface irregularities, which include some erosions on both sides, and joint space narrowing of the hips (From Burgos-Vargas, R. 2006, The juvenile-onset spondyloarthritides. In: Weisman MH, van der Heijde D, Reveille JD. Ankylosing spondylitis and the Spondyloarthropathies. Mosby. Philadelphia. pp 94–106).

Mentions: 2) If needed, which set of ASAS criteria is more appropriate for children, axial or peripheral? It seems clear that axial and peripheral SpA classifications have different purposes. While the former [11] is intended to identify the spinal and sacroiliac involvement in the early inflammatory stage of AS, the latter [12] relies on peripheral arthritis, enthesitis, and dactylitis as entry criteria (Table 3).Regarding axial involvement, children and adolescents may have both active sacroiliitis on MRI (Figure 3) and radiographic sacroiliitis grade 2 bilateral or grades 2 or 4 unilateral (Figure 4), but in most cases these events occur in association with peripheral arthritis and enthesitis (Figure 5).Axial symptoms, as isolated features, are unusual in youngsters. The ASAS axial SpA criteria suggest the need for a history of back pain for at least three months as entry criteria before performing MRI and/or radiographic studies of the sacroiliac joints. There seems to be no clear clinical rationale to perform MRI studies of the sacroiliac joints and the spine in children in the absence of back pain. Certainly, the logical criteria for children and adolescents is the ASAS peripheral SpA criteria since they include the most important signs and symptoms in patients with juvenile-onset SpA.Except for “good response to NSAIDs”, on that no specific reports in children exist, children and adolescents with juvenile-onset SpA could well fulfill all axial and peripheral ASAS SpA criteria (Table 6). The diagnostic properties of some of these criteria were determined during the validation of the Amor et al. [37] and ESSG [38] classification criteria of SpA [74] and in a comparative study of juvenile-onset AS and u-SpA with JRA [60]. As expected, the sensitivity of back pain in the validation study of SpA according ESSG [38] was very low, but its specificity very high (Table 5). In the latter study, sensitivity, specificity, and + LR of tarsitis and enthesopathy were very high suggesting that tarsitis should be considered an additional criterion in any classification criteria (Figure 6). The frequency of each criterion depends on the classification category. By definition, for example, IBP and radiographic sacroiliitis should be found in all patients with AS, whereas arthritis or enthesitis should be found in all patients with ERA. On the other hand, the definition of each criterion and its diagnostic value should be assessed in children. The question of whether ASAS criteria for axial and peripheral SpA [11,12] have any role in the classification of children with SpA, ERA, PsA, and even undifferentiated arthritis remains to be determined. Ideally, all related clinical conditions in children and adults should be encompassed under the same criteria in order to facilitate scientific communication and patients transition from childhood to adulthood medical care. From the therapeutic point of view, there should be some advantages if the management of juvenile and adult onset forms could have the same opportunity to be treated in the early inflammatory stage of the disease.


The assessment of the spondyloarthritis international society concept and criteria for the classification of axial spondyloarthritis and peripheral spondyloarthritis: A critical appraisal for the pediatric rheumatologist.

Burgos-Vargas R - Pediatr Rheumatol Online J (2012)

Grade 3 bilateral sacroiliitis in a 14-year-old boy with 6 years disease duration. There is subchondral sclerosis of the iliac bone, joint surface irregularities, which include some erosions on both sides, and joint space narrowing of the hips (From Burgos-Vargas, R. 2006, The juvenile-onset spondyloarthritides. In: Weisman MH, van der Heijde D, Reveille JD. Ankylosing spondylitis and the Spondyloarthropathies. Mosby. Philadelphia. pp 94–106).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3403902&req=5

Figure 4: Grade 3 bilateral sacroiliitis in a 14-year-old boy with 6 years disease duration. There is subchondral sclerosis of the iliac bone, joint surface irregularities, which include some erosions on both sides, and joint space narrowing of the hips (From Burgos-Vargas, R. 2006, The juvenile-onset spondyloarthritides. In: Weisman MH, van der Heijde D, Reveille JD. Ankylosing spondylitis and the Spondyloarthropathies. Mosby. Philadelphia. pp 94–106).
Mentions: 2) If needed, which set of ASAS criteria is more appropriate for children, axial or peripheral? It seems clear that axial and peripheral SpA classifications have different purposes. While the former [11] is intended to identify the spinal and sacroiliac involvement in the early inflammatory stage of AS, the latter [12] relies on peripheral arthritis, enthesitis, and dactylitis as entry criteria (Table 3).Regarding axial involvement, children and adolescents may have both active sacroiliitis on MRI (Figure 3) and radiographic sacroiliitis grade 2 bilateral or grades 2 or 4 unilateral (Figure 4), but in most cases these events occur in association with peripheral arthritis and enthesitis (Figure 5).Axial symptoms, as isolated features, are unusual in youngsters. The ASAS axial SpA criteria suggest the need for a history of back pain for at least three months as entry criteria before performing MRI and/or radiographic studies of the sacroiliac joints. There seems to be no clear clinical rationale to perform MRI studies of the sacroiliac joints and the spine in children in the absence of back pain. Certainly, the logical criteria for children and adolescents is the ASAS peripheral SpA criteria since they include the most important signs and symptoms in patients with juvenile-onset SpA.Except for “good response to NSAIDs”, on that no specific reports in children exist, children and adolescents with juvenile-onset SpA could well fulfill all axial and peripheral ASAS SpA criteria (Table 6). The diagnostic properties of some of these criteria were determined during the validation of the Amor et al. [37] and ESSG [38] classification criteria of SpA [74] and in a comparative study of juvenile-onset AS and u-SpA with JRA [60]. As expected, the sensitivity of back pain in the validation study of SpA according ESSG [38] was very low, but its specificity very high (Table 5). In the latter study, sensitivity, specificity, and + LR of tarsitis and enthesopathy were very high suggesting that tarsitis should be considered an additional criterion in any classification criteria (Figure 6). The frequency of each criterion depends on the classification category. By definition, for example, IBP and radiographic sacroiliitis should be found in all patients with AS, whereas arthritis or enthesitis should be found in all patients with ERA. On the other hand, the definition of each criterion and its diagnostic value should be assessed in children. The question of whether ASAS criteria for axial and peripheral SpA [11,12] have any role in the classification of children with SpA, ERA, PsA, and even undifferentiated arthritis remains to be determined. Ideally, all related clinical conditions in children and adults should be encompassed under the same criteria in order to facilitate scientific communication and patients transition from childhood to adulthood medical care. From the therapeutic point of view, there should be some advantages if the management of juvenile and adult onset forms could have the same opportunity to be treated in the early inflammatory stage of the disease.

Bottom Line: The ASAS criteria evolved from the idea that the earlier the recognition of patients with ankylosing spondylitis, the better the efficacy of tumor necrosis factor blockers.The application of those specific strategies in children and adolescents with SpA seems limited because the most important manifestation in the early stage of disease is not IBP, but peripheral arthritis and enthesitis.In this instance, the logical approach to juvenile onset SpA according to ASAS criteria should not be through the axial criteria but rather the peripheral set of criteria.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Rheumatology, Hospital General de México, Faculty of Medicine, Universidad Nacional Autónoma de México, Dr, Balmis 148, Colonia Doctores, México, DF 06720, Mexico. burgosv@prodigy.net.mx.

ABSTRACT
This review refers to the origin and current state of the assessment of the SpondyloArthritis International Society (ASAS) criteria for the classification of axial and peripheral spondyloarthritis (SpA) and the possible implications in the pediatric population. The ASAS criteria evolved from the idea that the earlier the recognition of patients with ankylosing spondylitis, the better the efficacy of tumor necrosis factor blockers. Strategies included the development of new concepts, definitions, and techniques for the study of clinical signs and symptoms. Of relevance, the new definition of inflammatory back pain (IBP) and the introduction of sacroiliitis by magnetic resonance imaging represented the most important advance in the early identification of AS in the "pre-radiographic stage" of the disease. AS is considered in this paper as a disease continuum with symptoms depending on age at onset. The application of those specific strategies in children and adolescents with SpA seems limited because the most important manifestation in the early stage of disease is not IBP, but peripheral arthritis and enthesitis. In this instance, the logical approach to juvenile onset SpA according to ASAS criteria should not be through the axial criteria but rather the peripheral set of criteria.

No MeSH data available.


Related in: MedlinePlus