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In the Clinic |

Low Back Pain

Roger Chou, MD
Ann Intern Med. 2014;160(11):ITC6-1. doi:10.7326/0003-4819-160-11-201406030-01006
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Low back pain has a lifetime prevalence of nearly 80%, and spinal disorders are the fourth most common primary diagnosis for office visits in the United States (1). Low back pain is also costly, accounting for a large and increasing proportion of health care expenditures without evidence of corresponding improvements in outcomes (2). In most patients, the specific cause of low back pain cannot be identified, and episodes generally resolve within days to a few weeks with self-care. Up to one third of patients, however, report persistent back pain of at least moderate intensity 1 year after an acute episode, and 1 in 5 report substantial limitations in activity (3). Because low back pain is common, can lead to substantial disability, and can become chronic, proficiency in evaluation and management is important.

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Inflammatory Back Pain as a Screening Tool
Posted on June 25, 2014
Paramvir Sidhu MD, Mandeep Brar MD
Franciscan Medical Group, Tacoma WA
Conflict of Interest: None Declared
We read Dr Chou’s review (1) on back pain published in your journal with great interest. This article made some excellent points about management of back pain. However, we feel that it did not sufficiently stress the need for differentiating inflammatory from mechanical back pain and contained some inaccuracies with regards to prevalence of ankylosing spondylitis (AS) in patients with back pain in general and inflammatory back pain (IBP) in particular.
Most studies have shown that prevalence of axial spondyloarthritis including AS in patients with chronic back pain is around five percent rather than the much lower prevalence suggested in this article. In this article Dr Chou states that positive predictive value of inflammatory back pain criteria is low in patients with back pain due to low prevalence of ankylosing spondylitis, implying that inflammatory back pain criteria of limited utility. However, studies have shown that prevalence of axial spondyloarthritis including AS in patients referred for further evaluation due to IBP alone is around 15% and even higher in groups with IBP and other risk factors. For example, prevalence of axial spondyloarthritis has been found to be around 1in3 in patients referred for IBP and positive HLA B27 (2,3,4). Therefore, IBP is a very useful clinical screening too for axial spondyloarthritis.
This article also fails to provide the reader a clear algorithm with regards to back pain patients that need referral to a rheumatologist further evaluation for possible axial spondyloarthritis like AS. We recommend that patients with chronic back pain meeting criteria for IBP should be considered for a referral to a rheumatologist for a comprehensive evaluation for inflammatory spondyloarthritis, especially if they have additional risk factors like positive HLA B27, inflammatory bowel disease, uveitis or psoriasis.

References:
1.Chou R. Low Back Pain. Ann Intern Med. 2014;160:ITC6-1.
2.Rudwaleit, M., Metter, A., Listing, J., Sieper, J. & Braun, J. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum. 54, 569–578 (2006).
3.Hermann, J., Giessauf, H., Schaffler, G., Ofner, P. & Graninger, W. Early spondyloarthritis: usefulness of clinical screening. Rheumatology (Oxford) 48, 812–81
4.Weisman, M. H. et al. Development and validation of a case ascertainment tool for ankylosing spondylitis. Arthritis Care Res. (Hoboken) 62, 19–27 (2010).
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