SPONDYLOARTHROPATHIES

Prof. Dr. Şansın Tüzün

Definition

• A family inflammatory arthritides characterized by

involvement of both synovium and entheses leading to

spinal and oligoarticular peripheral artritis,principally in

genetically predisposed (HLA B27 +) individuals

• Infective causes are considered likely

Ankylosing spondylitis, reactive arthritis, Psöriatic arthritis and enteropathic arthritis are the principle clinical entities

Clinical Features

• Sacroiliitis or spondylitis may be dominant

clinical problem

• Peripheral arthritis is typically asymmetric and

involves the lower limb

• Entesopathy is prominent at both axial and

peripheral skeletal sites

• Inflammatory bowel disease is common

• Extra-articular features;uveitis,carditis,skin

and mucous membrane lesions

• Patients are seronegative for rheumatoid

factor

• HLA-B27 is present in most individuals

Spondyloarthropathies

Inflammatory back pain—Characteristics

• Morning stiffness

• Back pain improves with exercise

• Persistence for at least 3 months

• Insidious onset before age 40

Classification Criteria for Spondiloarthropathy

Inflammatory or Synovitis

spinal pain Asymmetric

Predominantly

in lower limbs

Add one or more of the following

• Positive family history (AS, psoriasis, uveitis reactive arthritis,inflammatory bowel disease)

• Psoriasis

• İnflammatory bowel disease

• Urethritis or cervicitis(nongonococcal), or acute diarrhea

• Buttock pain

• Enthesopathy

• Sacroiliitis

InflammatoryArthritis

Psoriatic skin and nail changes

Enthesopathy

• Pathologic alteration at an

enthesis (a site of

insertion of a tendon or

ligament into bone)

• Manifests radiographically

as ossification of entheses

Common Sites of Enthesitis in Patients with Spondyloarthropathies

• Achilles tendon insertion on the calcaneus

• Plantar fascia insertion on the calcaneus

• Patellar tendon insertion on the tibial tubercle

• Superior and inferior aspects of the patella

• Metatarsal heads

• Base of the fifth metatarsal

• Spinal ligament insertions on the vertebral bodies

ANKYLOSING SPONDYLITIS

• Chronic systemic inflammatory disorder

that mainly affects the axial skeleton

• Sacroiliitis is its hallmark

• Strong genetic predisposition with

HLA-B27

Clinical Features

• Typical presentation, is with low back pain of insidious onset

• Age less than 40 years• Persistance for more than three months• Morning stiffness• Improvement with exercise• Arthritis of hips, shoulders and entesopathies

are common• Limitation of spinal mobility

• Acute anterior uveitis as an extra-articular

manifestation

• With psoriasis,chronic inflammatory bowel

disease, reactive arthritis in some patients

• Good symptomatic response to NSAID

Posture in advanced ankylosing spondylitis

Spondyloarthropathies

Enthesopathy

Erosion

New bone

Radiologic Findings

• Squaring of the vertebral bodies

• Bamboo spine

• Osteopenia

• Bilateral sacroiliitis

Physical Examination

• Muscle spasm and loss of the normal

lordosis

• Mobility of the lumber spine is decreased

symmetrically in both anterior and lateral

planes

• Lomber schober < 3 cm

• Peripheral joint involvement (%20-%30) – Hip– Shoulder

• Enthesopathic features;– Plantar fasciitis– Achilles tendinitis

Laboratory Findings

• HLA-B27 (90%)

(Not a routine screening procedure)

• ESR elevation is moderate

• There are no pathognomotic tests

New York Criteria for AS

1- Presence of history of pain at dorsalumbar junction

or in lumber spine

2- Limitation of motion in anterior flexion lateral flexion

and extension

3- Limitation of chest expansion to 2.5 cm or less at

the fourth intercostal space

Requirements

• Either one positive radiographs and one or

more clinical criteria, or grade 3-4 unilateral

or grade 2 bilateral sacroiliit with clinical

criterion 2 or with clinical criteria 1 and 3

Management

• Early diagnosis, patient education and physical therapy are essential for the successful management of AS

• The goals of physical therapy- to restore and maintain posture and movement to as near normal as possible

• Self-management with exercises must be continued on a lifelong basis

• NSAID relieve pain and stiffness and facilitate pyhsical therapy

• Sulfasalazine appears to be the most effective of the second-line drugs

• Non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation

• Disease-modifying antirheumatic drugs (DMARDs)

may help relieve pain in joints other than the spine

and pelvis.

• The DMARD most often studied and prescribed for

ankylosing spondylitis is sulfasalazine, which is a

combination of aspirin and an antibiotic

• Dosage should be started at 500 mg/day and

increased by 500 mg/day at 1-wk intervals to 1 to 2 g

bid maintenance

“Biologic agents" or anti-TNF-alpha’’

• Drugs reduce inflammation by blocking a protein called tumor

necrotizing factor (TNF) that causes inflammation

• Anti-TNF treatment should be given to patients with persistently

high disease activity despite conventional treatments

• Beneficial effect is prominent in peripheral joint involvement

rather than axial disease

• Etanercept

• Infliximab

• Adalimumab

Copyright ©2006 BMJ Publishing Group Ltd.

Zochling, J et al. Ann Rheum Dis 2006;65:442-452

Back stretches

Chest expansion

Upper back and shoulder stretch

Hip and back stretches

Comparison of Spondyloarthropathies

AS Reiter PA Intestinal A.

Sex M>F M>F F>M F=M

Onset >20 >20 Any age

Any age

Uveitis + ++ + +

Peripheral

joints

Lower limb often

Lower limb usually

Upper>lower

lower> upper

AS Reiter PA Intestinal artrit

Sacroiliitis always often often often

Plantar spurs common common common ?

HLA-B27 90% 90% 20% 5%

Enthesopathy + + + +?

Response to therapy

+++ + ++ +

Urethritis - + - -

Conjunctivities + +++ + +

Skin inv - + + +

Spine inv +++ + + +

Symmetry + - - +