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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
spinal pain
or
Synovitis
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
Inflammatory
Arthritis
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
Zochling, J et al. Ann Rheum Dis 2006;65:442-452
Copyright ©2006 BMJ Publishing Group Ltd.
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>l lower>
ower
upper
AS
Reiter
PA
often
Intestinal
artrit
often
Sacroiliitis
Plantar spurs
always
often
common
common common
HLA-B27
Enthesopathy
Response to
therapy
90%
+
+++
90%
+
+
20%
+
++
5%
+?
+
Urethritis
Conjunctivities
Skin inv
+
-
+
+++
+
+
+
+
+
+++
+
+
-
+
-
+
+
Spine inv
Symmetry
?