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SPONDYLOARTROPATHIES 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 İnfective 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-overt or covert-is common Extra-articular features, including uveitis,carditis,skin and mucous membrane lesions,occur in the minority Patients are seronegative for rheumatoid factor HLA-B27 is present in most individuals Classification Criteria for Spondiloarthropathy İnflammatory spinal pain or Synovitis Asymmetric, Predominantly in lower limbs Add one or more of the following Positive family history (AS, Psöriasis, Uveitis, reactive arthritis,inflammatory bowel disease) Psöriasis İnflammatory bowel disease Urethritis or cervicitis(nongonococcal), or acute diarrhea Buttock pain Enthesopathy Sacroiliitis Enthesopathy Pathologic alteration at an enthesis(a site of insertion of a tendon or ligament into bone Manifests radiographically as ossification of entheses Primer entesopathy (lat. Epicondylit, med. Epicondylit) Sekonder entesopathy (with spondyloarthropathies) ANKYLOSING SPONDYLITIS Chronic systemic inflammatory disorder that mainly affects the axial skeleton Sacroiliitis is its hallmark Strong genetic predisposition with HLAB27 Primary; idiopathic 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 İmprovement with exersize Arthritis of hips, shoulders and entesopathies are common Limitation of spinal mobility Radiologic Findings Squaring of the vertebral bodies Bamboo spine Osteopenia Bilateral sacroiliitis Acute anterior uveitis as an extraarticular manifestation With psöriasis,chronic inflammatory bowel disease, reactive arthritis in some patients Good symptomatic response to NSAID Physıcal 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,especially Enthesopathic features;plantar fasciitis achilles,tendinitis Laboratory Findings HLA-B27 (90%) (should not be used as a routine screening procedure) ESR is frequently but not invariably elevated 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 In Turkey 1436 persons studied, all of them were males and in 2 of them AS found HLA-B 27 of these people are not studied The prevelance of AS was %0.14 In Canada this ratio was %6.20 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 Comparison Of Spondyloarthropathies AS Reiter PA Sex M>F M>F F>M Onset >20 >20 + ++ Any age + Uveitis Peripheral joints Intestinal A. F=M Any age + Lower Lower Upper lower> limb limb >lower upper often usually AS Sacroiliitis Plantar spurs HLA-B27 Enthesopathy Response to therapy urethritis Conjunctivities Skin inv Spine inv Symmetry Reiter PA always often often common commo common n 90% 90% 20% + + + +++ + ++ Intestinal artrit often ? 5% +? + + + +++ + + +++ + + + - + + - + + +
