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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%
+?
+
+
+
+++
+
+
+++
+
+
+
-
+
+
-
+
+
+