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

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

Copyright ©2006 BMJ Publishing Group Ltd. Zochling, J et al. Ann Rheum Dis 2006;65:

Back stretches

Chest expansion

Upper back and shoulder stretch

Hip and back stretches

Comparison of Spondyloarthropathies ASReiter PA Intestinal A. Sex M>FM>FM>FM>FF>MF>MF=M Onset >20 Any age Uveitis Peripheral joints Lower limb often Lower limb usually Upper>l ower lower> upper

ASReiter PAIntestinal artrit Sacroiliitisalwaysoften Plantar spurs common ? HLA-B27 90% 20% 5% Enthesopathy ? Response to therapy Urethritis Conjunctivities Skin inv Spine inv Symmetry