The Spondylarthropathies

Paul Baillie

Birmingham

Contents

• What are they?• Common Features• Classification Criteria• Details of each one

What are they?• Inflammatory arthropathies• HLA B27 association• Enthesis and Synovial involvement

– Ankylosing Spondylitis (AS)– Juvenile AS– Psoriatic Arthropathy– Sacroilitis– Reiter’s Syndrome (Reactive)– Enteropathic Arthritis

Common Features• Association with HLA B27• Seronegativity (Lack of association with RhF)• Sacroiliitis • Enthesitis

– Plantar Fasciitis – Achilles Tendonitis

• Eye Inflammation – Conjunctivitis, Uveitis• Osteitis• Dactylitis• Mucocutaneous lesions

– Mouth ulcers– Keratoderma Blenorrhagica

Classification Criteria• European

Spondylarthropathy Study group (ESSG) Criteria

• Inflammatory Spinal Pain or Synovitis

• Plus 1 more of…– Alternate Buttock Pain– Sacroiliitis– Enthesopathy– Positive Family Hx– Psoriasis– IBD– Urethritis / Cerviitis /

Diarrhoea

• AMOR criteria• Need a score of 6 or more

– Lumbar or dorsal pain or stiffness

– Assymetric Oligoarthritis – Buttock Pain – Alternate Buttock Pain– Sausage like toe or digit– Heel or enthesopathic pain– Iritis– Nongonococcal Urethritis /

Cervicitis– Acute Diarrhoea within 1 month– Psoriasis / Balanitis / IBD– Sacroiliitis on radiology– HLA B27 or Family Hx– Prompt response to NSAIDS

Ankylosing Spondylitis

• Chronic Inflammatory disease of the spine and sacroiliac joints

• Young Men• HLA B27! – 97%• Typical Patient

Spinal Movement• Syndesmophytes

– Bony proliferations due to enthesitis between ligaments and vertebrae

– These can fuse together causing ankylosisLoss of spinal movementsDecreased Thoracic Expansion

• In a few this progresses to kyphosis, neck hyperextension (question mark posture) and spino-cranial ankylosis

• In later stages, calcification of ligaments with leads to a BAMBOO SPINE appearance

Extra-articular Manifestations of AS

• Peripheral Assymetrical Arthritis• Enthesopathy – heel, tibial and ischial tuberosity• Acute Anterior Uveitis (Iritis)

– 1/3 pts!– Can cause blindness!

• Colitis• Aortitis & Aortic Regurge• Pulmonary Apical Fibrosis (rare)• Secondary Amyloidosis

Iritis with Synechia

New York Criteria for Diagnosing AS

Definite ankylosing spondylitis if the radiological criterion is present plus at least one clinical criterion.Probable ankylosing spondylitis if three clinical criteria are present alone, or if the radiological criterion is present but no clinical criteria are present.

Clinical Criteria:1. Limited lumbar motion (all directions)2. Low back pain for >3months, improved

with exercise but not with rest1. Reduced chest expansion (for age and sex)

X-ray – either…Bilateral Grade 2-4 SacroiliitisUnilateral Grade 3-4 Sacroiliitis

X-ray Grade

0 Normal

1 Suspicious

2 Minimal change small areas of erosion / sclerosis

3 Definite. Moderate to advanced sacroiliitis

4 Total Ankylosis (fusion)

Schober’s Test

Dimples of Venus

Investigative Findings in AS

• Raised ESR & CRP• Elevated IgA• Normocytic Anaemia• Elevated Alk Phos

(increased bone turnover)

Treatment of AS• Non-Pharmalogical

– Physio – Intense Exercise Regime– OT– Hydrotherapy

• Pharmacological– NSAID– DMARD

• Steroid Sparing Agents• Methotrexate• Anti-TNF

– Corticosteroid

• Surgery– Hip Replacement– Spinal Osteotomy (rare)

Psoriatic Arthritis

• 10-40% of those with Psoriasis• Can present before skin changes

• Patterns of arthritis1. Symmetrical Polyarthritis2. DIP joints3. Assymetrical Oligoarthritis4. Spinal (AS-like)5. Psoriatic Mutilans

X ray in Psoriatic A.

• Erosive Changes

• Pencil in Cupdeformity(severe)

Treatment of Psoriatic Arthritis• Non-pharmacological

– OT– Physio– Hydrotherapy– Orthodontist

• Pharmacological– NSAIDs– DMARDs

• SSA, Methotrexate, Cy A, Gold, Penecillamine– Corticosteroids– Biological Agents

Reactive Arthritis(Reiter’s Syndrome)

• Inflammatory arthritis developing a few weeks after a gut or GU infection.

• It is a sterile arthritis typically affecting the lower limb.• It may be chronic or relapsing

• OrganismsGU

-Chlamydia

-Neisseria

Gut

-Salmonella

-Shigella

-Yersinia

-Campylobacter

Extra-articular manifestations of Reiter’s Syndrome

• Inflammatory Eye Disease (Iritis)• Keratoderma Blenorhagica• Circinate Balanitis• Apthous Ulcers• Enthesitis• Aortic Incompetance

Classic Triad

• Can’t see, Can’t pee and Can’t climb a tree

Conjunctivitis – Urethritis - Arthritis

Investigations for Reiter’s

• Xray may show– Enthestis with periosteal reaction

• Raised ESR and CRP • Culture Stool sample (diarrhoea)• Serum Serology

Treatment for Reiter’s• Generally self-limitingSymptomatic relief

– Rest– Splint affected joints?– NSAIDs or local steroid injections

• DMARDS (rarely)– Sulfasalazine– Methotrexate

• NB – treating the original infection may make little or no difference to the arthritis

Enteropathic Arthritis

• Arthritis with Ulcerative Colitis or Crohn’s Disease

• 20% with IBD get Peripheral Arthritis

• 10% with IBD get spondylitis

Spondylarthropathies Summary• HLA B27

• Common Symptoms– Enthesitis– Iritis– Spondylitis

• Includes:– Ankylosing Spondylitis (AS)– Juvenile AS– Psoriatic Arthropathy– Sacroilitis– Reiter’s Syndrome (Reactive)– Enteropathic Arthritis