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SPONDYLOARTHROPATHY

(SPONDYLOARTHRITIS)
DEFINITION
 Group of multisystem inflammatory disorders
affecting various joints,
 Psoriatic arthritis
 Enteropathic/Inflammatory bowel disease –
associated spondyloparthropathy
 Ankylosing spondylitis
 Reactive arthritis (including Reiter‟s syndrome)
 Juvenile-onset spondyloarthritis
 Undifferentiated spondyloarthropathy




COMMON FEATURES
 Axial spondyloarthritis
 low back pain (sacroilitis, spondylitis)
 Peripheral arthritis
 Pain and swelling in legs>arms
 Asymmetric, oligoarticular
 Seronegative rheumatoid factor
 Enthesitis (inflmmation at osseus insertion
sites of tendons and ligaments)
 Extra-articular features
 Mucocutaneous, uveitis
 Male predominance <40, familial clustering
 HLA-B27 association(>90%), absence
autoAb

I. AXIAL SPONDYLOARTHRITIS

2. PERIPHERAL ARTHRITIS
3. ENTHESITIS
 Dactylitis („sausage-like' digit)
 Tendonitis
 Fasciitis
 Spondylitis

Enthesitis is primary lesion in spondyloathropathy;
synovitis is main lesion in RA
4. EXTRA ARTICULAR FEATURE
 Uveitis


ANKYLOSING
SPONDYLITIS
I. ANKYLOSING SPONDYLITIS (AS)
 Also known as Marie-Strumpell disease or Bechterew‟s disease
 Chronic inflammatory disorder of axial skeleton affecting the SI
joint and the spine
 Hallmark : bilateral sacroilitis
 Most common spondyloarthropathy
 •Onset at 40 years or younger.
•Insidious in onset and present for at least 3 months.
•Morning stiffness is present and improves with exercise.
•Pain occurs at night.
•No improvement with rest.
ETIOPATHOGENESIS
SYMPTOMS






PE: SPINAL MOBILITY TEST
Modified Schober test
PE: SPINAL MOBILITY TEST
 occiput-to-wall distance
(tragus to wall test)
Stand with heels against wall,
ask patient to touch the back
of his head to the wall
Normal distance <10cm, no
gap in between
If >10cm or +ve gap, indicates
thoracic or cervical disease or
both
PE: MEASUREMENT OF CHEST EXPANSION
 useful in determining the degree of costovertebral
joint involvement.
 Ask the patient to put shoulders above the head and
perform full expiration and full inspiration. At 4
th

interspace in men/below the breast in women,
measure the expansion value.
 N >5cm, abN <5cm / 2.5cm less than N value
PE: LUMBAR SPINE MOBILITY
 Lumbar Spine Side Flexion
test
Heels against wall, hip width
apart, back against the wall,
fingers extending down on the
side. Measure distance from
fingers to floor. Then ask patient
to flex to the side with back
against the wall, re-measure and
note the difference.

PE: HIP MOBILITY
 Hip Abduction test
Knees straight, toes
pointing up, spread out the
legs as far as they can and
measure btw both malleoli
Normal = 120cm, ,120cm
indicates restriction
PE: CERVICAL MOBILITY
 Cervical Spine Rotation Test
Inclinometer is placed on forehead (to measure
degree of inclination) and ask the patient to turn
the head to left and right as far as they can
without moving the upper body.
Normal is approximately 90degree rotation.
LABORATORY FINDINGS
 Mild anemia (15%)
 ↑ ESR,CRP - often without a definite correlation with disease
activity (75%)
 ↑ALP
 ↑serum IgA
 -ve rheumatoid factor, anti CCP, ANA
 +ve HLA-B27

Screening for HLA-B27 in all patients with back pain is not useful
because more than 95% of these patients do not have a
spondyloarthropathy. In patients with inflammatory back pain or
sacroiliitis on plain radiographs, the addition of a positive HLA-B27
result increases the likelihood of a diagnosis of an axial
spondyloarthropathy. The diagnostic specificity of the HLA-B27 test
increases with an associated decrease of prevalence in the target
population
XRAY – (I) SACROILITIS
Sacroilitis grading can be achieved using plain films according to the New York
criteria
4
.
 grade 0 - normal
 grade I - some blurring of the joint margins - suspicious
 grade II - minimal sclerosis with some erosion
 grade III -
 definite sclerosis on both sides of joint
5

 severe erosions with widening of joint space (pseudowidening) with or without ankylosis
 grade IV - complete ankylosis


X-RAY – (II) SPONDYLITIS
Radiographic changes in the
spine occur initially in the
lumbar spine and gradually
ascend the spine, generally in
a continuous fashion.
 squaring of vertebral
bodies
 progression to erosions and
sclerosis of the anterior
corners of the vertebral
bodies (“shiny corners”)
 ossification of the anulus
fibrosus (syndesmophyte
formation)
 over many years, spinal
fusion (“bamboo spine)
(I) SQUARING OF VERTERBRAL BODIES
In lumbar spine, progression of disease leads to
 Straightening (caused by loss of lordosis)
 Reactive sclerosis (caused by osteitis of anterior corners of the vertebral
bodies )
 With subsequent erosion, leading to “squaring” of vertebral bodies (loss
of normal concavity of anterior border)
(II) SHINY CORNERS (ROMANUS LESIONS)
 Inflammation at the site of insertion of the annulus fibrosus resulted in
osteitis (progression to erosions and sclerosis of the anterior corners of
the vertebral bodies)
(III)SYNDESMOPHYTE FORMATION
 Progressive ossification leads to formation of marginal
syndesmophyte, visible as bony bridges connecting successive
vertebral bodies anteriorly and laterally
(III) SYNDESMOPHYTE FORMATION
(IV) BAMBOO SPINE
 Complete fusion results in a complete rigidity of the
spine, a condition known as bamboo spine.
DYNAMIC MRI WITH FAT SATURATION
 > Short-tau inversion recovery (STIR) sequence
 > T1-weighted images with contrast enhancement
 Can detect abN at earlier stages
 Highly sensitive and specific for identifying early intra-articular inflammation, cartilage
changes and u/l bone edema in sacroilitis
 The Berlin MRI spine score14 15 is a modification of the ankylosing spondylitis spine MRI-
activity (ASspiMRI-a) scoring system for active inflammatory lesions of the spine

MODIFIED NEW YORK CRITERIA 1984

ASSESSMENT OF SPONDYLOARTHRITIS
INTERNATIONAL SOCIETY (ASAS)


BATH ANKYLOSING SPONDYLITIS DISEASE
ACTIVITY INDEX (BASDAI)
 Scores ≥4 : suboptimal control of disease (good candidates for either a
change in their medical therapy or for enrollment in clinical trials
evaluating new drug therapies directed at Ankylosing Spondylitis.
ANKYLOSING SPONDYLITIS DISEASE ACTIVITY
SCORE (ASDAS)

TREATMENT
EXERCISE PROGRAM

NSAID
 Effective for reducing symptoms
 Have disease-controlling property
ANTI-TNF
 Anti-TNFα – if pt refratory to physical therapy
and other interventions
infliximab (Remicade), IV infusion every 2-6-8
weeks at a dose of 5 mg/kg;
etanercept (Enbrel), SC injection of 50 mg once
weekly
adalimumab (Humira), SC injection of 40 mg
biweekly
golimumab (Simponi), SC injection of 50 mg
once a month

SIDE EFFECTS OF ANTI-TNF
 Serious infection (Disseminated TB)
 Hematologic disorder (pancytopenia)
 Demyelinating disorders
 Exacerbation of congestive heart failure
 SLE-related autoAb and C/M
 Hypersensitivity infusion or injection site reactions
 Severe liver disease
Use is restricted for patients with definitive diagnosis
and active dx (BASDAI ≥4) that is inadequately
responsive to 2 different NSAID

CONVENTIONAL DMARD
 Conventional DMARD which plays a
dominant role in RA tx has no proven efficary
for axial AS, but a limited efficacy for
peripheral manifestation
 - sulfasalazine: 2g/d for 4mths (for peripheral
manifestation)
 - methotrexate: trials reveal no superiority
over placebo

PSORIATIC
ARTHRITIS
PSORIATIC ARTHRITIS
 Inflammatory arthritis that occurs in
individuals with psoriasis
 Affects male and female equally
 Peak age at diagnosis: 20-40
 Dermatological features of psoriasis
precede arthritis in 90%

 There is a strong association with
nail involvement, particularly for DIP
joint arthritis.

I. SKIN LESIONS

II. NAIL LESIONS
 Pitting nail
 Horizontal ridging
 Onycholysis
 Yellowish discoloration of nail margins
 Dystrophic hyperkeratosis

III. ARTHRITIS
 The patterns are not fixed and the patterns
that persist chronically often differs from that
of initial presentation.
 Recent use of simpler scheme:
 1) oligoarthritis
 2) polyarthritis
 3) axial athritis

WRIGHT AND MOLL
CLASSIFICATION
 ASYMMETRIC
OLIGOARTHRITIS (70-80%)
 Generally mild and most common
 Involves a knee or a large joint with
few small joints
 SYMMETRIC POLYARTHRITIS
(5-20%)
 Ddx with RA, is typically milder,
less tender and with less cases of
deformity
 DIP PREDOMINANT (10%)
 Ddx with OA, this type usually
affects distal interphalangeal joint
 SPONDYLITIS (5-20%)
 Ddx with AS, more neck
involvement, less thoracolumbar,
nail changes
 ARTHRITIS MUTILANS (<5%)
 Widespread shortening of digits
“telescoping”, with ankylosis and
contractures in other digits

SYMMETRIC POLYARTHRITS

DIP PREDOMINANT

ARTHRITIS MUTILANS

XRAY
 Peripheral joint features:
 Large eccentric erosions
 Tuft resorption
 Destructive changes
 “Pencil-in-cup” deformities in DIP
(arthritis mutilans)
 Proliferative changes
 Fluffy periostitis,“wkiskering”
(periosteal bone formation)
 Ivory phalanx
(endosteal bone formation)
 Bony ankylosis and joint fusion
 Spinal changes (ddx AS)
 “chunky syndesmophyte” (paravertebral
ossification)


marginal bone erosions with adjacent
irregular bone proliferation
PENCIL-IN-CUP DEFORMITY
The deformity occurs in arthritis
mutilans due to marked osteolysis
- “pencilling”(distal head of a bone
becomes pointed)
- adjacent joint surface becomes
cup-like
FLUFFY PERIOSTITIS, “WHISKERING”
IVORY PHALANX
 Increased density throughout the osseous structures due to
sclerosis of an entire phalanx, typically the great toe, is likely the
result of bony proliferation as an exaggerated healing response
to injured bone
• Narrowed joint space (*)
• Subchondral cyst (Arrowhead)
• Marginal erosions (thin arrow)
• New periosteal bone formation (thick arrow)
• Endosteal bone formation (ivory phalanx)

SPINAL CHANGES
 Sacroilitis
 Asymmetric

 Spondylitis
 > cervical spine,
 < lumbar spine
 “chunky syndesmophyte”
 Comma-shaped paravertebral
ossification

DDX
 General imaging differential considerations include
 rheumatoid arthritis
 there is a MCP joint predominance in rheumatoid arthritis(RA) vs
interphalangeal predominant distribution in PsA
 bone proliferation not a feature in RA
 Osteoporosis not a feature in PsA
 erosive osteoarthritis
 “gull wing” central erosions are present in erosive OA vs “mouse
ears” peripheral bare area erosions in PsA
 Heberden nodes are usually not inflammatory
 reactive arthritis (Reiter syndrome)
 tends to involve feet > hands
 Gout
 Often involves other sites and is accompanied by tophi

1. DDX WITH RA

2. DDX WITH OA
 A and B. Mouse Ears.(Pso)
 Note the combination of erosions
and fluffy periostitis produces the
mouse ears appearance in
psoriasis.

 C and D. Gull Wings.(OA)
 Observe that the biconcave
articular contour produces the
gull wings appearance of erosive
osteoarthritis.
3. DDX AS (ANKYLOSING SPONDYLITIS)

ASSESMENT

TREATMENT
Mild joint dx
- NSAIDS
- Intra-articular
steroids
Moderate-severe
- Systemic oral
DMARDs
- Biologics
REACTIVE ARTHRITIS
II. REACTIVE ARTHRITIS (RE-A)
 Can‟t SEE, can‟t PEE, can‟t climb TREES
 Reiter‟s syndrome:
Conjunctivitis
Urethritis
Postinfectious arthritis
 Predilection for the lower extremity
 Soft Tissue swelling
 Osteoporosis
 Uniform loss of joint space
 Marginal erosions
 Periostitis >>
 Deformity
ENTEROPATHIC ARTHRITIS
III. ENTEROPATHIC ARTHRITIS (EA)

Bilateral and symmetric bone erosions, bone sclerosis,
and widening of sacroiliac joints
 Hyperparathyroidism
Bilateral and symmetric bone sclerosis and irregularity of sacroiliac
joints (arrow). Note marked widening of sacroiliac joints and renal
dialysis catheter.
UNDIFFERENTIATED AND
JUVENILE ONSET SPA

IV. JUVENILE ONSET SPONDYLOARTHROPATHY
Composite images of ankylosing tarsitis in a
second patient, a 16-year-old boy with 9 years'
disease duration and complete ankylosis of the
tarsal bones and grade 2 bilateral sacroiliitis.
(A) Flat foot and swelling around the ankle.
(B) Complete ankylosis of the tarsal bones
and enthesophytes at the plantar fascia
attachment.
(C) T
2
-weighted fat-saturation MRI showing
edema (white spots) in several tarsal
bones, joint spaces, and surrounding fat.
(D) Posterior and
(E) coronal views showing the same changes
in the bones and joint spaces seen in (C),
but also demonstrating distorted
architecture of the tarsus and, notably,
edema around the tendons.
UNDIFFERENTIATED SPNDYLOARTHROPATHY
 The term “undifferentiated spondyloarthropathy” is used to
describe manifestations of a spondyloarthropathy in patients who
do not meet criteria for any of the well-defined
spondyloarthropathies.
 Over time, a small proportion of these patients develop a well-
defined spondyloarthropathy.
 However, most patients have less specific symptoms, including
inflammatory back pain, unilateral or alternating buttock pain,
enthesitis, dactylitis and, occasionally, extra-articular
manifestations.
 Patients with undifferentiated spondyloarthropathy generally have
a good prognosis and often respond well to NSAID therapy.
 Treatment of patients with more severe disease is similar to that
for ankylosing spondylitis.

SAPHO SYNDROME
SAPHO SYNDROME
 Syndrome of synovitis, acne, pustulosis,
hyperostosis and osteitis (SAPHO) is characterized
by a variety of skin and musculoskeletal
manifestations.
 ESR is usually elevated, sometimes dramatically
 Bacteria culture: >Proprionibacterium acnes
 Coexistence of IBD in 8% patients
 B27 only +ve in minority patients
 Diagnostic test: bone scan or CT scan
 High does NSAID relieves bone pain.

DERMATOLOGICAL MANIFESTATION
 Palmoplantar pustulosis
 Acne conglobata
 Acene fulminans
 Hidradenitis suppurativa
MUSCULOSKELETAL MANIFESTATION
 Sternoclavicular and spinal hyperostosis
 Chronic recurrent foci of sterile osteomyelitis
 Axial or peripheral arthritis
WHIPPLE’S DISEASE
WHIPPLE’S DISEASE


Clinical examination of rheumatic disease patient
http://www.arthritis.co.za/the%20clinical%20examinatio
n%20technique.html
AS objective tests http://www.youtube.com/watch?v=c-
IeFZkPEoE&list=PLB376ABEAA66A984D
Xrays collection of SpA,RA, OA
http://pubs.rsna.org/doi/full/10.1148/radiol.2482062110
Can‟t miss signs in rheumatologic dx
http://reference.medscape.com/features/slideshow/dise
ases-plain-radiography#20