Used to refer to a family of diseases that share certain clinical features which are inflammation of axial joints , asymmetric oligoarthritis, and enthesitis , eye and bowel inflammation. a strong association with the human leukocyte antigen (HLA) B27.
The SpA family consists of the following disorders: • Ankylosing spondylitis • SpA associated with psoriasis or psoriatic arthritis • Undifferentiated spondyloarthritis (USpA) • Reactive arthritis. • SpA associated with Crohns disease and ulcerative colitis • Juvenile onset spondyloarthritis
The prevalence of SpA in a Caucasian population is approximately 0.5% - 2%. Ankylosing spondylitis and USpA are the most frequent types of SpA. Much less frequent is reactive arthritis
CLINICAL MANIFESTATIONS Musculoskeletal featuresInflammatory back pain, peripheral arthritis, enthesitis, and dactylitis.1. Inflammatory back pain — Back pain is the most common symptom, being present in about 70% of patients. Onset before the age of 40 years. Insidious onset. Improvement with exercise. No improvement with rest.
Peripheral arthritis —The peripheral arthritis in SpA usually has an acute onset.predominantly involves the lower extremities, especially the knees and ankles.Arthritis is typically asymmetrical
EnthesitisThe enthesis is the site of insertion of ligaments, tendons, joint capsule, to bone. Enthesitis which refers to inflammation around the enthesis. They are usually associated with swelling,severe pain and tenderness.
Dactylitis (sausage digits) Also known sausage toe or sausage finger. Dactylitis is not specific for SpA. It is also seen in the digits which are involved with tuberculosis, syphilis, sarcoidosis and sickle cell disease
Inflammatory eye disease Conjunctivitis-The symptoms subside within a few weeks. Anterior uveitis-The initial attack is usually acute and unilateral. Patients complain of redness, pain, and photophobia.
Is a chronic inflammatory disease of the axial skeleton manifested by back pain and progressive stiffness of the spine. It affects young adults with a peak age of onset between 20 and 30 years. Male to female prevalance is 3:1
CLINICAL FEATURES back pain Buttock pain Limited spinal mobility and chest expansion Hip pain Shoulder pain Peripheral arthritis
TMJ involvement Enthesitis Constitutional features — may have fatigue and Fever Acute anterior uveitisAtlantoaxial-axial subluxation —It can lead to spinal cord compression. Cauda equina syndrome — Is a rare complication
Pulmonary disease Patients have restriction in chest expansion due to costovertebral rigidity. Apical pulmonary fibrosis.Renal disease Analgesic abuse nephropathy. IgA nephropathy . It is uncommon. Secondary amyloidosis is also can affect the kidneys
CLASSIFICATION CRITERIA —The criteria consists of a subset of clinical parameters and a subset of radiological parameters:Clinical parameters • Low back pain and stiffness for more than three months that improves with exercise, but is not relieved by rest • Limitation of motion of the lumbar spine in both the sagittal and frontal planes • Limitation of chest expansion relative to normal values correlated for age and sexRadiological parameters • Sacroiliitis grade >2 bilaterally • Sacroiliitis grade 3 to 4 unilaterally A patient is regarded as having definite AS if he or she fulfills at lest one radiological parameter plus at least one clinical parameter.
History . Physical examination —Reduced range of motion of the low back —modified Schober test• With the patient standing erect, the position of the 5th lumbar spinous process is marked by a pen; additional marks are made 10 cm above and 5 cm below in the midline.• The patient bends forward maximally and the distance between the upper and lower marks is measured.People with normal spinal mobility have an increase in the measured distance of 5 cm.
Occiput to wall distance — Increasing occiput to wall distance is associated with loss of lumbar and cervical lordosis and increasing thoracic spinal kyphosis.
Chest expansion Chest expansion is measured at the level of the 4th intercostal space. The expansion is usually 5 cm or more. An expansion of less than 2.5 cm is abnormal.Sacroiliac joint tendernessPatients with pain in the region of the sacroiliac joints may have tenderness, elicited by direct pressure over the sacroiliac joint
Laboratory testing Acute phase reactants — CRP & ESR are elevated HLA-B27 testing —Among Caucasians, HLA-B27 is present in 95% those with AS.HLA-B27 is present in about 8 percent of this population.
ImagingAn abnormal appearance of sacroiliac (SI) joint on plain radiographs is a hallmark of longstanding AS.The changes are widening, erosions, sclerosis, or ankylosis of the SI jointsMRI of the pelvis is the most sensitive and specific evaluation for sacroiliitis .
Imaging of the spine Squaring of the vertebral bodies due to anterior and posterior spondylitis is an early sign of spinal involvement due to AS
Late stages of AS are associated with bridging syndesmophytes, ankylosis of the facet joints, calcification of the anterior longitudinal ligament and anterior atlantoaxial (C1-C2) subluxation.
GOALS OF THERAPY : • Symptomatic relief — To reduce the symptoms such as pain and stiffness. Restore function — To return the patient to the best possible functional capacity. Prevent joint damage Prevent spinal fusion & complications Minimize extraspinal and extraarticular manifestations.
PHYSICAL THERAPY AND EXERCISE Home-based or supervised group and individual exercise programs can help to maintain the function and relief of symptoms. An initial evaluation and training by a physio- therapist should be part of the therapeutic regimen.
PHARMACOLOGIC THERAPY Nonsteroidal antiinflammatory drugsUnless contraindicated, NSAIDs should be the first line of treatment for all symptomatic AS patients. SulfasalazinePrior to the discovery of anti-TNF therapies in AS, the only disease-modifying agent that had been demonstrated to be useful in AS.
Tumor necrosis factor alpha antagonistsEg - etanercept, infliximab, adalimumab. Approximately 80 percent of patients with AS respond to treatment with one of these agents. Improvement noted in-• Patient assessment of pain• A functional assessment,• Degree of inflammation as assessed by morning stiffness
Predictors of response The following parameters are predictors of a good response to TNF antagonists.• Younger age• Shorter disease duration• Good functional ability• Elevated ESR and CRP• Presence of HLA-B27
Methotrexate Some studies have suggested that methotrexate may be effective in some patients with AS. Currently a lack of evidence to support the use of methotrexate in the treatment of AS.
Glucocorticoids systemic glucocorticoids on a long-term basis for patients with AS is not recommended. Injection of a long-acting corticosteroid into the sacroiliac joints may be beneficial in patients with marked pain at the sacroiliac joints
Psoriatic arthritis is an inflammatory arthritis associated with psoriasis. Psoriatic arthritis (PsA) affects women and men equally.
CLASSIFICATION CRITERIA — following criteria be used to classify a patient has having psoriatic arthritis: • Presence of musculoskeletal inflammation (an inflammatory arthritis, enthesitis, or back pain); PLUS three points from the following:• Skin psoriasis (present) - 2 points previously present by history- 1 point A family history of psoriasis- 1 point• Nail lesions (onycholysis, pitting) - 1 point• Dactylitis (present or past, documented by a rheumatologist) – 1point• Negative rheumatoid factor - 1point• Juxtaarticular bone formation on radiographs - 1 point
Patterns of arthritis• Distal arthritis, characterized by involvement of the distal interphalangeal (DIP) joints.• Asymmetric oligoarthritis in which less than five small or large joints• Symmetric polyarthritis, similar to rheumatoid arthritis.• Arthritis mutilans, characterized by deforming and destructive arthritis.• Spondyloarthritis
Dactilitis Enthesitis Nail lesions — include nail pits, onycholysis, nailbed hyperkeratosis, and splinter hemorrhages. Ocular involvement — Uveitis.
Radiologic changes Typical radiological changes include lysis of the terminal phalanges, fluffy periostitis and new bone formation at the site of enthesitis, gross destruction of isolated joints.
The approach to the treatment of PsA includes therapy for both skin and joint disease. Non steroidal anti inflamatory drugs. Methotrexate — only limited observational data showing efficacy in PsA
Leflunomide Promising results with leflunomide were noted in an uncontrolled trial. Leflunomide is also effective in controlling skin disease.TNF inhibitors Clinical trials have proven the efficacy of TNF inhibition in psoriatic arthritis
Refers to patients who do not meet established criteria for ankylosing spondylitis, reactive arthritis, psoriatic arthritis, or SpA related to inflammatory bowel disorders. major clinical feature is back pain Most patients with USpA are young men. positive for HLA-B27 .
A substantial proportion of patients will evolve into a more specifically classifiable subset such as AS or Psa. With a longer period of observation, a greater proportion may progress to definite ankylosing spondylitis