This document provides an overview of spondyloarthritis (SpA), a group of disorders that share features of inflammation of the axial skeleton and peripheral joints. Key points include: - Major features are inflammation of the sacroiliac joints and spine, as well as peripheral arthritis, enthesitis, and dactylitis. - Associated features can include eye, bowel, skin and genital inflammation. There is also an association with HLA-B27 and inflammatory bowel disease. - Imaging plays an important role, as plain radiographs may be initially normal but can show sacroiliitis over time. MRI is more sensitive for detecting early sacroiliitis and spinal changes. - While

1. SPONDYLOARTHRITIS
Su Yin MD
RHEUMATOLOGY

2. INTRODUCTION
• a family of disorders that share certain clinical features:
• most distinguishing features are inflammation of axial joints (especially the sacroiliac [SI]
joints)
• asymmetric oligoarthritis (especially of the lower extremities)
• dactylitis (sausage digits)
• enthesitis (inflammation at sites of ligamentous or tendon attachment to bone)
• Additional features:
• skin and genital lesions
• eye and bowel inflammation
• an association with preceding or ongoing infectious disorders
• positive family history
• elevated acute phase reactants
• a strong association with the human leukocyte antigen (HLA)-B27
• Forms of spondyloarthritis
• Ankylosing spondylitis (AS)
• Non-radiographic axial SpA (nr-axSpA)
• Peripheral SpA
• SpA associated with psoriasis or psoriatic arthritis
• SpA associated with Crohn disease and ulcerative colitis
• Reactive arthritis
• Juvenile-onset SpA
Keratoderma Blenorrhagicum
Circinate
Balinitis
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3. Case:
G.N. is a 55 year old man on ustekinumab for psoriasis referred to
rheumatology clinic for neck stiffness with concern of ankylosing spondylitis.
Patient previously attributed his neck and back pains/stiffness to his prior
injuries including neck/head impact from a fall at 10 years old and whiplash
with MVA in late 20s. Upon further questioning, didn’t really have any
significant spine symptoms between 10 to 20 years old. Since his 20s into his
early 30s, he did note progressive stiffness in his back and neck with
decreasing ROM. Stiffness initially improved with exertion and worsened with
rest.
He also developed psoriasis at age 21 and has been treated by dermatology
since then. Was on etanercept then switched to adalimumab without benefit
so back to etanercept which eventually lost efficacy so most recently has been
on ustekinumab for the past year along with light therapy.
Since his switch to ustekinumab, he notes more neck stiffness as well as
buttock pain with prolonged sitting.

4. Case continued:
Colonoscopy in 2013 showed mild Crohn’s in his ileum.
He has also been having uveitis seen by ophthalmology treated with steroid
eye drops.
Denies history of dactylitis or enthesitis.
PMH:
ASTHAM
Hepatitis C – negative PCR (hepatitis B core Ab+)
Psoriasis
Mild Crohn’s
Uveitis
FH: noncontributory
SH: occasional beer, former smoker, chews tobacco, previous drug use

5. Major musculoskeletal features
• Low back pain/inflammatory back pain
• chronic low back pain - more than 3 months’ duration
• Most cases onset is before age 45.
• inflammatory back pain is present in 70 to 80% with axial SpA.
• insidious onset
• most often before the age of 40 years
• improvement with exercise but not with rest; and pain at night.
• also observed in 20 to 25 % of back pain from other causes so
only a minority of individuals with symptoms of inflammatory
back pain will have SpA, and the lack of typical features of
inflammatory back pain does not always exclude axial SpA in a
chronic back pain patient
• In some axial SpA, a good response to treatment with a NSAID is an
additonal feature. Patients with back pain of any causes may improve
with an NSAID, but marked improvement in pain within 24 to 48 hours
is more typical of SpA.
HISTORY - CLINICAL MANIFESTATIONS

6. Clinical manifestations
• Peripheral arthritis
• acute onset
• often predominantly involves the lower extremities, especially the knees and ankles;
and is with swelling.
• frequently asymmetrical and often affects only one to three joints.
• severity ranges from mild to disabling.
• When compared with other rheumatic diseases, the sensitivity and specificity of
asymmetric oligoarthritis for SpA are 41 and 87%, respectively, so, the presence of
asymmetrical oligoarthritis is very suggestive of SpA, but absence not be helpful in
excluding this possibility.
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7. CLINICAL MANIFESTATIONS
• Enthesitis (enthesopathy)
• inflammation around the enthesis, which is the site of insertion of ligaments, tendons,
joint capsule, or fascia to bone, and is relatively specific to SpA.
• The most common observable enthesitis is swelling at the heels, at the insertion of the
Achilles tendon, or at the insertion of the plantar fascia ligament into the calcaneus.
Usually associated with severe pain and tenderness. During physical examination, the
patient with plantar fasciitis may have difficulty walking on the heels when barefoot.
Swelling at the side of the Achilles tendon can be appreciated when the patient is
observed in the standing position from behind. On palpation, there is tenderness at the
sites of insertion of the Achilles tendon and/or of the plantar fascia on the calcaneus.
• Other sites of enthesitis which are not swollen but which can be painful and/or tender
include those at the iliac crests, greater trochanters, epicondyles at the elbows, tibial
plateaus, costochondral junctions at the sternum, humeral tuberosities, manubrial-
sternal joints, occiput, and spinous processes.
https://www.aad.org/mobile-psoriasis/images/cs-
topical-psoriatic-b.png

8. CLINICAL MANIFESTATIONS
• Dactylitis (sausage digits)
• Characteristic feature of SpA, especially psoriatic arthritis and occasionally reactive
arthritis
• Not specific for SpA and may also be seen when digits are involved with
tuberculosis, syphilis, sarcoidosis, sickle cell disease, and tophaceous gout.
• also known sausage toe or sausage finger.
• Unlike synovitis, where the swelling is confined to the joints, the entire digit is
swollen.
• Joints do not show the discrete palpable fusiform swelling of synovitis, and there
may be surprisingly little pain or tenderness.
• Other musculoskeletal features
• Additional musculoskeletal features often seen in patients with SpA include anterior
chest wall or rib cage pain. These are relatively nonspecific.
• More specific for axial SpA is pain that alternates between the left and the right
gluteal regions.
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9. CLINICAL
MANIFESTATIONS
Major non-musculoskeletal features —
• Inflammatory eye disease
• Several forms of ocular inflammatory disease can be associated with SpA, including
conjunctivitis and anterior uveitis.
• Conjunctivitis is typically non-purulent and transient, with symptoms subsiding within a few
weeks.
• more serious is anterior uveitis (iritis). The initial attack is usually acute and unilateral and may
be the presenting problem. There can be redness, pain, and photophobia. Uveitis may be the
first problem to require medical evaluation and should raise suspicion of SpA. About 50% of
patients with acute recurrent unilateral anterior uveitis have a form of SpA. Although ocular
inflammation usually responds to topical therapy, 10% can become chronic and threaten
permanent impairment of vision.
• An accurate diagnosis of uveitis requires slit-lamp examination by an ophthalmologist or other
expert in uveitis. Episodes of uveitis do not necessarily parallel the course of arthritis.

10. CLINICAL MANIFESTATIONS
• Inflammation of the bowel mucosa – SpA is associated with the presence of
inflammatory bowel disease.
• In a systematic review, the pooled prevalence of inflammatory bowel disease
among patients with ankylosing spondylitis (AS) was 6.8%.
• Conversely, musculoskeletal symptoms are the most common extraintestinal
symptoms in patients with inflammatory bowel disease.

11. CLINICAL MANIFESTATIONS
• Psoriasis – Psoriasis is associated with all forms of SpA.
• Psoriasis is present in up to approximately 10 percent of patients with AS.
• In patients with AS, it was found that peripheral joint involvement is more frequently
seen with concomitant psoriasis, and the disease course may be more severe than in
patients without psoriasis.
• May be inverse psoriasis in skin folds or perineal areas.
• PsA may occur in about up to 30% of pts with psoriasis. May occur at some time as
onset of psoriasis, but rarely may precede skin disease.
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ythrodermic-psoriasis.jpg
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12. CASE - PHYSICAL EXAM
VITAL SIGNS
Ht: 179 cm
Wt: 87.4 kg
BMI: 27.28
BP: 138/68
PHYSICAL EXAM:
GENERAL: wdwn overwt wm, nad, aaox3
HEENT: Pupils equal, round, and reactive to light. Extraocular motions are intact with no nystagmus.
No exophthalmos.
Oropharynx: mmm, w/o ulcers.
NECK: decreased ROM all planes. Thyroid non-nodular, not enlarged.
NODES: No cervical lymphadenopathy.
HEART: Normal S1, S2. Regular rate and rhythm. No audible murmur, gallop or rub. LUNGS: Clear to
auscultation bilaterally.
ABDOMEN: Soft.
EXTREMITIES: Normal muscular development. No cyanosis, clubbing, or pitting edema.
MSK: occiput to wall 10cm, lateral bend 4cm, Schober’s 11.5cm, o/w no synovitis/swelling/ttp in joints
of the RUE/RLE/LUE/LLE and spine.
NEUROLOGIC: CN II-XII grossly intact. Gait is normal.
Mental status is normal.
PSYCH: normal affect
SKIN: erythematous papules scattered B hands, more scaly plaques BLE, o/w No suspicious lesions in
visualized areas.

13. SPINE EXAM
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14. https://image.slidesharecdn.com/ankylosingspondylitis-161213091109/95/ankylosing-spondylitis-ben-22-638.jpg?cb=1481620441

15. https://image.slidesharecdn.com/ankylosingspondylitisrelease-151110020933-lva1-app6892/95/ankylosing-spondylitis-self-study-materials-for-medical-students-40-
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16. CASE - DATA
LABS:
+HLA B27 otherwise unremarkable
Colonoscopy biopsy pathology from 2013
Final Diagnosis
1. TERMINAL ILEUM, BIOPSY:
A. Small intestinal mucosa with patchy moderate active ileitis with
ulceration.
B. No granulomas are seen.
C. AFB stain for mycobacteria is negative.
2. CECUM, BIOPSY: A. Colonic mucosa, within normal limits. B. No
granulomas are seen. C. AFB stain for mycobacteria is negative.

17. CASE IMAGING

21. LABORATORY FINDINGS
• There are no lab findings that are absolutely specific for SpA. Most
commonly abnormal labs are HLA-B27 and elevated acute phase reactants,
and, in reactive arthritis, those associated with the preceding infections.
• HLA-B27 – In most ethnic groups, more than 90% of patients with AS and
50 to 70 % of patients with other forms of SpA are positive for HLA-B27.
HLA-B27 testing is frequently obtained in patients suspected of SpA;
however, a positive HLA-B27 by itself is not diagnostic of SpA, since a
significant proportion of subjects in the general population are also positive.
The diagnosis of axial SpA should be doubted if both HLA-B27 and imaging
(including MRI) for sacroiliitis are negative.
• Acute phase response – Acute phase responses, including the ESR and
levels of CRP, are increased in between 35 and 50% of patients with axial
SpA. Elevated levels of CRP are also a predictor of radiographic progression
and for a good response to tumor necrosis factor (TNF)-blocker therapy.

22. IMAGING
• Several characteristic imaging findings that may be seen in SpA.
• Plain radiographs —
• Normal radiographs in early disease
• Plain radiographs of the spine, involved peripheral joints, and entheses may
demonstrate abnormalities in longstanding SpA though enthesopathy not specific
for SpA.
• Axial radiographs —
• The only plain radiographic findings that are specific for SpA are those of
sacroiliitis.
• May take several years from the onset of disease before radiographic sacroiliitis
becomes apparent.
• In less than 5% of AS patients, AS-typical syndesmophytes, ossification originating
from the intervertebral ligaments that may bridge the vertebral bodies, may be
found in the spine in the absence of radiographic sacroiliitis.
• At least 50% of patients with AS develop syndesmophytes of the spine in the
course of their disease. These syndesmophytes have a typical appearance and are
easily differentiated from degenerative spinal osteophytes.

23. IMAGING
• Plain radiographs of the sacroiliac (SI)
joints can be graded based upon the
presence of the characteristic
radiographic findings:
• Grade 0: Normal
• Grade 1: Suspicious changes
• Grade 2: Minimal abnormality –
Small localized areas with
erosions or sclerosis, without
alteration in the joint width
• Grade 3: Unequivocal abnormality
– Moderate or advanced
sacroiliitis with erosions, evidence
of sclerosis, widening, narrowing,
or partial ankylosis
• Grade 4: Severe abnormality –
Total ankylosis
The sacroiliac joints are normal and are graded
as grade 0.
UpToDate

24. IMAGING
• Radiographs of peripheral joints and entheses — There is some variation in
the degree and type of radiographic change seen in different types of SpA.
• In patients with axial SpA, the most severe peripheral joint involvement observed
on plain radiographs is in the hip joints, where extensive destructive changes
may occur.
• Though the knees might show considerable swelling, sometimes persistent for
years, radiographs of the knees in patients with SpA often show only mild
osteoarthritic changes.
• Similarly, radiographic changes in the shoulders are usually only minor in
patients with AS.
• Fluffy erosions can sometimes be seen in areas of enthesitis, such as the heels,
although these findings are not specific for SpA.
• Radiographic changes in peripheral joints are common in patients with psoriatic
arthritis, even relatively early in the disease course.
• Changes can develop in the course of psoriatic arthritis that exhibit a pattern
usually not seen in other forms of inflammatory arthritis of coexisting erosive
changes and new bone formation within the same joint or in different joints
within the same digit.
• Other typical changes include lysis of the terminal phalanges; fluffy periostitis, as
well as new bone formation, at the site of enthesitis; gross destruction of
isolated joints; “pencil-in-cup” appearance; and the occurrence of both joint lysis
and ankylosis in the same patient.
• Patients with psoriatic arthritis may exhibit more damage at the knees than
patients with other forms of SpA.
• In patients with arthritis associated with inflammatory bowel disease, plain film
radiographs of the peripheral joints demonstrate soft-tissue swelling,
juxtaarticular osteoporosis, mild periostitis, and effusions, usually without
erosions or destruction. Radiographic abnormalities in the joints are common,
even in asymptomatic patients.
Psoriatic arthritis associated
with pencil-in-cup abnormality
in the distal interphalangeal
(DIP) joints of the first and
second fingers (arrows), plus
early changes in the DIP joint of
the fourth finger. Other changes
include ankylosis in the DIP
joint in the fifth finger
(arrowhead) and destruction of
the wrist.
UpToDate

25. IMAGING
• Magnetic resonance imaging — can reveal changes consistent with SpA, including sacroiliitis and
spinal changes, but is usually not necessary in patients with abnormalities on plain radiography. MRI
abnormalities of the SI joints in the face of normal plain radiographs can be important in helping to
establish the diagnosis of nr-axSpA.
• MRI of sacroiliac joints —
• SI joint findings on MRI that are characteristic of SpA include active inflammatory lesions of the SI
joints, which appear as high-intensity bone marrow edema (BME) on short tau inversion recovery
(STIR) or on T2 with fat absorption images.
• Typical locations are the subchondral or periarticular bone marrow.
• Specific definitions for active sacroiliitis have been formulated for use with some classification criteria.
• Additional findings may be present, but generally do not satisfy classification criteria for MRI
evidence of sacroiliitis. These include other active inflammatory lesions such as synovitis, enthesitis or
capsulitis; and structural lesions, such as fat deposition, sclerosis, erosions, or bony ankylosis.
• Although BME is suggestive of SpA, it can also be seen in other diseases such as infection,
malignancy, and osteitis condensans ilii.
• MRI of the spine — Typical spondylitis-related MRI lesions are triangular in shape and are located
at one or more of the four corners of the vertebrae. They include BME observed with the STIR or the
T2 with fat absorption sequences, as well as fatty deposits observed as high-intensity lesions in the
T1-weighted sequences.
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26. TREATMENT
• NSAIDS
• TNF inhibitors (adalimumab, certolizumab, infliximab, golimumab)
• Sulfasalazine – for UC/Crohn’s, mild benefit for arthritis
• Methotrexate – more for peripheral disease
• Leflunomide – more for peripheral disease
• Steroids – try to avoid if possible (high doses required in limited study, may flare up psoriasis
upon withdrawal)
• Secukinumab (IL 17A inhibitor) – for AS and PsA (may trigger IBD)
• Ixekizumab (IL 17 inhibitor) – approved for psoriasis/psoriatic arthritis (may trigger IBD)
• Ustekinumab (IL 23/IL 12 inhibitor) - approved for psorasis/psoriatic arthritis and Crohn’s (no
benefit for AS)
• Apremilast (phosphodiesterase-4 Enzyme Inhibitor) - approved for psorasis/psoriatic arthritis only
• abatacept (inhibitor of T cell activation) – approved for psoriatic arthritis only
• tofacitinib (JAK kinase inhibitor) - approved for PsA and UC

27. Another case:
70s year old man
History of IBD (initially
diagnosed
as UC then later felt to
be Crohn’s) for 50 years.
Diagnosed with AS 20
years ago.
Has only been on
sulfasalazine.
More recently having
skin lesions likely
psoriasis.

29. QUESTIONS?
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content/uploads/2015/02/Ankylosing-
spondylitis.jpg
Lumbar spine in diffuse idiopathic skeletal
hyperostosis (DISH)