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Spondyloarthropathy

• Spondyloarthropathy (SpA) is a frequent, chronic, inflammatory condition with

potential disabling outcomes.

• A recent epidemiologic study performed in Brittany (France) evaluated the disease

prevalence as 0.49% compared with that of rheumatoid arthritis (RA) as 0.64%

• Many SpA patients have mild disease with a good clinical response to nonsteroidal

antiinflammatory drugs (NSAIDs).

• Nevertheless, some patients have clinical, biological, or radiological elements of poor prognosis or are refractory to NSAIDs with

persistent signs of active disease.

• In this set of patients, the initiation of slow-acting drugs (sulphasalazine or methotrexate)

might at best induce symptomatic improvement.

• The recent development of biotherapies such as tumor necrosis factor (TNF)-a blockers and their use in SpA have demonstrated promising

results.

Diagnosis of

spondyloarthropathies

Classification criteria

• SpA consists of several disorders, with ankylosing spondylitis (AS) as the prototype of

this group of inflammatory conditions:

reactive arthritis,

psoriatic arthritis, arthritis related to inflammatory bowel

disease (Crohn’s disease and ulcerative colitis), and the

undifferentiated forms of the disease.

These subgroups are characterized by: • axial or peripheral articular involvement

• enthesitis, • potential extra-articular manifestations, and

• high association to a genetic factor of predisposition, the tissue antigen HLA-B27.

• ankylosing spondylitis (AS)• reactive arthritis,

• psoriatic arthritis, • arthritis related to inflammatory bowel disease

• undifferentiated forms

• A common familial aggregation of SpA cases is another characteristic of this group of

diseases.

• These disorders are difficult to differentiate because they can occur simultaneously or

sequentially.

• axial or peripheral articular involvement• enthesitis,

• potential extra-articular manifestations

DIFFERENTIATION OF INFLAMMATORY VERSUS MECHANICAL LOW BACK PAIN

• Two sets of criteria have been proposed:

1) the Amor criteria,

and the

2)European Spondyloarthropathy Study Group (ESSG) criteria

the Amor criteria

• New York diagnostic criteria have been proposed, but they imply radiographic evidence of sacroiliitis for AS diagnosis.

• An incremental frequency of radiographic sacroiliitis over time has been demonstrated in SpA (40% prevalence after 10

years of disease duration, 86% prevalence after 20 years of disease duration)

• Thus, because of a frequent absence of radiographic sacroiliitis at the beginning of the disease, this radiologic item

appears to be an inappropriate request in early diagnosis.

Clinical presentation of the spectrum

ofspondylo

arthropathy

Management and monitoring of patients

Distancia Occipucio - Pared

Axial involvement: Clinical features

The following localizations of the disease are considered as axial involvement:

• sacroiliac joints,• spine,

• anterior chest wall, and • root joints (hip and shoulder).

Sacroiliitis

• Is responsible for pain and functional impairment caused by inflammation with a

long-term evolution often resulting in ankylosis of the sacroiliac joints.

• In some cases, a persistent inflammation without ankylosis leads to chronic pain and

functional disability.

• Anteroposterior Ferguson view of the sacroiliac joints in a patient with AS. The area of the sacroiliac joint inferior to the arrows is imaged by the Ferguson view and not by an anteroposterior view. Note the bilateral, symmetric involvement with erosions and

eburnation

bilateral sacroiliitis

• MR image of the sacroiliac joints in a patient with undifferentiated spondyloarthropathy. Axial T1-weighted image with fat suppression after intravenous administration of Gd-DTPA

demonstrates increased signal intensity in the subchondral bone marrow within the iliac and sacral sides of the right joint (arrows) and early erosions of the left joint (arrowhead).

Spinal involvement• Can be related to vertebral ligament inflammation or

interapophyseal joint inflammation. Both afflictions can be responsible for night pain, morning stiffness,

and reduction in spinal mobility.

• Vista lateral de la columna lumbosacra que muestra esquina brillante (puntas de flecha), la cuadratura de los cuerpos vertebrales, y la formación temprana sindesmofito (flechas)

en un paciente con EA

• Lateral view of the lumbosacral spine

showing syndesmophytes of AS,

giving it a bamboo appearance

• Lateral view of the cervical spine in a

patient with PsA. The posterior spinous

processes show erosive changes at ligamentous

attachments (arrowheads).

MR (sagittal STIR) images of the lumbar spine of a patient with AS. (a) Note the areas of marrow edema within the anteroinferior corners of the third and fourth lumbar vertebrae, respectively (arrows). (b) Four weeks after the start of therapy with anti–tumor necrosis factor the areas of edema had resolved and so had the patient's symptoms (arrows).

• Secondary vicious attitudes can be explained by the analgesic position (fetal position) unconsciously

taken by the patient during the second part of the night during inflammatory phases of the disease.

Anterior chest wall pain

• Is observed in about 15% of patients who have SpA and can be related to

sternoclavicular, manubriosternal, or sternocostal arthritis.

• Anterior chest wall involvement together with costovertebral joint involvement can lead to

decreased chest expansion and impaired respiratory function.

Shoulder and hip involvement

• Can be responsible for severe disability.

• Moreover, hip arthritis (defined as the presence of pain localized in the groin associated with lameness) has been

considered as a criterion of poor outcome prognosis.

Laboratory parameters of inflammation.

• In patients suffering from isolated axial involvement, an increase in C-reactive protein (CRP) is not a rare phenomenon; it is observed

in about 40% of patients.

An increase in CRP might be

correlated with the clinical

severity of the disease and

might be considered to be a potential predisposing

factor of structural

progression.

• In clinical trial, NSAIDs had little effect on erythrocyte sedimentation rate (ESR) or CRP.

• At variance, recent data on TNF-a blocking agents demonstrate a huge effect on both

markers of inflammation.

Definition of active axial disease

• Pain and disability can reflect the inflammatory process and the structural

damage caused by the disease.

• level of night disturbance, duration and intensity of the morning stiffness, level of

pain, and functional disability.

• The remaining question when considering second-line drugs is whether or not an

objective demonstration of inflammation is necessary (eg, CRP elevation, inflammatory

signals assessed by MRI, or abnormal vascularization of the entheses using

ultrasonography).

• Musculoskeletal ultrasound features in

psoriatic arthritis:

• A, Right plantar fascia thickening compared

with the left.

• C, Power Doppler ultrasound through

left third finger at the metacarpophalangeal

joint confirming increased vascularity

(synovitis).

• Musculoskeletal ultrasound features in

psoriatic arthritis:

• B, Transverse section through left third

finger at the metacarpophalangeal

joint showing right tenosynovitis.

• D, Right Achilles tendinitis with

calcaneal erosion.

Definition of severe axial disease

• The severity of axial disease is defined by radiologic damages such as bamboo spine.

• An active disease despite optimal NSAID treatment is usually considered to be a predictive factor of subsequent severity

defined by radiological progression.

Peripheral involvementClinical features

• Dactylitis and oligoarthritis of the lower limbs, predominantly involving knees and ankles, are characteristic of the peripheral involvement in

SpA and substantially differ from RA (polyarticular, bilateral, symmetrical arthritis

involving small joints).

• Sausage digits in a 14-year-old HLA-B27+ boy with onset of spondyloarthropathy at the age of 12.

Definition of active peripheral disease

• Activity of peripheral articular manifestations has a definition similar to the one that

describes activity in RA: number of swollen and tender joints together with biological

signs of inflammation.

EnthesitisClinical features

• The enthesitis is the anatomical site of insertion of a tendon, ligament, or articular capsule into bone. Local or regional pain occurring in an SpA patient usually reflects enthesitis, which is responsible for

local inflammation and local bone remodeling.

• Radiographic image of entheseal calcification and surface irregularity at calcaneal insertion and Achilles tendon insertion of a patient with SpA

Extra-articular manifestations

• Various extra-articular manifestations can be observed in SpA patients:

psoriasis,

gut inflammation with chronic diarrhea, uveitis,

cardiac manifestations,

Ankylosing Spondylitis (AS)

ETIOLOGY

• Animal and laboratory studies suggest that the HLAB27 molecule itself plays a key role,

and that involvement of class I major histocompatibility complex (MHC) antigens in

the presentation of microbial peptides is central to the pathogenic mechanism

(Klebsiella aeruginosa)

CLINICAL FEATURES

• The principal musculoskeletal lesions associated with AS are enthesitis and

synovitis, with sacroiliitis also involving adjacent bone.

• Inflammatory eye lesions, myocardial changes, gut mucosal lesions, and skin lesions are inconsistent but characteristic features of

AS.

• Spinal features of AS seldom appear before the age of 16 to 18 years.

• Before this age, children and teenagers may develop oligoarthritis—typically a swollen

knee or metatarsophalangeal (MTP) joint—sometimes associated with iritis and/or

enthesitis.

• Juvenile AS is remarkable because it does not involve the spine.

• The average age at onset is 26 years. Although the disease rarely begins after the age of 40

years, it is not uncommon for the diagnosis to be made only years later, well after that age.

• Earlier symptoms often are mild, ignored, or not recognized as being part of AS.

• The usual presenting symptom is inflammatory back pain that is insidious in onset, persistent for more than 3 months,

worsened by rest and improved by exercise.

• Night pain is a frequent symptom.

• Sacroiliitis, the most common initial feature, causes pain in the buttocks, typically

alternating between right and left in severity.

• This pain sometimes radiates down the thighs but never below the knee.

• A minority of patients present with oligoarthritis or enthesitis that particularly

affects the heel, or hip pain due to aggressive synovitis.

• Fatigue, a common and troublesome symptom, may be caused in large part by

impaired sleep caused by pain and stiffness.

• Other constitutional features may include fever and weight loss. Overt or subclinical

depression, accompanied by a loss of libido and reduced capacity for work, also may

contribute to lack of well-being.

• Spinal discomfort and stiffness typically ascend the spine over a period of

years, producing progressive spinal pain

and restriction.

• One of the first clinical signs is the disappearance

of the lumbar lordosis.

• Bamboo spine’ in a 49-year-old man with a 14-year

history of ankylosing spondylitis.

• This classic but uncommon

manifestation occurs at a late stage following inflammatory

disease.• Note the

calcification of the anterior fibres of

the annulus (arrow).

• This progression affects the costovertebral joints, reducing respiratory excursion, and the

cervical spine, limiting neck movement.

• Thoracic spine involvement may be associated with anterior chest pain and sternal/costal

cartilage tenderness, which can be particularly distressing for patients.

• Osteoporosis (which may be prevented by appropriate therapy) may lead to vertebral

and other fractures later in life.

• Spinal fractures are more common in patients who have severe involvement with rigidity.

• Aseptic spondylodiscitis may occur in patients with AS, especially in the thoracic spine

Enthesitis

• The central feature of AS is inflammation at entheses, the sites where tendons and

ligaments attach to bone.

• These inflammatory lesions initially lead to radiographic appearances of osteopenia or

lytic lesions, but subsequently reactive bone forms a new, more superficial enthesis, which develops into a radiologically detectable bony

overgrowth or spur.

• In the spine, enthesitis occurs at capsular and ligamentous attachments and discovertebral,

costovertebral, and costotransverse joints, with involvement also at bony attachments of interspinous

and paravertebral ligaments.

• Enthesitis accounts for much of the pain, stiffness, and restriction at sacroiliac and other

spinal joints.

• The phenomenon also occurs at extraspinal sites, producing potentially troublesome

symptoms.

• Such lesions most commonly affect the plantar fascia and Achilles tendon insertions

to the calcaneus, leading to disabling heel pain.

• Plantar fasciitis typically leads to the formation of fluffy calcaneal spurs visible on

heel radiographs after 6 to 12 months.

• Swelling of the right Achilles tendon in a 26-year-old man with spondyloarthritis

• A, Left Achilles tendon (AT), which was normal on both clinical and US examination. The short white arrows point to the edges of the tendon, and the white dotted line

(with arrows) indicates the depth of the tendon. B, Abnormal right side, with thickening and hypoechogenicity of the Achilles tendon extending to the insertion.

There is also a distended retrocalcaneal bursa. KFP, Kager's fat pad; ∗, fluid; ∗∗, fat pad or synovium.

Fat-suppressed magnetic resonance image of the foot of a young patient with

ankylosing spondylitis. The high signal is consistent

with marrow edema, reflecting acute plantar fasciitis

(white arrow). In addition, there is

retrocalcaneal bursitis (asterisk).

• Similar lesions may occur around the pelvis, costochondral junctions, tibial tubercles, and elsewhere, causing marked local tenderness

• Sternal and costochondral pain also reflect a combination of local enthesitis and referred

pain from the thoracic spine.

• This development frequently produces chest pain that must be distinguished from

myocardial ischemia.

Sacroiliitis

• Inflammation of the sacroiliac joints develops most frequently in the late teens or in the third decade of life, producing bilateral or

occasionally, unilateral buttock pain, usually worse after inactivity and sometimes

aggravated by weight bearing.

• Changes principally affect the lower anterior (synovial) portion of the sacroiliac joints and

are associated with juxta-articular osteopenia and osteitis.

• This condition leads to radiographic appearances of widening of the sacroiliac

joint.

• Endochondral ossification as a consequence of the osteitis gives the radiographic appearance

of erosion along the lower part of the sacroiliac joints.

• Osteitis appears as increased water content of adjacent bone, as seen on magnetic

resonance imaging (MRI).

• MRI is a valuable imaging modality for assessment of inflammation in both the sacroiliac joints and the spine. This can

frequently be an important aid in establishing an early diagnosis.

• Capsular enthesopathy also occurs over the anterior and posterior aspect of the joint

throughout its length, leading to sheets of ossification that ultimately obscure the joint

completely on standard radiographs, depicted as ankylosis of the sacroiliac joint.

Synovitis

• Synovitis is indistinguishable histologically and immunohistochemically from typical

rheumatoid disease.

• Peripheral joint synovitis may precede, accompany, or follow the onset of spinal

symptoms.

• Hips, knees, ankles, and MTP joints are affected most commonly. With the exception of the shoulders, upper limb joints are almost

never involved in AS.

• In further contrast to rheumatoid arthritis, peripheral joint synovitis usually is

oligoarticular, often asymmetrical, and frequently episodic rather than persistent

• Joint erosions, especially at the MTP joints, may lead to subluxation and deformity.

• Temporomandibular joints may be affected, leading to reduced mouth opening and

discomfort on chewing.

• Dactylitis may lead to pain in one or more toes that lasts many months.

Eye Lesions

• Acute anterior uveitis (iritis) develops at some time during the course of the disease in

approximately one third of patients with AS, and may be recurrent.

• Acute anterior uveitis in AS, typically unilateral and associated with redness, pain, and photophobia.

• The typical pattern is alternating, unilateral eye inflammation associated with pain , redness, lacrimation, photophobia, and

blurred vision.

• The occurrence of uveitis typically does not coincide with flares of arthritis.

• Untreated or inadequately treated iritis may lead rapidly to considerable scarring,

irregularity of the pupil, and visual impairment.

• Red, sore, gritty eyes or blurring of vision in a patient with AS require urgent ophthalmologic

examination.

Inflammatory Bowel Disease

• Sacroiliitis occurs in 6% to 25% of people with Crohn’s disease or ulcerative colitis.

• Patients with Crohn’s disease or ulcerative colitis frequently have unilateral sacroiliitis, and may also suffer from peripheral arthritis

and enthesitis.

• Similarly, inflammatory bowel disease may be present or develop in people with preexisting

AS.

• Indeed, approximately 60% of people with AS have subclinical changes in the small or large

bowel.

• There is speculation that these changes may relate to the pathogenesis of AS, but their true

significance is unknown.

• Even though some AS lesions closely resemble those of Crohn’s disease, the great majority of

such lesions never become symptomatic.

• Only about 10% to 15% of the patients with AS have overt ulcerative colitis or Crohn’s

disease

• In a minority of people with colitis and peripheral arthritis, peripheral joint disease

may diminish substantially after total colectomy.

• Active inflammatory bowel disease increases the risk and severity of osteoporosis.

• Crohn’s disease with extensive small bowel involvement also may lead to impaired vitamin D absorption and osteomalacia,

producing ill-defined musculoskeletal pain and difficulty with walking.

Cardiovascular Involvement

• Cardiac conduction abnormalities and myocardial dysfunction have been recorded in

a significant minority of people with AS

• Aortitis with dilatation of the aortic valve ring and aortic regurgitation has been

demonstrated in approximately 1% of patients.

• The risk of occurrence of aortic insufficiency and cardiac conduction abnormalities increase with age, disease duration, presence of HLA-

B27, and peripheral joint involvement.

Pulmonary Involvement

• Approximately 1% of patients develop progressive upper lobe fibrosis of the lungs.

• Rigidity of the chest wall results in the inability to extend the chest fully and to mild

restrictive lung function impairment, but rarely leads to ventilation insufficiency due to the compensation by increased diaphragmatic

contribution.

Neurologic Lesions

• Neurologic deficits are associated most often with cord or root lesions following spinal

fracture.

• Nerve root pain may arise from the cervical spine, especially when there is marked flexion

deformity.

• Long-tract signs, including quadriplegia, may follow spinal fracture dislocation after

relatively minor trauma and complicate spontaneous atlantoaxial subluxation.

• Subluxation also may lead to severe occipital headache.

Skin Involvement

• In various series, between 10% and 25% of the patients with typical AS have concomitant

psoriasis lesions.

Renal Consequences

• Although rarely seen today, secondary amyloidosis caused by longstanding AS is well

described.

IMAGING

• By definition, all patients fulfilling the modified New York

criteria show signs of sacroiliitis on radiographs.

• However, about 30% of the patients do not develop damage of the spine visible on

radiographs.

• If patients show no spinal damage after a certain disease duration (about 10 years), it is

unlikely that the patient will develop radiographic abnormalities of the spine at all.

• On the other hand, patients who have spinal damage are prone to develop more damage.

• Characteristic features on radiographs of the sacroiliac joints are pseudo-widening of the

joint space, sclerosis, erosions, and ankylosis

• Anteroposterior radiographs of the pelvis showing complete ankylosis of both sacroiliac joints and syndesmophyte formation in the lower lumbar

vertebrae.

• Many AS-related changes can be seen in the spine; squaring of the vertebrae, sclerosis,

erosions, syndesmophytes, bony bridging, and spondylodiscitis are the most relevant.

• Radiograph of the lateral cervical spine, demonstrating the formation of extensive bridging syndesmophytes that involve

almost the entire cervical spine.

Radiograph of the lateral lumbar spine with squaring of

L1 and syndesmophyte formation from L3 to L5.

• Syndesmophytes are characterized by axial growth that may lead to bridging phenomena.

For making a diagnosis, conventional radiography is still the preferred option.

• However, if the radiographs are persistently normal in the setting of high disease suspicion, MRI of the sacroiliac joints and spine can add

information.

• In contrast to conventional radiographs, MRI has the potential to demonstrate

inflammation, not merely the end results of inflammation on bone.

• Among MRI techniques for delineating inflammation, the short tau inversion recovery

(STIR) technique is preferred.

• MRI is also useful in visualizing enthesitis, for example, of the heel or Achilles tendon

insertion.

• Short tau inversion recovery (STIR) image of the sacroiliac joints revealing extensive inflammation (white) involving both the sacral and iliac sides of

the joints bilaterally.

• weighted, opposed-phase, gradient echo magnetic resonance image 3 minutes after the intravenous injection of gadolinium-DTPA in a 23-year-old man with

ankylosing spondylitis and severe inflammatory back pain localized mainly to the right side, of 3 years' duration. Acute sacroiliitis is demonstrated by the strong

contrast enhancement of the right sacroiliac joint (arrowheads), with impressive bone marrow edema (white arrow) and erosions (black arrow).

MAKING THE DIAGNOSIS

• As in many other diseases in which the etiology is not clearly defined (e.g., by the

isolation of a specific causative pathogen), the diagnosis of AS must rest on the combination of clinical features, radiological findings, and

laboratory results.

• There are no established diagnostic criteria for AS.

• On the other hand, classification criteria, used for the purpose of categorizing patients in

research studies, are available.

• The most widely used classification criteria for AS are the modified New York criteria.

• Although the New York criteria are useful in established disease, their heavy reliance on the demonstration of radiographic sacroiliitis diminishes

their applicability in patients with early disease.

AMOR’S CLASSIFICATION CRITERIA FOR

SPONDYLOARTHRITIS:

A patient is considered as suffering from a

spondylarthropathy if the sum

is ≥6.

AMOR’S CLASSIFICATION CRITERIA FOR

SPONDYLOARTHRITIS:

A patient is considered as suffering from a

spondylarthropathy if the sumis ≥6.

THE EUROPEANSPONDYLARTHROPATHY STUDY GROUP CRITERIA

Current Opinion in Rheumatology 2010

• Bone marrow oedema (BMO), reflecting active sacroiliitis

• Synovitis as an active inflammatory lesion appears as hyperintense signal on contrast-enhanced

• Capsulitis (arrows) is a hyperintense signal of the sacroiliac (SI) joint capsule. Anteriorly, the joint capsule gradually

continues into the periosteum of the iliac and sacral bones.