Spondyloarthritis

Noppamas Kaewkheaw Yossavadee Ruamcharoen

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Low back pain

Acute : <6 wks. Subacute : 6-12 wks. Chronic : > 12 wks. Mechanical back pain Inflammatory back pain

Inflammatory back pain

Characteristic of pain ?

2/3 criteria are fulfilled, sensitivity is 70% and specificity is 81% (positive likelihood ratio 3.7). 3/4criteria are fulfilled, sensitivity is 33% and specificity is 98% (positive likelihood ratio 12.4).

4/5 criteria are fulfilled, sensitivity is 77% and 80%, specificity is 92% and 72%, in the patients participating in the workshop and the validation cohort

European Spondyloarthropathy Study Group Criteria for Spondyloarthropathy

European Spondyloarthropathy Study Group Criteria for Spondyloarthropathy

Positive family history : presence in first-degree or
second-degree relatives of any of the following: (a) ankylosing spondylitis, (b) psoriasis, (c) acute uveitis, (d) reactive arthritis, (e) inflammatory bowel disease

Psoriasis : past or present, diagnosed by a physician Inflammatory bowel disease : past or present

Crohn s disease or ulcerative colitis diagnosed by a physician and confirmed by radiographic examination or endoscopy

 Urethritis, cervicitis, or acute diarrhea within 1

mo before arthritis : nongonococcal areas : past or present

Buttock pain alternating between right and left gluteal Enthesopathy : past or present spontaneous pain or
tenderness at sites of insertion of the Achilles tendon or plantar fascia

Sacroiliitis : bilateral grade 2 to 4 or unilateral grade

3 or 4, according to the following radiographic grading

= ankylosis

system : 0 = normal, 1 = possible, 2 = minimal, 3 = moderate, 4

Clinical Characteristics of Spondyloarthropathies

Typical pattern of peripheral arthritis : predominantly of lower limb, asymmetric Tendency toward radiographic sacroiliitis Absence of rheumatoid factor (seronegative oligoarthritis) Absence of subcutaneous nodules and other extra-articular features of rheumatoid arthritis Overlapping extra-articular features characteristic of the group (e.g., anterior uveitis) Significant familial aggregation Association with HLA-B27

Classification
Ankylosing spondylitis (AS) Psoriatic arthritis Reactive arthritis (Reiter s syndrome) Arthritis associated with inflammatory bowel disease Undifferentiated spondyloarthritis

Ankylosing spondylitis (AS)

ankylos = fusion or adhesions spondylos = spine/vertebral disk

Low Back Pain and Stiffness

Insidious in onset Deep in the gluteal region, dull in character, is difficult to localized Referred toward the iliac crest or greater trochanteric region or down the dorsal thigh (root compression) Typically alternates from side to side Awaken the patient from sleep, particularly during the second
half of the night

Low Back Pain and Stiffness

Pain and Stiffness that is worse in the morning (morning stiffness may last up to 3 hours) Coughing, sneezing, or other maneuvers that cause a sudden twist of the back may accentuate pain Improve by a hot shower, an exercise program, physical activity (do not improve with rest)

Chest pain
Thoracic spine (including costovertebral and costotransverse joints) and enthesopathy at the costosternal and manubriosternal joints Accentuated by coughing or sneezing (pleuritic) Reduction of chest expansion HLA-B27positive relatives

Enthesitis
Costosternal junctions Spinous processes iliac crests, greater trochanters, ischial tuberosities, tibial tubercles Heels (Achilles tendinitis, plantar fasciitis)

Peripheral Joint Arthritis

Hips and shoulders are the most frequently involved (35%) Hip disease is more common as a presenting manifestation in juvenile AS (mostly HLA-B27 positive) Knee joint Temporomandibular joint(10%)

Extraskeletal manifestations
Eye disease = Acute anterior uveitis or iridocyclitis (most common)

25% to 30% of patients at some time

during the course of the disease More common in B27-positive

Acute anterior uveitis

Acute and typically Unilateral, but the attacks may alternate Red and painful, with visual impairment Photophobia and increased lacrimation Subside in 4 to 8 weeks without sequelae
(if treatment is delayed, posterior synechiae and glaucoma may develop)

Cardiovascular
Ascending aortitis Aortic valve incompetence (AR) Conduction abnormalities, cardiomegaly, and pericarditis. Occur twice as often in patients with peripheral joint involvement

Pulmonary
Rare and Late manifestation (average 2 decades after the onset) Slowly progressive fibrosis of the upper lobes of the lungs (HRCT) Cough, Dyspnea, and sometimes Hemoptysis

Pulmonary
Ventilation is usually well maintained Vital capacity and total lung capacity may be moderately reduced (consequence of the restricted chest wall movement) Residual volume and functional residual capacity are usually increased

Neurologic
Caused by fracture, instability, compression, or inflammation (Arachnoiditis / arachnoid adhesions) Atlantoaxial joint subluxation, atlanto-occipital subluxation (2% commonly in patients with peripheral
arthritis)

cauda equina syndrome (gradual onset of urinary and

fecal incontinence, impotence, saddle anesthesia, and occasionally loss of ankle jerks)

Renal
IgA nephropathy (35%) and Renal impairment (27%) Amyloidosis (secondary type)

Osteoporosis
Falsely high BMD : presence of syndesmophytes Quantitative CT Increased occiput-to-wall distance is associated with vertebral fractures Specific therapy to prevent osteoporotic spinal fractures is effective

Modified New York criteria for ankylosing spondylitis

Limitations of criteria for AS

Radiographical sacroiliitis has been considered an finding in and a hallmark of AS It is present in around 90% of AS Takes on average 68 years between onset of back pain and making a definite diagnosis Results from the relatively late appearance of definite radiographical sacroiliitis on plain radiographs

Limitations of criteria for AS

Modified New York criteria do not perform well in early disease Some patients with non-radiographical axial SpA have high disease activity (signs and symptoms) and may require effective treatments Anti-TNF agents have been currently approved only for established AS and not for nonradiographical axial SpA.

Psoriatic arthritis (PsA)

The CASPAR criteria for PsA

Limitations of criteria for PsA

At present, there is no clear way of distinguishing recent-onset undifferentiated arthritis and PsA. It may be that MRI will be helpful in identifying entheseal disease or sacroiliitis In patients with disease duration of an average 1.1 years CASPAR criteria have a sensitivity of

99.1% but in very early PsA (average disease duration 15.8 weeks) the sensitivity was only

New Spondyloarthritis
Predominantly axial SpA with or without peripheral manifestation Predominantly peripheral SpA

Axial SpA
New concept structural approach Early detection

The concept of axial SpA

Assessment of SpondyloArthritis international Society (ASAS) criteria for axial SpA A probability approach based on likelihood ratios Evidence to the validity of inflammation of the SI joints on MRI as an important finding in early axial SpA MRI to the SI joint a sensitivity and specificity of around 90% each has been estimated

Sensitivity 82.9%, specificity 84.4% Imaging arm (sacroiliitis) alone has a sensitivity of 66.2% and a specificity of

97.3%.

SpA feature
Inflammatory back pain(IBP):at least 4 out of 5 1. age at onset <40 yrs 2. 3. 4. 5. insidious onset improvement with exercise no improvement with rest pain at night (with improvement upon getting up)

SpA feature
Arthritis : past or present active synovitis diagnosed by a physician Enthesitis (heel) : past or present spontaneous pain or tenderness at examination of the site of the insertion of the Achilles tendon or plantar fascia at the calcaneus

SpA feature
Uveitis : Past or present uveitis anterior, confirmed by an ophthalmologist Dactylitis : Past or present dactylitis, diagnosed by a physician Psoriasis : Past or present psoriasis, diagnosed by a physician Inflammatory bowel disease : Past or present Crohn s disease or ulcerative colitis diagnosed by a physician

SpA feature
Good response to NSAIDs : 2448 hours after a full dose of NSAID the back pain is not present anymore or much better Family history for SpA : Presence in firstdegree (mother, father, sisters, brothers,children) or seconddegree (maternal and paternal grandparents, aunts, uncles, nieces, and nephews) relatives of any of the following : (1) ankylosing spondylitis, (2) psoriasis, (3) acute uveitis, (4) reactive arthritis, (5) inflammatory bowel disease

SpA feature
Elevated CRP : C-reactive protein concentration above upper normal limit in the presence of back pain after exclusion of other causes HLA-B27 : Positive testing according to standard laboratory techniques

Peripheral SpA

Peripheral SpA
Peripheral manifestations only
Peripheral arthritis and/or Enthesitis and/or Dactylitis

Usually began before 45 years ESSG and Amor criteria in early 1990s
Not specifically for peripheral SpA

New ASAS classification criteria

Peripheral SpA

Sensitivity 77.8%, specificity 82.2%

Entry criteria
Current arthritis compatible with SpA
usually asymmetric and/or predominant involvement of the lower limb

Current enthesitis Current dactylitis

Additional SpA features

IBP Arthritis IBP in the past according to the rheumatologist s judgement Past or present peripheral arthritis compatible with SpA Past or present spontaneous pain or tenderness at examination of an enthesis

Enthesitis

Uveitis Dactylitis

Past or present uveitis anterior, confi rmed by an ophthalmologist Past or present dactylitis, diagnosed by a doctor

Psoriasis

Past or present psoriasis, diagnosed by a doctor

Additional SpA features

IBD Preceding infection Past or present Crohn s disease or ulcerative colitis Urethritis/cervicitis or diarrhoea within 1 month before the onset Presence in fi rst-degree (mother, father, sisters, brothers, children) or second-degree (maternal and paternal grandparents, aunts, uncles, nieces and nephews) relatives of any of the following: (1) ankylosing spondylitis, (2) psoriasis, (3) acute uveitis, (4) reactive arthritis, (5) IBD Positive testing according to standard laboratory techniques

Family history for SpA

HLA-B27

Sacroiliitis by imaging

Bilateral grade 24 or unilateral grade 34 sacroiliitis on plain radiographs, according to the modifi ed New York criteria, or active sacroiliitis on MRI according to the ASAS consensus defi nition

 2 sets of criterias
Sensitivity 79.5% Specificity 83.3%

Imaging of axial spondyloarthropathy

Plain film MRI spine

Sacroilitis
widening, erosions, sclerosis, or ankylosis 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 one or more of: erosions, evidence of sclerosis, widening, narrowing, or partial ankylosis Grade 4: severe abnormality total ankylosis

1. concentric joint space narrowing and collar osteophytes (black arrows) 2. whiskering or new bone formation at multiple entheses (white arrowheads).

flattening of the anterior surface of the L2 vertebral body (black arrows). A Romanus lesion is seen at the inferior corner/rim of the T12 vertebral body (white arrow).

Shiny corner sign

Squaring vertebra

a small erosion (Romanus lesion) at the anterior corner/rim of the L3 vertebral body (arrow). There is also adjacent sclerosis or a shiny corner (arrowheads).

Bamboo spine

1.ossification of the interspinous ligament :dagger sign (arrowhead). 2.ankylosis of the facet joints resulting in the tram track sign (arrows) paralleling the dagger sign

Enthesitis

MRI
Active inflammatory lesions such as bone marrow oedema (BMO)/ osteitis, synovitis, enthesitis and capsulitis associated with SpA can be detected by MRI. Among these, the clear presence of bone marrow oedema/osteitis was considered essential for defining active sacroiliitis. Structural damage lesions such as sclerosis, erosions, fat deposition and ankylosis can also be detected by MRI.

Assessment

BASDAI

- flex/extension - lateral bending - rotation