Spondyloarthropathies Notes

Sero-negative inflammatory arthritis (Spondyloarthropathies)

A group of inflammatory conditions, which typically affect the spine and enthesis (tendon and ligament insertions)

Associated with HLA-B27 gene

Distinct from RA because

• Seronegative (no RF)

• Males> Females

• Younger patients

Ankylosing Spondilitis

A chronic inflammatory disorder with eventually leads to ankylosis (fusion). Mainly affects the spine but can invade proximal joints of limbs

Pathogenesis

• Chronic inflammation of synovium, articular cartilage and ligaments

• Leads to ossification of joints

• After 10-15 years inflammation stops and disease process halts

Diagnostic criteria

1. Limitation of movement of lumbar spine in all 3 planes

2. Hx of pain in lumbar spine or at the dorso-lumbar junction

3. Limited chest expansion to <2.5cm measured at 4^th ICS

4. Sacroilitis – must have this +/- other symptoms

Clinical features

Early symptoms

• LBP (worse at night, gradual onset)

• Stiffness relieved by exercise

• Pain may progress up the back, SIJ, hips and down legs

Examination

• Limited lumbar spine movement

• Decreased chest expansion (ankylosis of costovertebral joints)

• Enthesis – usually Achilles tendon or plantar fascia

Schobar test for lumbar flexion

• Pt stands erect. Make mark over spinous process of L5 – make another mark 10cm above it and ask pt to bend forward. Distance normally exceeds 15cm

Wall test for cervical flexion deformity

• Pt stands erect with heels and buttocks against wall

• Instruct pt to extend neck maximally in attempt to touch wall with the occiput. Distance between occiput and wall measures degree of deformity

Extra-articular features

Eyes - Uveitis

Heart – Aortitis, cardiomegaly

Lungs – Apical pulmonary fibrosis

Renal – IgA nephropathy, amyloidosis

GI – Inflammatory bowel disease

Limbs - Neuropathy

Systemic – weight loss and fatigue

Investigations

Bloods – Raised EXR/CRP, normocytic anaemia

Xray

• Increased density over SIJ = bony oedema and eventual ankylosis of SIJ

• Squaring of vertebral bodies

• Bridging syndesmophytes (anterior longitudinal ligament)

• Bamboo spine

Eventually the patient has a ‘question mark’ posture

• Loss of lumbar lordosis

• Loss of cervical lordosis

• Excessive thoracic kyphosis

Management

Lifestyle

• Encourage exercise

• Physiotherapy

• Hydrotherapy

Assessing treatment (both questionnaires)

• BASDAI (Bath Ankylosing Spondilitis Disease Activity Index)

• BASFI (Bath Ankylosing Spondilitis Functional Index)

Reactive arthritis

= sterile inflammation of joint due to immune response to an...

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