Ankylosing & Enteropathic Arthritis Flashcards
What are the 4 inflammatory spondyloarthropathies?
- ankylosing spondylitis
- enteropathic arthritis
- psoriatic arthritis
- reactive arthritis
What is the most common inflammatory spondyloarthropathy?
ankylosing spondylitis
Which inflammatory spondyloarthropathy(ies) have a bilateral symmetric pattern of sacroiliitis?
ankylosing spondylitis
enteropathic spondylitis
Which inflammatory spondyloarthropathy(ies) can have a bilateral asymmetric OR unilateral pattern of sacroiliitis?
psoriatic arthritis
reactive arthritis
What is the only difference between ankylosing spondylitis and enteropathic arthritis?
presence of enterophathic disease
(identical in the spine)
Which seronegative spondyloarthropathy favours the upper extremity?
psoriatic arthritis
Which seronegative spondyloarthropathy favours the lower extremity?
reactive arthritis
What areas of the spine do the seronegative spondyloarthropathies prefer?
- SI
- thoracolumbar junction
- may affect c/s
What is the defining characteristic of seronegative spondyloarthropathies?
sacroiliitis
What are the relevant lab findings for seronegative spondyloarthropathies?
- RF negative
- HLA-B27 positive
- ^ESR & CRP
Inflammation of tendons and ligamentous attachments due to seronegative spondyloarthropathies causes _____ in the spine, and _____ outside of the spine/SI joints
syndesmophytes
enthesophytes
Ankylosing spondylitis and enteropathic arthritis cause ____ syndesmophytes
marginal
Psoriatic and reactive arthritis cause ____ syndesmophytes
non-marginal (AKA parasyndesmophytes)
Ossification due to inflammation where the IVD attaches to endplates is called ____
syndesmophytes
As opposed to RA, seronegative spondyloarthropathies like to result in ____ of joints
ankylosis (fusion)
Ossification outside of the spine where ligaments attach to bone is called _____
enthesophytes
Non-marginal syndesmophytes are also called ____
parasyndesmophytes
What are 2 other names for Ankylosing spondylitis (AS) that you should not use?
- Rheumatoid spondylitis
- Marie-Strumpell Disease
What is the age of onset for AS and Enteropathic arthritis (EA)?
15-35 yrs
Which gender is primarily affected by AS and EA?
Male > Female (10:1)
What is usually the first symptom of AS?
Low back/SI pain
What is a rhizomelic arthropathy?
arthropathy affecting the root of a limb (proximal)
AS and EA are considered _____ arthropathies, most commonly affecting the hips and shoulders
rhizomelic
What are the relevant lab findings of AS and EA?
- RF negative
- mild anemia
- ^ESR/CRP
- HLA-B27 positive (90% AS, 10-12% EA)
What pattern of sacroiliitis is seen in AS and EA?
bilateral symmetric sacroiliitis to fusion
In AS and EA, an exacerbation-remission pattern is evidenced by alternating of what 2 radiographic signs of vertebral involvement?
Exacerbation = erosions (Romanus lesions)
Remission = Shiny corner sign
What is the first radiographic sign of vertebral involvement in AS and EA?
Erosions (Romanus lesion):
inflammatory change (loss of bone) at corners of vertebrae where annulus inserts via Sharpey fibers
What are the radiographic signs of AS and EA in the spine?
- Romanus lesions (erosions)
- shiny corner sign (sclerosis)
- squaring of bodies –> barrel shaped bodies
- marginal syndesmophytes
- bamboo spine (poker spine)
- railroad/dagger/trolly track signs
- carrot-stick Fx –> Anderson lesion
- atlantoaxial instability (^ADI)
- ankylosis
Inflammation at the corners of vertebral bodies creating erosive change is called ____
Romanus lesions
Sclerosis that occurs at the corners of vertebral bodies due to AS and EA is called ____
shiny corner sign
In AS and EA over time, repeated exacerbation/remission patterns cause the normal anterior and posterior concavity of vertebral bodies to become more vertical, which is called _____
squaring of vertebral bodies
In AS and EA over time, repeated exacerbation/remission patterns cause the normal anterior and posterior concavity of vertebral bodies to become more convex, which is called _____
barrel shaped bodies
(later sign after squaring, less common)
Delicate egg shell ossifications from vertebral corner to corner along outer annular fibers are called ____
marginal syndesmophytes
Disc and vertebrae fusion create a radiographic sign on AP view called ____
bamboo spine
Facet joint involvement in AS and EA is seen radiographically as ____
railroad sign
(inflammation resulting in fusion of facets)
Ossification of the interspinous ligament in the lumbar region is seen radiographically as one long piece of bone on AP view called ____
dagger sign
(never call dagger sign on T-spine or Ferguson views)
What is trolley track sign?
rail road sign + dagger sign
(radiographic characteristic of AS & EA)
What is a carrot-stick fracture?
Fx through ankylosed spine
What is the stability of a carrot-stick fracture?
unstable
What is an Anderson lesion?
ankylosed spine can lose pain sensation, causing pt to be unaware of Fx which then heals non-union
What are the common clinical features of AS and EA?
- stiff, achy spine (synovial inflammation)
- exacerbation/remission pattern
- decreased spinal & rhizomelic jt ROM
- hyperkyphosis & fusion (later stage)
- bilateral
What are the radiographic characteristics of AS and EA in the SI joints (sacroilitis)?
- bilateral symmetric
- erosion & sclerosis of SI margins (rosary bead appearance)
- loss of cortical definition
- ghost joints (complete ankylosis, jt not visible)
What radiographic view should be used in a patient with LBP and suspected seronegative spondyloarthropathy?
Ferguson view
(25 deg tilt up at L/S junction)
Your patient has elevated ESR & CRP, mild anemia, negative Rheumatoid factor, and positive HLA-B27, but SI joints on appear normal radiographically. What follow-up imaging would you order?
MRI
What are the radiographic characteristics of AS and EA in the appendicular skeleton?
- enthesophytes (plantarcalcaneal, achilles)
- ankylosis
How do marginal syndesmophytes compare to non-marginal syndesmophytes?
Marginal = corner-to-corner, egg-shell thin
Non-marginal = past corners (not in mid-portion), thicker
What are the most common pre-existing enteropathic conditions of EA?
- Ulcerative colitis
- Crohn disease
- Whipple disease (gluten intol.)
(often misdiagnosed as IBS first)
What should your next step be if your patient presents with back pain and a history of inflammatory bowel disease?
radiographs
(EA until proven otherwise)
What are the less common pre-existing enteropathic conditions of EA?
GI infections:
- salmonella (chicken)
- shigella (fecal)
- yersinia
How does the timing of enteropathic symptoms correlate with arthritic symptoms of EA?
- diarrhea precedes arthritic outbreak
- ^gut Sx before & during arthritis attack
What are the clinical manifestations specific to EA?
same SSx as AS, plus enteropathic Sx (diarrhea, gut Sx)
If you discover your patient has irritable bowel symptoms, where would you refer them to?
gastroenterology
