Seronegative Inflammatory Arthropathies: Ankylosing Spondylitis Flashcards
what are seronegative inflammatory arthropathies
characterised by inflammation and/or arthritic disease of the spine, and an asymmetric oligoarthritis
named the shared features of spondyloarthropathies
- Seronegativity
- HLA B27
- Axial arthritis – pathology in spine and sacroiliac joints
- Enthesitis
- Dactylitis
- arthritis of joints and legs in an asymmetrical distribution
- Extra-articular manifestations e.g. iritis, psoriaform rashes, oral ulcers, aortic valve incompetence, inflammatory bowel disease
seronegativity
rheumatoid factor negative
dactylitis
inflammation of a whole digit (‘sausage digit’) due to soft tissue oedema, and tenosynovial and joint inflammation
what enthesopathies are common
achilles tendinits
plantar fasciitis
genetic factors
patients are often HLA B27 positive
HLA B27
associated with AS, reactive arthritis, crohns and uveitis
not a useful screening or diagnostic test unless patient also hass symptoms
AS
chronic inflammatory disase of the spine and sacro-iliac joints which can lead to eventual fusion of the intervertebral joints and IS joints
epidemiology
males more common
age of onset 20-40 years
what is required for diagnosis
modified NY criteria
- Clinical Criteria:
- Limited lumbar motion
- Lower back pain for ≥3 months (inflammatory pain)
- Reduced chest expansion
- Radiological Criteria:
- Bilateral, Grade 2 to 4, sacroiliitis on X ray
- Unilateral, Grade 3 to 4, sacroiliitis on X ray
Must have radiological criteria plus any clinical.
name some SpA features
inflammatory back pain
arthritis
enthesitis
uveitis
dactylitis
psoriasis
crohns/colitis
good response to NSAIDs
FH
HLA-B27
elevated CRP
where does the back pain radiate to
from sacroiliac joints to hips and buttocks
inflammatory - improves towards end of day
presentation
- spinal stiffness
- knee or hip arthritis - asymmetical distribution
- enthesitis
describe the spinal stiffness
morning
improves with exercise
what happens to the spine over time
loss of spinal movement and devlopment of question mark spine, with loss of lumbar lordosis and increased thoracic kyphosis
decreased thoracic expansion
name some extra articular features
- anterior uveitis and iritis
- CVS involvement - aortic incompetence (AR) and heart block
- pulmonary involvement
- neurological involvement
- amyloidosis
- asymptomatic enteric mucosal inflammation
what is AS associated with
osteoperosis, aortic valve incompetence and pulmonary apical fibrosis
treatment of anterior uveitis
- topical steroids - prednisolone forte
- mydiatrics eg tropicamide and cyclopentolate
what can uveitis/iritis lead to if untreated
blindness
enthesitis
inflammation of where the tendon inserts into the bone
usually achilles tendinitis or plantar fasciitis
diagnosis
history
examination
bloods
x ray
MRI
what is seen on examination
- Tragus/occiput to wall
- Reduced lateral flexion
- Decreased thoracic expansion
- Reduced forward flexion: Modified Schober test
tragus to wall test
what does the modified schober test measure
lumbar spine flexion
bloods
inflammaotry parametes
HLA B27
x ray
can be normal at time of presentation
sacroilitis
sclerosis and fusion of the SI joints and bony spurs from the vertebral bodies (syndesmophytes), which can bridge the intervertebral disc resulting in fusion - produces a bamboo spine
MRI
can detect earlier features such as bone marrow oedma and ethesitis of spinal ligaments
management
- physiotherapy and exercise
NSAIDs, anti-TNF inhibitors for more aggressive disease
DMARDs are useful for peripheral joint inflammation
there is an increased risk of osteoperotic spinal fractures, so consider biphosphonates
surgery
mainly reserved for knee and hip arthritis
kyphoplasty to straighten out the spine - controversial and carries considerable risk
dactylitis
what is recommended for back pain
exercise not rest
