Spondyloarthritis Flashcards
includes ankylosing spondylitis.
oligoarthritis
spondyloarthritis
enthesitis definition
swelling of tendon near where it inserts onto the bone (entheses)
Presence of enthesitis
highly suggestive of spondyloarthritis, and if severe, can extend along tendon and local ligaments causing dactylitis.
Four types of spondyloarthritis
ankylosing spondylitis,
psoriatic arthritis,
inflammatory bowel disease (with arthritis and reactive arthritis)
reactive arthritis
dactylitis
sausage digits,
seen with severe enthesitis (swelling of tendon and ligaments on bone)
1st line treatment for ankylosing spondylitis
What is defined as treatment failure for 1st line?
NSAIDs help relieve pain and stiffness.
Provides relieve to 70-80% of those with AS. continuous full dose NSAIDS provide relief and reduced sacroiliac and spine inflammation seen on MRI.
Treatment failure is when for weeks of full dose NSAID (doesn’t matter which)
Which joints are affected in ankylosing spondylitis?
sacroiliac joints, entheses, peripheral joints
Second line tx of anklyosing spondylitis
TNF alpha inhibitors; if not affordable or availalbe could use sulfasalazine for treatment of periphreal arthritis.
presentation of ankylosing spondylitis
chronic low back pain <40 yrs in men >women.
Extraarticular manifestations are
anterior uveitis,
aortic regurgitation due to aortitis or valve dysfunction
decreased chest expansion
osteopenia
low back pain (onset age <40 yrs) that is insidious in onset. Back pain is better with exercise and no improvement with rest and pain is present at night
characteristic symptoms of back pain in ankylosing spondylitis
clinical presentation of ankylosing spondylitis that doesn’t involve the back.
hip and buttock pain,
limited chest expansion and spinal mobility
see fevers, chills, fatigue, and weight loss enthesitis (inflammation at the site of tendon insertion into the bone)
acute anterior uveitis (unilateral pain, photophobia).
diagnosis of ankylosing spondylitis is based off of
clinical + radiological clinical:
low back pain/stiffness >3 months and improved with exercise and not relieved by rest
limited lumbar spine motion in sagittal and frontal planes
limited chest expansion relative to normal for age and sex
radiological:
Grade >2 sacroilitis bilaterally,
grade 3 and 4 sacriliitis unilaterally
which joints often get the enthesitis in ankylosing spondylitis?
seen at achilles tendon, plantar fascia, shoulder
why do we see limited chest wall expansion
due to costovertebral rigidity - normal chest wall expansion is >5cm after maximum force expiration followed by maxium inspiration.
Expansion that is <2.5 cm is considered abnormal and suggests AS.
pts who have kyphoscoliosis and deformity above T10 are at risk for
nocturnal hypoventilation and apneic events related to respiratory failure.
what is seen on XR in advanced ankylosing spondylitis?
bamboo spine
treatment of respiratory impairment from ankylosing spondylitis
treatment with pulmonary rehab and non invasive positive pressure ventilation
What is associated with Marfan syndrome?
increased arm span to height ratio
associated with aortic root dilation and dissection
ectopia lentis
mitral valve prolapse
pneumothorax.
inflammatory back pain characteristics that should make us think of ankylosing spondylitis?
insidious onset at age<40 yrs symptoms >3 months relieved with exercise but not at rest nocturnal pain
examination findings of ankylosing spondylitis
arthritis (sacroiliitis) reduced chest expansion and spinal mobility enthesitis (tenderness at tendon insertion sites) dactylitis (swelling of hands and toes) uveitis
complications of ankylosing spondylitis are:
osteoporosis/vertebral fractures aortic regurgitation cauda equinal
what valvular disorder is associated with ankylosing spondylitis
aortic regurgitation
laboratory evidence of ankylosing spondylitis
ESR and CRP elevation association with HLA-B27 association
what imaging to order if suspecting ankylosing spondylitis
XR of sacroilliac joints if negative need a MRI of the sacroiliac joints DO NOT get tricked into picking XR of lumbosacral spine to look for bamboo spine. Earliest place of dx is sacroiliac joints.
where on the body do we see enthesitis?
This is swelling, tenderness and pain at the tendon insertion sites.
seen at Achilles tendon at the heel, costosternal junction, shoulders, elbows, hips, iliac crests, tibial tuberosities.
what medical conditions can have enthesitis?
Can be isolated (plantar fasciitis) or can be seen with spondyloarthropathies (ankylosing spondylitis) or psoriatic arthritis or reactive arthritis) can be seen with RA but see synovitis more often.
highest incidence of ankylosing spondylitis is
ages 20-30 See low chest expansion <2 cm expansion with inspiration, cervical extension and lumbar flexion. Dactylitis and peripheral joint synovitis are possible.
what is initial treatment for ankylosing spondylitis
ROM exercises and NSAIDS
what mimics ankylosing spondylitis presentation?
reactive arthritis
reactive arthritis is a spondyloarthropathy with similar presentation with inflammatory back pain, enthesitis, peripheral arthritis but follows Chlamydia infection
what non pharmacological therapies can ankylosing spondylitis pts benefit from?
supervised physical therapy (postural training, ROM stretching,) smoking cessation local heat and cold packs. If not satisfactory can try TNF alpha.
why does positive pressure ventilation help with decreased chest wall expansion and pectus excavatum and kyphoscoliosis and morbid obiesty?
lung compliance is decreased due to decreased chest wall compliance This also happens because of atelectasis and air trapping and increases work of breathing. This can cause respiratory fatigue and failure. PTs are prone to nocturnal hypoventilation and apnea and can develop pulmonary hypertension and cor pulmonale NPPV eliminates hypoxemia and obstructive apneas and improves lung volumes and respiratory function.
bracing in adults who have severe kyphoscoliosis is
actively contraindicated in adults. only meant for immature adolescents
findings of X rays of advanced AS
see fusion of lumbar spine as “bamboo” spine
what is decreased chest wall expansion?
abnormal chest wall expansion is <2.5 cm
normal chest wall expansion is >5cm after maximum forced expiration followed by maximum inspiration.
suggestive of AS.
features that should make you suspect ankylosing spondylitis?
man <45 yrs
duration of lower back pain >3 months
insidious back pain onset
morning stiffness >30 minutes
improvement with exercise
no improvement with rest
awaking from pain alternating buttock pain
history of anterior uveitis
what to look for on XR of the sacroiliac joints during work up for ankylosing spondylitis?
look for evidence of sclerosis
widening and narrowing or partial ankylosis of sacroiliac joints
DISH vs Ankylosing spondylitis
DISH - non inflammatory condition involving the ossification of spinal ligaments and enthesis.
DISH can be asymptomatic or present in various ways including pain and stiffness in the spine, with thoracic spine being the most involved.
DISH is an old man’s dx - >45 years old.
