Spondyloarthritis

Question 1

oligoarthritis

Answer 1

spondyloarthritis

Question 2

enthesitis definition

Answer 2

swelling of tendon near where it inserts onto the bone (entheses)

Question 3

Presence of enthesitis

Answer 3

highly suggestive of spondyloarthritis, and if severe, can extend along tendon and local ligaments causing dactylitis.

Question 4

Four types of spondyloarthritis

Answer 4

ankylosing spondylitis,

psoriatic arthritis,

inflammatory bowel disease (with arthritis and reactive arthritis)

reactive arthritis

Question 5

dactylitis

Answer 5

sausage digits,

seen with severe enthesitis (swelling of tendon and ligaments on bone)

Question 6

1st line treatment for ankylosing spondylitis

What is defined as treatment failure for 1st line?

Answer 6

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)

Question 7

Which joints are affected in ankylosing spondylitis?

Answer 7

sacroiliac joints, entheses, peripheral joints

Question 8

Second line tx of anklyosing spondylitis

Answer 8

TNF alpha inhibitors; if not affordable or availalbe could use sulfasalazine for treatment of periphreal arthritis.

Question 9

presentation of ankylosing spondylitis

Answer 9

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

Question 10

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

Answer 10

characteristic symptoms of back pain in ankylosing spondylitis

Question 11

clinical presentation of ankylosing spondylitis that doesn’t involve the back.

Answer 11

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).

Question 12

diagnosis of ankylosing spondylitis is based off of

Answer 12

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

Question 13

which joints often get the enthesitis in ankylosing spondylitis?

Answer 13

seen at achilles tendon, plantar fascia, shoulder

Question 14

why do we see limited chest wall expansion

Answer 14

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.

Question 15

pts who have kyphoscoliosis and deformity above T10 are at risk for

Answer 15

nocturnal hypoventilation and apneic events related to respiratory failure.

Question 16

what is seen on XR in advanced ankylosing spondylitis?

Answer 16

bamboo spine

Question 17

treatment of respiratory impairment from ankylosing spondylitis

Answer 17

treatment with pulmonary rehab and non invasive positive pressure ventilation

Question 18

What is associated with Marfan syndrome?

Answer 18

increased arm span to height ratio

associated with aortic root dilation and dissection

ectopia lentis

mitral valve prolapse

pneumothorax.

Question 19

inflammatory back pain characteristics that should make us think of ankylosing spondylitis?

Answer 19

insidious onset at age<40 yrs symptoms >3 months relieved with exercise but not at rest nocturnal pain

Question 20

examination findings of ankylosing spondylitis

Answer 20

arthritis (sacroiliitis) reduced chest expansion and spinal mobility enthesitis (tenderness at tendon insertion sites) dactylitis (swelling of hands and toes) uveitis

Question 21

complications of ankylosing spondylitis are:

Answer 21

osteoporosis/vertebral fractures aortic regurgitation cauda equinal

Question 22

what valvular disorder is associated with ankylosing spondylitis

Answer 22

aortic regurgitation

Question 23

laboratory evidence of ankylosing spondylitis

Answer 23

ESR and CRP elevation association with HLA-B27 association

Question 24

what imaging to order if suspecting ankylosing spondylitis

Answer 24

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.

Question 25

where on the body do we see enthesitis?

Answer 25

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.

Question 26

what medical conditions can have enthesitis?

Answer 26

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.

Question 27

highest incidence of ankylosing spondylitis is

Answer 27

ages 20-30 See low chest expansion <2 cm expansion with inspiration, cervical extension and lumbar flexion. Dactylitis and peripheral joint synovitis are possible.

Question 28

what is initial treatment for ankylosing spondylitis

Answer 28

ROM exercises and NSAIDS

Question 29

what mimics ankylosing spondylitis presentation?

Answer 29

reactive arthritis

reactive arthritis is a spondyloarthropathy with similar presentation with inflammatory back pain, enthesitis, peripheral arthritis but follows Chlamydia infection

Question 30

what non pharmacological therapies can ankylosing spondylitis pts benefit from?

Answer 30

supervised physical therapy (postural training, ROM stretching,) smoking cessation local heat and cold packs. If not satisfactory can try TNF alpha.

Question 31

why does positive pressure ventilation help with decreased chest wall expansion and pectus excavatum and kyphoscoliosis and morbid obiesty?

Answer 31

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.

Question 32

bracing in adults who have severe kyphoscoliosis is

Answer 32

actively contraindicated in adults. only meant for immature adolescents

Question 33

findings of X rays of advanced AS

Answer 33

see fusion of lumbar spine as “bamboo” spine

Question 34

what is decreased chest wall expansion?

Answer 34

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.

Question 35

features that should make you suspect ankylosing spondylitis?

Answer 35

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

Question 36

what to look for on XR of the sacroiliac joints during work up for ankylosing spondylitis?

Answer 36

look for evidence of sclerosis

widening and narrowing or partial ankylosis of sacroiliac joints

Question 37

DISH vs Ankylosing spondylitis

Answer 37

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.