Textbook Reading

SPONDYLOARTHROPATHY

Presented By :
Wandry/Anggun/Nisa/Indra/Nizwan/Afifi

Advisors:
dr. Jansen
dr. Satria Prawira Putra
dr. Shandy Limansyahputra

Supervisor
Dr. dr. Karya Triko Biakto, Sp.OT(K)Spine

Orthopaedic and Traumatology Department

Medical Faculty of Hasanuddin University
Makassar
2016
Ankylosing Spondylitis
 Ankylosing Spondylitis
a chronic inflammatory disease characterized by a
variable symptomatic course & progressive involvement
of the sacroiliac and axial skeletal joints

Characteristics:
axial skeletal arthritis;
the absence of rheumatoid factor in serum (seronegative);
the lack of rheumatoid nodules;
the presence of a tissue factor on host cells, human
leukocyte antigen (HLA)-B27
 Epidemiology
Affects 1% to 2 % of whites
Genetic factor (HLA B-27)
:= 3:1
15 - 40 y.o.
 Pathogenesis

The pathogenesis of AS is unknown

Genetic predisposition to AS & to the seronegative
spondyloarthropathies in general exists.
Enthesitis = the hallmark that distinguish between
spondyloarthropathies from other arthritis
undergoes constant modification in response to
applied stress (target for inflammation)
 Pathogenesis

Characterized by ankylosis of joints and

ossification of ligaments surrounding the
vertebrae (syndesmophytes) and other
musculotendinous structure, such as the heels
and pelvis.
 Clinical History
Classic patient : man 15-40 y.o. with intermittent
dull low back pain
The associated stiffness is slowly progressive
(months-years)
Back pain (90-95% of patients) :
greatest in the morning
increased by periods of inactivity
Patients may have difficulty sleeping because of
pain & stiffness
 Clinical History

Flattening of the lumbal spine and loss of normal

lordosis are consistent with spinal involvement

Thoracic spine disease causes:

decreased motion at the costovertebral joints
reduced chest expansion
impaired pulmonary function
 Clinical History

The primary symptom of cervical spine disease is

neck stiffness and pain
Head protrude foward, making it difficult to look
straight ahead

Peripheral joint arthritis occur 30% of patient

 Neurologic Complications

Secondary to:
Atlantoaxial Subluxation due to immobilized state of
the calcified structures surrounding the spine
Spinal Fracture:
loss of normal flexibility
Spine more brittle and prone to fracture
Most common location is cervical
Spondylodiscitis a destructive lesion of the disc and its
surrounding vertebral bodies
 Extra-articular Manifestation
Constitutional manifestations of disease:
Fever
Fatigue
Weight loss
Iritis (inflammation of the ant. uveal tract of the eye)
Cardiac involvement
Proximal aortitis
Pulmonary involvement
Decreased chest expansion
 Physical Examination

Lumbosacral spine may found limitation of motion

of the axial skeleton (lateral bending or
hyperextension)

Percussion over the sacroiliac joints elicits pain in

most circumstances
 Physical Examination
Sacroiliac joint dysfunction test:
FABER maneuver (flexion abduction and external
rotation of the hip)
Gaenslen test (pressure on a hyperextended thigh with
a contralateral flexed hip),
Yoemans test (hyperextension of the thigh with a
prone patient)
Distraction of the pelvic wings anteriorly and
posteriorly.
 Physical Examination
Measurements of spinal motion, including:
Schober test (lumbar spine motion)
lateral bending of the lumbosacral spine
occiput to wall (cervical spine motion)
chest expansion

Asses limitation of motion and following progression of the

disease
 Physical Examination

Cervical spine evaluation includes measurement of

all planes of motion.
Chest expansion measure by asking patient to raise
their hand over the head and ask to take a deep
breath (normal chest expansion 2.5 cm)
Examination of the eyes, heart, lungs, and nervous
system may uncover unsuspected extra-articular
disease.
 Laboratory Data

Laboratory results are nonspecific & add little to

the diagnosis of AS.
Rheumatoid factor and antinuclear antibody are
characteristically absent.
The erythrocyte sedimentation rate is increased in
80% of patients with active disease.
 Laboratory Data

Histocompatibility testing (for HLA) is positive in

90% of AS patients but is also present in an
increased percentage of patients with other
spondyloarthropathies

It is not a diagnostic test for AS

 Radiographic Evaluation

The areas of the skeleton most frequently affected

include:
Sacroiliac
Apophyseal
Discovertebral
Costovertebral joints
 Radiographic Evaluation

Evaluation of the sacroiliac joints is difficult on a

conventional anteroposterior supine view of the
pelvis because of bony overlap and the oblique
orientation of the joint.

A Ferguson view of the pelvis (x-ray tube tilted 15

to 30 degrees in a cephalad direction) provides a
useful view of the anterior portion of the joint,
the initial area of inflammation in sacroiliitis.
 Radiographic Evaluation

Radiographic evaluation of the sacroiliac joints is

based on five observations :
(1) distribution,
(2) subchondral mineralization,
(3) cystic or erosive bony change,
(4) joint width
(5) osteophyte formation.
 Radiographic Evaluation
In the lumbar spine osteitis
affecting the anterior corners
of vertebral bodies is an early
finding
The inflammation associated
with osteitis causes loss of
the normal concavity of the
anterior vertebral surface,
resulting in a squared body
 Radiographic Evaluation

osteopenia of the calcification of disc

and ligamentous syndesmophytes Bamboo spine
bony structures
Diagnostic Criteria
 Treatment
Goal therapy:
Control pain & stiffness
Reduce inflammation
Maintain function
Prevent deformity
 Treatment
NSAIDs
Cyclooxygenase Inhibitors
Muscle Relaxants
Corticosteroids
Anti-Tumor Necrosis Factor- Inhibitors
 Prognosis

AS is benign
It is characterized by exacerbation & remissions
Patient with total fusion of spine -> may feel better
In a study of 1492 patients for 2 years the frequency
of patients with a total remission of disease was
less than 2%
Psoriatic Arthritis
 Psoriatic Arthritis

Patients with psoriasis who develop a characteristic

pattern of joint disease have psoriatic arthritis
Prevelance: 1% - 3% of the population
 Clinical Manifestation

Distal interphalangeal joints and assosiated with nail

disease
Asymmetrical oligoarthritis ( large & small joints
involved )
Dactylitis (diffuse swelling of a digit)
Percussion over the sacroiliac joints can elicit symptoms
over the affected side
limitation of motion in cervical spine -> primary
manifestation of neck involvement
 Radiology
Asymmetrical involvement of
the vertebral bodies
Non-marginal
syndesmophytes
Sacroiliitis: unilateral or
bilateral
Alterations in the cervical
spine:
joint space sclerosis
narrowing
anterior ligamentous
calcification
 Treatment

Treatment of psoriatic arthritis is similar to

treatment of RA
Immunosuppressive agents and TNF- inhibitors are
indicated for the treatment of peripheral arthritis
This disease should be treated early and
aggressively
Reactive Arthritis
 Reactive Arthritis

Reactive arthritis is associated with an infectious

agent causing an aseptic inflammation in joints
and other organs.

This disorder has been associated with the triad of

urethritis, arthritis, and conjunctivitis formerly
referred to as Reiter syndrome, a form of reactive
arthritis
 Reactive Arthritis

Reactive arthritis is the most common cause of

arthritis in young men and primarily affects the
lower extremity joints and the low back

The disease results from the interaction of an

environmental factor, usually a specific infection,
and a genetically predisposed host.
 Epidemiology

The male-to-female ratio in venereal infection is

10:1, and the ratio is 1:1 in large outbreaks
secondary to enteric infection.

Reactive arthritis is associated with HLA-B27 in

60% to 80% of individuals
 Clinical History
Classic patient : man about 25 y.o who develops
urethritis & a mild conjunctivitis, followed by the
onset of a predominantly lower extremity
oligoarthritis
Arthritis may occur 1-3 weeks after the initial
infection. In many patients, arthritis is the only
manifestation of disease.
Back pain is a frequent symptom of patients with
reactive arthritis.
 Physical Examination

On examination, men tend to have involvement in

the knees, ankles, and feet, and women have
more upper extremity disease.
Percussion tenderness over the sacroiliac joints
may be unilateral, correlating with asymmetrical
involvement in reactive arthritis.
 Prognosis
A self-limited illness, lasting 3 months to 1 year,
occurs in 30% to 40% of patients.
Another 30% to 50% develop a relapsing pattern of
illness with periods of complete remission.
The final 10% to 25% develop chronic, unremitting
disease associated with significant disability.
Enteropathic Arthritis
 Enteropathic Arthritis
Inflammation of the gut (ulcerative bowel dis. &
Crohn dis.) associated with extraintestinal
manifestations (include arthritis) peripheral &
axial skeleton joints
Articular involvement in inflammatory bowel
disease is divided into two forms:
Peripheral
Spondylitic
 Clinical Symptom
Ulcerative Coilitis Crohn Disease
Early: Generalized fatigue:
frequent bowel movements mild nonbloody diarrhea
with blood or mucus Anorexia
weight loss
Mild: cramping lower abdominal
abdominal pain pain
few bowel movements per day

Severe Disease:
Fatigue
weight loss
fever
extracolonic involvement
 Enteropathic Arthritis
Axial skeleton involvement in ulcerative colitis and
Crohn disease is similar.
Spondylitis antedates bowel disease in about one
third of patients (10-20 yrs)
The clinical and radiographic findings are similar to
findings of AS, including involvement of shoulders
and hips.
 Radiology
The radiographic changes of
spondylitis in inflammatory
bowel disease:
squaring of vertebral bodies
Erosions
widening
fusion of the sacroiliac joints
Symmetrical involvement of
sacroiliac joints
marginal syndesmophytes
involving the lumbar, thoracic,
or cervical spine
 Diagnose

pattern of peripheral arthritis:

upper extremity disease is uncommon in AS and reactive
arthritis
bilateral ankle arthritis is uncommon in psoriatic disease
erythema nodosum
iritis
 Treatment

similar to therapy for classic AS

TNF- inhibitors are effective agents for the bowel
and articular disease
 Prognosis

Depend on the severity of bowel disease

Severe ulcerative coilitis: mortality rate of
10%-20% >5 years.
Risk of developing cancer of the colon:
severe initial attack
continuous clinical activity Ulcerative coilitis

involvement of the entire colon

Crohn disease-> frequent reccurence
(mortality rate is lower than ulcerative coilitis)
Diffuse idiopathic skeletal hyperostosis
(DISH)
 Diffuse idiopathic skeletal
hyperostosis
another disease that may occur in the setting of
spondylitis.
Patients with AS and DISH should be easily
differentiated by careful radiographic evaluation
 Radiology
DISH may cause alterations
of the sacroiliac joints.
CT of the sacroiliac joints
differentiates the
hyperostotic joint changes
from changes associated
with joint erosion and
fusion.
 Diffuse idiopathic skeletal
hyperostosis
Also of note is the occurrence of fracture in
patients with DISH and patients with AS. The
convergence of two common diseases in the same
host, a middle-aged man, is likely. The occurrence
of AS and DISH of the cervical spine has been
reported.
Differential Diagnosis
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