Flags Psychosocial Serious pathology Employment Can’t emphasise their importance enough A test is no substitute for history
Rheumatological TL spine problems CANCER SEPSIS Inflammatory spinal disease – Ankylosing spondylitis – Psoriatic – Enteropathic – Reactive – Seronegative Fibromyalgia “Normal” back pain Fracture Crystal Rheumatoid Neurological Medical
Cancer and sepsis Symptoms Night pain Weight loss Unwell Fever Who gets Anyone Sepsis – Extremes of age – Diabetes – IVDU Cancer – Old age – Previous cancer
Seronegative (spondylo)arthropathies Common in same family Some shared genes E.g. B27 and spinal disease Axial involvement common Spondylitis Psoriatic SAPHO Enteropathic Undifferentiated Acne related Reiter’sASAS
Nature of the beast A disease of entheses Shared genetic background Body surface antigen exposure? – Psoriasis – Bowel inflammation – Elevated IgA levels Iritis/conjunctivitis
Ankylosing spondylitis Enthesis – Specialised tissue – Site where ligaments/tendon insert into bone
Some myths & corrections M:F 15:1M:F 3:1 X-rays diagnosticImaging a problem B27 helpful1% 6% Diagnosis easy4½ years AscendingNeck especially women
Differential All the seronegatives are variants on each other Don’t worry about the subtypes It’s the history stupid!
Diagnosing Ankylosing spondylitis ASAS Active (acute) inflammation on MRI, highly suggestive of SpA sacroiliitis Definite radiographic sacroiliitis Inflammatory back pain, arthiritis, enthesitis Uveitis, dactylitis, psoriasis, Crohn's disease (ulcerative colitis) Good response to NSAIDs Family history of SpA, Elevated CRP. Sacroiliitis on imaging + ≥ 1 Clinical feature HLA B27 + ≥ 2 Clinical features
The Diagnosis History Examination Non-specific tests Specific tests Diagnostic tests – very few
History Inflammatory back pain > 30 mins Worse on holiday Better at work especially if manual Worse in evenings It’s the history stupid!
HLA B27 Present in 5% of population Overall risk of AS ≈ 1% B27 positive ≈ 6% 1 st degree relative AS and B27 + 30% Depends on racial group Genotype different to phenotype Generally not a good test – but note ASAS