SPONDYLOARTROPATHIES Prof. Dr. Şansın Tüzün

Definition A family inflammatory arthritides characterized by involvement of both synovium and entheses leading to spinal and oligoarticular peripheral artritis,principally in genetically predisposed (HLA B27 +) individuals İnfective causes are considered likely Ankylosing spondylitis, reactive arthritis, Psöriatic arthritis and enteropathic arthritis are the principle clinical entities

Clinical Features Sacroiliitis or spondylitis may be dominant clinical problem Peripheral arthritis is typically asymmetric and involves the lower limb Entesopathy is prominent at both axial and peripheral skeletal sites

Inflammatory bowel disease-overt or covert-is common Extra-articular features, including uveitis,carditis,skin and mucous membrane lesions,occur in the minority Patients are seronegative for rheumatoid factor HLA-B27 is present in most individuals

Classification Criteria for Spondiloarthropathy İnflammatory or Synovitis spinal pain Asymmetric, Predominantly in lower limbs Add one or more of the following

Positive family history (AS, Psöriasis, Uveitis, reactive arthritis,inflammatory bowel disease) Urethritis or cervicitis(nongonococcal), or acute diarrhea Buttock pain Enthesopathy Sacroiliitis

Enthesopathy Pathologic alteration at an enthesis(a site of insertion of a tendon or ligament into bone Manifests radiographically as ossification of entheses Primer entesopathy (lat. Epicondylit, med. Epicondylit) Sekonder entesopathy (with spondyloarthropathies)

ANKYLOSING SPONDYLITIS Chronic systemic inflammatory disorder that mainly affects the axial skeleton Sacroiliitis is its hallmark Strong genetic predisposition with HLA-B27 Primary; idiopathic

Clinical features Typical presentation, is with low back pain of insidious onset Age less than 40 years Persistance for more than three months Morning stiffness İmprovement with exersize Arthritis of hips, shoulders and entesopathies are common Limitation of spinal mobility

Radiologic Findings Squaring of the vertebral bodies Bamboo spine Osteopenia Bilateral sacroiliitis

Acute anterior uveitis as an extra-articular manifestation With psöriasis,chronic inflammatory bowel disease, reactive arthritis in some patients Good symptomatic response to NSAID

Physıcal Examination Muscle spasm and loss of the normal lordosis Mobility of the lumber spine is decreased symmetrically in both anterior and lateral planes Lomber schober < 3 cm

Peripheral joint involvement(%20-%30) hip-shoulder,especially Enthesopathic features;plantar fasciitis achilles,tendinitis

Laboratory Findings HLA-B27 (90%) (should not be used as a routine screening procedure) ESR is frequently but not invariably elevated There are no pathognomotic tests

New york Criteria For AS 1-Presence of history of pain at dorsalumbar junction or in lumber spine 2-Limitation of motion in anterior flexion, lateral flexion and extension 3-Limitation of chest expansion to 2.5 cm or less at the fourth intercostal space

Requirements Either one positive radiographs and one or more clinical criteria, or grade 3-4 unilateral or grade 2 bilateral sacroiliit with clinical criterion 2 or with clinical criteria 1 and 3

In Turkey 1436 persons studied, all of them were males and in 2 of them AS found HLA-B 27 of these people are not studied The prevelance of AS was %0.14 In Canada this ratio was %6.20

Management Early diagnosis, patient education and physical therapy are essential for the successful management of AS The goals of physical therapy- to restore and maintain posture and movement to as near normal as possible

Self-management with exercises must be continued on a lifelong basis NSAID relieve pain and stiffness and facilitate pyhsical therapy Sulfasalazine appears to be the most effective of the second-line drugs

Comparison Of Spondyloarthropathies AS Reiter PA Intestinal A. Sex M>F F>M F=M Onset >20 Any age Uveitis + ++ Peripheral joints Lower limb often Lower limb usually Upper>lower lower> upper

AS Reiter PA Intestinal artrit Sacroiliitis always often Plantar spurs common ? HLA-B27 90% 20% 5% Enthesopathy + +? Response to therapy +++ ++ urethritis - Conjunctivities Skin inv Spine inv Symmetry