1. SPONDYLOARTROPATHIES
Prof. Dr. Şansın Tüzün

2. 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

3. 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

4. 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

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

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

7. 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)

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

11. 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

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

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

22. 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

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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

37. Comparison Of SpondyloarthropathiesAS
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

38. 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