Podcast
Questions and Answers
What is the primary clinical feature associated with spondyloarthritis?
What is the primary clinical feature associated with spondyloarthritis?
Which type of spondyloarthritis primarily affects the extremities?
Which type of spondyloarthritis primarily affects the extremities?
What is the estimated adult prevalence of ankylosing spondylitis in the general population?
What is the estimated adult prevalence of ankylosing spondylitis in the general population?
Which histocompatibility antigen is strongly correlated with ankylosing spondylitis?
Which histocompatibility antigen is strongly correlated with ankylosing spondylitis?
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What is the initial symptom most commonly reported in patients after the age of 40?
What is the initial symptom most commonly reported in patients after the age of 40?
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What is an early manifestation of axial spondyloarthritis?
What is an early manifestation of axial spondyloarthritis?
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Which measurement method is used to evaluate lumbar spine flexion?
Which measurement method is used to evaluate lumbar spine flexion?
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What progression of the sacroiliac joint is observed in advanced stages of axSpA?
What progression of the sacroiliac joint is observed in advanced stages of axSpA?
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Which of the following areas is NOT commonly associated with bony tenderness in ax-SpA?
Which of the following areas is NOT commonly associated with bony tenderness in ax-SpA?
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Which genetic factors are implicated in the pathogenesis of ankylosing spondylitis?
Which genetic factors are implicated in the pathogenesis of ankylosing spondylitis?
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What is the typical range of increase in distance during the modified Schober test for normal mobility?
What is the typical range of increase in distance during the modified Schober test for normal mobility?
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At what median age do initial symptoms of ankylosing spondylitis typically present?
At what median age do initial symptoms of ankylosing spondylitis typically present?
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In a severe untreated case of ax-SpA, which posture change is most likely to occur?
In a severe untreated case of ax-SpA, which posture change is most likely to occur?
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What is the normal measurement for chest expansion in ax-SpA assessment?
What is the normal measurement for chest expansion in ax-SpA assessment?
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Which statement regarding the course of ax-SpA is accurate?
Which statement regarding the course of ax-SpA is accurate?
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Which factors typically affect the measurement of shoulder motion in patients with ax-SpA?
Which factors typically affect the measurement of shoulder motion in patients with ax-SpA?
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What is the most common extraarticular manifestation associated with ankylosing spondylitis (AS)?
What is the most common extraarticular manifestation associated with ankylosing spondylitis (AS)?
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Which of the following laboratory findings is most consistent with patients who may have ankylosing spondylitis?
Which of the following laboratory findings is most consistent with patients who may have ankylosing spondylitis?
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Which symptom is NOT commonly associated with inflammatory back pain (IBP) related to ankylosing spondylitis?
Which symptom is NOT commonly associated with inflammatory back pain (IBP) related to ankylosing spondylitis?
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Which of the following heart conditions is associated with ankylosing spondylitis?
Which of the following heart conditions is associated with ankylosing spondylitis?
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What radiographic finding is typically observed in the early stages of sacroiliitis in ankylosing spondylitis?
What radiographic finding is typically observed in the early stages of sacroiliitis in ankylosing spondylitis?
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What percentage of ankylosing spondylitis patients develop overt inflammatory bowel disease?
What percentage of ankylosing spondylitis patients develop overt inflammatory bowel disease?
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Which finding is most characteristic of the progression of spinal changes in ankylosing spondylitis?
Which finding is most characteristic of the progression of spinal changes in ankylosing spondylitis?
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Which extraarticular feature is least likely to be observed in patients with ankylosing spondylitis?
Which extraarticular feature is least likely to be observed in patients with ankylosing spondylitis?
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Study Notes
Spondyloarthritis (SpA)
- SpA is a group of overlapping disorders sharing clinical features
- Types of SpA include ankylosing spondylitis (AS), reactive arthritis (ReA), psoriatic arthritis (PsA), and arthritis associated with inflammatory bowel disease (IBD)
- The cardinal clinical feature is inflammation of the sacroiliac joints (sacroiliitis) and the spine (spondylitis)
- Also includes inflammation of tendon insertion sites (enthesitis), inflammation of entire digits (dactylitis), and inflammation of one to four lower extremity joints (oligoarthritis)
- Disorders are classified as predominantly axial SpA, affecting the spine, pelvis, and thoracic cage, or predominantly peripheral SpA, affecting the extremities
- Axial spondyloarthritis (axSpA) is the most common inflammatory disorder affecting the axial skeleton, with variable involvement of peripheral joints and extraarticular structures
- Estimated adult prevalence of AS is ~0.17% (range 0.02-0.5%)
- AS shows a strong correlation with the histocompatibility antigen HLA-B27
- In North American whites, the prevalence of B27 is 6%, whereas it is 80-90% in patients with AS
- Sacroiliitis is a typical early manifestation of axSpA, and with progression, the eroded joint margins are replaced by fibrocartilage regeneration and then by ossification
- The larger erosions, progressive sclerosis, and focal narrowing of the articular space are notable features at a slightly later stage
- Eventually, complete ankylosis of the synovial and ligamentous portions of the sacroiliac space on both sides is apparent. The sclerosis may diminish.
- In the spine, outer annular fibers are eroded and replaced by bone, forming early syndesmophytes that could lead to a "bamboo spine"
- HLA-B27 plays a direct role in SpA pathogenesis
- ERAP1 and ERAP2 play a role in AS pathogenesis
- Genes related to TNF pathways are involved
- Genes in the IL-23/IL-17 innate immune cells play roles
- Gut microbiota dysbiosis is also a factor
- Initial SpA symptoms are often noticed in late adolescence or early adulthood, typically during the mid-20s. Symptoms begin after age 40 in 5% of patients
Clinical Manifestations
- Initial symptoms are often insidious, sharp or dull, deep pain in the lower lumbar or gluteal region. Low-back morning stiffness may last for a few hours.
- Pain decreases with activity and returns following inactivity. Within few months, pain tends to be constant and bilateral.
- Nocturnal pain can occur frequently causing the patient to tend to wake up and move around.
- Bony tenderness (likely from enthesitis or osteitis) may accompany back pain or stiffness
Common sites of bony tenderness
- Costosternal junctions
- Spinous processes
- Iliac crests
- Greater trochanters
- Ischial tuberosities
- Tibial tubercles
- Heels
Specific Findings
- Loss of spinal mobility, restricted anterior and lateral flexion and extension of the lumbar spine, and chest expansion.
- Pain in sacroiliac joints may be evoked by direct pressure or stress on the joints
Diagnostic Testing
- No single lab test is diagnostic of SpA.
- HLA-B27 is found in 75-90% of patients in most ethnic groups.
- ESR and CRP are not always elevated.
- Mild anemia may be present.
- Rheumatoid factor (RF), anti-cyclic citrullinated peptide (CCP), and antinuclear antibodies (ANAs) are mostly absent unless caused by another condition. ANAs might appear with anti-TNF therapy.
Radiographic Findings
- Radiography often shows sacroiliitis, typically symmetric.
- Initial radiographic findings include blurred cortical margins of the subchondral bone, followed by erosions and sclerosis.
- Later stages can show "pseudowidening" of the joint space with fibrous and then bony ankylosis, which can lead to the joints becoming obliterated
- In the lumbar spine, loss of lordosis, osteitis of the anterior corners of the vertebral bodies with consequent erosion and bone formation can cause "squaring" or even "barreling" of vertebral bodies. Progressive ossification leads to the formation of marginal syndesmophytes, visible on plain films as bony bridges connecting vertebral bodies
- Specific criteria exist for diagnosis. MRI can often help distinguish various subtypes of the condition.
Clinical Features for Chronic (≥3 months) Back Pain
- Onset of symptoms at ≤40 years
- Insidious onset
- Improvement in symptoms with exercise
- Lack of improvement with rest
- Night pain improving when getting up
- Morning stiffness greater than 30 minutes
- Back pain waking usually only in the latter half of the night
- Alternating buttock pain
Diagnosis of AS
- Classification criteria for ax-SpA, proposed by ASAS, are applicable to individuals with at least three months of back pain and age of onset under 45. Specific criteria exist
Treatment of AS
- Management of SpA should include an exercise program to maintain posture and range of motion
- Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line pharmacological treatment, reducing pain, tenderness, and increasing mobility
- Continuous high-dose NSAID therapy can potentially slow radiographic progression. Biologic therapy with anti-TNF agents can be helpful for patients with persistent symptoms despite NSAIDS.
- Before starting anti-TNF therapy, patients should be tested and treated for latent tuberculosis (TB) and hepatitis B if found.
Contraindications to TNF Inhibitors
- Active infection or high risk of infection
- History of multiple sclerosis
- Prior history of hematologic malignancy
- Systemic lupus erythematosus (SLE) or other related autoimmunity
Treatment of Uveitis
- Uveitis attacks are generally managed with local glucocorticoids and mydriatic agents. Systemic glucocorticoids, immunomodulating drugs, or anti-TNF therapy may be needed, if necessary.
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