Spondyloarthritides

Col Sharif Mohammad Rezaul Masud

MBBS, FCPS (Medicine)
Classified Specialist in Medicine
CMH Bogura
 Introduction
The spondyloarthritides comprise a group of
related inflammatory diseases that show overlap
in their clinical features and have a shared
immunogenetic association with HLA-B27.
The spectrum of spondyloarthritis (SpA)
includes:
 axial spondyloarthritis (axSpA) comprising:
 non-radiographic SpA (nr-axSpA)
 radiographic axSpA (ankylosing spondylitis [AS])

 reactive SpA
 psoriatic arthritis
 arthritis with inflammatory bowel disease
(enteropathic SpA).
Features common to all spondyloarthritides
Asymmetrical inflammatory oligoarthritis (lower >
upper limb)
History of inflammatory back pain
Sacroiliitis
Osteitis (bone marrow oedema on MRI)
Enthesitis (Achilles’ tendonitis, plantar fasciitis)
Dactylitis
Family history common
HLA-B27 association
Psoriasis (of skin and/or nails)
Uveitis
Sterile urethritis and/or prostatitis
Infammatory bowel disease
Aortic root lesions (aortic incompetence,
conduction defects)
In axSpA the axial skeleton is predominantly
affected.
In contrast to RA, in SpAs there are frequent and
notable non-synovial musculoskeletal lesions –
mainly inflammatory in nature – of ligaments,
tendons, periosteum and other bone lesions.
A hallmark lesion of SpAs is enthesitis, which is
inflammation at the site of a ligament or tendon
insertion into bone.
Dactylitis, inflammation of a whole finger or toe, may
also occur
There is a striking association with HLA-B27,
particularly for AS (> 95%).
For AS there is a male-to-female ratio of about 3:1.
 Axial spondyloarthritis
Axial spondyloarthritis (axSpA) is the
diagnostic term that includes patients
with
non-radiographic axial SpA (nr-axSpA)
and
ankylosing spondylitis (AS; also termed
radiographic axSpA,).
Classification criteria for axial spondyloarthritis (ASAS)

In patients with > 3 months’ back pain and age

at onset < 45 years, either A or B is present:
A: Sacroiliitis on imaging* plus ≥ 1 SpA feature
B: HLA-B27 plus ≥ 2 SpA features
SpA features are:
Inflammatory back pain
Crohn’s/colitis
Arthritis
Good response to NSAIDs
Enthesitis (heel)
SpA family history
Uveitis
HLA-B27
Dactylitis
Elevated CRP
Psoriasis
Sacroiliitis on imaging’ here is defined as either
active (acute) inammation on MRI highly
suggestive of sacroiliitis associated with SpA
or
Definite radiographic sacroiliitis according to the
modified New York criteria.
Inflammatory changes in the axial skeleton (such
as sacroiliitis) are characteristic of axSpA and
are visualised by MRI.
Radiographic alterations, such as new bone formation
with syndesmophytes and ankylosis, develop later in
the course of the disease and, by definition, are not
present in patients with nr-axSpA.
 Pathophysiology
Axial SpA arises from an interaction between
environmental pathogens and the host immune system
in genetically susceptible individuals.
Increased faecal carriage of Klebsiella aerogenes has
been reported in patients with AS and may relate to
exacerbation of both joint and eye disease.
There is evidence that axSpA is due to an abnormal
host response to the intestinal microbiota with
involvement of Th17 cells, which have a key role in
mucosal immunity.
This leads to production of various inflammatory
cytokines, including IL-23, IL-17 and TNF-α, which
play vital roles in the pathogenesis of enthesitis and
other inflammatory lesions.
 Clinical features
The cardinal feature of axSpA is inflammatory back
pain and early morning stiffness, with low back pain
radiating to the buttocks or posterior thighs if the
sacroiliac joints are involved.
Symptoms are exacerbated by inactivity and relieved
by movement.
Musculoskeletal symptoms may be prominent at
entheses, may be episodic and, if persistent, can
present as widespread pain and be mistaken for
fibromyalgia.
Axial
spondyloarthritis/ankylosing
spondylitis targets the spine,
sacroiliac joints, entheses and
large peripheral joints in a
asymmetrical pattern.
Fatigue is common.
A history of psoriasis (current, previous or in a first-
degree relative) and inflammatory bowel symptoms
(current or previous) are important clues.
A few patients develop marked kyphosis of the dorsal
and cervical spine that may interfere with forward
vision.
Physical signs
Reduced range of lumbar spine movements in all
directions, pain on sacroiliac stressing and a high
enthesitis index.
Entheses that are typically affected include Achilles’
insertion, plantar fascia origin, patellar ligament
entheses, gluteus medius insertion at the greater
trochanter and tendon attachments at humeral
epicondyles.
Acute anterior uveitis is the most common extra-
articular feature,
 Extra-articular features of axial
spondyloarthritis
Fatigue, anaemia
Anterior uveitis (25%)
Prostatitis (80% of men) and sterile urethritis
Inflammatory bowel disease (in up to 50%)
Osteoporosis
 Osteoproliferation and osteosclerosis
Cardiovascular disease (aortic valve disease 20%)
Amyloidosis (rare)
Atypical upper lobe pulmonary fibrosis (very rare)
 Investigations
FBC
Anaemia
Raised ESR and CRP (although these can be
normal)
X-rays
Ultrasound or MRI of entheses.
MRI of the sacroiliac joints and spine.
HLA-B27 positive.
Faecal calprotectin- inflammatory bowel disease.
DXA scanning or vertebral quantitative CT for
fragility fracture assessment.
# MRI is more sensitive for detection of early
sacroiliitis than X-rays and can also detect
infammatory changes in the lumbar spine. #
X-rays
In AS, X-rays of the sacroiliac joint show
Irregularity and loss of cortical margins
Widening of the joint space and subsequently
sclerosis.
Joint space narrowing and fusion.
Lateral thoracolumbar spine X-rays may show
Anterior ‘squaring’ of vertebrae due to erosion and
sclerosis of the anterior corners and periostitis of
the waist.
Bridging syndesmophytes may also be seen.
In advanced disease, ossification of the anterior
longitudinal ligament and facet joint fusion may
also be visible.
The combination of these features may result in the
typical ‘bamboo’ spine.
Erosive changes may be seen in the symphysis pubis,
ischial tuberosities and peripheral joints.
Osteoporosis is common and vertebral fractures may
occur.
Atlanto-axial dislocation can arise as a late feature.
 Management
Patient education.
NSAID use (optimally, once daily or slow
release taken at bedtime).
Physical therapy.
For severe and/or persistent peripheral joint
involvement, both SSZ and MTX are reasonable
therapy choices.
These medications have no impact on spinal
symptoms or disease progression.
Biologic therapy
In patients who fail to respond adequately or
who cannot tolerate NSAIDs
Antibody to TNF-α
Inflixmab
Adalimumab
Certolizumab
Golimumab
Antibody to IL-17A
Secukinumab
Ixekizumab
Anti-TNFα therapy is effective for both the axial and
peripheral lesions of axSpA.
Local glucocorticoid injections can be useful for
persistent plantar fasciitis, other enthesopathies and
peripheral arthritis.
Oral glucocorticoids may be required for acute
uveitis, but do not help spinal disease.
Severe hip, knee or shoulder arthritis with secondary
OA may require arthroplasty.
In AS, spinal osteotomy, to correct stoop and make
eyeline/posture ‘more normal’, can make a significant
difference to patients with severe ankylosed kyphotic
spines.
Prognosis
axSpA can remain mild and/or episodic in many
patients for many years but persistently high
inflammatory markers and functional incapacity are
markers of a poor outcome.
Over 75% of patients with AS are able to remain in
employment and enjoy a good quality of life.
Even if severe ankylosis develops, functional
limitation may not be marked, as long as the spine is
fused in an erect posture.