Spondyloarthritis
Spondyloarthritis
Spondyloarthritis
30
3 .
2/3 criteria are fulfilled, sensitivity is 70% and specificity is 81% (positive likelihood ratio 3.7). 3/4criteria are fulfilled, sensitivity is 33% and specificity is 98% (positive likelihood ratio 12.4).
4/5 criteria are fulfilled, sensitivity is 77% and 80%, specificity is 92% and 72%, in the patients participating in the workshop and the validation cohort
Psoriasis : past or present, diagnosed by a physician Inflammatory bowel disease : past or present
Crohn s disease or ulcerative colitis diagnosed by a physician and confirmed by radiographic examination or endoscopy
Buttock pain alternating between right and left gluteal Enthesopathy : past or present spontaneous pain or
tenderness at sites of insertion of the Achilles tendon or plantar fascia
Classification
Ankylosing spondylitis (AS) Psoriatic arthritis Reactive arthritis (Reiter s syndrome) Arthritis associated with inflammatory bowel disease Undifferentiated spondyloarthritis
Chest pain
Thoracic spine (including costovertebral and costotransverse joints) and enthesopathy at the costosternal and manubriosternal joints Accentuated by coughing or sneezing (pleuritic) Reduction of chest expansion HLA-B27positive relatives
Enthesitis
Costosternal junctions Spinous processes iliac crests, greater trochanters, ischial tuberosities, tibial tubercles Heels (Achilles tendinitis, plantar fasciitis)
Extraskeletal manifestations
Eye disease = Acute anterior uveitis or iridocyclitis (most common)
Cardiovascular
Ascending aortitis Aortic valve incompetence (AR) Conduction abnormalities, cardiomegaly, and pericarditis. Occur twice as often in patients with peripheral joint involvement
Pulmonary
Rare and Late manifestation (average 2 decades after the onset) Slowly progressive fibrosis of the upper lobes of the lungs (HRCT) Cough, Dyspnea, and sometimes Hemoptysis
Pulmonary
Ventilation is usually well maintained Vital capacity and total lung capacity may be moderately reduced (consequence of the restricted chest wall movement) Residual volume and functional residual capacity are usually increased
Neurologic
Caused by fracture, instability, compression, or inflammation (Arachnoiditis / arachnoid adhesions) Atlantoaxial joint subluxation, atlanto-occipital subluxation (2% commonly in patients with peripheral
arthritis)
Renal
IgA nephropathy (35%) and Renal impairment (27%) Amyloidosis (secondary type)
Osteoporosis
Falsely high BMD : presence of syndesmophytes Quantitative CT Increased occiput-to-wall distance is associated with vertebral fractures Specific therapy to prevent osteoporotic spinal fractures is effective
99.1% but in very early PsA (average disease duration 15.8 weeks) the sensitivity was only
New Spondyloarthritis
Predominantly axial SpA with or without peripheral manifestation Predominantly peripheral SpA
Axial SpA
New concept structural approach Early detection
Assessment of SpondyloArthritis international Society (ASAS) criteria for axial SpA A probability approach based on likelihood ratios Evidence to the validity of inflammation of the SI joints on MRI as an important finding in early axial SpA MRI to the SI joint a sensitivity and specificity of around 90% each has been estimated
Sensitivity 82.9%, specificity 84.4% Imaging arm (sacroiliitis) alone has a sensitivity of 66.2% and a specificity of
97.3%.
SpA feature
Inflammatory back pain(IBP):at least 4 out of 5 1. age at onset <40 yrs 2. 3. 4. 5. insidious onset improvement with exercise no improvement with rest pain at night (with improvement upon getting up)
SpA feature
Arthritis : past or present active synovitis diagnosed by a physician Enthesitis (heel) : past or present spontaneous pain or tenderness at examination of the site of the insertion of the Achilles tendon or plantar fascia at the calcaneus
SpA feature
Uveitis : Past or present uveitis anterior, confirmed by an ophthalmologist Dactylitis : Past or present dactylitis, diagnosed by a physician Psoriasis : Past or present psoriasis, diagnosed by a physician Inflammatory bowel disease : Past or present Crohn s disease or ulcerative colitis diagnosed by a physician
SpA feature
Good response to NSAIDs : 2448 hours after a full dose of NSAID the back pain is not present anymore or much better Family history for SpA : Presence in firstdegree (mother, father, sisters, brothers,children) or seconddegree (maternal and paternal grandparents, aunts, uncles, nieces, and nephews) relatives of any of the following : (1) ankylosing spondylitis, (2) psoriasis, (3) acute uveitis, (4) reactive arthritis, (5) inflammatory bowel disease
SpA feature
Elevated CRP : C-reactive protein concentration above upper normal limit in the presence of back pain after exclusion of other causes HLA-B27 : Positive testing according to standard laboratory techniques
Peripheral SpA
Peripheral SpA
Peripheral manifestations only
Peripheral arthritis and/or Enthesitis and/or Dactylitis
Usually began before 45 years ESSG and Amor criteria in early 1990s
Not specifically for peripheral SpA
Peripheral SpA
Entry criteria
Current arthritis compatible with SpA
usually asymmetric and/or predominant involvement of the lower limb
Enthesitis
Uveitis Dactylitis
Past or present uveitis anterior, confi rmed by an ophthalmologist Past or present dactylitis, diagnosed by a doctor
Psoriasis
HLA-B27
Sacroiliitis by imaging
Bilateral grade 24 or unilateral grade 34 sacroiliitis on plain radiographs, according to the modifi ed New York criteria, or active sacroiliitis on MRI according to the ASAS consensus defi nition
2 sets of criterias
Sensitivity 79.5% Specificity 83.3%
Sacroilitis
widening, erosions, sclerosis, or ankylosis Grade 0: normal Grade 1: suspicious changes Grade 2: minimal abnormality small localized areas with erosions or sclerosis, without alteration in the joint width Grade 3: unequivocal abnormality moderate or advanced sacroiliitis with one or more of: erosions, evidence of sclerosis, widening, narrowing, or partial ankylosis Grade 4: severe abnormality total ankylosis
1. concentric joint space narrowing and collar osteophytes (black arrows) 2. whiskering or new bone formation at multiple entheses (white arrowheads).
flattening of the anterior surface of the L2 vertebral body (black arrows). A Romanus lesion is seen at the inferior corner/rim of the T12 vertebral body (white arrow).
Squaring vertebra
a small erosion (Romanus lesion) at the anterior corner/rim of the L3 vertebral body (arrow). There is also adjacent sclerosis or a shiny corner (arrowheads).
Bamboo spine
1.ossification of the interspinous ligament :dagger sign (arrowhead). 2.ankylosis of the facet joints resulting in the tram track sign (arrows) paralleling the dagger sign
Enthesitis
MRI
Active inflammatory lesions such as bone marrow oedema (BMO)/ osteitis, synovitis, enthesitis and capsulitis associated with SpA can be detected by MRI. Among these, the clear presence of bone marrow oedema/osteitis was considered essential for defining active sacroiliitis. Structural damage lesions such as sclerosis, erosions, fat deposition and ankylosis can also be detected by MRI.
Assessment
BASDAI