Seronegative Spondyloarthropathies SpA

1. Seronegative SpondyloarthropathiesSpA Prof. ECE AYDOĞ Physical Medicine and Rehabilitation

2. Learning objectives: 1. be able to enumerate diseases in Spa group and describe common characteristics of Spa, differentiate diagnosis of inflammatory low back pain . 2. • be able to describe epidemiology and pathogenesis of ankylosing spondylitis • be able to enumerate articular and extraarticular finding of ankylosing spondylitis • be able to diagnose ankylosing spondylitis with the laboratory and imaging methods • be able to enumerate pharmacological and non pharmacological treatments of ankylosing spondylitis

3. Learning objectives: • 3. be able to enumerate clinical types, poor prognostic criteria and pharmacological treatment approaches of psoriatic arthritis. • 4. be able to enumerate clinical features, diagnostic and therapeutic approach of reactive arthritis and enteropathic arthritis.

4. Seronegative SpondylarthropathyRheumatoid Factor is negative HLA B27 positive

5. HLA-B27 associated spondyloarthropathies • Ankylosing spondylitis • Undifferentiated spondyloarthopathy • Reactive arthritis • Arthritis associated with inflammatory bowel disease (IBD) • Psoriatic spondyloarthritis • Juvenile enthesitis-related arthropathy • Iritis

6. Common features of spondylarthropathies • Familial clustering • Association with HLA-B27 • Axial joint involvement • Asymmetrical peripheral joint involvement • Enthesitis (the insertion of tensile connective tissue into bone). • Extra-articular signs • Negative rheumatoid factor

16. New Classification Criteria for SpA(ASAS) • (to be applied in patients with chronic back pain ≥ 3 months and age at onset of back pain<45 years) • the presence of sacroiliitis by radiography or by magnetic resonance imaging (MRI) plus at least one SpA feature ("imaging arm") • or the presence of HLA-B27 plus at least two SpA features ("clinical arm")

17. SpA features • Inflammatory back pain • Arthritis • Enthesitis (heel) • Uveitis • Dactylitis • Psoriasis • Crohn’s/colitis • Good response to NSAIDs • Family history for SpA • HLA-B27 • Elevated CRP

18. New Classification Criteria for ASASAS • Sensitivity: 82.9% • Specificity: 84.4% • ESSG kriterlerinden daha iyi

19. ANKYLOSİNG SPONDYLİTİS AS

20. Clinical Picture

21. ankylos; bent spondylos; vertebrae • Ankylosing spondylitis (AS) from Greek • Bechterew's disease, • Bechterew syndrome, • Marie Strümpell disease • Vladimir Bechterew of Russia in 1893, • Adolph Strümpell of Germany in 1897, and • Pierre Marie of France in 1898

22. Ankylosing Spondylitis • Chronic, systemic inflammatory disorder of the axial skeleton • Sacroiliitis is hallmark of the disease • Spondylous-spine • Strong genetic predisposition (HLA-B27)

23. Ankylosing Spondylitis • Commonest of SPA • Prevalence 0.2 - 0.86% • Male>female • About 90% of the patients express the HLA-B27 genotype. • Tumor necrosis factor-alpha (TNF α) and IL-1 are also implicated in ankylosing spondylitis.

24. Pathology • Axial joints • Largeperipheral joints • Entheses Inflammation;in subchondral bone marrow Reparation;development of chondroid metaplasia, followed by calcification of cartilage and formation of bone, particularly in the axial joints.

25. Pathology- Sacroiliac Joint • MRI reveals inflammation in the posteroinferior capsular region and subchondral bone of the synovial portion of the joint: • cellular infiltration with lymphocytes, macrophages, and plasma cells in the synovium and subchondral marrow as the earliest features of disease

26. Pathology-Sacroiliac Joint • Later features include the development of pannus extending from both synovium and subchondral bone marrow, with erosion of articular cartilage (widening of the joint space) and its replacement by granulation tissue

27. Pathology-Sacroiliac Joint • Reparative changes include cartilage metaplasia at sites of active inflammation, followed by its calcification and then replacement by endochondral bone, leading to obliteration of the joint space by ankylosis

28. Pathology-Spine • Chronic inflammation (lymphocytes, plasma cells, and macrophages) leads to resorption of bone (first observed in the outer annulus fibrosus, particularly at its insertion into the rim of the vertebral end plate). • This, followed by reparative changes in adjacent trabecular bone and bone apposition on the waist of the vertebral body during postinflammatory remodeling, accounting for the squaring and shining corner appearance on plain radiography

29. Pathology- Spine • Cartilage metaplasia of granulation tissue is followed by its calcification and then replacement by bone at the vertebral margin and in the outer annulus. • This extends across the vertical length of the disk, eventually leading to complete bony fusion of adjacent vertebrae and the appearance of a syndesmophyte on plain radiography.

31. Pathology-Spine • Extensive involvement of the entire spine results in the “bamboo spine” appearance on plain radiography. • The process of inflammation may also involve the central portion of the disk, which is best seen on MRI as spondylodiscitis.

32. Pathology- Spine Ankylosis in the apophyseal joints Ankylosis in the adjacent intervertebral disk Enthesitis: Costotransverse and costovertebral joints Supraspinous and intraspinous ligaments

33. Tenderness at : Achilles insertion Costochondral junctions Ischial tuberosities Enthesitis

34. Skeletal manifestations • Back pain insidious in onset • First clinical manifestation in 75%

35. Skeletal manifestations • Pain early is quite severe and aggravated by coughing, sneezing or sudden twisting • Felt deep in gluteal region and hard to localize • Worsen after prolonged periods of inactivity

36. Skeletal manifestations Chest pain • Costevertebral, • Costasternal, • Manubriosternal joints involvement (Enthesopathy)

37. Skeletal manifestations Extra-articular tenderness (Enthesopathy) Joints involvement • girdle or “root” joints (hips and shoulders) (up to %35) • knee joints, • temporomandibuler joints

38. Ankylosing SpondylitisExtra skeletal manifestations • Eye disease • Iritis %25-30 • Cardiac abnormalities%3.5 • Aortic valve imcompetence • Cardiac conduction disturbances • Pulmonary disease • Pulmonary apical fibrosis • Neurologic involvement • Spinal fracture, instability, compression, or inflam. • Atlantoaxial subluxation • Myelopathy • Cauda equina syndrome

39. Ankylosing SpondylitisExtra skeletal manifestations Renal involvement • Ig A nephropathy • Microscopic hematuria • Proteinuria • Amyloidosis Osteoporosis

40. Physical findings Spinal Mobility • Limitation of motion of the lumbar spine • Loss of normal lumbar lordosis

41. Modified Schober’s test of lumbar flexion

42. Physical findings Chest expansion • Reduction below 5 cm • Level of the 4 . intercostal space in males, and just below the breasts in females. • The amount of chest expansion is measured from deep expiration to full inspiration.

43. Tenderness at : Achilles insertion Costochondral junctions Ischial tuberosities Enthesitis

44. Sacroiliitis • Sacroiliac pain is often found in the early stage of AS. • Gaenslen, Mennel, Thrust, Patrick (Faber) test • These maneuvers stresses the sacroiliac joints. Increased pain during these maneuvers could be indicative of joint disease.

45. Gaenslen, Thrust, Patrick (Faber) test

46. Physical findings Posture • Limitation of nevk movements • Reduced occiput-wall distance or tragus-wall distance • Toracic kyphosis Disese duration of 10 years or more

47. Occiput-wall distance or tragus-wall distance

48. Laboratory tests • HLA B-27 + in majority of patients • Acute phase reactants • Mild increase Alk Phos • Mild anemia • Some elavation serum Ig A

49. Radiography Sacroiliitis: • Modified New York Criteria • 0 Normal • 1 suspicous • 2 minimal sacroiliitis • 3 modarete sacroiliitis • 4 ankylosis