Seronegative arthropathies (spondyloarthropathies(

DefinitionIt is a group of inflammatory

arthropathies that share distinctive clinical, radiological and genetic features .

Characterized by involvement of sacroiliac joint, by peripheral inflammatory arthropathy and by absence of Rheumatoid factor.

Mechanical LBP

Inflammatory LBP

Example Disc prolapse Spondyloarthropathy

History: Age Any age > young around 30 yrs.

Sex Any sex Males > females

Onset sudden Incidious

Associations Trauma, Spondylosis

HLA- B 27

Family H. -ve +ve

Morning Stif f. > 30 min. > One hour

Symptoms duration

> 4 Weeks > 3 Months

Effect of rest Improve the condit ion

Worsen the condit ion

Effect of exercises

Worsen the condit ion

Improve the condit ion

Examination:Location of pain Localized Diffuse

Symmetry of pain Unilateral Bilateral

Systemic Dis. -ve +ve

Deformit ies Scoliosis L. f lattening, D. & C. kyphosis

Neurological S. Sciatica, Femoral neuralgia or

radicular manifes.

With AS (post. lumbo-sacral

arachn. Divert icula,

Cauda Equina).Muscle spasm Asymmetrical Symmetrical

Spinal tendeness

Radiation

Localized

Down to heel

Diffuse, SIJ‘s tenderness

Not below the knees

It includes:

1- Ankylosing Spondylitis.

2-Enteropathic arthropathy. (Crohn's dis. & Ulcerative colitis).

3- Psoriatic Arthropathy.

4- Rieter 's syndrome.

5-Undifferentiated spondyloarthropathy.

Modefied New York Criteria for Ankylosing Spondylitis

1- Low back pain for at least 3 months, improved by exercise, not

rel ieved by rest.2- Limitation of lumbar spine

movement in frontal and sagittal planes.

3- Diminished chest expansion relative to normal values to age and

sex.4- Unilateral sacroil l it is G 3-4. or

bi lateral sacoil i i t is G 2-4.

Prevalence of all SpAs ~ 1-2 %,like RA.

Patient not fulfilling individual criteria but possessing many features from every disease, may be classified as having (uSpA).

They may be involved with other muco-cutaneous manifestation (iritis, psoriasis, conjunctivitis, oro-genital ulcers) Strong association with HLA-B27& +ve family history. Infection is implicated as a triggering factor.

Pathogenesis Unknown, theories, infection

with cer tain organism, or exposure to unknown antigen,

in a genetically susceptible patient ( HLA-B27), is

hypothesized to result in cl inical expression of AS.

Pathology Primary lesion is inflammation of the

enthesis i.e. enthesopathy) (the site of insertion of ligaments, joint capsule, tendon or fascia into bone).

Erosion , new bone formation at joint margin, narrowing of joint bony fusion ( ankylosis)

Peripheral arthritis, often asymmetrical & affecting more the lower limb joints.

FeaturesAnkylosing spondylitis

Reiter's syndrome

Psoriatic arthritis IBD

Prevalence 0.1% to 0.2% 0.1% 0.2% to 0.4% Rare

Age Late teens to early

adulthood

Late teens to early

adulthood

35 to 45 years Any age

Male / female 3:1 5:1 1:1 1:1

HLA-B27 90% to 95% 80% 40% 30%

Sacroiliitis

- Frequency %100 40% to 60% 40% 20%

- Distribution

Symmetric Asymmetric Asymmetric Symmetric

Syndesmophytes Delicate, marginal

Bulky, nonmarginal

Bulky, nonmarginal

Delicate, marginal

Peripheral arthritis - Frequency Ocassional Common Common Common

- Distribution Asymmetric, lower limbs

Asymmetric, lower limbs

Asymmetric, upper>lowerl. joint

Asymmetric, lower limbs

Enthesitis Common Very common Very common Occasional

DactylitisUncommon Common Common Uncommon

Skin lesions None Circinate balanitis, keratoderma blennorrhagica

Psoriasis Erythema nodosum, pyoderma gangrenosum

Nail changes None Onycholysis Pitting, onycholysis

Clubbing

Eye Acute anterior uveitis

Acute anterior uveitis, conjunctivitis

Chronic uveitis Chronic uveitis

Oral Ulcers Ulcers Ulcers Ulcers

C.V.S Aortic regurgitation, conduction defects

Aortic regurgitation, conduction defects

Aortic regurgitation, conduction defects

Aortic regurgitation

R.S Upper lobe fibrosis

None None None

G.I.T None Diarrhea None Crohn's disease, ulcerative colitis

U.T Amyloidosis, IgA nephropathy

Amyloidosis Amyloidosis Nephrolithiasis

G.U.T Prostatitis Urethritis, cervicitis

None None

X- ray for: I. Sacroiliac joint

Erosin, blurring, narrowing, reactive sclerosis and bony ankylosis.

II. Lumber Spine: - Vertebrae appear square due to erosion of

their corners “ squared off ” appearance. - Vertical bridging osteophytes or

“ syndesmophytes” spread up and down from v. body fusion bamboo sp.

-- Ossification of ant. Longitudinal ligament.-- MRI is more sensitive for detection of early &

inflammatory changes of SIJ.- Reiters syndrome:

- - soft tissue swelling. - - Joint space narrowing & erosion.

- - Sacroiliitis or spondylitis.- Psoriatc arthropathy:

- - Erosion &new bone formation at joint margin, bony fusion.

- - Whittling of the distal ends at the phalanges

- Extensive bone resorption “Opera glass” appearance.

- Sacroilitis & spondylitis.

Laboratory: 1. ESR & CRP. 2. HLA-B 27. 3- RF.

Differential diagnosis:1- Intervertebral disc lesion.

2- Trauma & degenerative lesion:. * Lumber spondylosis.

3- Vertebral fractures: * Direct trauma. * Sequlae of metabolic diseases. * Vertebral tumor.

4- Soft tissue lesions: * Sprains. * Tears of spinal ligaments. * Tears of dorsal muscles.5- Deformities & congenital defects: * Postural abnormalities: - Kyphosis. - Lordosis. - Scoliosis. * Congenital defects of vertebrae: - Spina bifida. - Spinal stenosis.

6- Arthritis & infectious lesion of the spine: * T.B.

* Osteomyelitis. 7- Neoplasm of the spine: Benign, malignant,

multiple myeloma.8- Metabolic bone diseases:

* Osteoporosis. * Osteomalacia9- Lesion of sacroiliac joint:

* OA10- Psychogenic.

13- Soft tissue lesions: * Enthesopathy at posterior iliac crest.

* Retroperitoneal fat herniation.14- Referred pain:

* Renal disorders. * Cancer pancreas.

* Dissecting aortic aneurysm. * Chronic duodenal ulcer.

* Pelvic disorders.

I. Medical ttt. Analgesics , NSAIDs or acetaminophen. Muscle relaxants for acute or chronic pain to

control muscle spasm & relief pain. Local steroid injection: for enthesopathies. Sulphasalazine &methotraxate: for peripheral

arthritis but have little effect on axial dis. TNF blockers are effective. Tetracycline for nonspecific urethritis. Avoid antimalarial in psoriasis as it cause

exfoliative reaction.

II. Physical ttt. Stay physically active. Spinal extension exercises Acupuncture: for trigger points. Transcutaneous electrical nerve stimulation

( TENS). Deep heat or Ice: to improve the muscle spasm

& relief pain. LASER & Interferential current: relief muscle

ache.

Stretching exercises: will alleviate the tight back muscles through pelvic tilting.

Low impact activities: as swimming, walking and bicycling can increase the overall fitness without straining the back.

Genetic councilling.