Date post: | 16-Jul-2015 |
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Health & Medicine |
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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.