What is Spondyloarthritis?
Spondyloarthropathy is joint disease of the vertebral column. Spondyloarthropathy with inflammation is called Spondyloarthritis. The term is often used for a specific group of disorders with certain common features, the group often being termed specifically seronegative spondylarthropathies (SPA). Seronegativity means, blood tests are negative for rheumatoid factor and antinuclear antibodies (ANA). They have an increased incidence of HLA –B27 gene. SpA encompasses Ankylosing Spondylitis (AS), Reactive Arthritis (ReA), Psoriatic Arthritis (PSA), enteropathic arthritis and undifferentiated SpA. The most common is Ankylosing Spondylitis. SPA has few characteristic manifestations. Enthesitis; means inflammation at the sites where ligaments and tendons attach to bones. Dactylitis means diffuse swelling of the fingers, either of the hands or feet. These diseases are associated with other diseases like psoriasis, uveitis and intestinal diseases.
How does SPA differ from Rheumatoid arthritis (RA)?
RA typically occurs in females in reproductive age group, polyarticular, small joints and upper limb predominant, symmetric and RF positivity. SPA is typically common in males, onset in less than 40 years age, large joints and lower limb predominance with low back pain indicating involvement of vertebrae. SPA can also be associated or involve other organs like uveitis, skin and alimentary/urinary tracts. It is strongly associated with HLA –B27 positivity and is negative for RF.
What is Ankylosing Spondylitis?
AS (from Greek ankylos-fused, spondylos-vertebrae, itis-inflammation) is a chronic inflammatory disease of the vertebrae with variable involvement of peripheral joints and non-articular structures predominantly affecting young males between 20-40 years of age. It is the prototype disease of SPA. It mainly affects joints in the spine and the sacroiliac joint in the pelvis, and can cause eventual fusion of the spine. The onset is with low back pain in most of the cases, associated with stiffness and limitation of movements which is worst in the morning and improves gradually as the day passes or with work and worsens with rest or after a period of inactivity. In few cases it may start with peripheral arthritis asymmetrically, involving the large joints of the lower limbs like knees and ankles. About 30% of the cases may have uveitis. With the progression of the disease, the spinal joints fuse and movements of the vertebra is lost and may also restrict the chest expansion leading to restrictive lung disease. Long term disease may also be complicated with heart and kidney involvement.
What is Reactive arthritis?
Reactive arthritis is an autoimmune condition that develops in response to an infection in another part of the body. The time when the patient presents with symptoms, the trigger/infection has been cured or is in remission, thus determination of the causative infection is difficult. The arthritis often is coupled with other characteristic symptoms; this is called Reiter’s Syndrome or Reiter’s arthritis. The manifestations include the triad of symptoms: an inflammatory arthritis of large joints, inflammation of the eyes in the form of conjunctivitis or uveitis and urethritis in men or cervicitis in women. Patients may develop mucocutaneous lesions, as well as psoriasis-like skin lesions. Enthesitis can involve the Achilles tendon resulting in heel pain. Not all affected persons have all the manifestations. The most common triggers are intestinal infections and sexually transmitted infections. It most commonly strikes individuals aged 20–40 years of age and is more common in men.
What is Psoariatic arthritis?
Psoriatic arthritis is a type of inflammatory arthritis that will develop in up to 20-30 percent of people who have psoriasis. Common symptoms of psoriatic arthritis include: arthritis of the vertebral and peripheral joints, dactylitis, enthesitis, and changes in the nails, such as pitting or separation from the nail bed. Involvement of the distal joints of fingers and nails are the characteristic features of PSA. There is no definitive test to diagnose psoriatic arthritis. Symptoms of psoriatic arthritis may closely resemble other diseases, including RA. Rheumatologists may use history, physical examinations, blood tests and x-rays to diagnose psoriatic arthritis. There are five main types of manifestations of psoriatic arthritis: Symmetric polyarthritis, Asymmetric oligoarthritis, Arthritis mutilans (is a severe, deforming and destructive arthritis), Spondylitis and Distal interphalangeal joints predominant.
How is Spondyloarthritis diagnosed?
Correct diagnosis requires a rheumatologist/physician to assess the patient’s medical history and do a physical exam. Candidates may need an X-ray of the sacroiliac joints. X-ray changes of the sacroiliac joints, known as sacroilitis, are a key sign of Spondyloarthritis. If X-rays do not show enough changes due to early presentation, but the symptoms are highly suspicious, doctor might order MRI, which shows these joints better and can pick up early involvement before X-ray can. Among the blood tests you may need is HLA-B27 gene along with ESR and CRP. However, having this gene does not mean Spondyloarthritis will always develop. Some people have the HLA-B27 gene but do not have arthritis and never develop arthritis.
How is Spondyloarthritis treated?
All patients should get physical therapy and do joint directed exercises. Most recommended are exercises that promote spinal extension and mobility. There are many drug treatment options. The first lines of treatment are the non steroidal anti-inflammatory drugs (NSAIDs), such as naproxen, ibuprofen, meloxicam or indomethacin. No one NSAID is superior to another. Given in the correct dose and duration, these drugs give great relief for most patients. For joint swelling that is localized, injections, of corticosteroid medications into joints or tendon sheaths can be effective quickly. For patients who do not respond to the above lines of treatment, Disease Modifying Anti-Rheumatic Drugs (DMARDs) such as sulfasalazine might be effective. These drugs relieve symptoms and may prevent damage to the joints. Anti-TNF drugs are very effective in treating both the spinal and peripheral joint symptoms of Spondyloarthritis. Anti-TNF agents which are approved for use in patients with Ankylosing Spondylitis are Infliximab, Etanercept, Adalimumab, Golimumab. These can also be used for the other diseases in SpA as well. However, anti‐TNF treatment is expensive and is not without side effects, including an increased risk for serious infections. Surgical treatment is very helpful in some patients. Total hip replacement is very useful for those with hip pain and disability due to joint destruction from cartilage loss. Spinal surgery is rarely necessary, except for those with traumatic fractures or to correct excess flexion deformities of the neck, where the patient cannot straighten the neck.
