1. The Spondylarthropathies
Paul Baillie
Birmingham

2. Contents
• What are they?
• Common Features
• Classification Criteria
• Details of each one

3. What are they?
• Inflammatory arthropathies
• HLA B27 association
• Enthesis and Synovial involvement
– Ankylosing Spondylitis (AS)
– Juvenile AS
– Psoriatic Arthropathy
– Sacroilitis
– Reiter’s Syndrome (Reactive)
– Enteropathic Arthritis

4. Common Features
• Association with HLA B27
• Seronegativity (Lack of association with RhF)
• Sacroiliitis
• Enthesitis
– Plantar Fasciitis
– Achilles Tendonitis
• Eye Inflammation – Conjunctivitis, Uveitis
• Osteitis
• Dactylitis
• Mucocutaneous lesions
– Mouth ulcers
– Keratoderma Blenorrhagica

5. Classification Criteria
• European
Spondylarthropathy Study
group (ESSG) Criteria
• Inflammatory Spinal Pain or
Synovitis
• Plus 1 more of…
– Alternate Buttock Pain
– Sacroiliitis
– Enthesopathy
– Positive Family Hx
– Psoriasis
– IBD
– Urethritis / Cerviitis /
Diarrhoea
• AMOR criteria
• Need a score of 6 or more
– Lumbar or dorsal pain or
stiffness
– Assymetric Oligoarthritis
– Buttock Pain
– Alternate Buttock Pain
– Sausage like toe or digit
– Heel or enthesopathic pain
– Iritis
– Nongonococcal Urethritis /
Cervicitis
– Acute Diarrhoea within 1 month
– Psoriasis / Balanitis / IBD
– Sacroiliitis on radiology
– HLA B27 or Family Hx
– Prompt response to NSAIDS

6. Ankylosing Spondylitis
• Chronic Inflammatory disease of the spine
and sacroiliac joints
• Young Men
• HLA B27! – 97%
• Typical Patient

7. Spinal Movement
• Syndesmophytes
– Bony proliferations due to enthesitis between
ligaments and vertebrae
– These can fuse together causing ankylosis
Loss of spinal movements
Decreased Thoracic Expansion
• In a few this progresses to kyphosis, neck
hyperextension (question mark posture) and
spino-cranial ankylosis
• In later stages, calcification of ligaments with
leads to a BAMBOO SPINE appearance

8. Extra-articular Manifestations of AS
• Peripheral Assymetrical Arthritis
• Enthesopathy – heel, tibial and ischial tuberosity
• Acute Anterior Uveitis (Iritis)
– 1/3 pts!
– Can cause blindness!
• Colitis
• Aortitis & Aortic Regurge
• Pulmonary Apical Fibrosis (rare)
• Secondary Amyloidosis
Iritis with Synechia

9. New York Criteria for Diagnosing
AS
Definite ankylosing spondylitis if the radiological criterion is present
plus at least one clinical criterion.
Probable ankylosing spondylitis if three clinical criteria are present
alone, or if the radiological criterion is present but no clinical criteria are
present.
Clinical Criteria:
1. Limited lumbar motion (all directions)
2. Low back pain for >3months, improved
with exercise but not with rest
1. Reduced chest expansion (for age and sex)
X-ray – either…
Bilateral Grade 2-4 Sacroiliitis
Unilateral Grade 3-4 Sacroiliitis
X-ray Grade
0 Normal
1 Suspicious
2 Minimal change small
areas of erosion /
sclerosis
3 Definite. Moderate to
advanced sacroiliitis
4 Total Ankylosis (fusion)

10. Schober’s Test
Dimples of Venus

11. Investigative Findings in AS
• Raised ESR & CRP
• Elevated IgA
• Normocytic Anaemia
• Elevated Alk Phos
(increased bone turnover)

12. Treatment of AS
• Non-Pharmalogical
– Physio – Intense Exercise Regime
– OT
– Hydrotherapy
• Pharmacological
– NSAID
– DMARD
• Steroid Sparing Agents
• Methotrexate
• Anti-TNF
– Corticosteroid
• Surgery
– Hip Replacement
– Spinal Osteotomy (rare)

13. Psoriatic Arthritis
• 10-40% of those with Psoriasis
• Can present before skin changes
• Patterns of arthritis
1. Symmetrical Polyarthritis
2. DIP joints
3. Assymetrical Oligoarthritis
4. Spinal (AS-like)
5. Psoriatic Mutilans

14. X ray in Psoriatic A.
• Erosive Changes
• Pencil in Cup
deformity
(severe)

15. Treatment of Psoriatic Arthritis
• Non-pharmacological
– OT
– Physio
– Hydrotherapy
– Orthodontist
• Pharmacological
– NSAIDs
– DMARDs
• SSA, Methotrexate, Cy A, Gold, Penecillamine
– Corticosteroids
– Biological Agents

16. Reactive Arthritis
(Reiter’s Syndrome)
• Inflammatory arthritis developing a few weeks after a gut
or GU infection.
• It is a sterile arthritis typically affecting the lower limb.
• It may be chronic or relapsing
• Organisms
GU
-Chlamydia
-Neisseria
Gut
-Salmonella
-Shigella
-Yersinia
-Campylobacter

17. Extra-articular manifestations of
Reiter’s Syndrome
• Inflammatory Eye Disease (Iritis)
• Keratoderma Blenorhagica
• Circinate Balanitis
• Apthous Ulcers
• Enthesitis
• Aortic Incompetance

18. Classic Triad
• Can’t see, Can’t pee and Can’t climb a tree
Conjunctivitis – Urethritis - Arthritis

19. Investigations for Reiter’s
• Xray may show
– Enthestis with periosteal reaction
• Raised ESR and CRP
• Culture Stool sample (diarrhoea)
• Serum Serology

20. Treatment for Reiter’s
• Generally self-limiting
Symptomatic relief
– Rest
– Splint affected joints?
– NSAIDs or local steroid injections
• DMARDS (rarely)
– Sulfasalazine
– Methotrexate
• NB – treating the original infection may make
little or no difference to the arthritis

21. Enteropathic Arthritis
• Arthritis with Ulcerative Colitis or Crohn’s
Disease
• 20% with IBD get Peripheral Arthritis
• 10% with IBD get spondylitis

22. Spondylarthropathies Summary
• HLA B27
• Common Symptoms
– Enthesitis
– Iritis
– Spondylitis
• Includes:
– Ankylosing Spondylitis (AS)
– Juvenile AS
– Psoriatic Arthropathy
– Sacroilitis
– Reiter’s Syndrome (Reactive)
– Enteropathic Arthritis