SlideShare une entreprise Scribd logo
1  sur  146
Télécharger pour lire hors ligne
Spondyloarthropathy
• Spondyloarthropathy (SpA) is a frequent, 
chronic, inflammatory condition with 
potential disabling outcomes. 
• A recent epidemiologic study performed in 
Brittany (France) evaluated the disease 
prevalence as 0.49% compared with that of 
rheumatoid arthritis (RA) as 0.64%
• Many SpA patients have mild disease with a 
good clinical response to nonsteroidal 
antiinflammatory drugs (NSAIDs).
• Nevertheless, some patients have clinical, 
biological, or radiological elements of poor 
prognosis or are refractory to NSAIDs with 
persistent signs of active disease. 
• In this set of patients, the initiation of slow-acting 
drugs (sulphasalazine or methotrexate) 
might at best induce symptomatic 
improvement.
• The recent development of biotherapies such 
as tumor necrosis factor (TNF)-a blockers and 
their use in SpA have demonstrated promising 
results.
Diagnosis 
of 
spondyloarthropathies
Classification criteria 
• SpA consists of several disorders, with 
ankylosing spondylitis (AS) as the prototype of 
this group of inflammatory conditions: 
 reactive arthritis, 
 psoriatic arthritis, 
arthritis related to inflammatory bowel 
disease (Crohn’s disease and ulcerative 
colitis), and the 
undifferentiated forms of the disease.
• ankylosing spondylitis (AS) 
• reactive arthritis, 
• psoriatic arthritis, 
• arthritis related to inflammatory bowel disease 
• undifferentiated forms 
These subgroups are characterized by: 
• axial or peripheral articular involvement 
• enthesitis, 
• potential extra-articular manifestations, and 
• high association to a genetic factor of 
predisposition, the tissue antigen HLA-B27.
• axial or peripheral articular involvement 
• enthesitis, 
• potential extra-articular manifestations 
• A common familial aggregation of SpA cases is 
another characteristic of this group of 
diseases. 
• These disorders are difficult to differentiate 
because they can occur simultaneously or 
sequentially.
DIFFERENTIATION OF INFLAMMATORY VERSUS 
MECHANICAL LOW BACK PAIN
• Two sets of criteria have been proposed: 
1) the Amor criteria, 
and the 
2)European Spondyloarthropathy Study 
Group (ESSG) criteria
the Amor 
criteria
Unjfsc easn
• New York diagnostic criteria have been proposed, but they 
imply radiographic evidence of sacroiliitis for AS diagnosis. 
• An incremental frequency of radiographic sacroiliitis over 
time has been demonstrated in SpA (40% prevalence after 10 
years of disease duration, 86% prevalence after 20 years of 
disease duration) 
• Thus, because of a frequent absence of radiographic 
sacroiliitis at the beginning of the disease, this radiologic item 
appears to be an inappropriate request in early diagnosis.
Unjfsc easn
Unjfsc easn
Clinical 
presentation of 
the spectrum 
of 
spondylo 
arthropathy
Management and monitoring of patients
Unjfsc easn
Distancia Occipucio - Pared
Unjfsc easn
Unjfsc easn
Unjfsc easn
Unjfsc easn
Unjfsc easn
Unjfsc easn
Unjfsc easn
Axial involvement: 
Clinical features
The following localizations of the disease are 
considered as axial involvement: 
• sacroiliac joints, 
• spine, 
• anterior chest wall, and 
• root joints (hip and shoulder).
Sacroiliitis 
• Is responsible for pain and functional 
impairment caused by inflammation with a 
long-term evolution often resulting in 
ankylosis of the sacroiliac joints. 
• In some cases, a persistent inflammation 
without ankylosis leads to chronic pain and 
functional disability.
• Anteroposterior Ferguson view of the sacroiliac joints in a patient with AS. The area of the 
sacroiliac joint inferior to the arrows is imaged by the Ferguson view and not by an 
anteroposterior view. Note the bilateral, symmetric involvement with erosions and 
eburnation
bilateral sacroiliitis
Unjfsc easn
Unjfsc easn
• MR image of the sacroiliac joints in a patient with undifferentiated spondyloarthropathy. 
Axial T1-weighted image with fat suppression after intravenous administration of Gd-DTPA 
demonstrates increased signal intensity in the subchondral bone marrow within the iliac and 
sacral sides of the right joint (arrows) and early erosions of the left joint (arrowhead).
Spinal involvement 
• Can be related to vertebral ligament inflammation or 
interapophyseal joint inflammation. Both afflictions 
can be responsible for night pain, morning stiffness, 
and reduction in spinal mobility.
• Vista lateral de la columna lumbosacra que 
muestra esquina brillante (puntas de flecha), 
la cuadratura de los cuerpos vertebrales, y la 
formación temprana sindesmofito (flechas) 
en un paciente con EA
• Lateral view of the 
lumbosacral spine 
showing 
syndesmophytes of AS, 
giving it a bamboo 
appearance
• Lateral view of the 
cervical spine in a 
patient with PsA. The 
posterior spinous 
processes show erosive 
changes at ligamentous 
attachments 
(arrowheads).
MR (sagittal STIR) images of the lumbar spine of a patient with AS. (a) Note the areas of marrow edema within the 
anteroinferior corners of the third and fourth lumbar vertebrae, respectively (arrows). (b) Four weeks after the start of 
therapy with anti–tumor necrosis factor the areas of edema had resolved and so had the patient's symptoms (arrows).
• Secondary vicious attitudes can be explained by the 
analgesic position (fetal position) unconsciously 
taken by the patient during the second part of the 
night during inflammatory phases of the disease.
Anterior chest wall pain 
• Is observed in about 15% of patients who 
have SpA and can be related to 
sternoclavicular, manubriosternal, or 
sternocostal arthritis.
• Anterior chest wall involvement together with 
costovertebral joint involvement can lead to 
decreased chest expansion and impaired respiratory 
function.
Shoulder and hip involvement 
• Can be responsible for severe disability. 
• Moreover, hip arthritis (defined as the 
presence of pain localized in the groin 
associated with lameness) has been 
considered as a criterion of poor outcome 
prognosis.
Laboratory parameters of 
inflammation.
• In patients suffering from isolated axial 
involvement, an increase in C-reactive protein 
(CRP) is not a rare phenomenon; it is observed 
in about 40% of patients.
An increase in 
CRP might be 
correlated with 
the clinical 
severity of the 
disease and 
might be 
considered to 
be a potential 
predisposing 
factor of 
structural 
progression.
• In clinical trial, NSAIDs had little effect on 
erythrocyte sedimentation rate (ESR) or CRP. 
• At variance, recent data on TNF-a blocking 
agents demonstrate a huge effect on both 
markers of inflammation.
Definition of active axial disease 
• Pain and disability can reflect the 
inflammatory process and the structural 
damage caused by the disease. 
• level of night disturbance, duration and 
intensity of the morning stiffness, level of 
pain, and functional disability.
• The remaining question when considering 
second-line drugs is whether or not an 
objective demonstration of inflammation is 
necessary (eg, CRP elevation, inflammatory 
signals assessed by MRI, or abnormal 
vascularization of the entheses using 
ultrasonography).
• Musculoskeletal 
ultrasound features in 
psoriatic arthritis: 
• A, Right plantar fascia 
thickening compared 
with the left. 
• C, Power Doppler 
ultrasound through 
left third finger at the 
metacarpophalangeal 
joint confirming 
increased vascularity 
(synovitis).
• Musculoskeletal 
ultrasound features in 
psoriatic arthritis: 
• B, Transverse section 
through left third 
finger at the 
metacarpophalangeal 
joint showing right 
tenosynovitis. 
• D, Right Achilles 
tendinitis with 
calcaneal erosion.
Definition of severe axial disease 
• The severity of axial disease is defined by 
radiologic damages such as bamboo spine. 
• An active disease despite optimal NSAID 
treatment is usually considered to be a 
predictive factor of subsequent severity 
defined by radiological progression.
Unjfsc easn
Unjfsc easn
Peripheral involvement 
Clinical features
• Dactylitis and oligoarthritis of the lower limbs, 
predominantly involving knees and ankles, are 
characteristic of the peripheral involvement in 
SpA and substantially differ from RA 
(polyarticular, bilateral, symmetrical arthritis 
involving small joints).
• Sausage digits in a 14-year-old HLA-B27+ boy with onset of 
spondyloarthropathy at the age of 12.
Definition of active peripheral 
disease 
• Activity of peripheral articular manifestations 
has a definition similar to the one that 
describes activity in RA: number of swollen 
and tender joints together with biological 
signs of inflammation.
Enthesitis 
Clinical features
• The enthesitis is the anatomical site of insertion of a 
tendon, ligament, or articular capsule into bone. 
Local or regional pain occurring in an SpA patient 
usually reflects enthesitis, which is responsible for 
local inflammation and local bone remodeling.
• Radiographic image of entheseal calcification and surface irregularity at 
calcaneal insertion and Achilles tendon insertion of a patient with SpA
Extra-articular manifestations 
• Various extra-articular manifestations can be 
observed in SpA patients: 
psoriasis, 
gut inflammation with chronic diarrhea, 
uveitis, 
cardiac manifestations,
Unjfsc easn
Ankylosing Spondylitis 
(AS)
ETIOLOGY 
• Animal and laboratory studies suggest that 
the HLAB27 molecule itself plays a key role, 
and that involvement of class I major 
histocompatibility complex (MHC) antigens in 
the presentation of microbial peptides is 
central to the pathogenic mechanism 
(Klebsiella aeruginosa)
CLINICAL FEATURES 
• The principal musculoskeletal lesions 
associated with AS are enthesitis and 
synovitis, with sacroiliitis also involving 
adjacent bone. 
• Inflammatory eye lesions, myocardial 
changes, gut mucosal lesions, and skin lesions 
are inconsistent but characteristic features of 
AS.
• Spinal features of AS seldom appear before 
the age of 16 to 18 years. 
• Before this age, children and teenagers may 
develop oligoarthritis—typically a swollen 
knee or metatarsophalangeal (MTP) joint— 
sometimes associated with iritis and/or 
enthesitis. 
• Juvenile AS is remarkable because it does not 
involve the spine.
• The average age at onset is 26 years. Although 
the disease rarely begins after the age of 40 
years, it is not uncommon for the diagnosis to 
be made only years later, well after that age. 
• Earlier symptoms often are mild, ignored, or 
not recognized as being part of AS.
• The usual presenting symptom is 
inflammatory back pain that is insidious in 
onset, persistent for more than 3 months, 
worsened by rest and improved by exercise. 
• Night pain is a frequent symptom.
• Sacroiliitis, the most common initial feature, 
causes pain in the buttocks, typically 
alternating between right and left in severity. 
• This pain sometimes radiates down the thighs 
but never below the knee.
• A minority of patients present with 
oligoarthritis or enthesitis that particularly 
affects the heel, or hip pain due to aggressive 
synovitis. 
• Fatigue, a common and troublesome 
symptom, may be caused in large part by 
impaired sleep caused by pain and stiffness.
• Other constitutional features may include 
fever and weight loss. Overt or subclinical 
depression, accompanied by a loss of libido 
and reduced capacity for work, also may 
contribute to lack of well-being.
• Spinal discomfort and 
stiffness typically ascend 
the spine over a period of 
years, producing 
progressive spinal pain 
and restriction. 
• One of the first clinical 
signs is the disappearance 
of the lumbar lordosis.
Unjfsc easn
• Bamboo spine’ in a 
49-year-old man 
with a 14-year 
history of 
ankylosing 
spondylitis. 
• This classic but 
uncommon 
manifestation 
occurs at a late 
stage following 
inflammatory 
disease. 
• Note the 
calcification of the 
anterior fibres of 
the annulus 
(arrow).
• This progression affects the costovertebral 
joints, reducing respiratory excursion, and the 
cervical spine, limiting neck movement. 
• Thoracic spine involvement may be associated 
with anterior chest pain and sternal/costal 
cartilage tenderness, which can be particularly 
distressing for patients.
Unjfsc easn
• Osteoporosis (which may be prevented by 
appropriate therapy) may lead to vertebral 
and other fractures later in life. 
• Spinal fractures are more common in patients 
who have severe involvement with rigidity. 
• Aseptic spondylodiscitis may occur in patients 
with AS, especially in the thoracic spine
Unjfsc easn
Unjfsc easn
Enthesitis 
• The central feature of AS is inflammation at 
entheses, the sites where tendons and 
ligaments attach to bone.
• These inflammatory lesions initially lead to 
radiographic appearances of osteopenia or 
lytic lesions, but subsequently reactive bone 
forms a new, more superficial enthesis, which 
develops into a radiologically detectable bony 
overgrowth or spur.
Unjfsc easn
• In the spine, enthesitis occurs at capsular and 
ligamentous attachments and discovertebral, 
costovertebral, and costotransverse joints, with 
involvement also at bony attachments of interspinous 
and paravertebral ligaments.
Unjfsc easn
Unjfsc easn
Unjfsc easn
• Enthesitis accounts for much of the pain, 
stiffness, and restriction at sacroiliac and other 
spinal joints. 
• The phenomenon also occurs at extraspinal 
sites, producing potentially troublesome 
symptoms.
• Such lesions most commonly affect the 
plantar fascia and Achilles tendon insertions 
to the calcaneus, leading to disabling heel 
pain. 
• Plantar fasciitis typically leads to the 
formation of fluffy calcaneal spurs visible on 
heel radiographs after 6 to 12 months.
• Swelling of the right Achilles tendon in a 26-year-old man with 
spondyloarthritis
• A, Left Achilles tendon (AT), which was normal on both clinical and US examination. 
The short white arrows point to the edges of the tendon, and the white dotted line 
(with arrows) indicates the depth of the tendon. B, Abnormal right side, with 
thickening and hypoechogenicity of the Achilles tendon extending to the insertion. 
There is also a distended retrocalcaneal bursa. KFP, Kager's fat pad; ∗, fluid; ∗∗, fat 
pad or synovium.
Fat-suppressed 
magnetic resonance 
image of the foot of 
a young patient with 
ankylosing 
spondylitis. The high 
signal is consistent 
with marrow edema, 
reflecting acute 
plantar fasciitis 
(white arrow). In 
addition, there is 
retrocalcaneal 
bursitis (asterisk).
• Similar lesions may occur around the pelvis, 
costochondral junctions, tibial tubercles, and 
elsewhere, causing marked local tenderness
Unjfsc easn
• Sternal and costochondral pain also reflect a 
combination of local enthesitis and referred 
pain from the thoracic spine. 
• This development frequently produces chest 
pain that must be distinguished from 
myocardial ischemia.
Sacroiliitis 
• Inflammation of the sacroiliac joints develops 
most frequently in the late teens or in the 
third decade of life, producing bilateral or 
occasionally, unilateral buttock pain, usually 
worse after inactivity and sometimes 
aggravated by weight bearing.
• Changes principally affect the lower anterior 
(synovial) portion of the sacroiliac joints and 
are associated with juxta-articular osteopenia 
and osteitis. 
• This condition leads to radiographic 
appearances of widening of the sacroiliac 
joint.
Unjfsc easn
• Endochondral ossification as a consequence of 
the osteitis gives the radiographic appearance 
of erosion along the lower part of the 
sacroiliac joints. 
• Osteitis appears as increased water content of 
adjacent bone, as seen on magnetic 
resonance imaging (MRI).
Unjfsc easn
• MRI is a valuable imaging modality for 
assessment of inflammation in both the 
sacroiliac joints and the spine. This can 
frequently be an important aid in establishing 
an early diagnosis. 
• Capsular enthesopathy also occurs over the 
anterior and posterior aspect of the joint 
throughout its length, leading to sheets of 
ossification that ultimately obscure the joint 
completely on standard radiographs, depicted 
as ankylosis of the sacroiliac joint.
Synovitis 
• Synovitis is indistinguishable histologically and 
immunohistochemically from typical 
rheumatoid disease. 
• Peripheral joint synovitis may precede, 
accompany, or follow the onset of spinal 
symptoms.
• Hips, knees, ankles, and MTP joints are 
affected most commonly. With the exception 
of the shoulders, upper limb joints are almost 
never involved in AS. 
• In further contrast to rheumatoid arthritis, 
peripheral joint synovitis usually is 
oligoarticular, often asymmetrical, and 
frequently episodic rather than persistent
• Joint erosions, especially at the MTP joints, 
may lead to subluxation and deformity. 
• Temporomandibular joints may be affected, 
leading to reduced mouth opening and 
discomfort on chewing. 
• Dactylitis may lead to pain in one or more toes 
that lasts many months.
Eye Lesions 
• Acute anterior uveitis (iritis) develops at some 
time during the course of the disease in 
approximately one third of patients with AS, 
and may be recurrent.
• Acute anterior uveitis in AS, typically unilateral and associated 
with redness, pain, and photophobia.
• The typical pattern is alternating, unilateral 
eye inflammation associated with pain , 
redness, lacrimation, photophobia, and 
blurred vision. 
• The occurrence of uveitis typically does not 
coincide with flares of arthritis.
• Untreated or inadequately treated iritis may 
lead rapidly to considerable scarring, 
irregularity of the pupil, and visual 
impairment. 
• Red, sore, gritty eyes or blurring of vision in a 
patient with AS require urgent ophthalmologic 
examination.
Inflammatory Bowel Disease 
• Sacroiliitis occurs in 6% to 25% of people with 
Crohn’s disease or ulcerative colitis. 
• Patients with Crohn’s disease or ulcerative 
colitis frequently have unilateral sacroiliitis, 
and may also suffer from peripheral arthritis 
and enthesitis.
• Similarly, inflammatory bowel disease may be 
present or develop in people with preexisting 
AS. 
• Indeed, approximately 60% of people with AS 
have subclinical changes in the small or large 
bowel. 
• There is speculation that these changes may 
relate to the pathogenesis of AS, but their true 
significance is unknown.
• Even though some AS lesions closely resemble 
those of Crohn’s disease, the great majority of 
such lesions never become symptomatic. 
• Only about 10% to 15% of the patients with 
AS have overt ulcerative colitis or Crohn’s 
disease
• In a minority of people with colitis and 
peripheral arthritis, peripheral joint disease 
may diminish substantially after total 
colectomy.
• Active inflammatory bowel disease increases 
the risk and severity of osteoporosis. 
• Crohn’s disease with extensive small bowel 
involvement also may lead to impaired 
vitamin D absorption and osteomalacia, 
producing ill-defined musculoskeletal pain and 
difficulty with walking.
Cardiovascular Involvement 
• Cardiac conduction abnormalities and 
myocardial dysfunction have been recorded in 
a significant minority of people with AS
• Aortitis with dilatation of the aortic valve ring 
and aortic regurgitation has been 
demonstrated in approximately 1% of 
patients. 
• The risk of occurrence of aortic insufficiency 
and cardiac conduction abnormalities increase 
with age, disease duration, presence of HLA-B27, 
and peripheral joint involvement.
Pulmonary Involvement 
• Approximately 1% of patients develop 
progressive upper lobe fibrosis of the lungs. 
• Rigidity of the chest wall results in the inability 
to extend the chest fully and to mild 
restrictive lung function impairment, but 
rarely leads to ventilation insufficiency due to 
the compensation by increased diaphragmatic 
contribution.
Neurologic Lesions 
• Neurologic deficits are associated most often 
with cord or root lesions following spinal 
fracture. 
• Nerve root pain may arise from the cervical 
spine, especially when there is marked flexion 
deformity.
• Long-tract signs, including quadriplegia, may 
follow spinal fracture dislocation after 
relatively minor trauma and complicate 
spontaneous atlantoaxial subluxation. 
• Subluxation also may lead to severe occipital 
headache.
Skin Involvement 
• In various series, between 10% and 25% of the 
patients with typical AS have concomitant 
psoriasis lesions.
Renal Consequences 
• Although rarely seen today, secondary 
amyloidosis caused by longstanding AS is well 
described.
IMAGING 
• By definition, all patients fulfilling the modified New York 
criteria show signs of sacroiliitis on radiographs.
• However, about 30% of the patients do not 
develop damage of the spine visible on 
radiographs. 
• If patients show no spinal damage after a 
certain disease duration (about 10 years), it is 
unlikely that the patient will develop 
radiographic abnormalities of the spine at all. 
• On the other hand, patients who have spinal 
damage are prone to develop more damage.
• Characteristic features on radiographs of the 
sacroiliac joints are pseudo-widening of the 
joint space, sclerosis, erosions, and ankylosis
• Anteroposterior radiographs of the pelvis showing complete ankylosis of 
both sacroiliac joints and syndesmophyte formation in the lower lumbar 
vertebrae.
• Many AS-related changes can be seen in the 
spine; squaring of the vertebrae, sclerosis, 
erosions, syndesmophytes, bony bridging, and 
spondylodiscitis are the most relevant.
• Radiograph of the lateral cervical spine, demonstrating the 
formation of extensive bridging syndesmophytes that involve 
almost the entire cervical spine.
Radiograph of the lateral 
lumbar spine with squaring of 
L1 and syndesmophyte 
formation from L3 to L5.
• Syndesmophytes are characterized by axial 
growth that may lead to bridging phenomena. 
For making a diagnosis, conventional 
radiography is still the preferred option. 
• However, if the radiographs are persistently 
normal in the setting of high disease suspicion, 
MRI of the sacroiliac joints and spine can add 
information.
• In contrast to conventional radiographs, MRI 
has the potential to demonstrate 
inflammation, not merely the end results of 
inflammation on bone.
• Among MRI techniques for delineating 
inflammation, the short tau inversion recovery 
(STIR) technique is preferred. 
• MRI is also useful in visualizing enthesitis, for 
example, of the heel or Achilles tendon 
insertion.
• Short tau inversion recovery (STIR) image of the sacroiliac joints revealing 
extensive inflammation (white) involving both the sacral and iliac sides of 
the joints bilaterally.
• weighted, opposed-phase, gradient echo magnetic resonance image 3 minutes 
after the intravenous injection of gadolinium-DTPA in a 23-year-old man with 
ankylosing spondylitis and severe inflammatory back pain localized mainly to the 
right side, of 3 years' duration. Acute sacroiliitis is demonstrated by the strong 
contrast enhancement of the right sacroiliac joint (arrowheads), with impressive 
bone marrow edema (white arrow) and erosions (black arrow).
MAKING THE DIAGNOSIS
• As in many other diseases in which the 
etiology is not clearly defined (e.g., by the 
isolation of a specific causative pathogen), the 
diagnosis of AS must rest on the combination 
of clinical features, radiological findings, and 
laboratory results.
• There are no established diagnostic criteria for 
AS. 
• On the other hand, classification criteria, used 
for the purpose of categorizing patients in 
research studies, are available. 
• The most widely used classification criteria for 
AS are the modified New York criteria.
• Although the New York criteria are useful in established disease, their 
heavy reliance on the demonstration of radiographic sacroiliitis diminishes 
their applicability in patients with early disease.
AMOR’S CLASSIFICATION 
CRITERIA FOR 
SPONDYLOARTHRITIS: 
A patient is considered 
as suffering from a 
spondylarthropathy if 
the sum 
is ≥6.
AMOR’S CLASSIFICATION 
CRITERIA FOR 
SPONDYLOARTHRITIS: 
A patient is considered as 
suffering from a 
spondylarthropathy if the sum 
is ≥6.
THE EUROPEAN 
SPONDYLARTHROPATHY 
STUDY GROUP CRITERIA
Current Opinion in Rheumatology 2010
Unjfsc easn
• Bone marrow oedema (BMO), reflecting active sacroiliitis
• Synovitis as an active inflammatory lesion appears as 
hyperintense signal on contrast-enhanced
• Capsulitis (arrows) is a hyperintense signal of the sacroiliac 
(SI) joint capsule. Anteriorly, the joint capsule gradually 
continues into the periosteum of the iliac and sacral bones.
Unjfsc easn

Contenu connexe

Tendances

seronegative Spondyloarthropathies: ankylosing spondylitis, psoriatic arthrit...
seronegative Spondyloarthropathies: ankylosing spondylitis, psoriatic arthrit...seronegative Spondyloarthropathies: ankylosing spondylitis, psoriatic arthrit...
seronegative Spondyloarthropathies: ankylosing spondylitis, psoriatic arthrit...Jamia Millia Islamia
 
Seronegative spondyloarthropathies
Seronegative  spondyloarthropathiesSeronegative  spondyloarthropathies
Seronegative spondyloarthropathiesSelf-employed
 
Spondyloarthropathies by Dr shyam sunder sharma
Spondyloarthropathies by  Dr shyam sunder sharmaSpondyloarthropathies by  Dr shyam sunder sharma
Spondyloarthropathies by Dr shyam sunder sharmadrshyamsundersharma
 
Ankylosing Spondylitis - Notes 2021
Ankylosing Spondylitis - Notes 2021Ankylosing Spondylitis - Notes 2021
Ankylosing Spondylitis - Notes 2021Best Doctors
 
Update pathogenesis of spondyloarthritis
Update pathogenesis of spondyloarthritisUpdate pathogenesis of spondyloarthritis
Update pathogenesis of spondyloarthritisJames Wei 魏正宗
 
Seronegative spondyloarthropathies
Seronegative spondyloarthropathiesSeronegative spondyloarthropathies
Seronegative spondyloarthropathiesairwave12
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitisMelanoflame
 
Axial Spondyloarthritis
Axial Spondyloarthritis Axial Spondyloarthritis
Axial Spondyloarthritis Ade Wijaya
 
Seronegative spondyloarthropathies
Seronegative spondyloarthropathiesSeronegative spondyloarthropathies
Seronegative spondyloarthropathiesRohit Rajeevan
 
Approach To A Patient With Polyarthritis
Approach To A Patient With PolyarthritisApproach To A Patient With Polyarthritis
Approach To A Patient With PolyarthritisPramod Mahender
 
Ankylosing spondylitis clinical feature and diagnosis
Ankylosing spondylitis clinical feature and diagnosisAnkylosing spondylitis clinical feature and diagnosis
Ankylosing spondylitis clinical feature and diagnosisdattasrisaila
 

Tendances (20)

SERO-NEGATIVE ARTHRITIS
SERO-NEGATIVE ARTHRITISSERO-NEGATIVE ARTHRITIS
SERO-NEGATIVE ARTHRITIS
 
seronegative Spondyloarthropathies: ankylosing spondylitis, psoriatic arthrit...
seronegative Spondyloarthropathies: ankylosing spondylitis, psoriatic arthrit...seronegative Spondyloarthropathies: ankylosing spondylitis, psoriatic arthrit...
seronegative Spondyloarthropathies: ankylosing spondylitis, psoriatic arthrit...
 
Seronegative spondyloarthropathy
Seronegative spondyloarthropathySeronegative spondyloarthropathy
Seronegative spondyloarthropathy
 
Seronegative spondyloarthropathies
Seronegative  spondyloarthropathiesSeronegative  spondyloarthropathies
Seronegative spondyloarthropathies
 
Ankylos ing spondylitis
Ankylos ing spondylitisAnkylos ing spondylitis
Ankylos ing spondylitis
 
Jd laredo SPA-spondyloarthritis jfim hanoi 2015
Jd laredo SPA-spondyloarthritis jfim hanoi 2015Jd laredo SPA-spondyloarthritis jfim hanoi 2015
Jd laredo SPA-spondyloarthritis jfim hanoi 2015
 
Spondyloarthropathies by Dr shyam sunder sharma
Spondyloarthropathies by  Dr shyam sunder sharmaSpondyloarthropathies by  Dr shyam sunder sharma
Spondyloarthropathies by Dr shyam sunder sharma
 
Ankylosing Spondylitis - Notes 2021
Ankylosing Spondylitis - Notes 2021Ankylosing Spondylitis - Notes 2021
Ankylosing Spondylitis - Notes 2021
 
Spondyloarthropathy
SpondyloarthropathySpondyloarthropathy
Spondyloarthropathy
 
Update pathogenesis of spondyloarthritis
Update pathogenesis of spondyloarthritisUpdate pathogenesis of spondyloarthritis
Update pathogenesis of spondyloarthritis
 
Seronegative spondyloarthropathies
Seronegative spondyloarthropathiesSeronegative spondyloarthropathies
Seronegative spondyloarthropathies
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 
Axial Spondyloarthritis
Axial Spondyloarthritis Axial Spondyloarthritis
Axial Spondyloarthritis
 
Seronegative spondyloarthropathies
Seronegative spondyloarthropathiesSeronegative spondyloarthropathies
Seronegative spondyloarthropathies
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 
Inflammatory arthritis an overview
Inflammatory arthritis an overviewInflammatory arthritis an overview
Inflammatory arthritis an overview
 
Approach To A Patient With Polyarthritis
Approach To A Patient With PolyarthritisApproach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
 
What is Spondyloarthritis? What is Psoriatic Arthritis?
What is Spondyloarthritis? What is Psoriatic Arthritis?What is Spondyloarthritis? What is Psoriatic Arthritis?
What is Spondyloarthritis? What is Psoriatic Arthritis?
 
Ankylosing spondylitis clinical feature and diagnosis
Ankylosing spondylitis clinical feature and diagnosisAnkylosing spondylitis clinical feature and diagnosis
Ankylosing spondylitis clinical feature and diagnosis
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 

En vedette

Seronegative Spondyloarthropathies
Seronegative SpondyloarthropathiesSeronegative Spondyloarthropathies
Seronegative SpondyloarthropathiesSri Harsha Gutta
 
Ankylosing spondylitis UG lecture
Ankylosing spondylitis UG lectureAnkylosing spondylitis UG lecture
Ankylosing spondylitis UG lectureDhananjaya Sabat
 
Biomedcode modeling human disease - at a glance
Biomedcode modeling human disease - at a glanceBiomedcode modeling human disease - at a glance
Biomedcode modeling human disease - at a glanceBiomedcode Hellas SA
 
ANKYLOSING SPONDYLITIS physiotherapy ppt
ANKYLOSING SPONDYLITIS  physiotherapy pptANKYLOSING SPONDYLITIS  physiotherapy ppt
ANKYLOSING SPONDYLITIS physiotherapy pptAravinth Mathi
 
Imaging mimics of sacroiliitis dr m.abdelbaky
Imaging mimics of sacroiliitis   dr m.abdelbaky Imaging mimics of sacroiliitis   dr m.abdelbaky
Imaging mimics of sacroiliitis dr m.abdelbaky Mohammad Abdelbaky
 
Ankylosing spondylitis pathogenesis
Ankylosing spondylitis pathogenesisAnkylosing spondylitis pathogenesis
Ankylosing spondylitis pathogenesisSitanshu Barik
 
Ankylosing Spondylitis
Ankylosing SpondylitisAnkylosing Spondylitis
Ankylosing Spondylitisshotbyaginger
 
Ankylosing spondylitis management
Ankylosing spondylitis managementAnkylosing spondylitis management
Ankylosing spondylitis managementSitanshu Barik
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitisAbigail Abalos
 

En vedette (12)

Seronegative Spondyloarthropathies
Seronegative SpondyloarthropathiesSeronegative Spondyloarthropathies
Seronegative Spondyloarthropathies
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 
Ankylosing spondylitis UG lecture
Ankylosing spondylitis UG lectureAnkylosing spondylitis UG lecture
Ankylosing spondylitis UG lecture
 
Biomedcode modeling human disease - at a glance
Biomedcode modeling human disease - at a glanceBiomedcode modeling human disease - at a glance
Biomedcode modeling human disease - at a glance
 
ANKYLOSING SPONDYLITIS physiotherapy ppt
ANKYLOSING SPONDYLITIS  physiotherapy pptANKYLOSING SPONDYLITIS  physiotherapy ppt
ANKYLOSING SPONDYLITIS physiotherapy ppt
 
Imaging mimics of sacroiliitis dr m.abdelbaky
Imaging mimics of sacroiliitis   dr m.abdelbaky Imaging mimics of sacroiliitis   dr m.abdelbaky
Imaging mimics of sacroiliitis dr m.abdelbaky
 
Ankylosing spondylitis pathogenesis
Ankylosing spondylitis pathogenesisAnkylosing spondylitis pathogenesis
Ankylosing spondylitis pathogenesis
 
Spondyloarthropaties
SpondyloarthropatiesSpondyloarthropaties
Spondyloarthropaties
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 
Ankylosing Spondylitis
Ankylosing SpondylitisAnkylosing Spondylitis
Ankylosing Spondylitis
 
Ankylosing spondylitis management
Ankylosing spondylitis managementAnkylosing spondylitis management
Ankylosing spondylitis management
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 

Similaire à Unjfsc easn

spondyloarthropathy.pptx
spondyloarthropathy.pptxspondyloarthropathy.pptx
spondyloarthropathy.pptxpriyankkumar59
 
Approach to low back ache
Approach to low back acheApproach to low back ache
Approach to low back acheAlankar Tiwari
 
Lower Back Pain - Part 2
Lower Back Pain - Part 2Lower Back Pain - Part 2
Lower Back Pain - Part 2cpppaincenter
 
seronegative arthopathy
seronegative arthopathyseronegative arthopathy
seronegative arthopathyBipulBorthakur
 
Hip and spine syndrome (PMR)
Hip and spine syndrome (PMR)Hip and spine syndrome (PMR)
Hip and spine syndrome (PMR)mrinal joshi
 
seronegative arthropathies.pptx
seronegative arthropathies.pptxseronegative arthropathies.pptx
seronegative arthropathies.pptxZOHAIB57
 
Ankylosing Spondylitis PPT pharmacotherapeutics II
Ankylosing Spondylitis PPT pharmacotherapeutics IIAnkylosing Spondylitis PPT pharmacotherapeutics II
Ankylosing Spondylitis PPT pharmacotherapeutics IIjesmitha2740
 
PDF Disfunción sacroiliaca evaluación y manejo
PDF Disfunción sacroiliaca evaluación y manejoPDF Disfunción sacroiliaca evaluación y manejo
PDF Disfunción sacroiliaca evaluación y manejoFtAndres
 
Ankylosing Spondylosis PPT.pptx
Ankylosing Spondylosis PPT.pptxAnkylosing Spondylosis PPT.pptx
Ankylosing Spondylosis PPT.pptxDivya Patel
 
Artritis-sle tifa.pptx
Artritis-sle tifa.pptxArtritis-sle tifa.pptx
Artritis-sle tifa.pptxameliavirshany
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitisMarwa Besar
 

Similaire à Unjfsc easn (20)

spondyloarthropathy.pptx
spondyloarthropathy.pptxspondyloarthropathy.pptx
spondyloarthropathy.pptx
 
Spinal infection
Spinal infectionSpinal infection
Spinal infection
 
Approach to low back ache
Approach to low back acheApproach to low back ache
Approach to low back ache
 
Lower Back Pain - Part 2
Lower Back Pain - Part 2Lower Back Pain - Part 2
Lower Back Pain - Part 2
 
AS.pptx
AS.pptxAS.pptx
AS.pptx
 
Sacroiliac Joint
Sacroiliac JointSacroiliac Joint
Sacroiliac Joint
 
ANKYLOSING SPONDYLITIS.pptx
ANKYLOSING SPONDYLITIS.pptxANKYLOSING SPONDYLITIS.pptx
ANKYLOSING SPONDYLITIS.pptx
 
seronegative arthopathy
seronegative arthopathyseronegative arthopathy
seronegative arthopathy
 
Hip and spine syndrome (PMR)
Hip and spine syndrome (PMR)Hip and spine syndrome (PMR)
Hip and spine syndrome (PMR)
 
seronegative arthropathies.pptx
seronegative arthropathies.pptxseronegative arthropathies.pptx
seronegative arthropathies.pptx
 
Ankylosing Spondylitis PPT pharmacotherapeutics II
Ankylosing Spondylitis PPT pharmacotherapeutics IIAnkylosing Spondylitis PPT pharmacotherapeutics II
Ankylosing Spondylitis PPT pharmacotherapeutics II
 
rheumatoid arthitis
rheumatoid arthitisrheumatoid arthitis
rheumatoid arthitis
 
PDF Disfunción sacroiliaca evaluación y manejo
PDF Disfunción sacroiliaca evaluación y manejoPDF Disfunción sacroiliaca evaluación y manejo
PDF Disfunción sacroiliaca evaluación y manejo
 
Ank spond and dish
Ank spond and dishAnk spond and dish
Ank spond and dish
 
Ankylosing Spondylosis PPT.pptx
Ankylosing Spondylosis PPT.pptxAnkylosing Spondylosis PPT.pptx
Ankylosing Spondylosis PPT.pptx
 
Artritis-sle tifa.pptx
Artritis-sle tifa.pptxArtritis-sle tifa.pptx
Artritis-sle tifa.pptx
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 
Lumbar spondylolisthesis ppt (4)
Lumbar spondylolisthesis ppt (4)Lumbar spondylolisthesis ppt (4)
Lumbar spondylolisthesis ppt (4)
 
Ra conference may 2017
Ra conference may 2017Ra conference may 2017
Ra conference may 2017
 
Lumbosacral radicular pain 1
Lumbosacral radicular pain 1Lumbosacral radicular pain 1
Lumbosacral radicular pain 1
 

Dernier

PSP3 employability assessment form .docx
PSP3 employability assessment form .docxPSP3 employability assessment form .docx
PSP3 employability assessment form .docxmarwaahmad357
 
Applied Biochemistry feedback_M Ahwad 2023.docx
Applied Biochemistry feedback_M Ahwad 2023.docxApplied Biochemistry feedback_M Ahwad 2023.docx
Applied Biochemistry feedback_M Ahwad 2023.docxmarwaahmad357
 
Pests of wheat_Identification, Bionomics, Damage symptoms, IPM_Dr.UPR.pdf
Pests of wheat_Identification, Bionomics, Damage symptoms, IPM_Dr.UPR.pdfPests of wheat_Identification, Bionomics, Damage symptoms, IPM_Dr.UPR.pdf
Pests of wheat_Identification, Bionomics, Damage symptoms, IPM_Dr.UPR.pdfPirithiRaju
 
Lehninger_Chapter 17_Fatty acid Oxid.ppt
Lehninger_Chapter 17_Fatty acid Oxid.pptLehninger_Chapter 17_Fatty acid Oxid.ppt
Lehninger_Chapter 17_Fatty acid Oxid.pptSachin Teotia
 
geometric quantization on coadjoint orbits
geometric quantization on coadjoint orbitsgeometric quantization on coadjoint orbits
geometric quantization on coadjoint orbitsHassan Jolany
 
biosynthesis of the cell wall and antibiotics
biosynthesis of the cell wall and antibioticsbiosynthesis of the cell wall and antibiotics
biosynthesis of the cell wall and antibioticsSafaFallah
 
Pests of tenai_Identification,Binomics_Dr.UPR
Pests of tenai_Identification,Binomics_Dr.UPRPests of tenai_Identification,Binomics_Dr.UPR
Pests of tenai_Identification,Binomics_Dr.UPRPirithiRaju
 
SCIENCE 6 QUARTER 3 REVIEWER(FRICTION, GRAVITY, ENERGY AND SPEED).pptx
SCIENCE 6 QUARTER 3 REVIEWER(FRICTION, GRAVITY, ENERGY AND SPEED).pptxSCIENCE 6 QUARTER 3 REVIEWER(FRICTION, GRAVITY, ENERGY AND SPEED).pptx
SCIENCE 6 QUARTER 3 REVIEWER(FRICTION, GRAVITY, ENERGY AND SPEED).pptxROVELYNEDELUNA3
 
Application of Foraminiferal Ecology- Rahul.pptx
Application of Foraminiferal Ecology- Rahul.pptxApplication of Foraminiferal Ecology- Rahul.pptx
Application of Foraminiferal Ecology- Rahul.pptxRahulVishwakarma71547
 
Identification of Superclusters and Their Properties in the Sloan Digital Sky...
Identification of Superclusters and Their Properties in the Sloan Digital Sky...Identification of Superclusters and Their Properties in the Sloan Digital Sky...
Identification of Superclusters and Their Properties in the Sloan Digital Sky...Sérgio Sacani
 
Q3W4part1-SSSSSSSSSSSSSSSSSSSSSSSSCI.pptx
Q3W4part1-SSSSSSSSSSSSSSSSSSSSSSSSCI.pptxQ3W4part1-SSSSSSSSSSSSSSSSSSSSSSSSCI.pptx
Q3W4part1-SSSSSSSSSSSSSSSSSSSSSSSSCI.pptxArdeniel
 
Digitized Continuous Magnetic Recordings for the August/September 1859 Storms...
Digitized Continuous Magnetic Recordings for the August/September 1859 Storms...Digitized Continuous Magnetic Recordings for the August/September 1859 Storms...
Digitized Continuous Magnetic Recordings for the August/September 1859 Storms...Sérgio Sacani
 
Contracts with Interdependent Preferences (2)
Contracts with Interdependent Preferences (2)Contracts with Interdependent Preferences (2)
Contracts with Interdependent Preferences (2)GRAPE
 
Role of herbs in hair care Amla and heena.pptx
Role of herbs in hair care  Amla and  heena.pptxRole of herbs in hair care  Amla and  heena.pptx
Role of herbs in hair care Amla and heena.pptxVaishnaviAware
 
Krishi Vigyan Kendras - कृषि विज्ञान केंद्र
Krishi Vigyan Kendras - कृषि विज्ञान केंद्रKrishi Vigyan Kendras - कृषि विज्ञान केंद्र
Krishi Vigyan Kendras - कृषि विज्ञान केंद्रKrashi Coaching
 
Gene transfer in plants agrobacterium.pdf
Gene transfer in plants agrobacterium.pdfGene transfer in plants agrobacterium.pdf
Gene transfer in plants agrobacterium.pdfNetHelix
 
M.Pharm - Question Bank - Drug Delivery Systems
M.Pharm - Question Bank - Drug Delivery SystemsM.Pharm - Question Bank - Drug Delivery Systems
M.Pharm - Question Bank - Drug Delivery SystemsSumathi Arumugam
 
soft skills question paper set for bba ca
soft skills question paper set for bba casoft skills question paper set for bba ca
soft skills question paper set for bba caohsadfeeling
 
TORSION IN GASTROPODS- Anatomical event (Zoology)
TORSION IN GASTROPODS- Anatomical event (Zoology)TORSION IN GASTROPODS- Anatomical event (Zoology)
TORSION IN GASTROPODS- Anatomical event (Zoology)chatterjeesoumili50
 
Principles & Formulation of Hair Care Products
Principles & Formulation of Hair Care  ProductsPrinciples & Formulation of Hair Care  Products
Principles & Formulation of Hair Care Productspurwaborkar@gmail.com
 

Dernier (20)

PSP3 employability assessment form .docx
PSP3 employability assessment form .docxPSP3 employability assessment form .docx
PSP3 employability assessment form .docx
 
Applied Biochemistry feedback_M Ahwad 2023.docx
Applied Biochemistry feedback_M Ahwad 2023.docxApplied Biochemistry feedback_M Ahwad 2023.docx
Applied Biochemistry feedback_M Ahwad 2023.docx
 
Pests of wheat_Identification, Bionomics, Damage symptoms, IPM_Dr.UPR.pdf
Pests of wheat_Identification, Bionomics, Damage symptoms, IPM_Dr.UPR.pdfPests of wheat_Identification, Bionomics, Damage symptoms, IPM_Dr.UPR.pdf
Pests of wheat_Identification, Bionomics, Damage symptoms, IPM_Dr.UPR.pdf
 
Lehninger_Chapter 17_Fatty acid Oxid.ppt
Lehninger_Chapter 17_Fatty acid Oxid.pptLehninger_Chapter 17_Fatty acid Oxid.ppt
Lehninger_Chapter 17_Fatty acid Oxid.ppt
 
geometric quantization on coadjoint orbits
geometric quantization on coadjoint orbitsgeometric quantization on coadjoint orbits
geometric quantization on coadjoint orbits
 
biosynthesis of the cell wall and antibiotics
biosynthesis of the cell wall and antibioticsbiosynthesis of the cell wall and antibiotics
biosynthesis of the cell wall and antibiotics
 
Pests of tenai_Identification,Binomics_Dr.UPR
Pests of tenai_Identification,Binomics_Dr.UPRPests of tenai_Identification,Binomics_Dr.UPR
Pests of tenai_Identification,Binomics_Dr.UPR
 
SCIENCE 6 QUARTER 3 REVIEWER(FRICTION, GRAVITY, ENERGY AND SPEED).pptx
SCIENCE 6 QUARTER 3 REVIEWER(FRICTION, GRAVITY, ENERGY AND SPEED).pptxSCIENCE 6 QUARTER 3 REVIEWER(FRICTION, GRAVITY, ENERGY AND SPEED).pptx
SCIENCE 6 QUARTER 3 REVIEWER(FRICTION, GRAVITY, ENERGY AND SPEED).pptx
 
Application of Foraminiferal Ecology- Rahul.pptx
Application of Foraminiferal Ecology- Rahul.pptxApplication of Foraminiferal Ecology- Rahul.pptx
Application of Foraminiferal Ecology- Rahul.pptx
 
Identification of Superclusters and Their Properties in the Sloan Digital Sky...
Identification of Superclusters and Their Properties in the Sloan Digital Sky...Identification of Superclusters and Their Properties in the Sloan Digital Sky...
Identification of Superclusters and Their Properties in the Sloan Digital Sky...
 
Q3W4part1-SSSSSSSSSSSSSSSSSSSSSSSSCI.pptx
Q3W4part1-SSSSSSSSSSSSSSSSSSSSSSSSCI.pptxQ3W4part1-SSSSSSSSSSSSSSSSSSSSSSSSCI.pptx
Q3W4part1-SSSSSSSSSSSSSSSSSSSSSSSSCI.pptx
 
Digitized Continuous Magnetic Recordings for the August/September 1859 Storms...
Digitized Continuous Magnetic Recordings for the August/September 1859 Storms...Digitized Continuous Magnetic Recordings for the August/September 1859 Storms...
Digitized Continuous Magnetic Recordings for the August/September 1859 Storms...
 
Contracts with Interdependent Preferences (2)
Contracts with Interdependent Preferences (2)Contracts with Interdependent Preferences (2)
Contracts with Interdependent Preferences (2)
 
Role of herbs in hair care Amla and heena.pptx
Role of herbs in hair care  Amla and  heena.pptxRole of herbs in hair care  Amla and  heena.pptx
Role of herbs in hair care Amla and heena.pptx
 
Krishi Vigyan Kendras - कृषि विज्ञान केंद्र
Krishi Vigyan Kendras - कृषि विज्ञान केंद्रKrishi Vigyan Kendras - कृषि विज्ञान केंद्र
Krishi Vigyan Kendras - कृषि विज्ञान केंद्र
 
Gene transfer in plants agrobacterium.pdf
Gene transfer in plants agrobacterium.pdfGene transfer in plants agrobacterium.pdf
Gene transfer in plants agrobacterium.pdf
 
M.Pharm - Question Bank - Drug Delivery Systems
M.Pharm - Question Bank - Drug Delivery SystemsM.Pharm - Question Bank - Drug Delivery Systems
M.Pharm - Question Bank - Drug Delivery Systems
 
soft skills question paper set for bba ca
soft skills question paper set for bba casoft skills question paper set for bba ca
soft skills question paper set for bba ca
 
TORSION IN GASTROPODS- Anatomical event (Zoology)
TORSION IN GASTROPODS- Anatomical event (Zoology)TORSION IN GASTROPODS- Anatomical event (Zoology)
TORSION IN GASTROPODS- Anatomical event (Zoology)
 
Principles & Formulation of Hair Care Products
Principles & Formulation of Hair Care  ProductsPrinciples & Formulation of Hair Care  Products
Principles & Formulation of Hair Care Products
 

Unjfsc easn

  • 2. • Spondyloarthropathy (SpA) is a frequent, chronic, inflammatory condition with potential disabling outcomes. • A recent epidemiologic study performed in Brittany (France) evaluated the disease prevalence as 0.49% compared with that of rheumatoid arthritis (RA) as 0.64%
  • 3. • Many SpA patients have mild disease with a good clinical response to nonsteroidal antiinflammatory drugs (NSAIDs).
  • 4. • Nevertheless, some patients have clinical, biological, or radiological elements of poor prognosis or are refractory to NSAIDs with persistent signs of active disease. • In this set of patients, the initiation of slow-acting drugs (sulphasalazine or methotrexate) might at best induce symptomatic improvement.
  • 5. • The recent development of biotherapies such as tumor necrosis factor (TNF)-a blockers and their use in SpA have demonstrated promising results.
  • 7. Classification criteria • SpA consists of several disorders, with ankylosing spondylitis (AS) as the prototype of this group of inflammatory conditions:  reactive arthritis,  psoriatic arthritis, arthritis related to inflammatory bowel disease (Crohn’s disease and ulcerative colitis), and the undifferentiated forms of the disease.
  • 8. • ankylosing spondylitis (AS) • reactive arthritis, • psoriatic arthritis, • arthritis related to inflammatory bowel disease • undifferentiated forms These subgroups are characterized by: • axial or peripheral articular involvement • enthesitis, • potential extra-articular manifestations, and • high association to a genetic factor of predisposition, the tissue antigen HLA-B27.
  • 9. • axial or peripheral articular involvement • enthesitis, • potential extra-articular manifestations • A common familial aggregation of SpA cases is another characteristic of this group of diseases. • These disorders are difficult to differentiate because they can occur simultaneously or sequentially.
  • 10. DIFFERENTIATION OF INFLAMMATORY VERSUS MECHANICAL LOW BACK PAIN
  • 11. • Two sets of criteria have been proposed: 1) the Amor criteria, and the 2)European Spondyloarthropathy Study Group (ESSG) criteria
  • 14. • New York diagnostic criteria have been proposed, but they imply radiographic evidence of sacroiliitis for AS diagnosis. • An incremental frequency of radiographic sacroiliitis over time has been demonstrated in SpA (40% prevalence after 10 years of disease duration, 86% prevalence after 20 years of disease duration) • Thus, because of a frequent absence of radiographic sacroiliitis at the beginning of the disease, this radiologic item appears to be an inappropriate request in early diagnosis.
  • 17. Clinical presentation of the spectrum of spondylo arthropathy
  • 29. The following localizations of the disease are considered as axial involvement: • sacroiliac joints, • spine, • anterior chest wall, and • root joints (hip and shoulder).
  • 30. Sacroiliitis • Is responsible for pain and functional impairment caused by inflammation with a long-term evolution often resulting in ankylosis of the sacroiliac joints. • In some cases, a persistent inflammation without ankylosis leads to chronic pain and functional disability.
  • 31. • Anteroposterior Ferguson view of the sacroiliac joints in a patient with AS. The area of the sacroiliac joint inferior to the arrows is imaged by the Ferguson view and not by an anteroposterior view. Note the bilateral, symmetric involvement with erosions and eburnation
  • 35. • MR image of the sacroiliac joints in a patient with undifferentiated spondyloarthropathy. Axial T1-weighted image with fat suppression after intravenous administration of Gd-DTPA demonstrates increased signal intensity in the subchondral bone marrow within the iliac and sacral sides of the right joint (arrows) and early erosions of the left joint (arrowhead).
  • 36. Spinal involvement • Can be related to vertebral ligament inflammation or interapophyseal joint inflammation. Both afflictions can be responsible for night pain, morning stiffness, and reduction in spinal mobility.
  • 37. • Vista lateral de la columna lumbosacra que muestra esquina brillante (puntas de flecha), la cuadratura de los cuerpos vertebrales, y la formación temprana sindesmofito (flechas) en un paciente con EA
  • 38. • Lateral view of the lumbosacral spine showing syndesmophytes of AS, giving it a bamboo appearance
  • 39. • Lateral view of the cervical spine in a patient with PsA. The posterior spinous processes show erosive changes at ligamentous attachments (arrowheads).
  • 40. MR (sagittal STIR) images of the lumbar spine of a patient with AS. (a) Note the areas of marrow edema within the anteroinferior corners of the third and fourth lumbar vertebrae, respectively (arrows). (b) Four weeks after the start of therapy with anti–tumor necrosis factor the areas of edema had resolved and so had the patient's symptoms (arrows).
  • 41. • Secondary vicious attitudes can be explained by the analgesic position (fetal position) unconsciously taken by the patient during the second part of the night during inflammatory phases of the disease.
  • 42. Anterior chest wall pain • Is observed in about 15% of patients who have SpA and can be related to sternoclavicular, manubriosternal, or sternocostal arthritis.
  • 43. • Anterior chest wall involvement together with costovertebral joint involvement can lead to decreased chest expansion and impaired respiratory function.
  • 44. Shoulder and hip involvement • Can be responsible for severe disability. • Moreover, hip arthritis (defined as the presence of pain localized in the groin associated with lameness) has been considered as a criterion of poor outcome prognosis.
  • 45. Laboratory parameters of inflammation.
  • 46. • In patients suffering from isolated axial involvement, an increase in C-reactive protein (CRP) is not a rare phenomenon; it is observed in about 40% of patients.
  • 47. An increase in CRP might be correlated with the clinical severity of the disease and might be considered to be a potential predisposing factor of structural progression.
  • 48. • In clinical trial, NSAIDs had little effect on erythrocyte sedimentation rate (ESR) or CRP. • At variance, recent data on TNF-a blocking agents demonstrate a huge effect on both markers of inflammation.
  • 49. Definition of active axial disease • Pain and disability can reflect the inflammatory process and the structural damage caused by the disease. • level of night disturbance, duration and intensity of the morning stiffness, level of pain, and functional disability.
  • 50. • The remaining question when considering second-line drugs is whether or not an objective demonstration of inflammation is necessary (eg, CRP elevation, inflammatory signals assessed by MRI, or abnormal vascularization of the entheses using ultrasonography).
  • 51. • Musculoskeletal ultrasound features in psoriatic arthritis: • A, Right plantar fascia thickening compared with the left. • C, Power Doppler ultrasound through left third finger at the metacarpophalangeal joint confirming increased vascularity (synovitis).
  • 52. • Musculoskeletal ultrasound features in psoriatic arthritis: • B, Transverse section through left third finger at the metacarpophalangeal joint showing right tenosynovitis. • D, Right Achilles tendinitis with calcaneal erosion.
  • 53. Definition of severe axial disease • The severity of axial disease is defined by radiologic damages such as bamboo spine. • An active disease despite optimal NSAID treatment is usually considered to be a predictive factor of subsequent severity defined by radiological progression.
  • 57. • Dactylitis and oligoarthritis of the lower limbs, predominantly involving knees and ankles, are characteristic of the peripheral involvement in SpA and substantially differ from RA (polyarticular, bilateral, symmetrical arthritis involving small joints).
  • 58. • Sausage digits in a 14-year-old HLA-B27+ boy with onset of spondyloarthropathy at the age of 12.
  • 59. Definition of active peripheral disease • Activity of peripheral articular manifestations has a definition similar to the one that describes activity in RA: number of swollen and tender joints together with biological signs of inflammation.
  • 61. • The enthesitis is the anatomical site of insertion of a tendon, ligament, or articular capsule into bone. Local or regional pain occurring in an SpA patient usually reflects enthesitis, which is responsible for local inflammation and local bone remodeling.
  • 62. • Radiographic image of entheseal calcification and surface irregularity at calcaneal insertion and Achilles tendon insertion of a patient with SpA
  • 63. Extra-articular manifestations • Various extra-articular manifestations can be observed in SpA patients: psoriasis, gut inflammation with chronic diarrhea, uveitis, cardiac manifestations,
  • 66. ETIOLOGY • Animal and laboratory studies suggest that the HLAB27 molecule itself plays a key role, and that involvement of class I major histocompatibility complex (MHC) antigens in the presentation of microbial peptides is central to the pathogenic mechanism (Klebsiella aeruginosa)
  • 67. CLINICAL FEATURES • The principal musculoskeletal lesions associated with AS are enthesitis and synovitis, with sacroiliitis also involving adjacent bone. • Inflammatory eye lesions, myocardial changes, gut mucosal lesions, and skin lesions are inconsistent but characteristic features of AS.
  • 68. • Spinal features of AS seldom appear before the age of 16 to 18 years. • Before this age, children and teenagers may develop oligoarthritis—typically a swollen knee or metatarsophalangeal (MTP) joint— sometimes associated with iritis and/or enthesitis. • Juvenile AS is remarkable because it does not involve the spine.
  • 69. • The average age at onset is 26 years. Although the disease rarely begins after the age of 40 years, it is not uncommon for the diagnosis to be made only years later, well after that age. • Earlier symptoms often are mild, ignored, or not recognized as being part of AS.
  • 70. • The usual presenting symptom is inflammatory back pain that is insidious in onset, persistent for more than 3 months, worsened by rest and improved by exercise. • Night pain is a frequent symptom.
  • 71. • Sacroiliitis, the most common initial feature, causes pain in the buttocks, typically alternating between right and left in severity. • This pain sometimes radiates down the thighs but never below the knee.
  • 72. • A minority of patients present with oligoarthritis or enthesitis that particularly affects the heel, or hip pain due to aggressive synovitis. • Fatigue, a common and troublesome symptom, may be caused in large part by impaired sleep caused by pain and stiffness.
  • 73. • Other constitutional features may include fever and weight loss. Overt or subclinical depression, accompanied by a loss of libido and reduced capacity for work, also may contribute to lack of well-being.
  • 74. • Spinal discomfort and stiffness typically ascend the spine over a period of years, producing progressive spinal pain and restriction. • One of the first clinical signs is the disappearance of the lumbar lordosis.
  • 76. • Bamboo spine’ in a 49-year-old man with a 14-year history of ankylosing spondylitis. • This classic but uncommon manifestation occurs at a late stage following inflammatory disease. • Note the calcification of the anterior fibres of the annulus (arrow).
  • 77. • This progression affects the costovertebral joints, reducing respiratory excursion, and the cervical spine, limiting neck movement. • Thoracic spine involvement may be associated with anterior chest pain and sternal/costal cartilage tenderness, which can be particularly distressing for patients.
  • 79. • Osteoporosis (which may be prevented by appropriate therapy) may lead to vertebral and other fractures later in life. • Spinal fractures are more common in patients who have severe involvement with rigidity. • Aseptic spondylodiscitis may occur in patients with AS, especially in the thoracic spine
  • 82. Enthesitis • The central feature of AS is inflammation at entheses, the sites where tendons and ligaments attach to bone.
  • 83. • These inflammatory lesions initially lead to radiographic appearances of osteopenia or lytic lesions, but subsequently reactive bone forms a new, more superficial enthesis, which develops into a radiologically detectable bony overgrowth or spur.
  • 85. • In the spine, enthesitis occurs at capsular and ligamentous attachments and discovertebral, costovertebral, and costotransverse joints, with involvement also at bony attachments of interspinous and paravertebral ligaments.
  • 89. • Enthesitis accounts for much of the pain, stiffness, and restriction at sacroiliac and other spinal joints. • The phenomenon also occurs at extraspinal sites, producing potentially troublesome symptoms.
  • 90. • Such lesions most commonly affect the plantar fascia and Achilles tendon insertions to the calcaneus, leading to disabling heel pain. • Plantar fasciitis typically leads to the formation of fluffy calcaneal spurs visible on heel radiographs after 6 to 12 months.
  • 91. • Swelling of the right Achilles tendon in a 26-year-old man with spondyloarthritis
  • 92. • A, Left Achilles tendon (AT), which was normal on both clinical and US examination. The short white arrows point to the edges of the tendon, and the white dotted line (with arrows) indicates the depth of the tendon. B, Abnormal right side, with thickening and hypoechogenicity of the Achilles tendon extending to the insertion. There is also a distended retrocalcaneal bursa. KFP, Kager's fat pad; ∗, fluid; ∗∗, fat pad or synovium.
  • 93. Fat-suppressed magnetic resonance image of the foot of a young patient with ankylosing spondylitis. The high signal is consistent with marrow edema, reflecting acute plantar fasciitis (white arrow). In addition, there is retrocalcaneal bursitis (asterisk).
  • 94. • Similar lesions may occur around the pelvis, costochondral junctions, tibial tubercles, and elsewhere, causing marked local tenderness
  • 96. • Sternal and costochondral pain also reflect a combination of local enthesitis and referred pain from the thoracic spine. • This development frequently produces chest pain that must be distinguished from myocardial ischemia.
  • 97. Sacroiliitis • Inflammation of the sacroiliac joints develops most frequently in the late teens or in the third decade of life, producing bilateral or occasionally, unilateral buttock pain, usually worse after inactivity and sometimes aggravated by weight bearing.
  • 98. • Changes principally affect the lower anterior (synovial) portion of the sacroiliac joints and are associated with juxta-articular osteopenia and osteitis. • This condition leads to radiographic appearances of widening of the sacroiliac joint.
  • 100. • Endochondral ossification as a consequence of the osteitis gives the radiographic appearance of erosion along the lower part of the sacroiliac joints. • Osteitis appears as increased water content of adjacent bone, as seen on magnetic resonance imaging (MRI).
  • 102. • MRI is a valuable imaging modality for assessment of inflammation in both the sacroiliac joints and the spine. This can frequently be an important aid in establishing an early diagnosis. • Capsular enthesopathy also occurs over the anterior and posterior aspect of the joint throughout its length, leading to sheets of ossification that ultimately obscure the joint completely on standard radiographs, depicted as ankylosis of the sacroiliac joint.
  • 103. Synovitis • Synovitis is indistinguishable histologically and immunohistochemically from typical rheumatoid disease. • Peripheral joint synovitis may precede, accompany, or follow the onset of spinal symptoms.
  • 104. • Hips, knees, ankles, and MTP joints are affected most commonly. With the exception of the shoulders, upper limb joints are almost never involved in AS. • In further contrast to rheumatoid arthritis, peripheral joint synovitis usually is oligoarticular, often asymmetrical, and frequently episodic rather than persistent
  • 105. • Joint erosions, especially at the MTP joints, may lead to subluxation and deformity. • Temporomandibular joints may be affected, leading to reduced mouth opening and discomfort on chewing. • Dactylitis may lead to pain in one or more toes that lasts many months.
  • 106. Eye Lesions • Acute anterior uveitis (iritis) develops at some time during the course of the disease in approximately one third of patients with AS, and may be recurrent.
  • 107. • Acute anterior uveitis in AS, typically unilateral and associated with redness, pain, and photophobia.
  • 108. • The typical pattern is alternating, unilateral eye inflammation associated with pain , redness, lacrimation, photophobia, and blurred vision. • The occurrence of uveitis typically does not coincide with flares of arthritis.
  • 109. • Untreated or inadequately treated iritis may lead rapidly to considerable scarring, irregularity of the pupil, and visual impairment. • Red, sore, gritty eyes or blurring of vision in a patient with AS require urgent ophthalmologic examination.
  • 110. Inflammatory Bowel Disease • Sacroiliitis occurs in 6% to 25% of people with Crohn’s disease or ulcerative colitis. • Patients with Crohn’s disease or ulcerative colitis frequently have unilateral sacroiliitis, and may also suffer from peripheral arthritis and enthesitis.
  • 111. • Similarly, inflammatory bowel disease may be present or develop in people with preexisting AS. • Indeed, approximately 60% of people with AS have subclinical changes in the small or large bowel. • There is speculation that these changes may relate to the pathogenesis of AS, but their true significance is unknown.
  • 112. • Even though some AS lesions closely resemble those of Crohn’s disease, the great majority of such lesions never become symptomatic. • Only about 10% to 15% of the patients with AS have overt ulcerative colitis or Crohn’s disease
  • 113. • In a minority of people with colitis and peripheral arthritis, peripheral joint disease may diminish substantially after total colectomy.
  • 114. • Active inflammatory bowel disease increases the risk and severity of osteoporosis. • Crohn’s disease with extensive small bowel involvement also may lead to impaired vitamin D absorption and osteomalacia, producing ill-defined musculoskeletal pain and difficulty with walking.
  • 115. Cardiovascular Involvement • Cardiac conduction abnormalities and myocardial dysfunction have been recorded in a significant minority of people with AS
  • 116. • Aortitis with dilatation of the aortic valve ring and aortic regurgitation has been demonstrated in approximately 1% of patients. • The risk of occurrence of aortic insufficiency and cardiac conduction abnormalities increase with age, disease duration, presence of HLA-B27, and peripheral joint involvement.
  • 117. Pulmonary Involvement • Approximately 1% of patients develop progressive upper lobe fibrosis of the lungs. • Rigidity of the chest wall results in the inability to extend the chest fully and to mild restrictive lung function impairment, but rarely leads to ventilation insufficiency due to the compensation by increased diaphragmatic contribution.
  • 118. Neurologic Lesions • Neurologic deficits are associated most often with cord or root lesions following spinal fracture. • Nerve root pain may arise from the cervical spine, especially when there is marked flexion deformity.
  • 119. • Long-tract signs, including quadriplegia, may follow spinal fracture dislocation after relatively minor trauma and complicate spontaneous atlantoaxial subluxation. • Subluxation also may lead to severe occipital headache.
  • 120. Skin Involvement • In various series, between 10% and 25% of the patients with typical AS have concomitant psoriasis lesions.
  • 121. Renal Consequences • Although rarely seen today, secondary amyloidosis caused by longstanding AS is well described.
  • 122. IMAGING • By definition, all patients fulfilling the modified New York criteria show signs of sacroiliitis on radiographs.
  • 123. • However, about 30% of the patients do not develop damage of the spine visible on radiographs. • If patients show no spinal damage after a certain disease duration (about 10 years), it is unlikely that the patient will develop radiographic abnormalities of the spine at all. • On the other hand, patients who have spinal damage are prone to develop more damage.
  • 124. • Characteristic features on radiographs of the sacroiliac joints are pseudo-widening of the joint space, sclerosis, erosions, and ankylosis
  • 125. • Anteroposterior radiographs of the pelvis showing complete ankylosis of both sacroiliac joints and syndesmophyte formation in the lower lumbar vertebrae.
  • 126. • Many AS-related changes can be seen in the spine; squaring of the vertebrae, sclerosis, erosions, syndesmophytes, bony bridging, and spondylodiscitis are the most relevant.
  • 127. • Radiograph of the lateral cervical spine, demonstrating the formation of extensive bridging syndesmophytes that involve almost the entire cervical spine.
  • 128. Radiograph of the lateral lumbar spine with squaring of L1 and syndesmophyte formation from L3 to L5.
  • 129. • Syndesmophytes are characterized by axial growth that may lead to bridging phenomena. For making a diagnosis, conventional radiography is still the preferred option. • However, if the radiographs are persistently normal in the setting of high disease suspicion, MRI of the sacroiliac joints and spine can add information.
  • 130. • In contrast to conventional radiographs, MRI has the potential to demonstrate inflammation, not merely the end results of inflammation on bone.
  • 131. • Among MRI techniques for delineating inflammation, the short tau inversion recovery (STIR) technique is preferred. • MRI is also useful in visualizing enthesitis, for example, of the heel or Achilles tendon insertion.
  • 132. • Short tau inversion recovery (STIR) image of the sacroiliac joints revealing extensive inflammation (white) involving both the sacral and iliac sides of the joints bilaterally.
  • 133. • weighted, opposed-phase, gradient echo magnetic resonance image 3 minutes after the intravenous injection of gadolinium-DTPA in a 23-year-old man with ankylosing spondylitis and severe inflammatory back pain localized mainly to the right side, of 3 years' duration. Acute sacroiliitis is demonstrated by the strong contrast enhancement of the right sacroiliac joint (arrowheads), with impressive bone marrow edema (white arrow) and erosions (black arrow).
  • 135. • As in many other diseases in which the etiology is not clearly defined (e.g., by the isolation of a specific causative pathogen), the diagnosis of AS must rest on the combination of clinical features, radiological findings, and laboratory results.
  • 136. • There are no established diagnostic criteria for AS. • On the other hand, classification criteria, used for the purpose of categorizing patients in research studies, are available. • The most widely used classification criteria for AS are the modified New York criteria.
  • 137. • Although the New York criteria are useful in established disease, their heavy reliance on the demonstration of radiographic sacroiliitis diminishes their applicability in patients with early disease.
  • 138. AMOR’S CLASSIFICATION CRITERIA FOR SPONDYLOARTHRITIS: A patient is considered as suffering from a spondylarthropathy if the sum is ≥6.
  • 139. AMOR’S CLASSIFICATION CRITERIA FOR SPONDYLOARTHRITIS: A patient is considered as suffering from a spondylarthropathy if the sum is ≥6.
  • 140. THE EUROPEAN SPONDYLARTHROPATHY STUDY GROUP CRITERIA
  • 141. Current Opinion in Rheumatology 2010
  • 143. • Bone marrow oedema (BMO), reflecting active sacroiliitis
  • 144. • Synovitis as an active inflammatory lesion appears as hyperintense signal on contrast-enhanced
  • 145. • Capsulitis (arrows) is a hyperintense signal of the sacroiliac (SI) joint capsule. Anteriorly, the joint capsule gradually continues into the periosteum of the iliac and sacral bones.