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    Spondyloarthritis

    Overview
    Causes
    Symptoms
    Prevention
    Diagnosis
    Treatment
    Where to Seek Treatment
    Singapore General Hospital
    Contributed by Dept of Orthopaedic Surgery

    Overview


    Spondyloarthritis is an infl ammatory rheumatic disease aff ecting the spine, joints and entheses (which are sites of insertion of a ligament, tendon, or articular capsule into bone, for example the Archilles tendonitis, plantar fasciitis). It is a collective group of several related diseases: Ankylosing spondylitis, Psoriatic arthritis, Enteropathic arthritis, Reactive arthritis, and Undiff erentiated spondyloarthritis.

    Ankylosing Spondylitis (AS)

    Ankylosing Spondylitis is a long-term disease that affects the joints in the spine, pelvis and, often, the peripheral joints such as hips, knees, ankles and feet as well. The main problem is chronic inflammation that may eventually cause the spine to fuse together.

    The condition usually starts with low back pain that is worse at night, in the morning, or after prolonged inactivity, and tends to improve with exercise. Limited expansion in the chest may occur as a result of inflammation of the joints between the ribs. As the disease progresses, any portion of the spine may be affected.

    The disease affects more males than females although females can also be affected. It tends to begin between age 20 and 40. Risk factors include having an affected family member and male gender.

    Psoriatic Arthritis

    Psoriasis is a scaly rash that can affect any part of the body, but most frequently the elbows, knees and scalp. In about 5 – 10% of patients with psoriasis, arthritis may also occur, giving rise to psoriatic arthritis. Apart from involvement of the spine, pelvis and joints, psoriatic arthritis is often accompanied by changes in the finger nails and toe nails such as the appearance of small pits.

    Enteropathic Arthritis

    Enteropathic arthritis is a form of spondyloarthritis that is associated with inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis, which typically causes inflammation of the intestines. About 1 in 6 people with inflammatory bowel disease will develop enteropathic arthritis affecting the spine and joints.

    Reactive Arthritis

    Reactive arthritis refers to a type of spondyloarthritis that may be triggered by certain germs which cause gastroenteritis or urinary tract infections. Reiter’s syndrome is a form of reactive arthritis which may also affect the eyes and the skin.

    Undifferentiated Spondyloarthritis

    Not all patients have classic signs and symptoms that fi t neatly into one of the categories outlined above, especially at the start of the illness. In such cases, the term, undifferentiated spondyloarthritis may be used.

    Causes

    This family of conditions are recognised as chronic autoimmune diseases with unknown cause, but genes may play a role and an infective trigger may sometimes be present.

    Symptoms

    In spondyloarthritis, there is inflammation of the spine, joints and entheses. If it involves fingers and toes, they may swell and take the appearance of ‘sausage digits’.

    All of these diseases display a variety of symptoms and signs, but they share many similarities, including:

    • sacroiliitis (inflammation of the joint between the pelvis and the spine) and spondylitis (inflammation of the joints between the spine)
    • presence of enthesitis (inflammation of an entheses) (defined above)
    • absence of positive blood test for rheumatoid factor (‘seronegative’)
    • a tendency to occur in more than one family member.

    Diagnosis on Symptoms

    It is important that you give a detailed history of your symptoms to your doctor as, often, the diagnosis can be made based on your symptoms. Specifi c symptoms of ankylosing spondylitis include stooped posture and back pain that is worse at night, in the morning or after inactivity.

    Neck, hip and heel pain, pain and swelling in the shoulders, knees and ankles, stiff ness in the back, limited chest expansion and range of motion involving the spine and hips, fatigue, mild fever, loss of appetite, loss of weight are also symptoms. Other uncommon complications include eye inflammation, lung fibrosis and disease of heart valves.

      Prevention

      Although there is no prevention or cure for spondyloarthritis, the awareness of risk factors and symptoms allows for early detection and treatment. Contact your doctor if you have symptoms suggestive of spondyloarthritis or if you have already been diagnosed with it and new symptoms or complications develop.

      Diagnosis

      In addition to taking a history and examination, your doctor may recommend certain blood tests such as a Full Blood Count, ESR, HLA-B27, and x-rays of the spine and pelvis to support the diagnosis.

      HLA-B27 is a known genetic marker for ankylosing spondylitis. However, most HLA-B27 individuals do not have the disease, therefore it is not advisable to have the test if you do not have symptoms of ankylosing spondylitis, even if you have an affected relative.

      Treatment

      As a first line treatment, your doctor may prescribe non-steroidal antiinflammatory drugs (NSAIDs) to reduce inflammation and pain. Occasionally corticosteroids may be prescribed for short-term use to suppress unwanted inflammation. Sometimes more potent drugs such as methotrexate or sulfasalazine may be prescribed if you do not respond well to NSAIDs or are dependent on high dose steroids.

      Newer drugs called TNF blockers which block inflammatory proteins, have been shown to be highly effective in treating arthritis of the joints as well as spinal arthritis. This group of medication include Enbrel®, Remicade® and Humira®.

      Surgery may very occasionally be needed if joint damage is severe and there are signifi cant secondary degenerative changes.

      Importance of Exercise

      Exercise plays a very important role in helping to improve posture by reducing stiffness and pain. Most patients will benefit from a daily home exercise regime as recommended by a physiotherapist. Excessive inactivity can certainly increase the risk for spinal fusion. However, bear in mind that if you have Ankylosing Spondylitis, you should avoid high impact sports and heavy weight bearing exercises due to the increased risk of spinal fracture.

      Outlook

      The symptoms of spondyloarthritis may either worsen, stabilise at any stage of the disease, or go into remission. The course of the disease is thus unpredictable.

      Symptoms may come and go at any time. However, unless there is a major flare, most people are able to carry out activities of daily living normally if the disease remains under control.

      In more extreme or long-term cases, damage of the joints and bones can lead to fusion of the joints in the spine or other areas, which can subsequently affect walking and function. As spondyloarthrits is a chronic disease, long-term follow up by a doctor is recommended.

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