Spondyloarthritis can be defined as a group of disorders that lead to inflammation of the spine, the joints, ligaments, tendons and the surrounding locations. These conditions can also affect the eyes, skin, gut, urinary tract as well as the lungs and heart on certain occasions. Spondyloarthritis can also be described as spondyloarthropathy that is accompanied by inflammation, and the group of disorders associated with it is specifically termed as seronegative spondylarthropathies. They are also characterized by negative rheumatoid factor as well as anti-nuclear antibody. Signs of enthesopathy can also be seen along with seronegative spondarthritides.
The various types of this disorder are caused by different factors. Ankylosing spondylitis is caused by hereditary links. Several genes have been identified that can lead to the development of this disorder. The most important among them is the HLA-B27 gene.
The exact causes that lead to psoriatic arthritis are not known. However, a genetic factor is believed to be responsible for it as well.
Reactive arthritis is caused by some preceding infection. Genital infections caused by the bacteria Chlamydia trachomatis is the most common infection associated with reactive arthritis. Other forms of bacteria commonly associated with this condition include:
- Ureaplasma urealyticum
- Campylobacter spp.
- Shigella spp.
- Yersinia spp.
- Salmonella spp.
There are also certain gastrointestinal infections or food poisoning that may trigger this disease.
Enteropathic spondylitis is caused by certain inflammatory bowel disorders like ulcerative colitis and Crohn’s disease.
Spondyloarthritis and Associated Conditions
A number of conditions are associated with the group of seronegative spondyloarthritis conditions. These include:
- Psoriatic arthritis
- Ankylosing Spondylitis
- Axial spondyloarthritis
- Peripheral spondyloarthritis
- Isolated acute anterior uveitis
- Undifferentiated spondyloarthritis
- Reactive arthritis (Reiter’s syndrome)
- Enteropathic spondylitis or arthritis, or spondylitis that is associated with various inflammatory bowel diseases such as Ulcerative colitis and Crohn’s disease
Whipple’s disease and Behçet’s disease are also included in this list by some sources.
Juvenile spondyloarthritis are another group of arthritic conditions that affect mostly children below 16 years of age and span through the adult life. The group includes various disorders, such as:
- Juvenile ankylosing spondylitis
- Undifferentiated spondyloarthropathy
- Reactive arthritis
- Psoriatic arthritis
- Spondylitis of the inflammatory bowel diseases
A number of symptoms can occur in the conditions associated with Spondyloarthritis. Some of the most common features of these disorders are mentioned below:
- Sausage digits
- Plantar fasciitis
- Achilles tenosynovitis
- Mucocutaneous lesions
- Pain, swelling and stiffness of the joints and bones
- Sacroiliitis, or inflammations of the joints between pelvis and spine
- Spondylitis or inflammation of the joints located between the spines
- If there is an involvement of the toes and fingers, they may swell up and take an appearance of sausage-like digits
- Presence of enthesitis, i.e., inflammations of an entheses, the site of insertion of tendons, ligaments or an articular capsule into the bone
- Absence of a positive blood test indicating a rheumatoid factor, i.e., seronegative
- A propensity to affect more than one family member
- Pain can be felt in the lower back area, which occurs most frequently in axial spondyloarthritis
- Peripheral spondyloarthritis, which involves swelling and painful sensations, numbness and tingling in arms and legs
- Spinal fusion may occur in some degrees, which is referred to as ankylosing spondylitis
- Signs of oligoarthritis can be observed generally along with asymmetrical presentation
- Extra-articular features may be present, such as an involvement of the skin, eyes and genitourinary tract
- There can also be an overlap between the various causative factors
While diagnosing spondyloarthritis, a doctor first evaluates the medical history of a patient and carries out a thorough physical exam. He or she may then recommend certain blood tests or imaging tests. The following tests are normally carried out to diagnose this group of conditions.
- CT scans
- MRI scans
- Complete blood count
- Musculoskeletal ultrasound scanning
- Erythrocyte sedimentation rate (ESR) test
- Dual-energy X-ray absorptiometry (DEXA) scans
Spondyloarthritis Differential Diagnosis
There are certain health conditions which show signs and symptoms similar to that of the Spondyloarthritis-related conditions. Thus, it is necessary to differentiate Spondyloarthritis from such similar disorders in order to accurately decide on the treatment plans. Here is a list of health issues that should be considered during the differential diagnosis.
Differential diagnoses for Ankylosing Spondylitis
The differential diagnoses for Ankylosing spondylitis comprise of the health issues mentioned below:
- Mechanical back pain
- Congenital spinal deformity
- Infections such as tuberculosis
- Primary or secondary neoplasms
- Degenerative conditions such as osteoarthritis
- Inflammatory conditions such as psoriatic arthritis, rheumatoid arthritis, reactive arthritis or Reiter’s syndrome
Differential diagnoses for Psoriatic Arthritis
The DDx for Psoriatic arthritis include the following conditions:
- Septic arthritis
- Reactive arthritis
- Secondary syphilis
- Rheumatoid arthritis
- Lupus erythematosus
Differential diagnoses for Isolated Acute Anterior Uveitis
The differential diagnoses for isolated acute anterior uveitis include other factors that may give rise to this syndrome, such as:
- Viral agents (Cytomegalovirus, Herpes zoster, Herpes simplex)
- Idiopathic causes
All Spondyloarthritis patients should be treated with physical therapy and joint-directed exercises. The most recommended exercises are the ones that facilitate spinal mobility and extension. There are also a number of drug options that can be used to treat Spondyloarthritis. The first in this line of treatment are NSAIDs or non-steroidal anti-inflammatory drugs such as meloxicam, ibuprofen, naproxen, or indomethacin. If administered in correct doses for an appropriate duration, these medications can bring great relief to most of the patients.
For swelling of joints that is localized and not widespread, shots or injections of corticosteroid drugs into joints or the tendon sheaths can be quickly effective.
Disease modifying anti-rheumatic drugs or DMARDs can be applied to those patients who do not respond well to the above mentioned modes of treatment. A popular drug in this category is Sulfasalazine (Azulfidine). They help in relieving the symptoms as well as protect the joints from damage. This group of drugs is especially helpful with arthrititic patients in whom the0020joints of arms and legs also get affected.
Taking oral doses of corticosteroids is not advisable, even though they can be quite effective. This is because the high doses of these medications required for having the best results often gives rise to many side effects. Patients having reactive arthritis can be treated with antibiotics. TNF alpha blockers are quite effective in curing both spinal as well as peripheral joint symptoms associated with spondyloarthritis. The various drugs in this category approved by the FDA for treating the patients of Ankylosing spondylitis include:
- Etanercept (Enbrel) – A dosage of 50 mg is administered by an injection under the skin for once on a weekly basis;
- Infliximab (Remicade) – Given intravenously through IV infusion every 6 to 8 weeks at doses of 5 mg/kg;
- Golimumab (Simponi) – It is injected at doses of 50 mg for once in a month under the patient’s skin;
- Adalimumab (Humira) – It is injected at doses of 40 mg every alternating week under the patient’s skin
Surgical treatment has also been very helpful in giving good results for some patients. A procedure called Total hip replacement is quite useful for individuals having pain in the hips as well as disability caused by joint destruction resulting from loss of cartilage. Spinal surgery is hardly necessary, and should be reserved only for people having traumatic fractures, i.e., broken bones caused by injuries or to correct the excess flexion abnormalities of the neck, which make it difficult for the patient to straighten his or her neck. Other surgical procedures that might help in relieving a patient of his or her pain include total joint replacement surgery and vertebral osteotomy.
The disease can lead to the following health complications:
- Lung fibrosis
- Inflammation of the eye
- Presence of amyloid deposits
- Immunoglobulin A nephropathy
- Cardiac conduction abnormalities
- Diseases affecting the heart valves
- Aortitis along with aortic regurgitation
- Side effects of various drugs and medications
- Severe kyphosis and frozen thorax with very limited movement of the spine
The outcome for Spondyloarthritis conditions may vary, depending on the specific type of inflammatory spondyloarthropathy disease. Patients of Ankylosing spondylitis enjoy a good prognosis, with 70% to 90% of patients becoming fully independent or having minimal long-term disability. If the condition becomes chronic and/or progressive, significant disability might be caused due to spinal fusion. Greater risk of mortality is present when compared to the general population. Psychological health of these patients may deteriorate, and care should be taken to prevent that. In case of individuals affected by acute anterior uveitis, the condition may recur after treatment. Reactive arthritis patients may experience recurrent spells of arthritis. Individuals having psoriatic arthritis have variable outcomes, based on the nature of their condition which can be mild or severe.
Although there are no definite ways to prevent the development of spondyloarthritis, being aware of the symptoms and risk factors of the various diseases associated with it helps in early detection and proper treatment. One should always consult a doctor if he or she is having the symptoms of spondyloarthritis, or have already been diagnosed with this disorder but is experiencing new complications or signs.
The following images show the characteristic physical features associated with Spondyloarthritis.
Picture 1 – Spondyloarthritis
Picture 2 – Spondyloarthritis Image