Ankylosing Spondylitis from rheumatoid spondylitis up to nonradiographic

Ankylosing Spondylitis from rheumatoid spondylitis up to non-radiographic SPA

Spondyloarthropathies (Sp. A) consist of ankylosing spondylitis , reactive arthritis, arthritis/spondylitis associated with psoriasis, and arthritis/ spondylitis associated with inflammatory bowel diseases.

Skeletal Manifestations & Extra-skeletal Manifestations

(1) Back pain 80% of the general population experience back pain at sometime of their life which most probably mechanical back pain

Calin criteria 1977 Berlin criteria eighteens ASAS criteria 2009 (Assessment of Spondylo. Arthritis international society )

Classification criteria are not diagnostic ones i. e. still cause is unknown & purpose of research rather than clinical

(2) chest pain +/_ tenderness & reduction of chest expansion

thoracic spine involvement & costo-vertebral and costo-transverse joints &enthesitis

(3) Enthesitis costosternal junctions spinous processes iliac crests greater trochanters ischial tuberosities tibial tubercles and heels (Achilles tendinitis or plantar fasciitis)

(4) Peripheral arthritis • • hips and shoulders juvenile AS hip involvement Lower limbs > upper limbs Oligo-articular and asymmetric

Extra-skeletal Manifestations

Eye Disease Acute anterior uveitis most common extra-articular manifestation of AS & no relationship to activity & painful red eye with visual impairment, Photophobia and increased lacrimation &Most attacks subside in 4 to 8 weeks without sequelae if early treatment & posterior synechiae and glaucoma

Cardiovascular Disease silent or overt & ascending aortitis, aortic valve incompetence, conduction abnormalities

Pulmonary Disease slowly progressive fibrosis of the upper lobes of the lungs & chest wall rigidity

Neurologic Involvement • osteoporotic spine + ossification of the posterior longitudinal ligament + inflammatory process fracture & compression & instability • Cauda equina syndrome

Renal Involvement • Ig. A nephropathy • Microscopic hematuria and proteinuria

Examination

Posture: forward slope of the neck & hyperkyphosis & loss of lumbar lordosis and protuberant abdomen & through osteoporotic deformities and disease activity Stiffness Spinal Mobility & Chest Expansion Tenderness Enthesitis & Sacroiliitis Through : Schober test (or its modifications) Chest Expansion Occiput to Wall

LABORATORY TESTS

* ESR * CRP * normochromic anemia * elevated serum alkaline phosphatase * elevated serum Ig. A * decreased high-density lipoprotein cholesterol

Classification Criteria

1966 thoracic pain and uveitis were removed from the Rome criteria

1968 New York criteria 1984 modified New York (m. NY) criteria

Thoracic pain & uveitis are obsolete Radiographic SI is mandatory New terms; definite & probable

Up to 1974, AS was termed as rheumatoid spondylitis then Wright et al initiated the use of the term of seronegative spondylarthritides

1977 Calin et al criteria of IBP

NY criteria radiograph is obligatory m. NY criteria depended upon Calin et al criteria Rome& Amor& ESSG criteria don’t necessitate radiograph Amor& ESSG criteria used Berlin criteria

At this time, MRI of the sacroiliac joints was defined however it was not well established or standardized

MRI can detect both inflammatory and structural changes

Appearance of classification criteria for reactive arthropathy and criteria for psoriatic arthropathy but there were many patients who could not be included in such specific classifications

ASAS *not but added to old criteria * Included early & 2 main categories *standardized MRI findings *clarify subsets of SPA *IBP criteria *HLA-B 27 (entry criterion)