...with psoriasis. Reactive arthritis must distinguished from other arthropathies. Arthritis occurs in about 30% of patients with inflammatory bowel disease. Undifferentiated SpA includes several related disorders. Radiographic evidence of sacroiliitis is a characteristic feature of AS. SpA management should include patient education and regular exercise. NSAIDs are the first line of treatment. The tumor necrosis factor a inhibitors are highly effective in patients with active AS and in those with PsA that is unresponsive to conventional therapy.

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Together the spondyloarthropathies (SpA) form a group of overlapping chronic inflammatory rheumatologic diseases that show a predilection for involvement of the axial skeleton, entheses (bony insertions of ligaments and tendons), and peripheral joints. They also may involve extraskeletal structures, especially the eyes, lungs, skin, and GI tract. These diseases are strongly associated with the HLA-B27 gene but lack association with rheumatoid factor (RF) and antinuclear antibodies. (1)

The SpA include ankylosing spondylitis (AS), psoriatic arthritis (PsA), reactive arthritis (ReA), arthritis of inflammatory bowel disease (IBD), and undifferentiated SpA. They are more common than previously recognized. Recent data from Europe and Asia suggest that as a group, the SpA might be as common as rheumatoid arthritis (RA); in Europe, the prevalence is 0.5% to 1%. (2-4)

Because there are no diagnostic criteria for the wider spectrum of the SpA, the diagnosis is based primarily on clinical findings. 1, 2, 4-8) European Spondylarthropathy Study Group (ESSG) classification criteria are used frequently to help the clinical diagnosis (Table 1). (9) Early diagnosis has become much more important in recent years as more effective therapeutic options have become available.

In this article, we describe the specific clinical entities in the SpA and their common laboratory and radiological features. Then we outline a variety of management strategies, including nonpharmacological modalities, pharmacological therapy, and ophthalmological or surgical referral.

DIAGNOSIS

Clinical manifestations

AS. The prototype of the SpA, AS primarily involves the sacroiliac joints and spine (Figure) and, often, the hip and shoulder joints; patients typically present with chronic inflammatory back pain .2,8 Symptoms usually start insidiously when patients are in their late teens or early 20s; men are affected roughly twice as frequently as women.

Patients with AS may awaken late at night or very early in the morning because of back pain and stiffness, which is eased with physical exercise or a hot shower. Enthesitis may cause pain and tenderness over the anterior chest wall, spinal processes, iliac crests, and sites of bony insertions of the Achilles and patellar tendons and plantar fascia. Peripheral arthritis, usually monoarticular or oligoarticular, is less common in primary AS than in "secondary" AS (in the context of PsA, ReA, or IBD).

Tenderness may be noted over the sacroiliac joints, spinal processes, and other bony prominences. In some patients, pain in the sacroiliac joint area may be elicited with sacroiliac stress testing by using maneuvers such as the FABERE test (hip Flexion, Abduction, External Rotation, and Extension). (8) Costovertebral and costotransverse joint involvement may result in diminished chest expansion. Gradual impairment of spinal mobility may be noted on lateral and forward flexion, hyperextension, and axial rotation of the lumbar and cervical spine. Limitation of forward flexion of the lumbar spine may be measured with the modified Schober test; occiput-to-wall distance measures the forward stooping deformity of the neck. (8)

Acute anterior uveitis, the most common extraskeletal manifestation of AS, occurs in up to 40% of patients with AS, especially those who possess the MA-B27 gene. (1, 2, 8) If not recognized and managed early, uveitis may lead to visual impairment. Subclinical lung abnormalities are somewhat common in patients with AS (10); however, clinical pulmonary manifestations are uncommon. Other less common extraskeletal manifestations of AS may involve the gut, aorta, or heart. Cauda equina syndrome is a rare neurological complication of AS. (1,2,8)

In the absence of diagnostic criteria for AS, the modified New York criteria are the most commonly used classification...

NOTE: All illustrations and photos have been removed from this article.



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