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SPONDYLOARTHRITIS
(SPONDYLOARTHROPATHIES) |
Spondyloarthritis (or spondyloarthropathy) is the overall name for a
family of inflammatory rheumatic diseases that can affect the spine and
joints, ligaments and tendons. These diseases can cause fatigue and pain
or stiffness in the back, neck, hands, knees, and ankles as well as inflammation
of the eyes, skin, lungs, and heart valves. While there is no course of
prevention at this time, treatment can reduce discomfort and delay the
development of spinal deformities.
Fast Facts
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Spondyloarthritis usually strikes young males, particularly
family members of those with these diseases.
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Nonsteroidal
Anti-inflammatory Drugs (NSAIDS) offer considerable symptom relief.
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A
regular regimen of recreational activities and back exercises
will improve comfort levels.
What
spondyloarthritis is
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| Over time, spondylitis results in pronounced curvature of
the spine (left). |
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The term spondyloarthritis (also known as spondyloarthropathy)
covers a group of closely related inflammatory diseases including arthritis
of the spine (sacroiliitis or spondylitis) and peripheral joints; as
well as inflammation in the area where ligaments and tendons attach to
bones (enthesitis or enthesopathy). These diseases can cause pain in
the spine, legs and arms as joints, ligaments, and tendons become inflamed
and/or predispose patients to spinal vertebral fractures. Skin rashes,
eye, and intestinal problems can also occur.
Diseases
that fall under spondyloarthritis umbrella can include: 1) ankylosing
spondylitis ; 2) reactive arthritis (known previously as Reiter's syndrome
) 3) psoriatic arthritis and psoriatic spondylitis, and 4) the arthritis
or spondylitis associated with the inflammatory bowel diseases, ulcerative
colitis and Crohn's disease. Still other patients may develop undifferentiated
spondyloarthritis. This means they have symptoms or signs of one of the
illnesses above, but don't develop the full blown disease.
What causes spondyloarthritis
The exact cause of spondyloarthritis is unknown. However, researchers
point to hereditary factors as playing an important role since these illnesses
tend to occur more often in family members of patients who have spondyloarthritis.
These patients usually share common genetic markers called HLA-B27, which
occurs in about seven percent of the population.
Other infections, such as chlamydia (which can cause urethritis or burning
on urination) and bacteria that cause intestinal dysentery (such as types
of salmonella, shigella, etc.), can trigger a certain type of reactive
arthritis that is a form of spondyloarthritis. Beyond these, no specific
infection has been linked to other types of the disease.
Who gets spondyloarthritis
Spondyloarthritis tends to impact those in their teens and 20s, and
young men two to three times more frequently than young women. (Psoriatic
arthritis does affect young men and women equally). Family members of
patients with spondyloarthritis run the highest risk of contracting these
diseases, particularly those with HLA genes.
The highest frequency appears in the far north in cultures such as Alaskan
and Siberian Eskimos and Scandinavians Lapps (Samis), as well as in certain
Native America tribes in the western U.S. and Canada. African-Americans
are least frequently affected. About one in 200 Caucasians have spondyloarthritis.
How spondyloarthritis is diagnosed
Diagnosis is made following a careful history and physical examination
of inflammatory back pain or arthritis of the leg as it differs from
other types of arthritis such as rheumatoid
arthritis.
Additional tests such as X-rays of the sacroiliac joints and spine
can confirm the presence of spondylitis. (Researchers are currently
developing MRI scans that will also diagnose the disease). If symptoms
and signs indicate, the physician will also check for the presence of
the HLA-B27 gene.
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| Red areas show location of inflammation in the sacroiliac
joints. |
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How spondyloarthritis is treated
Like many forms of arthritis, physical therapy and recreational exercise
at least 30 minutes per day can significantly improve pain and stiffness.
Additional back exercises at least five days per week will also improve
pain and function in patients with ankylosing spondylitis.
There is also a vast array of drug treatment options for spondyloarthropathy,
starting with nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen,
ibuprofen, diclofenac or indomethacin given at the outset of the disease
symptoms. No one specific NSAID is considered superior to another for
spondyloarthritis patients. These in and of themselves will generate considerable
relief for patients.
Disease modifying anti-rheumatic drugs (DMARDs) such as sulfasalazine and methotrexate have proven effective in treating accompanying arthritis
in the arms or legs, but not for arthritis of the spine or sacroiliac
joints.
Corticosteroids taken by mouth also can be effective. However, given
their side effects, particularly osteoporosis and infections, and new
agents now available (see below), these medications are not recommended
unless the more effective treatments cannot be used. Injections of depo-steroid
medications into joints or tendon sheaths are frequently used by clinicians
for symptomatic relief of local flares.
Antibiotics such as ciprofloxacin, given over a three-month course soon
after disease onset, may have a beneficial effect on the prognosis of
reactive arthritis, especially when triggered by Chlamydia trachomatis,
but not in other types of spondyloarthritis.
TNF alpha blockers (also
known as biologics) have been shown to be quite effective in treating
both the spinal and peripheral joint symptoms of spondyloarthritis, as
well as other problems such as psoriasis and intestinal inflammation.
There are three types currently available:
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infliximab (Remicade), which is used at a dose of 5
mg/kg given intravenously every six to eight weeks;
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etanercept (Enbrel), given 25 mg under the skin twice
weekly; and
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adalimumab (Humira), injected at a done of 40 mg. every
other week under the skin.
However,
anti-TNF treatment is expensive and not without complications, including
an increased risk for infections, especially tuberculosis. Therefore, NSAID and
DMARD therapy are tried first.
Some patients require surgical treatment. For those with ankylosing spondylitis,
a total hip replacement is the most common. However, because patients
with spondylitis are at increased risk for vertebral fracture, they may
experience often spinal cord damage. Typically, these patients must wear
a kind of brace called a “halo vest.” Surgical spinal fusion may be necessary
when spinal cord or nerve function is compromised.
Some patients seek surgical correction of the spinal deformities that
can occur with ankylosing spondylitis, called osteotomy. Given the extensive
complication rates, patients considering this procedure should consult
surgeons experienced with this type of operation.
Broader Health Impacts
Patients with spondyloarthritis can develop additional complications
which should be discussed with their physician. These can include:
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Osteoporosis which
occurs in up to half of patients with ankylosing spondylitis, especially
in those whose spines have fused, and can predispose to spinal fracture.
Treatments include calcium supplements, bisphosphonates and other
standard treatments for osteoporosis.
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Eye
inflammation, called uveitis, which occurs in about 40 percent
of those with spondyloarthritis. Usually steroid eye drops are effective,
though more severe cases may require stronger treatments by an
ophthalmologist.
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Inflammation of the aortic valve in the heart which
can occur over times in patients with spondylitis. This should
be monitored with the physician.
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Psoriasis and intestinal inflammation
which may be so severe as to require more specialized treatment
by a dermatologist or gastroenterologist.
Living with spondyloarthritis
Despite the pain, fatigue and stiffness that characterize these diseases,
most patients with spondyloarthritis can have long and productive lives,
particularly with the newer treatments available. Regular physical exercise
is essential to reduce spinal fusion and deformities and to maintain joint
and cardiovascular health.
Patient support groups are also available through the Spondylitis Association
of America, the Psoriasis Foundation or the Arthritis Foundation. (see
links below). These individuals and medical practitioners can be provide
valuable information and support.
Points to Remember
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Spondyloarthritis is a type of arthritis that occurs
in the spine and peripheral joints (hands, knees, ankles, etc.) that
can also involve the skin, intestines, and eyes.
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Those
in their teens and 20s, particularly males, are affected most
often. Family members of spondyloarthritis patients are at the highest
risk.
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Newer treatments have helped a great deal in controlling
the symptoms and signs.
To find a rheumatologist
For a listing of rheumatologists in your area, click
here.
Learn more about rheumatologists and rheumatology
health professionals.
For more information
The American College of Rheumatology has compiled this list to give you
a starting point for your own additional research. The ACR does not endorse
or maintain these Web sites, and is not responsible for any information
or claims provided on them. It is always best to talk with your rheumatologist
for more information and before making any decisions about your care.
Spondylitis Association of America
www.spondylitis.org
The Psoriasis Foundation
www.psoriasis.org
The Arthritis Foundation
www.arthritis.org
Updated June 2005
Written by John D. Reveille, MD, and reviewed by the American
College of Rheumatology
