Spondyloarthritis

Introduction to Spinal Arthritis Spinal arthritis (SpA), formerly known as seronegative spinal arthropathy (seronegativespondyloarthropathies) or spondyloarthropathies (SpAs), is a group of chronic inflammatory rheumatic diseases with specific pathophysiology, clinical, and radiation. Academic and genetic characteristics, inflammatory low back pain with or without peripheral arthritis, combined with certain characteristics of extra-articular manifestations are the unique symptoms and signs of such diseases. Such diseases include: ankylosing spondylitis (AS), reactive arthritis (ReA), psoriatic arthritis (PsA), arthropathy of inflammatory bowel disease (IBD), Undifferentiated spinal arthritis and juvenile chronic arthritis. Reiter's syndrome (RS) is synonymous with reactive arthritis and is rarely used. These diseases are often caused by young and middle-aged people. Except for the gender difference in the incidence of psoriatic arthritis, there are more men than women in other diseases. Spinal arthritis has a strong correlation with the HLA-B27 gene, which makes its concept well unified. The true concept of seronegative spondyloarthropathy was confirmed more than a decade ago by Wright et al. The term "serum-negative spondyloarthropathy" is used to describe a class of related heterogeneous diseases with many of the same clinical, radiological, and serological features, as well as familial and genetic relationships. These diseases initially included ankylosing spondylitis, reactive arthritis, Wright syndrome, ulcerative colitis and Crohn's disease-associated joint disease, Whipple's disease and Behcet's disease. These diseases have many different points and similarities, including rheumatoid factor negative, no subcutaneous nodules, radiographic ankle arthritis with or without inflammatory peripheral arthritis and familial aggregation. basic knowledge The proportion of sickness: 0.0031% Susceptible people: no special people Mode of infection: non-infectious Complications: spinal arthritis

Cause of spinal arthritis

B27 antigen increased (45%)

B27 antigen was significantly increased in all diseases included in spinal arthritis. Studies have shown that ankylosing spondylitis and reactive arthritis have similar B27 antigenic frequencies. Peripheral arthritis of inflammatory bowel arthritis is evidence of parenteral involvement, but its B27 antigen expression is not elevated. However, 75% of patients with inflammatory bowel disease who develop spondylitis are associated with B27 antigen. These findings suggest that the pathogenesis of inflammatory bowel disease arthritis is similar to that of ankylosing spondylitis, and patients with inflammatory bowel arthritis carrying HLA-B27 have a higher risk of developing ankylosing spondylitis. The incidence of HLA-B27 is not increased in patients with simple psoriasis. There is no evidence of increased B27 in patients with peripheral psoriatic arthritis, but 45% of psoriatic spondylitis has B27 antigen, but with ankylosing spondylitis and reaction. The association between arthritis and B27 antigen was significantly reduced. Nonetheless, these studies confirm that psoriatic arthritis should be included in spinal arthritis. These data suggest that other factors must play a role in inflammatory arthritis in the spine. Certain forms of juvenile chronic arthritis should also be included in the category of spinal arthritis, and children with oligoarthritis have a higher B27 frequency. However, Whipple's disease and Behcet's disease are no longer included in spinal arthritis due to lack of correlation with HLA-B27 and other characteristics.

Environmental factors (35%)

HLA-B27-positive monozygotic twins have different incidences and 10% of patients with ankylosing spondylitis do not have HLA-B27, indicating that environmental factors are also important. Among the non-genetic virulence factors, there are more infections. In the HLA-B27 transgenic mouse study, it was also found that transgenic mice lived in a sterile environment and did not develop ankylosing spondylitis, suggesting that environmental factors are indispensable conditions for HLA-B27-related diseases. However, although many studies have shown that ankylosing spondylitis is associated with infection, there is no definitive evidence to date that the initiation of ankylosing spondylitis is associated with pathogenic bacteria, and the role of microorganisms in ankylosing spondylitis is unclear. Tumor necrosis factor- (TNF-), a cytokine that acts through two tumor necrosis factor receptors (TNFR1 and TNFR2), may be involved in the pathogenesis of ankylosing spondylitis. Immunohistochemical analysis found that TNF- is an important cytokine that mediates inflammation in the ankle joint of patients with ankylosing spondylitis, which also contributed to the first trial of TNF inhibitors for the treatment of ankylosing spondylitis.

Spinal arthritis prevention

The severity of clinical manifestations of this type of disease varies greatly. Some patients have repeated and continuous progress, and some have been in a relatively static state for a long time, and can work and live normally. Several cases of spinal arthritis progress gradually, and may develop into a typical ankylosing spondylitis. After treatment, the condition may also be controlled. The age of onset is small, hip involvement is earlier, recurrent iridocyclitis, delayed diagnosis, untimely and unreasonable treatment, and poor prognosis for long-term functional exercise. Although the emergence of biological agents has greatly improved the prognosis of this disease, the disease is still a chronic progressive disease, and should be followed up for a long time under the guidance of a specialist.

Spinal arthritis complications Complications spinal arthritis

Spinal rigidity occurs in the late stages of ankylosing spondylitis and psoriatic arthritis. In addition to the central axis (spine) joints of spinal arthritis, peripheral joint involvement is also a common manifestation. As a chronic systemic inflammatory disease, spinal arthritis is often accompanied by the involvement of organs such as skin and mucous membranes.

Spinal arthritis symptoms Common symptoms Hip pain persistent low back pain with morning stiffness, morning stiffness, thoracic spine pain, low back pain, bamboo spine

1. Axis involvement

Spinal arthritis and ankylosing spondylitis and psoriatic arthritis are mainly caused by central axis involvement. The generalized central axis range should refer to the pelvis to the cervical vertebrae, including the hip joint; the narrow central axis involvement mainly refers to the neck, chest, lumbar vertebrae and ankle joints. Axonal spondylitis includes bone joints, ligament tendons, and attachment points.

The central axis involved early and late stages, mainly in the early stage of inflammatory low back pain, but the performance of ankle arthritis has not been shown on the radiation line. These patients are often easily missed or misdiagnosed clinically. The clinical manifestations in the late stage are very obvious, including ankle arthritis, part or full involvement of the spine, changes in body shape, limited mobility, and imaging changes, which are easily diagnosed by the clinic, but even if it is correctly diagnosed clinically, its treatment often misses The optimal treatment period, or the patient has experienced functional limitations or disability. Therefore, we must pay attention to the diagnosis and treatment of the early axial involvement of ankylosing spondylitis, so as to control the disease as soon as possible.

(1) alternating hip pain

This is the most common early symptom in patients with ankylosing spondylitis. It is characterized by pain on one side of the buttocks or hips. It is more obvious. In severe cases, the hip activity is limited, and it is not allowed to walk. After treatment for a period of time, it can be improved, but it can be repeated, and there may be alternating bilateral attacks. Because the ankle is located deep in the buttocks, these symptoms are caused by inflammation of the ankle or hip joint. Although patients with ankylosing spondylitis and mechanical low back pain may have hip pain, patients with ankylosing spondylitis are more specific in that they first have pain on one side of the buttocks and gradually alternating hip pain.

(2) inflammatory low back pain

Low back pain in patients with spinal arthritis often has insidious onset. The initial site is located in the lumbar and hip area, and gradually develops toward the back. It is often evident in the latter half of the night, accompanied by obvious stiffness, which can lead to difficulties in turning over at night, and in the early morning. When getting up, the back of the waist is obviously stiff and needs to be improved after the activity. The duration of this morning stiffness is related to the severity of the patient's condition. The lighter can be relieved in a few minutes, and the heavy ones last not only for hours or even days. This type of inflammatory low back pain is an external manifestation of inflammation of the facet joints of the spine and attachment inflammation. Inflammatory low back pain is one of the most hallmark features of ankylosing spondylitis. It is a powerful tool for screening and identifying patients with chronic low back pain as a central axis of spinal arthritis. The following five parameters can better explain inflammatory low back pain, including: 1 symptom improvement after activity; 2 night pain; 3 occult onset; 440 years old before onset; 5 no improvement after rest. If the patient has chronic low back pain > 3 months and meets at least 4 of the above 5, it is considered as inflammatory low back pain.

(3) front chest wall pain

Patients with spinal arthritis often have pain around the anterior chest wall. In severe cases, there may be swelling of the sterno-stem joint. This is due to sternal stalk joint, sterno-stem joint and rib cage arthritis. The inflammation gradually develops, which may lead to the decrease of thoracic activity. Therefore, most of the classification criteria for ankylosing spondylitis include limited chest expansion.

(4) spinal rigidity

Spinal rigidity occurs in the late stages of ankylosing spondylitis and psoriatic arthritis. Mainly due to ossification of the vertebral ligament, vertebral ribs and thoracic rib joints, often leading to impaired mobility of the spine and increased risk of fracture. In the late stage of ankylosing spondylitis, extensive paravertebral soft tissue calcification, ligament strip or band ossification, vertebral bone erosion often leads to bone hyperplasia across the edge of the intervertebral disc, called ligament callus, is the intervertebral disc annulus The manifestation of ossification itself, after the formation of extensive ligament callus, presents a typical "bamboo-like spine". Psoriasis arthritis of the spine type often manifests as asymmetrical ligament callus formation, paravertebral ossification, which is characterized by ossification of the ligament between the middle of adjacent vertebral bodies to form a bone bridge, and is asymmetrically distributed.

2. Peripheral joint involvement

In addition to the central axis (spine) joints of spinal arthritis, peripheral joint involvement is also a common manifestation. Peripheral joints in the usual sense, including all joints except the spine (middle-axis joint), whether the shoulder and hip joints of patients with ankylosing spondylitis belong to the peripheral or mid-axis joints, there are still many controversies. In many patients with spinal arthritis, peripheral joint swelling and pain occur first. After several years, symptoms of low back pain appear. These patients are easily misdiagnosed as other types of arthritis and cannot be treated promptly and correctly, thus delaying patient treatment. And even caused the patient's disability. The incidence of peripheral joints in spinal arthritis is related to the age of the patients. The smaller the age of onset, the more obvious the involvement of peripheral joints and the higher the disability.

The main features of peripheral joint involvement in ankylosing spondylitis are: lower extremity joints (knee, ankle joint) more than upper limb joints, single/oligoarticular joint involvement more than multiple joint involvement, asymmetry more than symmetry. Unlike rheumatoid arthritis, except for the hip joint, the symptoms of arthritis or joint pain in the knee and other joints are mostly intermittent, and the clinical symptoms are mild. X-ray examination is mainly based on soft tissue swelling around the joints. Imaging evidence of bone destruction can be found in arthroscopy. Synovial hyperplasia and inflammatory exudation can often be seen under arthroscopy. There are few or rare serious consequences of bone erosion, destruction and joint destruction of affected joints.

Psoriatic arthritis can involve the interphalangeal joints of the distal hand. This is different from rheumatoid arthritis, which is often caused by the proximal interphalangeal joints. The joints are sometimes heavier and can be similar to rheumatoid arthritis. Erosion, destruction, and this is different from other types of spinal arthritis.

3. Adhesion point inflammation

Adhesion inflammation is a characteristic lesion of spinal arthritis, and other diseases are less common. In the spine, attachment inflammation can be seen in the attachment of the bursae and ligaments, as well as in the intervertebral disc, rib joints and rib transverse joints. The pain, stiffness and mobility limitation of the spinal joints are mostly due to attachment inflammation. Adhesive point inflammation also affects many external axis of the central axis, which is manifested as local swelling and pain in the corresponding parts. Common parts include: heel (including heel or Achilles tendon), local swelling around the knee joint, ischial tuberosity, sputum The anterior superior iliac crest, pubic symphysis, and rib cartilage junction.

4. Skin and mucous membrane involvement

As a chronic systemic inflammatory disease, spinal arthritis is often accompanied by the involvement of organs such as skin and mucous membranes.

(1) Psoriasis: Psoriasis rash occurs before psoriatic arthritis, and a small number of patients develop arthritis first, followed by a rash. Skin psoriasis lesions occur in the scalp and extremities, especially in the elbows and knees. They are scattered or distributed. Pay special attention to the skin lesions in the hidden parts, such as hair, perineum, buttocks, umbilicus, etc. Pimples or plaques, round or irregular, with rich silvery white scales on the surface, a shiny film after removing scales, and visible spotted hemorrhage. This feature has diagnostic significance for psoriasis. The presence of psoriasis is an important difference from other inflammatory arthritis. There is no direct relationship between the severity of skin lesions and the severity of arthritis, and only 35% are related.

(2) Nail lesions: About 80% of patients with psoriatic arthritis have nail lesions, while patients with arthritic psoriasis have only 20% of nail lesions. A lesion is a feature of psoriatic arthritis. Common manifestations are apical-like depressions, and multiple depressions in the nails of the distal interphalangeal joints of inflammation are characteristic changes of psoriatic arthritis. Others have deck thickening, turbidity, black hair or white armor, uneven surface, lateral grooves and mediastinum, often under the horny hyperplasia, severe cases may have a nail stripping, sometimes forming a spoon-shaped nail.

(3) purulent skin keratosis: empyema keratosis is hyperkeratosis of the diseased skin. It refers to skin lesions beginning to appear as vesicles on the basis of erythema, and then develop into macules, papules and nodules, usually without tenderness, and can be fused into clusters. After rupture, the skin is keratinized to form a thick layer of sputum. Mainly distributed in the soles of the feet, can also occur in the palms, scrotum and other parts. The appearance of lesion rash is often difficult to distinguish from psoriatic rash. In addition, patients often have finger and toe deck lesions, such as nail thickening, turbidity, malnutrition, hyperkeratosis, and even nail detachment.

(4) Nodular erythema: nodular erythema is a red or purple-red painful inflammatory nodule that is prone to acute onset of the calf. The skin lesions suddenly occur, generally bilaterally symmetrical, from broad beans to walnuts. Large, up to 10 or more, consciously painful or tender, medium hardness. After 3 to 4 weeks, the nodules gradually subsided, leaving temporary pigmentation. The lesion can also be found on the thigh, the upper arm extension side, and the like.

(5) Conjunctivitis: Conjunctivitis is the most common ocular complication of reactive arthritis and is rare in other types of spinal arthritis. Patients usually present with unilateral or bilateral involvement, hyperemia of the eyes, tearing of the eyes, mucopurulent secretions with papillary projections on the surface of the conjunctiva, which is easily associated with other types of infectious conjunctivitis or "red eye disease". Confusion, the symptoms subsided in 2-7 days.

(6) whirlpool balanitis: usually refers to the painless superficial moist ulcers appearing near the glans and urethra. The surface is moist and begins to be small blisters. The symptoms of congestion around are not obvious. Occasionally, superficial ulcers can be merged into It is plaque-like and covers the entire glans. It is obviously red and the tenderness is not obvious. Sometimes the inside of the foreskin, the penis and the scrotum can be affected. More common in patients with reactive arthritis.

(7) Oral ulcers: superficial ulcers mainly present in the buccal mucosa and tongue. The initial stage is small blisters, and the parts are in the upper jaw, gums, tongue and cheeks. The course of the disease is transient, usually no pain and discomfort. Symptoms are easily overlooked. Patients with reactive arthritis and spinal arthritis with intestinal lesions are more common.

(8) Enteritis: Ulcerative colitis and arthritis associated with Crohn's disease are called inflammatory bowel arthritis. About 6% of patients with ankylosing spondylitis have intestinal mucosal inflammation visible to the naked eye or under the microscope. The site of inflammation is mainly distributed in the ileum, and occasionally there are reports of microscopic colitis.

5. Other performance

(1) Systemic symptoms: Reactive arthritis is more common in moderate to high fever, while other types of spinal arthritis often have low to moderate fever in severe cases. Weight loss, anemia, and general malaise are also common when the condition is severe.

(2) Other organ involvement: Meningitis is the most common ocular damage associated with spinal arthritis. It is reported in the literature that about 25% of patients may develop ocular uveitis. Common manifestations of cardiac involvement in ankylosing spondylitis include valvular insufficiency (aortic and mitral regurgitation), varying degrees of cardiac conduction dysfunction, and left ventricular dysfunction. Due to the stiffness of the thoracic vertebrae, ribs and thoracic rib joints, thoracic expansion is limited. The most common pulmonary pleural involvement in ankylosing spondylitis is fibrotic lesions of the upper lung, with an incidence of 1.3% to 30%. Spinal fractures in advanced ankylosing spondylitis are not uncommon. The most common form of kidney disease in ankylosing spondylitis is secondary amyloidosis. IgA nephropathy is not common in ankylosing spondylitis. Other common kidney manifestations include mesangial proliferative glomerulonephritis.

Examination of spinal arthritis

Laboratory examination

The positive rate of HLA-B27 gene in patients with ankylosing spondylitis is 90% to 95%, but only about 10% of HLA-B27-positive people in the population have ankylosing spondylitis. Therefore, although HLA-B27 is examined for ankylosing spondylitis It is highly specific and sensitive, but the HLA-B27 test results can not be used as a basis for diagnosis, nor can it predict the prognosis of patients, and can only increase the possibility of diagnosis.

During the active period, patients with increased erythrocyte sedimentation rate (ESR), increased C-reactive protein (CRP), thrombocytosis, and mild anemia. Rheumatoid factor (RF) negative and immunoglobulins are slightly elevated.

2. Imaging examination: X-ray, CT, MRI

X-ray findings have diagnostic implications for ankylosing spondylitis. The earliest changes in ankylosing spondylitis occur in the ankle joint. The X-ray film showed blurred subchondral bone, bone erosion, blurred joint space, increased bone density and joint fusion. Usually according to the degree of X-ray arthritis lesions are divided into 5 grades: 0 is normal; Grade I is suspicious; Grade II has mild ankle arthritis; Grade III has moderate ankle arthritis; Grade IV is joint Fusion is strong.

For clinically suspicious cases, and X-ray films have not shown clear or more than two grades of bilateral arthritis changes, computerized tomography (CT) should be used. The advantage of this technique is also that there are fewer false positives. However, since the upper part of the ankle anatomy is a ligament, the joint gap irregularity and widening of the imaging due to its attachment cause difficulty in judgment. In addition, subchondral aging of the ankle joint part of the ankle joint, which is similar to joint space stenosis and erosion, is a natural phenomenon and should not be considered abnormal.

Magnetic resonance imaging (MRI) is superior to CT in the diagnosis of ankle inflammation and spinal inflammation. Only MRI can show grade 0 lesions of ankylosing spondylitis. The advantage of MRI is to observe ankylosing spondylitis. The morphology and signal changes of the synovial cartilage and sub-articular bone of the ankle joint achieve the purpose of early detection and diagnosis of ankylosing spondylitis.

Musculoskeletal ultrasound

Musculoskeletal ultrasound has gradually become a powerful imaging method for the evaluation of inflammatory arthritis, in the diagnosis of spondylitis, tendonitis, synovitis, bursitis and cysts, bone and cartilage, and for spinal arthritis There are unique advantages in the assessment of sexuality, prognosis and treatment effects.

Diagnosis and diagnosis of spinal arthritis

Diagnostic criteria

(1) The European Spinal Arthrosis Research Group (ESSG) in 1991 proposed a classification criteria for the entire group of spinal arthritis, although not for clinical diagnosis, but for the identification of atypical or undifferentiated spinal joints. There is indeed a certain clinical guiding significance in inflammation. The ESSG standard focuses on two main features of spinal arthritis: inflammatory low back pain and asymmetric oligoarthritis, which can be diagnosed as spinal arthritis if one additional condition is added.

ESSG classification criteria for spinal arthritis

Inflammatory spinal pain or synovitis (asymmetry or joints of the lower extremities) plus at least one of the following:

Positive family history

psoriasis

Inflammatory bowel disease

Urethritis, cervicitis or acute diarrhea

Alternating gluteal pain

Tendon attachment point inflammation

Ankle arthritis

(2) In 2004, the International Association for the Evaluation of Spinal Arthritis (ASAS) initiated an international collaboration to develop classification criteria for central and peripheral spinal arthritis, and in 2009 completed the standard for central axis spinal arthritis. X-ray ankle arthritis required by the New York standard revised in this standard is only a part of imaging arthritis, not a necessary condition, and is shown by magnetic resonance in patients without radiological arthritis. Joint inflammation is also an important reference indicator, and it also combines various clinical manifestations (such as inflammatory low back pain, arthritis, Achilles tendinitis, etc.) and laboratory tests (HLA-B27 and CRP), which is more beneficial. Diagnosis of early disease.

a) ASAS classification criteria for central axis spinal arthritis (for patients with chronic low back pain, age of onset is less than 45 years old)

Imaging of ankle arthritis plus at least one of the features of spinal arthritis or HLA-B27 positive plus at least 2 other features of spinal arthritis

Characteristics of spinal arthritis: inflammatory low back pain; arthritis; Achilles tendinitis; uveitis; toeitis; psoriasis; Crohn's disease/colitis; NSAIDS treatment effective; family history of spinal arthritis; HLA- B27 positive; elevated CRP;

Imaging arthritis: MRI showed active (acute) inflammation, highly suggestive of spastic arthritis associated with spinal arthritis; X-ray showed clear ankle arthritis consistent with revised New York criteria.

Differential diagnosis

Rheumatoid arthritis

In the early stage of ankylosing spondylitis, it is particularly necessary to identify rheumatoid arthritis when peripheral arthritis is predominant. 1 Ankylosing spondylitis is common in men with rheumatoid arthritis. 2 Ankylosing spondylitis has an ankle joint without exception, and rheumatoid arthritis has few ankle joint lesions. 3 Ankylosing spondylitis is affected from the bottom to the top of the spine, while rheumatoid arthritis only invades the cervical spine. 4 peripheral arthritis in ankylosing spondylitis is a small number of joints, asymmetry, and the lower extremity joints are often accompanied by tendonitis; in rheumatoid arthritis, multiple joints, symmetry and limbs and joints can be Onset. 5 ankylosing spondylitis rheumatoid nodules visible in rheumatoid arthritis. 6 rheumatoid factor of ankylosing spondylitis is negative, while the positive rate of rheumatoid arthritis accounts for 60% to 95%. 7 Ankylosing spondylitis is predominantly HLA-B27 positive, while rheumatoid arthritis is associated with HLA-DR4.

2. Gouty arthritis

Some patients with this disease have a longer duration of arthritis of the lower extremities, and sometimes blood uric acid does not increase during the onset of the disease. At this time, it is often necessary to distinguish from peripheral arthritis caused by ankylosing spondylitis. At this time, it is necessary to comprehensively identify the clinical features of the two diseases.

3. Non-specific low back pain

Such patients with low back pain are the most common in clinical practice. These diseases include: lumbar muscle strain, lumbar tendon, spinal osteoarthritis, cold irritative low back pain, etc. These low back pain diseases have no inflammatory waist of ankylosing spondylitis. The characteristics of back pain, X-ray or CT examination of the ankle joint, and erythrocyte sedimentation rate, C-reactive protein and other related tests are easy to identify.

4. Lumbar disc herniation

Disc herniation is one of the common causes of inflammatory low back pain. The disease is limited to the spine, no fatigue, weight loss, fever and other systemic manifestations, all laboratory tests including erythrocyte sedimentation rate are normal. The main difference between it and ankylosing spondylitis can be confirmed by CT, MRI or spinal angiography.

5. Tibial dense osteitis

More common in young women, the main manifestations of chronic lumbosacral pain and stiffness. Clinical examination showed no abnormalities other than waist muscle tension. The diagnosis mainly relies on the anterior and posterior X-ray plain film or CT of the ankle joint. The typical manifestation is that there are obvious osteosclerosis areas in the lower 2/3 of the humerus along the ankle joint. The triangle is pointed upward and the density is uniform. Invasion of the ankle joint surface, no joint stenosis or erosion, it is different from ankylosing spondylitis. The disease has no obvious characteristics of sitting and lying for a long time, and it is not as effective as ankylosing spondylitis when treated with NSAIDs. Some women with early ankylosing spondylitis are more difficult to distinguish from this disease. The MRI examination of the ankle joint may be helpful, but it is still necessary to judge the clinical situation comprehensively. It is recommended to follow up the observation for patients who are difficult to identify.

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