Axial Spondyloarthritis & Ankylosing Spondylitis
This work is based on the SPADE tool.
Primary criteria:
Buttock and back pain/stiffness prior to 45.
FIRST onset of symptoms lasts for 3+ months with the onset prior to 45 years of age. Onset of symptoms most prevalent in 30’s (men: 35 yoa & women: 30 yoa).
Buttock symptoms (<alternating buttock symptoms) are more prevalent than spinal symptoms due to sacroiliitis.
Pain and stiffness eased by movement and aggravated by rest.
Symptoms can wake the patient during the second half of the night and in the morning usually lasting for 30mins to 1-2 hours. Symptoms may persist all day.
Responsive to NSAIDs within 48 hours.
Secondary criteria:
Fatigue.
Inflammatory bowel changes can cause malabsorbtion problems.
Personal history of enthesitis.
Most common site is calcaneum (achilles/plantar fascia), then the patella tendon attachments (patella & tibial tuberosity) and less common lateral and medial epicondyle, shoulder and ischial tuberosity (hamstring).
Personal or family history of peripheral arthritis e.g. AxSpa, AS, reactive arthritis. History of swellings such as dactylitis.
Dactylitis (sausage fingers and toes) within itself warrants referral for general inflammatory pathologies.
Like RA swelling tends to effect the small joints: wrist, 2-5 MCP & MTP, interphlx joints, ankles and elbows. NOTE: can have a concurrent OA effecting 1 MCP & MTP. Look for a positive squeeze test of the finger and toe joints.
Reactive arthritis (Reiter's syndrome) develops several days to weeks after a GIT or GU infection or STI. Symptoms include: pain and stiffness, conjunctivitis, urinary problems, inflammation of the prostate gland or cervix, enthesitis <calcaneum, dactylitis, skin problems (e.g. mouth ulcers or a rash on the soles of the feet and palms) and low back pain worse in bed and in morning. Can last for several months is often self limiting but can have recurrences.
Personal or family history of psoriasis or psoriatic arthritis.
30% of people with psoriasis develop inflammatory arthritis.
Most common psoriatic patches in AxSpa is the scalp (50%), also: behind the ears, elbows, knees, lumbosacral area, naval and buttock crease.
Less common: pustular psoriasis (rare, needs emergency treatment) and guttate psoriasis (can be triggered by strep infection - pharyngitis or perianal)
8. Personal or family history of uveitis (<iritis).
9. Personal or family history of inflammatory bowel disease (IBD) i.e. crohn’s or ulcerative colitis NOT inflammatory bowel syndrome (IBS).
Differentially diagnose IBD from IBS by in IBD mucous in stools and patients get up at night to pass stools.
10. Personal or family history of autoimmune diseases.
11. Blood tests
11a. HLA-B27 positive.
Can be negative of HLA-B27 and still have AxSpa.
11b. ESR or CRP
In AxSpa ESR and CRP are normal. They are used to help differentiate diagnose AxSpa from other inflammatory pathologies. No blood tests confirm or exclude AxSpa.
12. Sacroiliitis shown by MRI.
Additional notes:
NICE: if suspicious of AxSPA and MRI was negative MRI again in twelve months time having been off NSAIDs for one week prior. Ankylosing syndesmophytes (boney growths in the ligaments of the spine) creates a bamboo spine (fusion).
AxSpa gives an increased risk of osteoporosis.