RHEUMATOLOGIC, IMMUNOLOGIC, & ALLERGIC DISORDERS CMDT 2024 863

! Clinical Findings formed by the ossification of the annulus fibrosus and cal-
cification of the anterior and lateral spinal ligaments.
A. Symptoms and Signs
The onset of SpA is usually gradual, with intermittent bouts ! Differential Diagnosis
of back pain that may radiate into the buttocks. The back Low back pain due to mechanical causes, disk disease, and
pain is worse in the morning and associated with stiffness degenerative arthritis is very common. Onset of back pain
that lasts hours. Pain and stiffness improve with activity, in before age 30 and an “inflammatory” quality of the back
contrast to back pain due to mechanical causes, which pain (ie, profound morning stiffness and pain that improve
improves with rest and worsens with activity. As the disease with activity) should raise the possibility of ankylosing
advances, symptoms progress in a cephalad direction and spondylitis. In contrast to ankylosing spondylitis, RA pre-
back motion becomes limited, with the normal lumbar dominantly affects multiple, small, peripheral joints of the
curve flattened and the thoracic curvature exaggerated. hands and feet. RA spares the sacroiliac joints and only
Chest expansion is often limited due to costovertebral joint affects the cervical component of the spine. Bilateral sac-
involvement. In advanced cases, the entire spine becomes roiliitis indistinguishable from ankylosing spondylitis is
fused, allowing no motion in any direction. Acute arthritis seen with spondyloarthropathy associated with IBD. Sac-
of the peripheral joints occurs in about 50% of cases, and roiliitis associated with reactive arthritis and psoriasis
permanent changes in the peripheral joints—most com- often asymmetric or even unilateral. Osteitis condensans
monly the hips, shoulders, and knees—are seen in about ilii (sclerosis on the iliac side of the sacroiliac joint) is an
25%. Enthesopathy, a hallmark of the spondyloarthropa- asymptomatic, postpartum radiographic finding that is
thies, can manifest as swelling of the Achilles tendon at its occasionally mistaken for sacroiliitis. Diffuse idiopathic
insertion, plantar fasciitis (producing heel pain), or dacty- skeletal hyperostosis (DISH) causes exuberant osteophytes
litis, which is fusiform “sausage” swelling of a finger or toe. (“enthesophytes”) of the spine that may be difficult to dis-
Anterior uveitis is associated in up to 25% of cases and tinguish from the syndesmophytes of ankylosing spondyli-
may be a presenting feature of ankylosing spondylitis. Car- tis. The enthesophytes of DISH are thicker and more
diac involvement, characterized by atrioventricular con- anterior than the syndesmophytes of ankylosing spondyli-
duction defects, aortic regurgitation, or aortic root tis, and sacroiliac joints are normal in DISH.

! Treatment
widening, occurs in 3–5% of patients with longstanding
severe disease. Pulmonary fibrosis of the upper lobes, with
progression to cavitation and bronchiectasis mimicking NSAIDs remain first-line treatment of ankylosing spondy-
tuberculosis, may rarely occur, characteristically long after litis. TNF inhibitors have well-established efficacy for
the onset of skeletal symptoms. NSAID-resistant axial disease; responses are often substan-
tial and durable. TNF inhibitors may also have disease-
B. Laboratory Findings modifying effects and slow radiographic progression.
ESR is elevated in 85% of cases, and autoantibodies are nega- Secukinumab and ixekizumab (monoclonal antibodies
tive. Anemia of chronic disease may be present but is often against soluble IL-17A) and tofacitinib and upadacitinib
mild. HLA-B27 is found in 90% of White and 50% of Black (small molecule Jak inhibitors) are highly effective and FDA
patients with ankylosing spondylitis. Because this antigen approved for the treatment of radiographic and nonradio-
occurs in 8% of healthy White persons and 2% of healthy graphic axial spondyloarthritis. Sulfasalazine (1000 mg
Black persons, it is not a specific diagnostic test and is most orally twice daily) may be useful for peripheral arthritis but
useful when there is intermediate probability of disease. lacks effectiveness for spinal and sacroiliac joint disease.
Corticosteroids have minimal impact in ankylosing spon-
C. Imaging dylitis and can worsen osteopenia. All patients should be
referred to a physical therapist for instruction in postural
The earliest radiographic changes are usually in the sacro- exercises and a safe exercise program.
iliac joints. Patients who have symptoms and findings of
ankylosing spondylitis and sacroiliitis evident by MRI, but ! Prognosis
not by conventional radiographs, are classified as having
Most patients have persistent symptoms over decades; rare
nonradiographic axial spondyloarthritis. Ten percent to
individuals experience long-term remissions. The severity
twenty-five percent of patients with nonradiographic axial
of disease varies greatly, with about 10% of patients having
spondyloarthropathy will progress to radiographic spon-
work disability after 10 years. Developing hip disease
dyloarthropathy (erosion and sclerosis of sacroiliac joints
within the first 2 years of disease onset presages a worse
on radiograph) in 10 years. The sacroiliitis of ankylosing
prognosis. Biologic agents provide symptomatic relief,
spondylitis is bilateral and symmetric. Inflammation where
improve quality of life, and may slow disease progression
the annulus fibrosus attaches to the vertebral bodies ini-
for many patients with ankylosing spondylitis.
tially causes sclerosis (“the shiny corner sign”) and then
characteristic squaring of the vertebral bodies. The term
“bamboo spine” describes the late radiographic appearance Ramiro S et al. ASAS-EULAR recommendations for the man-
agement of axial spondyloarthritis: 2022 update. Ann Rheum
of the spinal column in which the vertebral bodies are
Dis. 2023;82:19. [PMID: 36270658]
fused by vertically oriented, bridging syndesmophytes

CMDT24_Ch22_p0824-p0879.indd 863 15/05/23 9:42 AM