Spondyloarthritis is an ancient inflammatory autoimmune disease that dates back to the time of Egyptian mummies 5000 years ago. X-rays of the spine of an ancient mummified pharaoh showed evidence of spondylitis. This is unlike Rheumatoid Arthritis that can not be traced back beyond the last three hundred years.
Undifferentiated Spondyloarthritis often goes undiagnosed for years. The average time from development of symptoms to diagnosis was 8 years in our previously presented study. The reasons for delay in diagnosiss are several:
1. These patients often look normal, and their appearance do not match the severity of their complaints.
2. There are no good diagnostic blood tests for this condition
3. HLA-B27 test is only positive in 25% of these patients
4. X-Ray changes may take years to show evidence if spondylitis or sacroiliitis in these patients
5. Although physicians are aware of this condition, it is often overlooked as a cause of significant pain in these patients
6. A sizable number of these patients end up with chiropractors who provide temporary relief to these patients and these patients often stay with them for years and thus going undiagnosed
7. Fibromyalgia and depression are used too often loosely as a cause of pain in these patients
8. About 20 percent of these patients will have low positive ANA of 1:40 to 1:160 and may get diagnosed as Lupus or Undifferentiated connective tissue disease
9. Close to 16% of these patient have a low positive rheumatoid factor and may get diagnosed as rheumatoid arthritis.
Spondyloarthritis is a unique form of inflammatory arthritis in that it can cause :
a. Spinal inflammation that can affect the neck all the way to the tailbone. It can affect different parts of the spine including Neck and upper back, middle back between shoulder blades, lower back, and finally just above buttocks and tailbone
b. Arthritis in upper and lower extremity joints
c. Inflammation in the area of attachment of tendons to the bone
Spinal pain
1. Back pain here, unlike all other back pains, becomes worse with sitting as well as with rest. Often patients have to keep shifting from one side to other when sitting or driving to relieve the discomfort. At times, they have to get up and move around to relieve the pain.
2. Unlike all other back pains, back pain here improves initially with activity. Although it gets better with activity, it can still get worse with increase in activity as well.
3. It can be limited to the upper back and neck area only causing night and rest pain. This often interferes with sleep as patient can not lay in one spot for a long time.
4. It can be limited to the middle back area that can cause pain with both activity and rest. This is often worse at the end of the day and at the time of sleep.
5. It can cause inflammation in sacroiliac joints causing buttock pain. Patients often can distinguish between this and low back pain.
6. Pain can radiate around the pelvis into either hips but unlike other causes of pelvic and hip pain it does improve with activity. This pain is often confused with sciatic pain that often gets worse with activity.
7. It can cause pain in tailbone with difficulty sitting. This pain can come by itself or it can often come after a fall or injury.
Arthritis
Arthritis here has a different onset and presentation than other inflammatory arthritis including rheumatoid arthritis. These differences are outlined below:
1. Arthritis here often involve one to three joints.
2. It can involve any joint but often single joint is involved in the joints of hands, knees or ankles.
3. It is often dramatic in onset with significant pain and swelling.
4. Joint involvement here is asymmetric. This means it can involve the right knee but not the left knee.
5. The involvement here often involves one side of the body more than the other side. This involvement does not correlate with being right or left handed.
6. It can involve only the interphalangeal joint in the big toe.
7. It can cause sausage toe or finger swelling (called dactylitis) with swelling of the entire digit.
8. There can be involvement of the chest wall causing pain in costochondral junctions.
9. It can cause rib tendonitis.
Enthesopathy or Enthesitis
Inflammation in the area of attachment of tendons, ligaments, fascia, and joint capsule to the bone is called Enthesitis or enthesopathy and more recently being described as enthesis organ.
The idea of enthesis organ is based on the fact that there are other structures that are functionally involved besides the area of attachment. These areas include fibrocartilage area over the bone, synovial fat pad, and bursal sacs in the area.
Enthesitis can involve many areas in the body but most commonly affects the heels where Achilles’ tendons attach to the calcaneus. Other areas include:
1. Suboccipital muscles attachment to occipital bone
2. Deep muscle attachments to spinous processes
3. Manubriosternal joints
4. Distal scapula attachment
5. Costochondral junctions
6. Humeral tuberosities
7. Epicondyles at the elbows
8. Distal ulna
9. Iliac crest and spine
10. Ischial tuberosity
11. Greater trochanter
12. Patella
13. Tibial plateau
14. Achilles’ tendon attachment to calcaneus
15. Plantar fascia attachment to calcaneus
16. Mid foot involvement with tarsitis
17. Plantar aponeurosis attachment on the base of the fifth metatarsal bone and on the metatarsal heads
Furthermore, Undifferentiated Spondyloarthritis :
– is fairly common
– usually presents as back pain at night and with rest in women more often than men
– occurs in women who are younger, usually between ages of 20 to 50
– is familial and often there are other family members with similar back pains
– should be suspected in anyone who has back pain with family history of Ulcerative Colitis, Crohn’s Colitis, or Psoriasis
– should be considered in anyone who has back pain that improves with activity
TeachMeMedicine.Org 