Axial spondyloarthritis

Axial spondyloarthritis is a chronic inflammatory disease with a predominant lesion of the spine and sacroiliac joints. Pathology develops under the combined influence of hereditary factors and environmental triggers. The disease is manifested by intense pain in the back and pelvic area, stiffness of movements, contractures and deformities of the axial skeleton. For diagnosis, radiography and MRI of bones, ultrasound of joints, analysis of acute phase indicators are prescribed. Treatment of the disease includes pharmacotherapy (NSAIDs, hormones, genetically engineered drugs) in combination with physiotherapy and physical therapy.

General information
The prevalence of axial spondyloarthritis among adults ranges from 0.02% to 2%, which depends on the degree of prevalence of the HLA-B27 gene in the population. In Russia, pathology affects 0.1-0.2% of the population, the maximum frequency is observed in residents of the northern regions. The peak incidence of spondyloarthritis occurs in the age group of 25-35 years, and up to 20% of cases of the disease debut in adolescents. Men get sick 3-6 times more often than women, although recent scientific studies in rheumatology indicate a decrease in sex differences.

Reasons
The etiological structure of axial spondyloarthritis has not yet been established. The leading role in the development of the disease is assigned to hereditary predisposition – the carriage of genes that increase the risk of pathological immune reactions and autoimmune pathologies. The contribution of HLA-B27, which is up to 23% in the structure of the genetic risk of rheumatic joint diseases, has been most studied. Additional genes are also isolated: IL1, ERAP1, IL23R and KIF21B.

Pathology has a multifactorial origin, so the presence of certain genes cannot be an independent cause of the onset of the disease. Of great importance are the influences of the external environment, which act as triggers of damage to the axial skeleton and peripheral joints. These include injuries, hypothermia, psychoemotional stresses. Antigenic stimulation has a certain role in the presence of chronic foci of infection.

Pathogenesis
The pathological process begins at the sites of attachment of ligaments, tendons and joint capsules to the bones. First, foci of inflammation appear in the musculoskeletal system, which are usually localized in the axial part of the skeleton. The second stage of the disease is the formation of syndesmophytes – vertical bone outgrowths on the vertebral bodies. They form in areas of chronic inflammation that cause osteoproliferation.

Axial spondyloarthritis
Axial spondyloarthritis
Classification
Axial spondyloarthritis is divided into 2 large categories, taking into account the X-ray picture. If the lesion of the spine is accompanied by sacroiliitis, this type of disease is called ankylosing spondylitis. Otherwise, they talk about non-pathogenic axial spondyloarthritis. Of practical value for rheumatologists is the classification of the disease according to clinical manifestations, which is distinguished by 3 consecutive stages:

Early (non-pathogenic). At this stage, the pain syndrome is not accompanied by pathological changes on radiographs, but there are reliable MRI signs of joint damage.
Expanded. During pelvic radiography, unilateral or bilateral sacroiliitis is determined. At the same time, there are no significant structural changes in the study of the spine.
Late. It is characterized by combined radiological signs of pelvic lesions (sacroiliitis) and spine (syndesmophytes).
In-depth diagnosis uses the ASDAS index, according to which low, moderate, high and very high activity of the disease is distinguished. According to immunological characteristics, HLAB27-positive and HLAB27-negative variants of spondyloarthritis are distinguished. To assess the motor activity of patients, functional classes from I to IV are used, taking into account the degree of preservation of working capacity and non-professional activity.

Symptoms of axial spondyloarthritis
The first sign of the disease in most patients is back pain, especially in the lumbar region. It has a chronic character, lasts for several months in a row or with a break. The pain syndrome begins for no apparent reason. At first, it has a low intensity and does not significantly disrupt the patient’s activity, with time the symptoms increase. The pain increases with prolonged stay in one position, decreases after physical activity.

Axial spondyloarthritis is characterized by pain attacks in the pre-morning hours, which disrupt the patient’s sleep, force him to wake up and take medications. In the morning, there is stiffness in the back and large joints. The symptoms are accompanied by pain in the buttocks, which at first is alternating, as the disease progresses, they become bilateral.

Many patients complain of pain in the knee and ankle joints caused by peripheral arthritis. Due to inflammation at the place of attachment of the Achilles tendon during walking, severe pain occurs in the heel area. In rare cases, the first manifestation of the disease is eye damage, peeling psoriatic plaques on the skin, abdominal pain and dyspeptic disorders as symptoms of IBD.

With the long-term existence of the disease, posture disorders occur due to ankylosis of the spine. Patients have characteristic poses of “supplicant” and “proud”. Due to the defeat of the hip joints, patients limp, or they have a “duck gait”. Many complain about the inability to continue working in specialties that require physical strength, mobility and endurance.

Complications
A typical consequence of axial spondyloarthritis is ankylosis and joint contractures, which significantly limit the patient’s mobility. As a result, the ability to work is impaired, patients are limited in the choice of professions, sports activities and active leisure activities. With the long-term existence of the disease, systemic osteoporosis develops, subluxation in the atlantoaxial joint, cervical-thoracic kyphosis.

The clinical picture of the disease is often complicated by extra-skeletal manifestations, which are the result of pathological immuno-inflammatory processes. It is characterized by a lesion of the visual organ in the form of uveitis, the manifestation of psoriasis, involvement of the kidneys in the process according to the type of IgA-nephropathy. Some patients have inflammatory bowel diseases: Crohn’s disease, ulcerative colitis.

One of the most dangerous complications is aortic lesion and the development of aortic heart defects, which end in cardiovascular insufficiency. Some patients suffer from life-threatening forms of arrhythmia. Long-term nephropathy often turns into chronic renal failure. Over time, most patients develop secondary systemic amyloidosis.

Diagnostics
Suspicion of axial spondyloarthritis requires a comprehensive examination by a rheumatologist, which includes anamnesis collection, physical examination, laboratory and instrumental research methods. For correct diagnosis, international ASAS criteria are used, which were introduced into practice in 2009. In the process of diagnosis , the following methods are carried out:

Functional tests. To determine ankylosis of the lumbar spine, lateral flexion is measured and a modified Schober test is performed. The presence of cervical kyphosis is assessed by measuring the distance from the back of the head to the wall in a standing position. Stiffness in TBS is determined by narrowing the distance between the ankles to less than 100 cm with the maximum possible dilution of the legs.
Radiography. Instrumental diagnostics begin with an X-ray examination of the pelvic bones and spine. According to its results, the presence and degree of sacroiliitis, the proliferation of osteophytes in the vertebrae are determined. According to the indications, radiography of the hip, knee and other joints is performed.
MRI of the pelvis. The study shows an active inflammatory process in the sacroiliac joints, which is characteristic of the first stage of sacroiliitis. The activity of inflammation is assessed by the strength of the hyperintensive signal in T1 mode, which corresponds to bone marrow edema.
Ultrasound of the joints. Ultrasound diagnostics is performed as an additional method for the inflammatory process in the hip joints, ankle and other areas of the musculoskeletal system. Echosonography is informative for the diagnosis of enteritis, which are poorly detected by other methods of instrumental visualization.
Laboratory diagnostics. To assess the degree of activity of axial spondyloarthritis, a clinical blood test is performed with the measurement of ESR, a study of the island of phase parameters, a detailed biochemical blood test. To identify patients at risk, an analysis for HLA-B27 is performed.
Differential diagnosis
To make a diagnosis, it is necessary to exclude rheumatoid arthritis and other systemic diseases of the connective tissue, which are accompanied by damage to the articular joints. If symptoms appear shortly after the infection, differential diagnosis with reactive arthritis and Reiter’s syndrome is performed. Intense back pain requires differentiation with osteochondrosis, intervertebral hernia, vertebral fractures.

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