Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:50

Spondyloarthropathies 1363

Imaging

■Always do plain AP view of the pelvis to evaluate for sacroiliitis.

■The diagnosis of spondyloarthropathy is almost certain if there is

significant sacroiliitis.

■If plain x-ray for sacroiliitis is ambiguous or negative but spondy-

loarthropathy is highly suspected on clinical grounds, proceed to

MRI of the sacroiliac joint. Bone edema as visualized by STIR or T2

w/ fat absorption technique is characteristic of spondyloarthropa-

thy.

■Plain x-ray of AP view of pelvis also allows assessment of hip joints.

■If assessment of spine is needed, a single lateral view of the lumbar

& cervical spine will allow visualization of squaring of vertebrae,

syndesmophytes or fusion as “bamboo spine.”

differential diagnosis

N/A

management

What to Do First

■Assess disease activity & functional status & impending disability

(see “Assessment” in http://www.asas-group.org)

■Begin pt education

general measures

■Posture training to prevent flexion contracture of cervical spine

■Stretching exercises to improve mobility

■Daily exercise (eg, swimming)

specific therapy

■NSAIDs, selective COX-2 inhibitor, celecoxib, if indicated

■CT-guided steroid injection of sacroiliac joints may provide local

relief of pain from sacroiliitis up to 10 months

■Sulfasalazine w/gradual increase in dose for early or mild disease

w/peripheral joint involvement. Stop if not effective after a 4-month

trial. Not useful for spinal pain.

■Methotrexate is of unproven efficacy. Discontinue if not effective

after a 6-month trial.

■TNF antagonists (eg, etanercept, infliximab, adalumimab) may pro-

vide dramatic response within days of initiating therapy. Risk of

infection & high cost mandate reserving for refractory disease (For

guideline, see “Publications” in http://www.asas-group.org).

■Total hip replacement for unrelieved hip pain or disability