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Ermann J. Rethinking spondyloarthritis: beyond lumping and splitting. Curr Opin Rheumatol 2025; 37:207-214. [PMID: 40357628 DOI: 10.1097/bor.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2025]
Abstract
PURPOSE OF REVIEW The classification of spondyloarthritis (SpA) has long been debated, with ongoing discussions about whether to "lump" various subtypes together or "split" them into smaller distinct disease categories. This review explores the evolution of the SpA concept and discusses novel approaches that move beyond traditional models of SpA classification. RECENT FINDINGS Since its introduction in the 1970s, the SpA concept has undergone substantial modifications, incorporating advances in genetics, imaging, and clinical research. The recognition of axial and peripheral SpA as distinct yet overlapping entities has reshaped classification and drug approval processes. Data-driven methodologies have provided new insights into disease heterogeneity. Recent research highlights the limitations of traditional classification systems, emphasizing the need for unbiased approaches that integrate clinical and molecular features. SUMMARY Current historically derived classification paradigms for SpA are largely based on clinical phenotype and fail to capture the full spectrum of disease heterogeneity. Defining SpA subsets by incorporating genetic and immunological characteristics may improve diagnostic precision and improve outcomes. Future research should focus on refining classification frameworks across the entire clinical spectrum of SpA to improve patient stratification, guide treatment decisions, and address existing gaps in SpA care.
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Affiliation(s)
- Joerg Ermann
- Brigham and Women's Hospital
- Harvard Medical School, Boston, Massachusetts, USA
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Michelena X, López-Medina C, De Miguel E, Moreno-Ramos MJ, Queiro R, Marzo-Ortega H, Juanola X. How Are We Addressing Axial Psoriatic Arthritis in Clinical Practice? Rheumatol Ther 2024; 11:1441-1456. [PMID: 39422869 PMCID: PMC11557781 DOI: 10.1007/s40744-024-00722-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 10/01/2024] [Indexed: 10/19/2024] Open
Abstract
Psoriatic arthritis (PsA) is a chronic inflammatory disease affecting the musculoskeletal system, skin and nails. In addition to peripheral joints, inflammation of the spine and sacroiliac joints may occur. Yet, research into this axial phenotype has lagged behind partly because of the challenge in its clinical identification with a lack of specific clinical, molecular or imaging biomarkers. In the absence of a validated definition of what constitutes axial PsA (axPsA), guidelines for the management of axial involvement in PsA in clinical practice are scarce. On the basis of a literature review and their clinical expertise, a group of rheumatology experts provide their opinion to aid the diagnosis and management of axial PsA in clinical practice.
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Affiliation(s)
- Xabier Michelena
- Rheumatology, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
| | - Clementina López-Medina
- Rheumatology, Maimónides Institute for Biomedical Research of Córdoba (IMIBIC)University of CordobaReina Sofía University Hospital, Córdoba, Spain
| | | | | | - Rubén Queiro
- Rheumatology, Faculty of Medicine, Asturias University Hospital, Sección de inmunología traslacional del instituto de investigación sanitaria del Principado de Asturias (ISPA), University of Oviedo, Oviedo, Spain
| | - Helena Marzo-Ortega
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Xavier Juanola
- Rheumatology, Bellvitge University Hospital, Barcelona, Spain
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Davies BM, Khan DZ, Barzangi K, Ali A, Mowforth OD, Nouri A, Harrop JS, Aarabi B, Rahimi-Movaghar V, Kurpad SN, Guest JD, Tetreault L, Kwon BK, Boerger TF, Rodrigues-Pinto R, Furlan JC, Chen R, Zipser CM, Curt A, Milligan J, Kalsi-Rayn S, Sarewitz E, Sadler I, Widdop S, Fehlings MG, Kotter MR. We Choose to Call it 'Degenerative Cervical Myelopathy': Findings of AO Spine RECODE-DCM, an International and Multi-Stakeholder Partnership to Agree a Standard Unifying Term and Definition for a Disease. Global Spine J 2024; 14:503-512. [PMID: 35769029 PMCID: PMC10802519 DOI: 10.1177/21925682221111780] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Modified DELPHI Consensus Process. OBJECTIVE To agree a single unifying term and definition. Globally, cervical myelopathy caused by degenerative changes to the spine is known by over 11 different names. This inconsistency contributes to many clinical and research challenges, including a lack of awareness. METHOD AO Spine RECODE-DCM (Research objectives and Common Data Elements Degenerative Cervical Myelopathy). To determine the index term, a longlist of candidate terms and their rationale, was created using a literature review and interviews. This was shared with the community, to select their preferred terms (248 members (58%) including 149 (60%) surgeons, 45 (18%) other healthcare professionals and 54 (22%) People with DCM or their supporters) and finalized using a consensus meeting. To determine a definition, a medical definition framework was created using inductive thematic analysis of selected International Classification of Disease definitions. Separately, stakeholders submitted their suggested definition which also underwent inductive thematic analysis (317 members (76%), 190 (59%) surgeons, 62 (20%) other healthcare professionals and 72 (23%) persons living with DCM or their supporters). Using this definition framework, a working definition was created based on submitted content, and finalized using consensus meetings. RESULTS Degenerative Cervical Myelopathy was selected as the unifying term, defined in short, as a progressive spinal cord injury caused by narrowing of the cervical spinal canal. CONCLUSION A consistent term and definition can support education and research initiatives. This was selected using a structured and iterative methodology, which may serve as an exemplar for others in the future.
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Affiliation(s)
- Benjamin M. Davies
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
- Myelopathy.org, UK
| | - Danyal Z Khan
- Department of Neurosurgery, Walton Centre, UK
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, UK
| | - Kara Barzangi
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
| | - Ahmad Ali
- Department of Neurosurgery, Walton Centre, UK
| | - Oliver D. Mowforth
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
- Myelopathy.org, UK
| | - Aria Nouri
- Department of Neurosurgery, Geneva University Hospital, University of Geneva, Switzerland
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Iran
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - James D. Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Lindsay Tetreault
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Brian K. Kwon
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Timothy F Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto - Hospital de Santo António, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Portugal
| | - Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
| | - Robert Chen
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | | | - Armin Curt
- University Spine Center, Balgrist University Hospital, Switzerland
| | | | | | | | | | | | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mark R.N. Kotter
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
- Myelopathy.org, UK
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Abstract
PURPOSE OF REVIEW This review encompasses a detailed history of spondyloarthritis (SpA) evolution as early as the 17th century, continues on to the current concept of SpA, and ends with current gaps in our understandings of SpA. RECENT FINDINGS Until the early 1960s, ankylosing spondylitis and other SpA family members were considered to be variants of rheumatoid arthritis (RA). The formal medical community separated them from RA at that time, and shortly thereafter they were recognized to be inter-connected based on shared clinical, laboratory, and imaging features. The last two decades have witnessed the formal distinction between axial and peripheral SpA and the connections that exist between nonradiographic and radiographic axial SpA. Recent studies have revealed different microbial compositions among patients with SpA and healthy controls and also between HLA-B27 positive and negative healthy individuals. SUMMARY Further investigation of the roles of intestinal microbiome and physical force transduction toward SpA pathogenesis, strategies to improve delay in SpA diagnosis, biomarkers to better predict radiographic progression, and modification of current classification criteria to better address the axial and peripheral groups are gaps in our understandings that pose top priorities for SpA research.
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Castells Navarro L, Buckberry J. Back to the beginning: Identifying lesions of diffuse idiopathic skeletal hyperostosis prior to vertebral ankylosis. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2020; 28:59-68. [PMID: 31951851 DOI: 10.1016/j.ijpp.2019.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 11/29/2019] [Accepted: 12/07/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To better understand the pathogenesis of DISH, identifying early or pre-DISH lesions in the spine and investigating the relationship between spinal and extra-spinal manifestations of DISH. MATERIAL 44 skeletonized individuals with DISH from the WM Bass Donated Skeletal Collection. METHODS For each vertebra, location, extension, point of origin and appearance of vertebral outgrowths were recorded. The size of the enthesophytes at the olecranon process, patella and calcaneal tuberosity was measured with digital callipers. RESULTS At either end of the DISH-ankylosed segment, isolated vertical outgrowths arising from the central third of the anterior aspect of the vertebral body can usually be observed. These bone outgrowths show a well-organized external cortical layer, an internal structure of trabecular bone and usually are unaccompanied by or show minimal associated endplate degeneration. Analysis of the relationship between spinal and extra-spinal manifestations (ESM) suggests great inter-individual variability. No correlation between any ESM and the stage of spinal DISH was found. CONCLUSIONS Small isolated outgrowths represent the earliest stages of the spinal manifestations of DISH. The use of ESM as an indicator of DISH should be undertaken with great caution until the relationship between these two features is understood. SIGNIFICANCE Improved accuracy of paleopathological diagnostic criteria of DISH. LIMITATIONS Small sample comprised of only individuals with DISH. FUTURE RESEARCH: micro-CT analysis to investigate the internal structure of the spinal lesions. Analysis of extra-spinal enthesophytes in individuals with and without DISH to understand their pathogenesis and association with the spinal lesions in individuals with DISH.
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Affiliation(s)
- Laura Castells Navarro
- School of Archaeological and Forensic Sciences, University of Bradford, Bradford, BD7 1DP, UK.
| | - Jo Buckberry
- School of Archaeological and Forensic Sciences, University of Bradford, Bradford, BD7 1DP, UK
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Degenerative Cervical Myelopathy: A Brief Review of Past Perspectives, Present Developments, and Future Directions. J Clin Med 2020; 9:jcm9020535. [PMID: 32079075 PMCID: PMC7073521 DOI: 10.3390/jcm9020535] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/30/2020] [Accepted: 02/13/2020] [Indexed: 01/15/2023] Open
Abstract
Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord injury in developed countries; its prevalence is increasing due to the ageing of the population. DCM causes neurological dysfunction and is a significant cause of disability in the elderly. It has important negative impacts on the quality of life of those affected, as well as on their caregivers. DCM is triggered by a variety of degenerative changes in the neck, which affect one or more anatomical structures, including intervertebral discs, vertebrae, and spinal canal ligaments. These changes can also lead to structural abnormalities, leading to alterations in alignment, mobility, and stability. The principle unifying problem in this disease, regardless of the types of changes present, is injury to the spinal cord due to compression by static and/or dynamic forces. This review is partitioned into three segments that focus on key elements of the past, the present, and the future in the field, which serve to introduce the focus issue on "Degenerative Cervical Myelopathy and the Aging Spine". Emerging from this review is that tremendous progress has been made in the field, particularly in recent years, and that there are exciting possibilities for further advancements of patient care.
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Su J, Cui L, Yang W, Shi H, Jin C, Shu R, Li H, Zeng X, Wu S, Gao X. Baseline high-sensitivity C-reactive protein predicts the risk of incident ankylosing spondylitis: Results of a community-based prospective study. PLoS One 2019; 14:e0211946. [PMID: 30768617 PMCID: PMC6377123 DOI: 10.1371/journal.pone.0211946] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 01/24/2019] [Indexed: 01/22/2023] Open
Abstract
Background A hospitalized-based cohort study suggested that elevated C-reactive protein (CRP) levels are associated with radiographic sacroiliitis progression in ankylosing spondylitis (AS) patients. However, data from community-based populations are limited. Objective We sought to determine the association between elevated CRP levels and AS diagnosis in a prospective community-based study of 129,681 Chinese adults over a follow-up period of 8 years. Methods We measured the plasma CRP concentration at baseline and every 2 years thereafter with the high-sensitivity (hs)-CRP test. Incident AS cases were confirmed on the basis of modified New York diagnostic criteria after review of medical records. We used Cox proportional-hazard models to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for AS on the basis of hs-CRP concentrations, adjusting for age, sex, education, income, cigarette smoking, alcohol intake, physical activity, body mass index, blood-pressure status, blood glucose status, total cholesterol, history of cardiovascular disease, and use of antihypertensives, lipid-lowering agents, and aspirin. Results During 1,033,609 person-years (average 7.97 ± 1.36 years per person) of follow-up, we identified 55 incident AS cases. Baseline hs-CRP was positively associated with the risk of future AS. Compared with hs-CRP <1 mg/L, the HR was 1.28 (95% CI 0.54–3.08) for hs-CRP of 1.00–2.99 mg/L, 4.71 (95% CI 2.26–9.81) for hs-CRP of 3.00–9.99 mg/L, and 19.8 (95% CI 9.6–40.9) for hs-CRP ≥10.00 mg/L (P-trend <0.001) after adjustment for potential confounders. We found similar results after excluding AS cases that occurred in the first 2 years of follow-up, and using the cumulative average hs-CRP concentration as a predictor. Conclusion This is the first study in a community-based cohort to demonstrate that CRP plasma concentrations predict the risk of future AS, thus providing a test that is easy to routinely perform in the clinic to assess for AS risk.
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Affiliation(s)
- Jinmei Su
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Liufu Cui
- Department of Rheumatology, Kailuan General Hospital, Tangshan, China
| | - Wenhao Yang
- Department of Rheumatology, Kailuan General Hospital, Tangshan, China
| | - Huijing Shi
- Department of Rheumatology, Kailuan General Hospital, Tangshan, China
| | - Cheng Jin
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
- Department of Nutritional Science, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Rong Shu
- Department of Rheumatology, Kailuan General Hospital, Tangshan, China
| | - Hongfen Li
- Department of Central Laboratory, Kailuan General Hospital, Tangshan, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- * E-mail: (XZ); (SW)
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
- * E-mail: (XZ); (SW)
| | - Xiang Gao
- Department of Nutritional Science, Pennsylvania State University, University Park, Pennsylvania, United States of America
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Aguila Maldonado R, Ruta S, Valuntas ML, García M. Ultrasonography assessment of heel entheses in patients with spondyloarthritis: a comparative study with magnetic resonance imaging and conventional radiography. Clin Rheumatol 2017. [PMID: 28647902 DOI: 10.1007/s10067-017-3723-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The aim of the present study was to determine the agreement between ultrasonography (US), magnetic resonance imaging (MRI), and conventional radiography (CR) in the detection of findings indicative of enthesopathy in spondyloarthritis (SpA) patients. A cross-sectional study was performed in 40 SpA patients. Heel entheses (Achilles tendon and plantar fascia) were bilaterally examined by US, MRI, and CR. The three imaging modalities were carried out by three independent operators blinded to the other imaging modality data. Soft tissue abnormalities indicative of enthesopathy as thickening, structural changes, and bursitis were assessed by both US and MRI, and cortical bone abnormalities indicative of enthesopathy as erosions and enthesophytes were assessed by the three imaging modalities. The unweighted kappa values between US and MRI were 0.80, 0.66, 0.69, 0.70, and 0.70 for thickening, structural changes, bursitis, enthesophytes, and bone erosions, respectively. With respect to the detection of enthesophytes, the unweighted kappa values between CR and both US and MRI were 0.78 and 0.76, respectively. At last, for the recognition of bone erosions, the unweighted kappa values between CR and both US and MRI were 0.38 and 0.45, respectively. Using MRI as standard reference method, US was more sensitive with respect to CR revealing bone erosions. The present study provides evidence about the high overall agreement between US and MRI for all abnormal comparable findings at entheseal level and between US, MRI, and CR for the detection of enthesophytes in SpA patients.
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Affiliation(s)
- Rodrigo Aguila Maldonado
- Servicio de Reumatología, Hospital "Gral. San Martín" de La Plata, Calle 1 y 70 (1900), La Plata, Buenos Aires, Argentina.
| | - Santiago Ruta
- Seccion Reumatología, Servicio Clínica Médica, Hospital Italiano de Buenos Aires, La Plata, Argentina
| | - María Laura Valuntas
- Servicio de Tomografía computada y Resonancia magnética, Sanatorio IPENSA, La Plata, Buenos Aires, Argentina
| | - Mercedes García
- Servicio de Reumatología, Hospital "Gral. San Martín" de La Plata, Calle 1 y 70 (1900), La Plata, Buenos Aires, Argentina
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Do Caucasians and East Asians have Different Outcomes Following Surgery for the Treatment of Degenerative Cervical Myelopathy?: Results From the Prospective Multicenter AOSpine International Study. Spine (Phila Pa 1976) 2016; 41:1428-1435. [PMID: 26974832 DOI: 10.1097/brs.0000000000001555] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective multicenter cohort study. OBJECTIVE The aim of this study was to compare outcomes of surgery for the treatment for degenerative cervical myelopathy (DCM) between Caucasians and East Asians. SUMMARY OF BACKGROUND DATA Numerous studies have indicated that race can influence both disease prevalence and clinical prognosis in a variety of medical conditions; however, none have evaluated the impact of race on surgical outcomes in patients with DCM. METHODS Four hundred and seventy-nine patients with symptomatic DCM were enrolled in the prospective AOSpine CSM-International study at 16 global sites. Preoperatively, and at each follow-up, patients were evaluated using the modified Japanese Orthopedic Association scale (mJOA), the Nurick score, the Neck Disability Index (NDI), and the Short- Form 36 (SF-36) Health Survey. A mixed-model analytic approach was used to evaluate differences in outcomes between races at 24 months postoperatively, while controlling for relevant baseline characteristics and surgical factors. RESULTS Three hundred and twenty-four (67.64%) patients were Caucasian and 106 (22.13%) were East Asian. There was no difference in the incidence of ossification of the posterior longitudinal ligament (OPLL) between the two races; however a greater percentage of Caucasians in India (46.15%) and Turkey (41.38%) displayed evidence of OPLL than Caucasians in other regions (P < 0.001). The frequency of spondylosis was significantly higher in Caucasians (P < 0.001). Caucasians had a longer duration of symptoms (27.33 ± 34.47 months) than East Asians (23.11 ± 35.68 months) (P < 0.001), and a lower preoperative score on the SF-36 Physical Component Score (33.85 ± 9.04) than East Asians (37.47 ± 8.67) (P < 0.001). At 24 months after surgery, there were no differences in functional status or QOL between East Asians and Caucasians, after adjusting for baseline characteristics, surgical preferences, and disease causation. Rates of perioperative complications were not significantly different between the races (P = 0.261). CONCLUSION Decompressive surgery for DCM results in comparable functional gains and is equally safe in Caucasians and East Asians. LEVEL OF EVIDENCE 2.
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Rothschild BM. Return to clinical in contrast to serologically-based diagnoses. World J Rheumatol 2016; 6:1-8. [DOI: 10.5499/wjr.v6.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/19/2015] [Accepted: 11/17/2015] [Indexed: 02/06/2023] Open
Abstract
The future of rheumatology is predicated upon a return to basics. The advent and facile availability of laboratory testing led to reduction of emphasis on clinical skills. Recognition that immunologic abnormalities are not limited to individuals who clearly have related pathology provides new motivation for reorientation of training programs to assure that graduates have appropriate information gathering, diagnostic and procedural skills. Inadequate accessibility to rheumatologic care requires innovative approaches and especially training and educating those individuals who provide primary care. While the rheumatologist can elicit the patient’s history remotely, telerheumatology will be feasible only when the individual interacting physically with the patient has confidence in their examination skills and when those skills have been validated. Named syndromes or diseases will be modified to avoid impugning the individual or compromising their future access to health, disability and life insurance. Interventions will be pursued in a more cost-effective, evidence-based manner. The future of rheumatology is dependent upon the rheumatologist’s ability to amortize the inadequate reimbursement for direct patient interaction, depending on skills of interpretation of standard X-rays, ultrasound performance and results.
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Klang E, Aharoni D, Hermann KG, Herman A, Rimon U, Shazar N, Eshed I. Magnetic resonance imaging of pelvic entheses--a systematic comparison between short tau inversion recovery (STIR) and T1-weighted, contrast-enhanced, fat-saturated sequences. Skeletal Radiol 2014; 43:499-505. [PMID: 24453026 DOI: 10.1007/s00256-013-1814-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 12/13/2013] [Accepted: 12/29/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the contribution of contrast material in detecting and evaluating enthesitis of pelvic entheses by MRI. MATERIALS AND METHODS Sixty-seven hip or pelvic 1.5-T MRIs (30:37 male:female, mean age: 53 years) were retrospectively evaluated for the presence of hamstring and gluteus medius (GM) enthesitis by two readers (a resident and an experienced radiologist). Short tau inversion recovery (STIR) and T1-weighted pre- and post-contrast (T1+Gd) images were evaluated by each reader at two sessions. A consensus reading of two senior radiologists was regarded as the gold standard. Clinical data was retrieved from patients' referral form and medical files. Cohen's kappa was used for intra- and inter-observer agreement calculation. Diagnostic properties were calculated against the gold standard reading. RESULTS A total of 228 entheses were evaluated. Gold standard analysis diagnosed 83 (36%) enthesitis lesions. Intra-reader reliability for the experienced reader was significantly (p = 0.0001) higher in the T1+Gd images compared to the STIR images (hamstring: k = 0.84/0.45, GM: k = 0.84/0.47). Sensitivity and specificity increased from 0.74/0.8 to 0.87/0.9 in the STIR images and T1+Gd sequences. Intra-reader reliability for the inexperienced reader was lower (p > 0.05). CONCLUSIONS Evidence showing that contrast material improves the reliability, sensitivity, and specificity of detecting enthesitis supports its use in this setting.
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Affiliation(s)
- Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Aviv University, Tel Hashomer, 52621, Tel Aviv, Israel
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Rothschild B. What qualifies as rheumatoid arthritis? World J Rheumatol 2013; 3:3-5. [DOI: 10.5499/wjr.v3.i1.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 01/11/2013] [Accepted: 01/24/2013] [Indexed: 02/06/2023] Open
Abstract
Expansion of diagnostic criteria for rheumatoid arthritis and deletion of exceptions increases sensitivity, but at the expense of specificity. Two decades later, modification of criteria included the caveat: “absence of an alternative diagnosis that better explains the synovitis.” That puts great faith in the diagnostic skills of the evaluating individual and their perspectives of disease. The major confounding factor appears to be spondyloarthropathy, which shares some characteristics with rheumatoid arthritis. Recognition of the latter on the basis of marginally distributed and symmetrical polyarticular erosions, in absence of axial (odontoid disease excepted) involvement requires modification to avoid failure to recognize a different disease, spondyloarthropathy. Skeletal distribution, pure expression of disease in natural animal models and biomechanical studies clearly rule out peripheral joint fusion (at least in the absence of corticosteroid therapy) as a manifestation of rheumatoid arthritis. Further, such studies identity predominant wrist and ankle involvement as characteristic of a different disease, spondyloarthropathy. It is important to separate the two diagnostic groups for epidemiologic study and for clinical diagnosis. They certainly differ in their pathophysiology.
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Groch KR, Marcondes MCC, Colosio AC, Catão-Dias JL. Skeletal abnormalities in humpback whales Megaptera novaeangliae stranded in the Brazilian breeding ground. DISEASES OF AQUATIC ORGANISMS 2012; 101:145-158. [PMID: 23135142 DOI: 10.3354/dao02518] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Skeletal tissues of 49 humpback whales Megaptera novaeangliae that stranded between 2002 and 2011 along the Abrolhos Bank seashore and its adjacent waters in Brazil were studied. Twelve (24.5%) animals presented pathological changes in one or more bones. Degenerative changes and developmental malformations were most frequent (10.2% each), followed by inflammatory/infectious and traumatic lesions (8.2% each). Infectious diseases led to severe lesions of the caudal vertebrae of 2 whales. In one of these individuals, the lesions involved 6 caudal vertebrae, leading to ankylosis of 3 vertebrae. Degenerative changes were observed in the vertebral columns of 3 animals, involving the joints of 13 ribs of 1 individual, and in the humerus of 1 whale. Traumatic lesions, such as osseous callus in the ribs, were observed in 4 animals. In 1 whale, the rib showed severe osteomyelitis, possibly resulting from the infection of multiple fractures. Developmental abnormalities such as spina bifida on 3 cervical vertebrae of 1 whale, fusion of spinal processes on thoracic vertebrae of 1 individual and fusion of the first 2 ribs unilaterally or bilaterally in 4 animals were found. Chronic infectious conditions found in the axial skeleton may have restrained spinal mobility and had detrimental effects on the general health of the animals, contributing to stranding and death. To our knowledge, this is the first systematic study on skeletal lesions in stranded humpback whales.
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Affiliation(s)
- Kátia R Groch
- Instituto Baleia Jubarte, Caravelas, Bahia 45900-000, Brazil.
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Zeidler H, Amor B. The Assessment in Spondyloarthritis International Society (ASAS) classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general: the spondyloarthritis concept in progress. Ann Rheum Dis 2011; 70:1-3. [PMID: 21163805 DOI: 10.1136/ard.2010.135889] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Classification and epidemiology of spondyloarthritis. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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Cisneros JC, Gomes Cabral U, de Beer F, Damiani R, Costa Fortier D. Spondarthritis in the triassic. PLoS One 2010; 5:e13425. [PMID: 20976231 PMCID: PMC2954804 DOI: 10.1371/journal.pone.0013425] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 09/24/2010] [Indexed: 12/02/2022] Open
Abstract
Background The evidence of several forms of arthritis has been well documented in the fossil record. However, for pre-Cenozoic vertebrates, especially regarding reptiles, this record is rather scarce. In this work we present a case report of spondarthritis found in a vertebral series that belonged to a carnivorous archosaurian reptile from the Lower Triassic (∼245 million years old) of the South African Karoo. Methodology/Principal Findings Neutron tomography confirmed macroscopic data, revealing the ossification of the entire intervertebral disc space (both annulus fibrosus and nucleus pulposus), which supports the diagnosis of spondarthritis. Conclusions/Significance The presence of spondarthritis in the new specimen represents by far the earliest evidence of any form of arthritis in the fossil record. The present find is nearly 100 million years older than the previous oldest report of this pathology, based on a Late Jurassic dinosaur. Spondarthritis may have indirectly contributed to the death of the animal under study.
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Affiliation(s)
- Juan Carlos Cisneros
- Centro de Ciências da Natureza, Universidade Federal do Piauí, Teresina, Brazil.
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Falsetti P, Acciai C, Lenzi L, Frediani B. Ultrasound of enthesopathy in rheumatic diseases. Mod Rheumatol 2008; 19:103-13. [PMID: 19002749 DOI: 10.1007/s10165-008-0129-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Accepted: 09/08/2008] [Indexed: 11/24/2022]
Abstract
Enthesopathy is the pathologic change of the insertion of tendons, ligaments and joint capsules on the bone. It is a cardinal feature of spondyloarthropathies (SpA), but it can occur in other rheumatic disease. Recent studies using magnetic resonance imaging (MRI) and ultrasonography (US) have demonstrated that enthesopathy can often be asymptomatic, in both the axial and peripheral skeleton. Therefore, a systematic US study of peripheral entheses could be useful in the diagnostic process of patients with rheumatic diseases, in particular SpA. Recently, power Doppler US (PDUS) has been proved to be useful for differentiating mechanical/degenerative and inflammatory enthesopathy and for monitoring the efficacy of therapy. This article reviews the main histopathologic aspects of enthesopathy and describes the normal US features of enthesis and the basic US features of enthesopathy, in its various stages. The usefulness of US and PDUS in the diagnosis and assessment of enthesopathy is discussed on the basis of the literature and our experience.
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Affiliation(s)
- Paolo Falsetti
- Department of Clinical Medicine, Rheumatology Section, University of Siena, viale Bracci, 53100 Siena, Italy.
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Eshed I, Bollow M, McGonagle DG, Tan AL, Althoff CE, Asbach P, Hermann KGA. MRI of enthesitis of the appendicular skeleton in spondyloarthritis. Ann Rheum Dis 2007; 66:1553-9. [PMID: 17526551 PMCID: PMC2095313 DOI: 10.1136/ard.2007.070243] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2007] [Indexed: 11/04/2022]
Abstract
Entheses are sites where tendons, ligaments, joint capsules or fascia attach to bone. Inflammation of the entheses (enthesitis) is a well-known hallmark of spondyloarthritis (SpA). As entheses are associated with adjacent, functionally related structures, the concepts of an enthesis organ and functional entheses have been proposed. This is important in interpreting imaging findings in entheseal-related diseases. Conventional radiographs and CT are able to depict the chronic changes associated with enthesitis but are of very limited use in early disease. In contrast, MRI is sensitive for detecting early signs of enthesitis and can evaluate both soft-tissue changes and intraosseous abnormalities of active enthesitis. It is therefore useful for the early diagnosis of enthesitis-related arthropathies and monitoring therapy. Current knowledge and typical MRI features of the most commonly involved entheses of the appendicular skeleton in patients with SpA are reviewed. The MRI appearances of inflammatory and degenerative enthesopathy are described. New options for imaging enthesitis, including whole-body MRI and high-resolution microscopy MRI, are briefly discussed.
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Affiliation(s)
- Iris Eshed
- Department of Radiology, Charité Medical School, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
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Abstract
STUDY DESIGN A retrospective study. PURPOSE To categorize the MR appearance of ischemic vertebral collapse and to correlate surgical and histologic findings. OVERVIEW OF LITERATURE X-ray and MRI findings of delayed posttraumatic vertebral collapse shows several patterns. Histopathologic signs of osteonecrosis were present only in minor portion of cases sampled for biopsy of delayed post-traumatic vertebral collapse in the literature. METHODS Twenty-one patients (22 vertebral bodies), with surgically and histopathologically proven ischemic vertebral collapse were included. The patients were examined with a 1.5 T MR imager. Spin echo T1- and T2-weighted images were obtained in axial and sagittal planes. Two experienced musculoskeletal radiologists, who reached consensus, evaluated the MR images. Then, MR-pathology correlations were made. RESULTS Four different MR patterns were identified. Fluid patterns, were seen in 14% (3/22) of the affected vertebral bodies, and were characterized by hypo-intense signals on T1-weighted images, and hyper-intense signals, similar to water, on T2-weighted images. Extensive bone necrosis was predominant. Compression pattern, the most common pattern, found in 41% (9/22 vertebral bodies), was characterized by a marked decrease of anterior column height. Bone necrosis, granulation tissue, marrow fibrosis, and reactive new bone formation were found in relatively equal proportion. Granulation pattern, seen in 27% (6/22 vertebral bodies), was characterized by hypo-intense signals on T1-weighted images, and intermediate signals on T2-weighted images. Extensive granulation tissue was predominant. Mixed patterns were present in 18% (4/22), of the vertebral bodies. CONCLUSIONS Awareness of histopathologic correlation of MR patterns in patients with delayed post-traumatic vertebral collapse may facilitate effective interpretation of clinical MR images of the spine.
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Braun J, Sieper J. Early diagnosis of spondyloarthritis. ACTA ACUST UNITED AC 2006; 2:536-45. [PMID: 17016479 DOI: 10.1038/ncprheum0296] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Accepted: 07/17/2006] [Indexed: 02/07/2023]
Abstract
The term 'spondyloarthritis', which is preferred to 'spondyloarthropathy', refers to a group of similar diseases with distinct clinical features and a common genetic predisposition, rather than one disease with different clinical presentations. Mainly for clinical purposes, five disease subtypes are recognized: ankylosing spondylitis (AS), psoriatic spondyloarthritis, reactive spondyloarthritis, spondyloarthritis associated with inflammatory bowel disease, and undifferentiated spondyloarthritis. Irrespective of the disease subtype, the main clinical manifestations of spondyloarthritides are inflammatory back pain, peripheral arthritis, enthesitis and anterior uveitis, while other organ manifestations are rare. The need for a standardized, evidence-based approach to disease classification led to the development of the European Spondyloarthropathy Study Group preliminary criteria for spondyloarthritis in 1991, which confirmed the unifying concept of this group of diseases. In the past 10 years, the work of the European Spondyloarthropathy Study Group has been taken over by the Assessments in AS working group. There is still a considerable delay in diagnosis of AS and, because of the well-documented efficacy of anti-tumor-necrosis-factor therapy for all spondyloarthritis subtypes, diagnostic criteria (especially for early forms of spondyloarthritis) are needed. Diagnosis can be achieved by determination of the predominant clinical manifestation, and by the inclusion of sensitive diagnostic tools for early disease (such as HLA-B27 genotype and MRI) in the criteria set. In addition, because of the high incidence of back pain in affected individuals, the development of practical screening parameters that facilitate referral to the rheumatologist is important.
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Huber LC, Moritz F, Gay S. Spondylarthritides and related entities: Entheses and hypotheses. ACTA ACUST UNITED AC 2006; 56:4-8. [PMID: 17195191 DOI: 10.1002/art.22291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Peloso PM, Braun J. Expanding the armamentarium for the spondyloarthropathies. Arthritis Res Ther 2004; 6 Suppl 2:S36-43. [PMID: 15228620 PMCID: PMC2833456 DOI: 10.1186/ar1012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2003] [Accepted: 02/04/2004] [Indexed: 12/16/2022] Open
Abstract
Ankylosing spondylitis (AS) is a member of the family of spondyloarthropathies, which are inflammatory arthritides largely involving the axial skeleton and commonly accompanied by peripheral arthritis. Genetic factors, particularly the presence of HLA-B27, are major contributors to the susceptibility for AS. Despite some therapeutic advances, the treatment options for patients with AS and related disorders have been limited. Several lines of evidence have led to the hypothesis that patients with AS might benefit from treatment with tumor necrosis factor (TNF). Specifically, TNF concentrations are known to be significantly elevated in the synovium of patients with rheumatoid arthritis (RA), in the inflamed gut of patients with inflammatory bowel disease, and in the inflamed sacroiliac joints of patients with AS. The anti-TNF agents have been shown to be of benefit in, and currently have indications for, RA (etanercept, infliximab, adalimumab), Crohn's disease (infliximab), and psoriatic arthritis (etanercept). Because the spondyloarthropathies share pathogenetic mechanisms with the above-specified disease states, studies have been conducted to evaluate the effectiveness of anti-TNF agents in several disorders, including AS. Data from clinical trials so far with infliximab and etanercept show that patients with AS and related disorders achieve significant improvement in clinical signs and symptoms based on validated outcomes measures. Computed tomography and magnetic resonance imaging (MRI) can facilitate the early diagnosis of AS. Studies with infliximab using MRI together with updated scoring methods demonstrated significant decreases in associated spinal inflammation. TNF antagonist therapy is well tolerated in patients with AS, with a side effect profile consistent with the prior experience of patients with RA.
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Affiliation(s)
- Paul M Peloso
- University of Iowa Health Care, Department of Internal Medicine, Iowa City, IA USA
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Muche B, Bollow M, François RJ, Sieper J, Hamm B, Braun J. Anatomic structures involved in early- and late-stage sacroiliitis in spondylarthritis: a detailed analysis by contrast-enhanced magnetic resonance imaging. ARTHRITIS AND RHEUMATISM 2003; 48:1374-84. [PMID: 12746910 DOI: 10.1002/art.10934] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To localize inflammatory and chronic changes to defined areas in the sacroiliac joints in patients with early-stage compared with late-stage spondylarthritis (SpA), using magnetic resonance imaging (MRI). METHODS Using MRI, 93 patients with SpA and inflammatory back pain who had radiographs of the sacroiliac joints were examined, comprising 31 patients with ankylosing spondylitis (AS) and 62 with other SpA subsets, including 48 with undifferentiated SpA (uSpA). MRI was performed using T1-weighted, T2*-weighted, STIR, and dynamic contrast-enhanced (gadolinium diethylenetriaminepentaacetic acid) sequences. Two readers retrospectively analyzed the images by differentiating 9 areas of the sacroiliac joints: the ventral and caudal joint capsule, cavum, subchondral bone, bone marrow, ligament entheses, and ligaments; the sacral and iliac sides were tabulated separately. RESULTS By MRI, sacroiliitis was more often bilateral in AS (84%) than in uSpA (48%) (P = 0.01). Inflammatory changes were found in a mean +/- SD 4.7 +/- 2.9 regions/joint, with involvement of 4.5 +/- 3.2 regions in early disease versus 5.2 +/- 2.3 regions in late disease (P not significant [NS]). Involvement of the iliac side of the sacroiliac joints was found to be more frequent than the sacral side in early disease (58% versus 48%; P < 0.01) as compared with that in late disease (58% versus 63%; P NS). The dorsocaudal parts of the synovial joint and the bone marrow were the most frequently inflamed structures in early disease (P < 0.001 for ventral versus dorsal joint capsule). In contrast, involvement of the entheses was more common in advanced disease (early 43% versus late 86%; P < 0.001). Similarly, the ligaments were more frequently involved in the late stages (early 26% versus late 40%; P = 0.06). Both patterns of bone marrow inflammation (focal and diffuse) were observed in equal frequencies in early and late disease (17% and 42% versus 26% and 43%, respectively; P NS). HLA-B27-positive patients (n = 80) had more entheseal involvement than did HLA-B27-negative patients (n = 13) (60% versus 39%; P = 0.05). HLA-B27-negative patients had a shorter disease duration (2.2 years versus 4.4 years; P = 0.05) and were more often female (62%; P = 0.02). When all pathologic changes were assessed, the STIR sequence (performed in 62 patients) was less sensitive than the contrast-enhanced sequences in that it was not able to show all relevant changes in 27% of these patients (n = 17), failing to reveal inflammation of the cavum in 15 patients and of the bone marrow and joint capsule in 1 patient each. CONCLUSION As visualized by MRI, sacroiliitis in SpA is characterized by involvement of different joint structures. Whereas the iliac and the sacral side of the sacroiliac joints are almost equally affected, the dorsocaudal synovial part of the joint is involved significantly more often than the ventral part, especially in early disease. Sacroiliac enthesitis is not a special feature of early sacroiliac inflammation.
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Affiliation(s)
- B Muche
- Free University, Berlin, Germany
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Abstract
Ankylosing spondylitis (AS) is a complex, potentially debilitating disease that is insidious in onset, progressing to radiological sacroiliitis over several years. Patients with symptomatic AS lose productivity owing to work disability and unemployment, have a substantial use of healthcare resources, and reduced quality of life. The pathogenesis of AS is poorly understood. However, immune mediated mechanisms involving human leucocyte antigen (HLA)-B27, inflammatory cellular infiltrates, cytokines (for example, tumour necrosis factor alpha and interleukin 10), and genetic and environmental factors are thought to have key roles. The detection of sacroiliitis by radiography, magnetic resonance imaging, or computed tomography in the presence of clinical manifestations is diagnostic for AS, although the presence of inflammatory back pain plus at least two other typical features of spondyloarthropathy (for example, enthesitis and uveitis) is highly predictive of early AS. Non-steroidal anti-inflammatory drugs (NSAIDs) effectively relieve inflammatory symptoms and are presently first line drug treatment. However, NSAID treatment has only a symptomatic effect and probably does not alter the disease course. For symptoms refractory to NSAIDs, second line treatments, including corticosteroids and various disease modifying antirheumatic drugs, are employed but are of limited benefit. Emerging biological therapies target the inflammatory processes underlying AS, and thus, may favourably alter the disease process, in addition to providing symptom relief.
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Affiliation(s)
- J Sieper
- Department of Gastroenterology and Rheumatology, UKBF, Free University, Hindenburgdamm 30, 12200 Berlin, Germany.
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Braun J, van der Heijde D, Dougados M, Emery P, Khan MA, Sieper J, van der Linden S. Staging of patients with ankylosing spondylitis: a preliminary proposal. Ann Rheum Dis 2002; 61 Suppl 3:iii9-23. [PMID: 12381507 PMCID: PMC1766734 DOI: 10.1136/ard.61.suppl_3.iii19] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Patients with ankylosing spondylitis (AS) are characterised by a wide range of clinical presentations, radiographic profiles, and outcomes, which are not well differentiated by current diagnostic and classification systems for the disorder. Inadequacies in these systems may limit clinicians' ability to manage their patients with AS appropriately and act as an obstacle to reasonable comparison of therapeutic trial results. A standardised staging system for AS is therefore proposed that would provide a more detailed categorisation of patients based on assessment of structural damage, peripheral joint and organ involvement, presence of concomitant diseases, and the severity and extent of disease activity and functional impairment. The proposed system needs to be evaluated closely and amended as needed to assure its usefulness in clinical and research settings.
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Affiliation(s)
- J Braun
- Rheumazentrum Ruhrgebiet, Landgrafenstrasse 15, 44652 Herne, Germany.
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Braun J, Sieper J. Building consensus on nomenclature and disease classification for ankylosing spondylitis: results and discussion of a questionnaire prepared for the International Workshop on New Treatment Strategies in Ankylosing Spondylitis, Berlin, Germany, 18-19 January 2002. Ann Rheum Dis 2002; 61 Suppl 3:iii61-7. [PMID: 12381512 PMCID: PMC1766727 DOI: 10.1136/ard.61.suppl_3.iii61] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND There is currently no universal consensus on nomenclature for spondyloarthropathy (SpA), or on activity and severity criteria for ankylosing spondylitis (AS). METHOD Points of agreement and majority opinions among 28 international experts in the field were identified by questionnaire. Agreement was defined as >80% concurrence, clear majority as >60% concurrence, and a majority or trend as >50% concurrence. RESULTS Respondents agreed on the need for one term that reflects the inflammatory nature of the disease, but no agreement was reached on a specific term. Agreement included subdivision of patients with SpA into AS, psoriatic arthritis, inflammatory bowel disease associated arthritis, and undifferentiated spondyloarthritis/spondyloarthropathy. A majority of experts defined active disease as fulfilling classification criteria for AS and/or a SpA, and disease activity measured by a Bath AS Disease Activity Index (BASDAI) score >4 determined by two patient visits during a two month period, but no maximum radiographic score. The majority of participants considered failure of treatment response to non-steroidal anti-inflammatory drugs (NSAIDs) alone to be a prerequisite for active/severe AS, and 15/28 (54%) thought that NSAID treatment failure should be defined as lack of response to two or more NSAIDs. CONCLUSIONS Respondents agreed that a two to five year study is the ethical method to demonstrate effects of anti-tumour necrosis factor alpha (TNFalpha) therapy on radiographic progression of AS, and that inclusion criteria should include a certain level of disease activity (measured by BASDAI) and failure of certain treatments. After the efficacy of anti-TNFalpha therapy in AS and psoriatic arthritis is proved, respondents agreed that more studies will be needed to show efficacy for other SpA subsets.
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Affiliation(s)
- J Braun
- Rheumazentrum Ruhrgebiet, Landgrafenstrasse 15, 44652 Herne, Germany.
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François RJ, Braun J, Khan MA. Entheses and enthesitis: a histopathologic review and relevance to spondyloarthritides. Curr Opin Rheumatol 2001; 13:255-64. [PMID: 11555725 DOI: 10.1097/00002281-200107000-00003] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There are two types of entheses: fibrous, by Sharpey's fibers in membranous bone, and fibrocartilaginous, on endochondral bone, with discontinuous cement lines at the interface between insertion and bone. The connection of hyaline cartilage to subchondral bone is a kind of fibrocartilaginous enthesis. Fibrocartilages are structurally, chemically, and biomechanically intermediate between tendon and cartilage. Enthesitis is not the sole pathologic feature of spondyloarthritides. Synovitis and subchondral bone marrow changes outside the ligamentous insertions, and cartilage proliferation, are important too. In the subentheseal bone marrow and in the synovium, CD8+ T cells play a central role. Imaging of early changes is better achieved by ultrasonography and even better by magnetic resonance imaging than by radiography. No single immunologic target can be identified. The G1 domain of aggrecan is the best candidate, but this does not apply to fibrous entheses. In these complex pathologic conditions, no single abnormality can thus far be designated as a unique hallmark.
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Affiliation(s)
- R J François
- Laboratoire de Rhumatologie, Hôpital Militaire Reine Astrid, Brussels, Belgium.
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Schumacher HR, Bardin T. The spondylarthropathies: classification and diagnosis. Do we need new terminologies? BAILLIERE'S CLINICAL RHEUMATOLOGY 1998; 12:551-65. [PMID: 9928495 DOI: 10.1016/s0950-3579(98)80037-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The present classification of a number of arthropathies linked to the B27 antigen under the term spondylarthropathy emphasises the frequent familial aggregation and clustering during follow-up of these diseases. This article is an attempt to review the progress elicited by the introduction of classification criteria for spondylarthropathy and the limitations of the concept. In particular, we address the continued need for better understanding of aetiology and pathogenesis. This makes it likely that we will need new classifications in the future and that this will evolve along with improvements in disease understanding. Working classifications that include the infectious triggers and features of the host response might be useful to guide new approaches.
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Affiliation(s)
- H R Schumacher
- University of Pennsylvania, Rheumatology Division, Philadelphia 19104, USA
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Rothschild BM. Commented glossary for rheumatic spinal diseases. Ann Rheum Dis 1996; 55:76-7; author reply 77-8. [PMID: 8572743 PMCID: PMC1010089 DOI: 10.1136/ard.55.1.76-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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