Spondylarthritis: Pain due to Inflammation of the Back and Joints of the Hands and Legs

Spondylarthritis is a chronic inflammatory rheumatic disease in which the lower part of the spine is primarily affected by inflammation. It is also associated with inflammation of the joints of the limbs, but also with problems with the eyes or the digestive system. 

In addition, the damage extends to the tendon attachments. The most serious condition is the progression of the disease to the stage of ankylosis, i.e. stiffening of the spine.

Stiffening of the spine as a result of spondylarthritis is already referred to as:
Ankylosing spondylarthritis or also Bechterev's disease - Morbus Bechterev.

Spondylarthropathy, as the progressive inflammation of the spine and joints is otherwise referred to, brings together a number of specific diseases. These have common features, but also some differences.

SpA = spondylarthropathy. 
Arthritis with spondylitis = spondylarthritis.

SpA is thus a rheumatic inflammatory disease of the spine and peripheral joints, i.e. the joints of the limbs. It includes several subtypes.

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Spondylarthropathy and classification

Spondylarthritis = chronic rheumatic inflammatory disease of the spine and peripheral joints.

Spondyloarthritis affects the spine, mainly in the lower part of the spine, in the lumbar and sacral regions. However, the most severe damage occurs at the level of the junction of the spine and pelvis. This is referred to as the sacroiliac joint.

Inflammation of this joint is professionally called as sacroileitis. 

Rheumatic process damages the axial skeleton and peripheral joints

• axial skeleton = axis = spine
• peripheral joints = joints of the limbs such as shoulders, elbows, hips, knees, ankles or small joints of the hands and feet

Depending on which damage predominates, it is also divided into axial spondylarthritis and the peripheral form.

Axial SpA - axSpA / peripheral SpA - p-SpA

The negative impact on these areas is common to each form of SpA.

In addition, they are also characterized by the association of other health complications. These can extend to connective tissues throughout the body.

Thus, rheumatism also affects the eyes, skin, blood vessels, heart, but also the intestine and digestive system in general.
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Table: Spondylarthritis is divided into several subtypes

 These diseases have common features:

• rheumatic inflammatory diseases
• absence of rheumatoid factor (RF) = seronegativity and absence of rheumatoid nodules
• frequent oligoarthritis - inflammation of up to 4. joints, at the same time may be associated with dactylitis - swelling of the sausage-type fingers
• sacroileitis and spondylarthritis - inflammation of SI joints and spine
• familial occurrence and association with HLA-B27 marker
• extra-articular manifestations involving the eyes, skin, mucous membranes, cardiovascular or digestive system

Because in these diseases there is no positive rheumatoid factor:
They are also referred to as seronegative spondylarthritis.

The disease mainly affects young people, between the ages of 20 and 40. There is no significant difference in the sexes affected.

It may go unnoticed for a long time, non-specifically, which may lead to misdiagnosis or late diagnosis. Yet, early detection and early treatment play a significant role.

In rheumatic diseases, early diagnosis in conjunction with treatment is of great importance.

The cause of this disease is not exactly known. It is reported that several factors are involved in the development of spondylarthritis. It is therefore a multifactorial action.

The presence of HLA-B27 gene positivity is a risk factor. However, not every person with its presence will develop rheumatic disease. 

It is reported that there is a higher risk of an outbreak if a family member is positive for this marker.

An example is also simultaneous inflammation of the gut and joint in HLA positivity, as in Crohn's disease or ulcerative colitis. This subtype of SpA is referred to as enteropathic spondylarthritis.

The worldwide prevalence of SpA is reported to be approximately 0.5 to 1.9%.

External factors are added to the genetic basis. An example in this case is the overcoming of an infection caused by a pathogen - bacteria, virus, often chlamydia. The presence of this trigger in a predisposed person will kick-start the development of the disease. And this is true in the case of reactive SpA.

Rheumatic diseases are autoimmune diseases that are caused by an immune disorder. Disease-altered immunity attacks the body's own cells and tissues. Why this happens is also unknown.

The inflammatory process mainly attacks structures such as tendon attachments.
Inflammation of the tendon attachment is referred to as enthesitis.

The tendons and ligaments are pathologically altered by inflammation, which over time can lead to complete stiffening of the spine, and thus to ankylosis. Alternatively, it may be a peripheral form when the joints of the limbs are affected.

It is reported to be mainly in the joints of the lower limbs.

This is the main difference from other rheumatic diseases, where the cartilage, more precisely the synovial layer, which is the lining of the joint, is primarily damaged.

Spondylarthritis is characterized by the presence of a certain group of symptoms.

First of all, there are spinal problems, followed by peripheral joint disorders. In addition, extra-articular problems are also associated.

Depending on what symptoms predominate, the disease is also classified into:

1. axial SpA - predominant damage to the axial skeleton = damage to the spine and sacroiliac joint
2. peripheral SpA - if peripheral joints such as shoulders, elbows, hips, knees, ankles or small joints of the fingers and toes are more damaged

Example of the axial form:

Pain predominates in the lower back, i.e. in the area of the lower back, sacrum and SI joint. It can extend to the gluteal muscles, buttocks. The pain is accompanied by stiffness of the spine, which is most pronounced in the morning after waking up. 

Back pain at rest and during the night is also common. After warming up, the pain eases.

In the peripheral form, they are more pronounced:

Pain and stiffness will mainly affect the joints of the lower limbs, such as the hip joint and knee. This will be accompanied by pain in the heel and foot due to inflammation of the calcaneus or swelling of the toe - dactylitis.

Of course, depending on the subtype, there are also symptoms related to inflammation of the eye or intestine and other parts of the body. For example, damage to the aortic valve or the heart and heart valves is serious.

A possibility is the occurrence of SpA manifestations such as:

• back pain, low back pain, low back pain, SI joint pain = axial form
• pain in the hip
• joint pain - most often joints of the lower limbs = peripheral form
• swelling of the joint
• heel, leg, foot pain = tendonitis = enthesitis
• stiffness of joints, spine = typical is morning stiffness and after time inactivity
• restriction of movement in the joint = impairment of function
• the pain is worsened by:
  • inactivity
  • prolonged monotonous position, sitting, standing, lying down
  • possibly excessive physical strain
• the pain is relieved by:
  • stretching
  • moderate load
  • warm-up
• swelling of the finger or fingers - dactylitis = sausage digits
• extra-articular symptoms:
  • fatigue
  • general weakness and debility
  • abdominal pain - inflammation of the intestine
  • diarrhea
  • loss of appetite
  • problem with digestion
  • inflammation of the eye, redness of the conjunctiva, itching of the eye, uveitis
  • skin rash, psoriasis and others
  • aphthae (canker sore) on the mucous membrane of the mouth
  • elevated body temperature

Typical is the presence of inflammatory back pain. 

Inflammatory back pain is defined by ASAS - Assessment of SpondyloArthritis international Society (ASAS) as follows:

1. onset of difficulties before the age of 40
2. lower back pain had a gradual onset
3. the difficulties are alleviated by warming up
4. rest and inactivity do not bring any pain relief
5. pain at night, i.e. during rest, improves in the morning after waking up and warming up

Diagnosis is based on medical history and physical examination. The medical history contains relevant information such as the onset and course of the disease and the presence of inflammatory pain in the back or joints of the limbs, plus any extra-articular complaints that may be present.

This is complemented by a laboratory blood test to detect HLA-B27 positivity. However, this marker can be positive even in a person who never develops arthritis. The absence of RF - rheumatoid factor, which is negative in SpA, is also of great importance.

The examination also includes CRP and others.

The basic imaging methods include X-ray, CT, MRI or ultrasound. 

Puncture of the joint and collection of synovial fluid may be important to determine septic arthritis. Alternatively, arthroscopy may be necessary. Associated indigestion should be investigated endoscopically, i.e. by colonoscopy or sigmoidoscopy.

If necessary, other examinations necessary for differential diagnosis are performed.

Classification is based on:

• the presence of lower back pain for 3 months or more
• onset of difficulties before 45 years of age

1. sacroileitis on imaging + 1 SpA symptom
2. HLA-B27 positivity + 2 SpA symptoms

Imaging methods

1. acute inflammation and/or...
2. definitive radiographic picture of sacroileitis

SpA symptoms

1. inflammatory back pain
2. arthritis
3. enthesitis
4. inflammation of the eye
5. swelling of the finger - dactylitis
6. skin symptoms - psoriasis
7. Crohn's disease or ulcerative colitis
8. good response to NSAID treatment
9. family history of SpA disease
10. HLA-B27
11. elevated CRP

The disease is long-term, lifelong. It usually has a gradual onset and occurs in young adulthood, in people of both sexes, especially between the ages of 20 and 40. 

However, there are also juvenile forms that occur before the age of 16.

Rheumatic diseases are lifelong, with a so-called relapsing-remitting course.

Remission is a period that is characterized by a lack in disease activity. Symptoms subside and the person is relatively free of disease manifestations.

Subsequently, after some time, a relapse occurs. Relapse is a recurrence of a past condition.

Back to the beginning...

Typical is the initial appearance of discomfort in the lower back, lower back and sacrum. In the case of axial spondyloarthritis, it is reported to affect men more frequently.

The most severe degree of the disease is the fusion and stiffening of the vertebrae of the spine,
which severely to completely restricts the movement of the damaged part of the spine.

In children, on the contrary, peripheral disability is more common. Then children may complain of pain in the hands, legs, feet, but also in the hips and knees. In this case, swelling of the fingers may also occur.

In spondylarthritis, extra-articular discomforts are associated. Often inflammation of the eye or intestines and other tissues and organs is added. 

IBD, i.e. non-specific inflammatory bowel disease, represented by Crohn's disease or ulcerative colitis, is largely accompanied by inflammation of the joints. This form of SpA is referred to as enteropathic.

The skin is similarly affected. An example of a rheumatic disease that connects the joints and skin is psoriatic arthritis, where the characteristic psoriasis of the skin is present with inflammation of the joints.

In addition, there are also cases when these diseases occur together with disorders of the cardiovascular system, diseases of the aorta. Damage to the heart valves is a serious risk of deterioration of health, which is also associated with heart failure or heart attack or stroke.