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<v ->So those are some basic facts about Rheumatoid Arthritis.

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Let's move on now and look

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at some basic facts about Spondyloarthropathies or SpA.

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We'll be talking about sacroiliitis,

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but I'm not gonna start there.

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Let me first define what this is.

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Spondyloarthropathy and it's often abbreviated

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SpA is a term that's been introduced

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over the last, my guess, 20 or 30 years to label a group

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of disorders that involve the axial skeleton

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especially the spine and sacroiliac joints.

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So if we start with that,

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you can see the classic disease shown green

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is ankylosing spondylitis, but around the perimeter

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six other disorders shown in orange

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which are considered part

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of the ring that makes up spondyloathropathy

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inflammatory bowel disease, reactive arthritis

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what we used to call Writer's syndrome, uveitis psoriasis,

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undifferentiated SpA and juvenile SpA.

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Okay, so there is a class of diseases

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but the classic one in that class is ankylosing spondylitis.

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Now what's interesting about SpA is that

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the initial clinical and imaging abnormalities may appear

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either in the axial skeleton, which we would love to see

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'cause it narrows down immediately

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the differential diagnosis

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or in the extra axial skeleton.

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They're fancy abbreviations for those two possibilities.

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And there are a number of other findings that are seen

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and I will emphasize those during this lecture.

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Now they've tried to come up with diagnostic

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criteria for SpA.

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and this is one of the classification systems

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and criteria that has been introduced

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by the SpA international society.

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Sacroiliitis on imaging

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plus one other feature listed here where HLA- B27 positivity

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with two other features.

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And they arranged these features

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and I'm not gonna read them all.

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So they spell out spine ache.

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All right.

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So that was beautiful.

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It probably took a while to get those in order

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in order to spell out spine ache.

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But those are the features and I would call your attention.

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The things such as enthesitis certainly important.

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Ductilitis certainly important.

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Inflammatory bowel disease, HOA-B27

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a lot of these so that I think are still

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pretty much established diagnostic criteria for SpA.

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So herein is our difficulty.

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I'm gonna show you two cases.

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This is a 16 year old male.

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He presented with toe and heel pain.

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So in this particular example of SpA

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the abnormalities are far

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from the axial skeleton there as far distal, as you can go.

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They're involving the fifth toe out at the end

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with a lot of marrow edema,

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and they're involving the calcaneus.

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So that's what was the initial presentation

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One month later, things moved slightly centrally

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with synovitis involving the hip,

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and Paracentesial bone destruction shown

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in the bottom image in the middle of this slide.

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And then, six months later,

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enthesitis appeared here

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in the area of the issue tuberosity.

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So this disease has changed, but even up to six months,

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we don't see the sacroiliac joint involvement.

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And we don't see the spine involvement.

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These can be very tricky

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particularly when they don't involve the axial skeleton.

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Here's another one.

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This is a 19 year old male with hip pain.

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This is the earliest finding the hip joint may be

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slightly narrowed on the conventional radiograph here.

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Superiorly hard to tell

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about the cartilage in this particular

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MR Image.

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Following gadolinium, there's fluid

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which is a low signal.

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And this is a lining of synovium which has high signal.

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Now this patient had synovitis, but I would ask you

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as you look at it,

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is that too much enhancement in the synovium?

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I mean, it's not very thick.

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We don't have criteria in some of these cases to be certain

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but there was soft tissue enhancement

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around the joint as well.

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So this was synovitis in the hip

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and it was only later on three months where

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sacroiliac joint involvement became apparent.

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Tricky case because not beginning

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in the sacroiliac joint or spine.