Clinical case 1

A 34 year old man is referred by his general practitioner with a 4 month history of low back pain. He does not report any
stiffness in the morning but he admits to having pain below his left heel. A year earlier he had suffered from a
self-limiting painful red eye as well as pain in the left shoulder and swelling in the right knee. NSAIDs gave only
moderate relief. He denied any skin, bladder or bowel problems. There is no history of trauma and no relevant family
history.
On examination the only sign is slight restriction of lateral lumbar flexion.
A plain radiograph of his pelvis is reported as normal.

1. What would you do? Select the two correct answers.

a. Ask for Magnetic Resonance Imaging of the sacroiliac joints
True. Radiographic changes at the SIJ may be difficult to interpret, especially in adolescents and young adults when
joint irregularity and ill-defined margins may be normal. The joint follows an oblique course and no single x-ray view
looks through its entire length. An antero-posterior view shows both anterior and posterior margins and is sufficient for
most purposes. Radiographic changes on a plain radiograph reflect consequences of inflammation which reflects
damage rather than the inflammation itself. MRI has become an invaluable tool in early diagnosis as it can detect active
inflammation in the spine and sacroiliac joints that is not visible on plain radiography. Sacroiliitis can be detected by MRI
years before radiographic sacroiliitis is apparent.
b. Perform a local injection for his heel pain
False. The heel pain is causing only minor clinical symptoms so treatment modalities other than injection would be more
appropriate initially.
c. Send the patient for physiotherapy
False. Obviously, far too early. You do not even know what the patient suffers from.
d. Ask for immunological lab tests
True. Tissue typing for HLA-B27 is useful as part of the clinical assessment. It should be used appropriately and
interpreted in the clinical context. It is by no means a screening test. HLA-B27 is the primary disease susceptibility gene
for AS, and is thought to contribute about 49% of the population-attributable genetic risk of AS for Caucasians.
e. Tell the patient not to work for 3 weeks, and to rest regularly
False. In general, rest is bad for patients with low back pain. In patients with inflammatory low back pain exercise
relieves rather than aggravates the pain.

2. When making a diagnosis of SpA. Which one of the following is correct?

a. Differentiating between the SpA subtypes is very important because it affects treatment
False. The SpA subtype does not affect treatment decisions. Treatment is more dependent on the disease pattern.
b. A diagnosis of SpA cannot be possible if a patient is older than 45 years
False. It is very rare for symptoms of SpA to first begin after 45 years of age, but the disease is diagnosed at an older
age in many patients. This occurs particularly in those patients with mild symptoms.
c. Diagnosis is usually delayed by a few months since onset of symptoms
False. Diagnosis is typically delayed by 5-6 years especially in patients with an early or incomplete picture.
d. Individuals who are HLA-B27 negative are likely to be diagnosed earlier than HLA-B27 positive individuals.
False. The converse is true. Individuals who are HLA-B27 positive and have a positive family history are likely to be

diagnosed earlier than HLA-B27 negative individuals.

e. Enthesitis frequently occur at sites that bear greater physical stress.
True. Examples include the Achilles tendon.
Blood test were carried out and revealed a minimally raised CRP, negative HLA-B27 and a normal blood count.
3. Regarding laboratory investigations. Which two of the following statements are correct?
a. In SpA rheumatoid factor is often positive.
False. Rheumatoid factor is negative and is not indicated in the investigation of low back pain
b. HLA-B27 should be routinely checked in young patients presenting with low back pain.
False. Routine HLA-B27 is not helpful since 8% of normal individuals are positive, of who over 90% never develop the
disease. At present there is no preventive cure and there is no way to identify individuals who will develop the disease.
c. An increased ESR is one of the criteria in the ASAS classification criteria for axial SpA.
False. A raised CRP is one of the criteria in the ASAS classification criteria for axial SpA not ESR.
d. About 15% of patients have a normochromic normocytic anaemia on presentation.
True.
e. No laboratory tests are specific for SpA.
True. Unfortunately there is no specific laboratory test for diagnosis of SpA.

4. Regarding imaging in SpA. Which two of the following statements are correct?
a. On plain radiography erosions are typically seen in the upper part of the sacroiliac joint and on the iliac side.
False. Erosions of the sacroiliac joint are typically seen in the lower part of the sacroiliac joints and on the iliac side. This
is because the iliac side is lined by thinner cartilage.
b. It takes several years from onset of disease before radiographic sacroiliitis becomes apparent.
True. That is why plain radiographs are not sensitive for early disease
c. MRI is highly sensitive in detecting early inflammatory changes of the sacroiliac joints and spine
True. MRI is the imaging modality of choice to diagnose pre radiographic SpA.
d. Active spinal inflammation is one of the main criteria in the classification criteria for axial SpA.
False. Active sacroiliitis is one of the criteria. Although spinal inflammation can occur early on this has not been included
in the validation studies.
e. A negative MRI of the spine and sacroiliac joints excludes a diagnosis of SpA
False. Diagnosis of SpA can still be made on clinical grounds. In case of a negative MRI presence of HLA-B27 plus 2
other SpA features is needed.
Two weeks later this gentleman presents with an acute painful left red eye.
5. Regarding extra articular manifestations. Which three of the following statements are NOT correct?
a. Uveitis is the most common extra articular manifestation in SpA
False. This statement is correct. Uveitis occurs in 20-30% of patients with AS. It is usually unilateral and involves the
anterior elements.
b. Attacks of uveitis usually resolve spontaneously after 4 to 5 days

True. Attacks usually resolve after 2-3 months with treatment. Urgent ophthalmological treatment is needed to prevent
permanent visual loss.
c. Two-thirds of patients with SpA have associated asymptomatic inflammation of their bowel
False. This statement is correct. Inflammatory bowel lesions are asymptomatic in the majority of patients.
d. Enteropathic arthritis tends to affect lower limb joints and is typically erosive
True. This statement is false. Enteropathic arthritis tends to affect lower limb joints but is not usually erosive
e. In enteropathic SpA, joint inflammation fluctuates with bowel symptoms
True. Arthritis does not usually follow bowel symptoms.
f. Heart block is the most common cardiac manifestation
False. This statement is correct. Cardiac features are rare but may be severe. Heart block is the most frequent
manifestation. Aortic insufficiency secondary to an aseptic endocarditis can also be a severe cardiac manifestation of
the disease.
Clinical case 2
A 36 year old lady presents with a one year history of low back pain which is worse at rest. Her brother is a known
sufferer from AS. There is limitation of lumbar movements in all planes. She had some x-rays recently and told she
might have AS.

1. Which three of the following are the early radiographic changes of AS?
a. Vertebral squaring
True. In early AS X-rays may be normal. Early spinal features include vertebral squaring, syndesmophytes and vertebral
corner erosions.
b. Ankylosing of the lumbar spine
False. In advanced disease there is ankylosis, and ligamentous ossification.
c. Erosions at the vertebral corners
True. Early radiographic spinal features include vertebral squaring, syndesmophytes and vertebral corner erosions
d. Bilateral grade 3 sacroiliitis
False. This is a late stage. Early radiographic changes at the SIJ include blurring, erosions and widening of the SIJ.
e. Widening of the SIJ
True. Early radiographic changes at the SIJ include blurring, erosions and widening of the SIJ.
f. Ankylosing of the SIJ
False. This occurs in advanced disease.
X-rays shows vertebral squaring and syndesmophytes at the lumbar spine. There is bilateral grade 2 sacroiliitis at the
SIJ.
2. What three further investigations would you like to carry out?
a. HLA B27
False. You have enough information to make a diagnosis of AS.
b. BASDAI

True. BASDAI is a measure of disease activity which facilitates monitoring of disease activity and response to therapy. It
covers fatigue, axial involvement, peripheral articular involvement, enthesopathy and morning stiffness.
c. MRI of the lumbar spine
False. There is no indication for an MRI at this stage
d. Spinal measurements
True. Spinal measurement include cervical rotation, tragus-to-wall distance, occiput to wall, lateral spinal flexion, lumbar
flexion (modified Schober's test). The intermalleolar distance measures movement at the hip.
e. VAS spinal pain
True. VAS spinal pain is one of the recommended assessments of disease activity.
f. Bone scintigraphy
False. Bone scintigraphy is highly unspecific to be of use in SpA.
She has a BASDAI of 8, CRP of 30. Schober's test was 3 cm, tragus wall distance was 15cm and chest expansion was
2 cm. She did not respond to a trial of 2 sequential NSAIDs. After discussion with her you start anti-TNF therapy and
give her a follow up after 3 months. At follow up she was found to have a BASDAI of 3 and CRP had normalized. 2
years later she presents to A and E with increasing pain in her back over the lower thoracic area. She reports slipping in
the bathroom the week before.
3. How would you proceed? Select the most appropriate management from the following options.
a. Give NSAIDs and refer to physiotherapy
False. The nature of this acute back pain is different from the usual inflammatory pain. The underlying cause has to be
found before treatment is given
b. Stop the anti-TNF
False. The history is not in keeping with inflammatory pain, such a step would be inappropriate
c. Perform a neurological examination
True. A neurological examination should be performed in patients presenting with acute onset of back pain.
d. Perform a lateral thoracic spine X-ray and if normal reassure the patient
False. Diagnosis of cervical and thoracic fractures is notoriously difficult on plain radiography. One needs to have a high
index of suspicion and have a lower threshold for MRI in these patients.
e. Perform an urgent bone density scan
False. A bone density would not help in the acute setting.
Plain radiographs of the spine showed advanced changes of ankylosing spondylitis without any fractures.
4. In such a patient which statements are correct?
a. Spine rigidity makes vertebral fractures unlikely in SpA patients
False. Osteoproliferation increases spine rigidity, while inflammation contributes to osteoporosis of the spine. Both
factors predispose to vertebral fractures after minimal trauma.
b. Multiple vertebral compression fractures may occur without or with minimal trauma
True. Ankylosis alters the biomechanical properties of the spine. The forces required to fracture the spine in SpA is
much less than in a normal spine.
c. Diagnosis of vertebral fractures on plain radiographs is difficult due to spinal deformities, overlapping structures and
osteoporosis

True. Diagnosis of vertebral fractures on plain radiographs is difficult due to spinal deformities, overlapping structures
and osteoporosis.
d. Major neurological complications are not very common following vertebral fractures in SpA
False. Several studies reported a high prevalence (between 29% and 91%) of major neurological complications after
clinical vertebral fractures.
e. Neurological impairment may occur several days following a vertebral fracture
True. Delayed neurological impairment can occur.
f. The risk of osteoporosis is not increased
False. In AS there is an increased risk for osteoporosis due to inflammation and reduced mobility.

5. Which one of the following is NOT a surgical indication in patients with SpA?
a. Spinal osteotomies for severe kyphosis to improve the eye level
False. This is an indication for surgery. Spinal osteotomies are indicated in severe kyphosis where there is severe
impairment of function and pain. Spinal osteotomies can improve function and decrease back pain
b. In cases of pseudoarthrosis and back pain failing conservative treatment, spinal fusion can decrease back pain
False. This is an indication for surgery
c. Fusion for unstable segments
False. This is an indication for surgery
d. Total hip arthroplasty for hip pain and limitation of movement
False. This is an indication for surgery
e. Spinal fusion for loss of lumbar lordosis
True. Loss of lumbar lordosis is not an indication for surgery.

6. Which one of the following can be identified on MRI in a patient with SpA?
a. Occult fracture
False. Spinal fractures in SpA often involve 3 column fractures which are highly unstable
b. AVN
False.
c. Anterior and posterior ligament tears
False.
d. Posterior column fracture
False. MRI is particularly sensitive to show lesions in the posterior column
e. Traumatic spondylolisthesis
False.
f. Cord compression
False.

g. All of the above

True. All are true. MRI shows abnormalities in AS that may not be clear or even identifiable on plain radiography. MRI is
a very useful tool to evaluate AS patients with spinal fracture for the possibility of 3-column involvement.