This document provides an overview of ankylosing spondylitis and related spondyloarthropathies. It discusses the definition, epidemiology, etiology, pathological anatomy, clinical manifestations, diagnostic criteria and evaluation, and treatment of these conditions. Key points include that ankylosing spondylitis is a chronic inflammatory disease associated with the HLA-B27 gene, it predominantly affects the spine and sacroiliac joints, and diagnosis involves assessing symptoms of inflammatory back pain and structural damage visible on imaging studies according to criteria from ASAS.

1. MD OLMOS TUFIÑO ROSA R2 PG MI

2. Ankylosing spondylitis
Reiter's syndrome (reactive or arthritis)
Arthropathy of inflammatory bowel disease (Crohn's disease, ulcerative
colitis)
Psoriatic arthritis
Undifferentiated spondyloarthropathies
Juvenile chronic arthritis and ankylosing spondylitis of juvenile onset
Spondyloarthropathies

3. Angkylos and spondylos
Is a chronic inflammatory disease associated with the
human leukocyte antigen (HLA-B27)
Extra-articular Manifestations
DEFINITION

4. In 1666-1698 Bernard Corner
By Waters :
1693- 1824
1824 -1885
1897 -1931
1936 - 1950
In 1850, Brodie
In 1896, Roentgen had discovered the radiographic technique; but 1930
History

5. BEFORE Y AFTER 1950
LUMPERS SPLITTERS
1963 SAR
SA- ES-AP, SR
NOT KNOWN ETIOLOGY
History

6. 1968 BERNAR AMOR SPA- S. REITER , COMMON GENETIC BASIS
1970: spondyloarthropathy
Moll et al: seronegative spondyloarthropathy
History

8. Servicio de Rhumatologie,
universitaire hopital Reina
Sofía, departamento de
Médecine, Université de
Cordoue, Córdoba, España.
Joint Bone Spine (factor de
impacto: 2,75). 02/2000; 67 (6):
516-20.Fuente: PubMed
Recomendación 12. No se recomiendan los criterios de ESSG ni los de
Amor para la clasificación de las EsA [2b, B, 74,3%].

9. Spondyloarthropathies seronegative

10. Predisposition in certain population groups, such as American Indians or
tribes near the Arctic
Europe 0.3 or 1.8% of the population
In Japan 0.3 to 6.9 in Finland and 7.3 in USA per people 100,000 / year
Mexico is 0.9% among general
Caucasian 0.05%
prevalence of HLA-B27, around 2.5%
Epidemiology

11. Males (3 to 5 times more)
Onset after 50 years is exceptional
Epidemilogy

12. Multifactorial
Genetic factors : CMH HLA-B27 16% Immune Hypothesis
FNT &
HLA BW22-B40-B42- B16
Environmental factors:
K. pneumonia, Shiguella,Y. enterocolitica
Hypothesis arthritogenic
Etiology

13. HLA B- 27 ------- CMH CLASE I
ETIOLOGY

14. ETIOLOGY

15. Hypothesis I: molecular mimicry between arthritogenic bacteria and HLA-B27------ A
Hypothesis b: Arthritogenic
Etiology

16. THE ROLE OF T CELLS
Etiology

17. FOLDING INSUFFICIENT HLA B-27
Formation of a misfolded form of HLA-B27 within the endoplasmic reticulum
of an antigen-presenting cell and the elicitation of stress and
proinflammatory responses
ETIOLOGY

18. Homodimers on the cell surface and noncanonical recognition of HLA-B27
Generation of additional forms of HLA-B27, such as free heavy chains and
dimers on the cell surface, and their interactions with T cells, natural killer
cells and antigen-presenting cells.
ETIOLOGY

19. - L T CD8 AND PRESENTATION OF THE SURFACE ANTIGENS OF HLA B27
A DECREASEDTHE AMOUNT DUE EXPLANATION OF
PATHOPHYSIOLOGY A NEW KNOWLEDGE
- ANY OTHERTHEORY EXCLUDES AND CAN NOT EVEN
EXPLAINTHE PATHOGENESIS
Conclusions

20. PATHOLOGICAL ANATOMY

21. ENTHESITIS
EVOLVES A FIBROSIS AND OSSIFICATION
JOINT INJURIES
EARLYTHRUST: DISCITIS - sacroiliitis
LATE THRUST: SYNDESMOPHYTES
INJURY AP EXTRAARTICULAR
ENTESOPATICAS
EYE
CARDIOVASCULAR
PULMONARY
SKIN
MUCOUS
PATHOLOGICAL ANATOMY

22. ENTHESITIS
SYNDESMOPHYTES
SQUARING VERTEBRAL BODIES
PLATFORMSVERTEBRAL DESTRUCTION
ACHILLESTENDINITIS
PATHOLOGICAL ANATOMY

23. PATHOLOGICAL ANATOMY

24. PATHOLOGICAL ANATOMY

25. Clinical manifestations
skeletal
Clinical manifestations
extraskeletal
Diagnostic criteria
Physical examination
CLINICAL MANIFESTATIONS

26. INFLAMMATORY BACK PAIN
CHEST PAIN
SENSITIVITYTENDERTO PALPACION
JOINT MANIFESTATIONS
EXTRAAXIALIES
CLINICAL MANIFESTATIONS
SKELETAL

27. Clinical history as a screening test for ankylosing spondylitis
A controlled study of 138 subjects demonstrated that the clinical history may be sensitive (95%)
and specific (85%) in the differential diagnosis of ankylosing spondylitis when reliance of five
specific historic features is made. Back pain that is insidious in onset, in a patient younger than
40 years, persisting for at least three months, associated with morning stiffness and improving
with exercise is characteristic of inflammatory spinal disease
INFLAMMATORY BACK PAIN

28. Inflammatory back pain in ankylosing spondylitis: a reassessment of the
clinical history for application as classification and diagnostic criteria
We assessed the clinical history of 213 patients (101 with AS and 112 with MLBP)
younger than 50 years who had chronic back pain. Single clinical parameters and
combinations of parameters were compared between the AS and MLBP patient
groups.
ASAS IBP criteria mnemonic for criteria “Ipain
S: 77% E 91.7%
CB: > E < S
CC: > S < E
Ozgocmen S, Akgul O, Khan MA. Mnemotécnico para la evaluación de los
criterios de la sociedad internacional espondiloartritis. J Rheumatol. 2010; 37 :.
1978
CRITERIA BERLIN

29. DIFFERENTIAL DIAGNOSIS

30. PLEURITIC PAIN
TENDERNESS
IN FAMILIES WITH HLA B.27 (+) IN ABSENCE OF SACROILETITIS
CHEST PAIN

31. FREQUENTLY
COSTOSTERNAL UNIONS
SPINOUS PROCESSES
ILIAC CRESTS
GREATERTROCHANTERS
ISCHIALTUBEROSITIES
TIBIALTUBERCLES AND HEELS
SENSITIVITYTENDERTO PALPACION

32. HIPS
KNEES
FEET
JOINT MANIFESTATIONS
EXTRAAXIALIES

33. EYE
CARDIAC
INTESTINAL
PULMONARY
NEUROLOGICAL
RENAL
SECONDARY OSTEOPOROSIS
Extra-articular Manifestations

34. PULMONARY DISEASE:
PULMONARY FUNCTION
DISORDERS: LIMITED
PULMONARY FIBROSIS
INJURY
PLEUROPULMONARY
PATHOLOGYVAVULAR
LOCK A-V
CARDIOVASCULAR
RISK
NSAID NEPHROPATHY,
IGA, AMILOISE DEPOSIT
(RENAL AMYLOIDOSIS)
INTESTINAL
ULCERATIVECOLITIS
DISEASE CROHN
2-6%
RECURRENT
UNILATERAL UVEITIS
95% HLA B27+
NEUROLOGICAL
MANIFESTATIONS:
HORSETAIL SYNDROME
SPINE FRACTURES
ROOT INJURYSECONDARY
OSTEOPOROSIS

38. PHYSICAL EXAMINATION

39. PHYSICAL EXAMINATION

40. LATERAL BENDINGTHE COLUMN

41. PHYSICAL EXAMINATION
TEST SCHOBER

42. INTERMALLEOLAR DISTANCE

43. PHYSICAL EXAMINATION

44. PHYSICAL EXAMINATION

45. PHYSICAL EXAMINATION
sacroiliitis

46. PCR
VSG
ALKALINE PHOSPHATASE
NORMOCHROMIC NORMOCYTIC ANEMIA
LABORATORYTESTS

47. RADIOLOGICAL IMAGES

48. RADIOLOGICAL IMAGES

49. RADIOLOGICAL IMAGES

50. RADIOLOGICAL IMAGES: ARTHRITIS
PERIFERICA

51. RADIOLOGICAL IMAGES: ENTHESITIS
I-M

52. RADIOLOGICAL IMAGES

53. RADIOLOGICAL IMAGES
SACROILIITIS ASAS
ACUTE INFLAMMATORY
INJURY
EDEMA OSEO - OSTEITIS
SYNOVITIS
ENTHESITIS
CAPSULITIS
STRUCTURAL DAMAGE
SUBCHONDRAL SCLEROSIS
EROSION
BONE MARROW FAT
DEPOSITS PERIARTICULAR
BRIDGES AND BONE
ANCHYLOSIS

54. SACROILIITIS ASAS - EDEMA OSEO -
OSTEITIS

55. SACROILIITIS ASAS. EDEMA OSEO -
OSTEITIS

56. SACROILIITIS ASAS. SYNOVITIS

57. SACROILIITIS ASAS -
ENTHESITIS

58. SACROILIITIS ASAS - CAPSULITIS

59. STRUCTURAL DAMAGE
SUBCHONDRAL SCLEROSIS

60. EROSION

61. BONE MARROW FAT DEPOSITS
PERIARTICULAR

62. BRIDGES AND BONE ANCHYLOSIS

64. DIAGNOSIS

65. DIAGNOSIS
Recomendación 12. No se recomiendan
los criterios de ESSG ni los de Amor para
la clasificación de las EsA [2b, B, 74,3%].

66. 1. SUSPECT DIAGNOSED
2. EARLY DIAGNOSIS:
2. PROGRAM ESPERANZA ( ESPAÑA)
3. ESPIDEP ( GERMANY)
DIAGNOSIS

67. DIAGNOSIS

68. DIAGNOSIS

69. DIAGNOSIS . CRITERIA ASAS
M Rudwaleit1 D van der Heijde2 R Landewé3 N Akkoc4 J Brandt5 C T Chou6 M Dougados7 F Huang8 J Gu9 Y Kirazli10 F Van
den Bosch11 I Olivieri12 E Roussou13 S Scarpato14 I J Sørensen15 R Valle-Oñate16 U Weber17 J Wei18 J Sieper

71. Area Domain Measurement / Instrument
ACTIVITY
(General and nightly)
spinal pain Horizontal
scale with numerical descriptors (1-10)
Patient global assessment Horizontal scale with numerical descriptors (1-10)
BASDAI
Overall rating of health Horizontal scale with numerical descriptors (1-10)
fatigue Horizontal scale with numerical descriptors (1-10)
joint count Count of 44, 78/76 or 68/66 or 28 joints
enthesitis Validated index (MASES, San Francisco, Berlin, etc)
dactylitis Present / absent and acute / chronic
Acute phase reactants ESR,CRP
spinal Stiffness Horizontal scale with numerical descriptors (1-10)

72. Area Domain Measurement / Instrument
Function
spinal mobility chest expansion
Test Schöber
Occiput-wall distance
cervical rotation
Lateral flexion of the spine
BASMI
General
function
BASFI
HAQ
structural Damage X-ray
Based on the criteria of NewYork Scale
(sacroiliac joints)
mSASSS (column) or BASRI (spine and hip)
ASspiMRI

73. EVALUATION ACTIVITY

74. EVALUATION ACTIVITY

75. EVALUATION ACTIVITY
Patient global assessment

76. joint count

77. enthesitis

78. EVALUATION OF ACTIVITY- BASDAI

79. ACTIVITY CRITERIA AND REFERRAL
ASDAS
Lukas et al. Ann RheumDis 2009;68:18-24
van derHeiijdeD et al. Ann Rheum Dis. 2008 Dec 5. [Epubahead of print]

80. ASDAS
Lukas et al. Ann RheumDis 2009;68:18-24
van derHeiijdeD et al. Ann Rheum Dis. 2008 Dec 5. [Epubahead of print]

82. BASFI

83. BASMI

84. BASMI

85. BASMI

86. IDF

88. Simple radiology

89. BASRI

90. MSASSS

92. EVALUATION OF ACTIVITY
AS-sspiRMI

93. 1. PHYSICAL REHABILITATION
2. PHARMACOLOGICAL THERAPY
DMARD
NSAIDs
BIOLOGICAL
NEW DRUGS
3. MEASURING INSTRUMENTSTREATMENT RESPONSE
1. BASDAI
2. ASA 20
3. ASS40
4. ASAS BETTER PART
5. ASDAS
TREATMENT

94. ASAS20
AINES

95. BIOLOGICOS
ASAS40

97. 1. FRONTLINE
NSAIDS
COX-2 INHIBITORS
2. SECOND LINE
METHOTREXATE: NO EVIDENCE
STEROIDS
SULFASALAZINE
3. BIOLOGICAL:
TNF INHIBITORS
4. ALTERNATIVETHERAPIES
ABATACEPT INHIBITINGT CELL COSTIMULATION (CTLA-4Ig)
THE IL-1 RECEPTOR ANTAGONIST ANAKINRA HAS BEEN STUDIED IN PATIENTS
WITH AS
APREMILAST IS A PHOSPHODIESTERASE-4
TALIDOMIDA INHIBITING DE FNT
RITUXIMAB INHIBITING C20
TOCILIZUMAB MONOCLONAL ANTIBODY DESIGNEDTO INHIBIT BOTH SIGNALS
THROUGHTHE MEMBRANE AND SOLUBLE IL-6R
TREATMENT

98. EFFICIENCY SHORT
AND LONG TERM
INFLIXIMAB
5 mg/kg 0-2-6 y 8
RESPONSE VARIABLE
37-67%
ADALIMUMAB
40 mg c/ 2 s
ASAS 40
IMPROVEMENT
CRITERIA OF 54% VS
12.5 PLACEBO GROUP
ETANERCEP
25 MG SC 2 V X S
BASDAI 66.1%
IMPROVEMENT IN
RELATION TO
PLACEBO GROUP 50%
GOLIMUMAB
50-100 mg 1 v/ moth
IMPROVEMENT
CRITERIA ASAS 40% IN
RELATION TO 12% OF
PLACEBO
BIOLOGICAL: TNF INHIBITORS

99. A historical perspective of the spondyloarthritis
Henning Zeidlera, Andrei Calinb and Bernard Amorc
Current Opinion in Rheumatology 2011, 23:327–333
Hospital Clinicoquirúrgico Intermunicipal "Mártires del 9 de Abril
«www.ncbi.nlm.nih.gov/pubmed/21519270
PATOGENIA DE LAS ESPONDILOARTROPATÍAS SERONEGATIVAS
Dr. Modesto González Cortiñas
Rev Cubana Med 1998;37(1):28-35
Genetic aspects of susceptibility, severity, and clinical expression in ankylosing spondylitis
Matthew A. Brown, MB, BS, MD, FRACP, Alison M. Crane, PhD, and B. Paul Wordsworth, MRCP
Current Opinion in Rheumatology 2002, 14:354–360
Pathogenesis of ankylosing spondylitis and reactive arthritis
Tae-Hwan Kima, Wan-Sik Uhma and Robert D. Inman Curr Opin Rheumatol 17:400—405. ª 2005
Lippincott Williams & Wilkins.
Classification criteria for spondyloarthropathies Published online: December 18, 2012.
www.wjgnet.com
REFERENCES

100. http://www.asas-group.org/mission-statement.php
http://www.ser.es/practicaClinica/espoguia/espondilitis_anquilosante_6/evaluacion.php
Servicio de Rhumatologie, universitaire hopital Reina Sofía, departamento de Médecine,
Université de Cordoue, Córdoba, España. Joint Bone Spine (factor de impacto:
2,75). 02/2000; 67 (6): 516-20.Fuente: PubMed
HLA-B27, arthritis and spondylitis in an isolated community in Papua New Guinea. Br J
Rheumatol. 1990 Apr;29(2):97-100. González-Rodríguez M y cols. 2013 mexico
Sociedad Española de Reumatologia Guias Espondiloartritis 2009 Ariza-Ariza
R, Hernandez-Cruz B, Navarro-Sarabia F.
Physical function and health-related quality of life of Spanish patients with ankylosing
spondylitis. Arthritis
Rheum. 2003 Aug 15;49(4):483-7.
REFERENCES

101. Manifestaciones extraarticulares y complicaciones de la espondiloartritis anquilosante J.
Gratacós Unidad de Reumatología. Hospital de Sabadell. Institut Universitari ParcTaulí.
Universidad Autónoma de Barcelona. Sabadell. Barcelona España. 2009.
Mecanismos de la enfermedad: la inmunopatogénesis de espondiloartropatías Colina
Gaston Naturaleza de Práctica Clínica de Reumatología (2006) 2 , 383-392 doi : 10.1038 /
ncprheum0219
Las espondiloartropatias seronegativas: interacción entre la genética y el entorno
(entrevista). Documento Ciba-Geigy 1990;(4):5-7 .-The contribution of genes outside the
major histocompatibility complex to susceptibility to ankylosing spondylit
KELLEY REUMATOLOGIA CLINICA VII EDICION
Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history
for application as classification and diagnostic criteria. Ozgocmen S, Akgul O, Khan
MA. Mnemotécnico para la evaluación de los criterios de la sociedad internacional
espondiloartritis. J Rheumatol. 2010; 37 :. 1978
Osteoporosis and vertebral fractures in ankylosing spondylitis
Piet Geusensa,b, Debby Vossea and Sjef van der Lindena Current Opinion in
Rheumatology 2007, 19:335–339
Cardiovascular risks in spondyloarthritides
Sylvia Heeneman and Mat J.A.P. Daemen Current Opinion in Rheumatology 2007, 19:358–
362
REFERENCES

102. Classification criteria for spondyloarthropathies
Ozgur Akgul, Salih Ozgocmen, Division of Rheumatology, Department of
Physical Medicine and Rehabilitation, Erciyes University, Gevher Nesibe
Hospital, 38039 Kayseri,Turkey Author contributions: Akgul O and Ozgocmen
S collectively reviewed the literature and drafted the manuscript. 2011
December 18; 2(12): 107-115 Online Submissions:
http://www.wjgnet.com/2218-5836office
Diagnóstico precoz de espondiloartritis
Juan Mulero Mendoza
Servicio de Reumatología. Hospital Puerta de Hierro. Madrid. España.
Reumatol Clin. 2007;3 Supl 2:S15-8 15
Diagnostico precoz de las espondiloartropatı´as en Espan˜a: el programa
ESPeranza
Cristina Ferna´ndez Carballido, en nombre del Grupo ESPeranza
Hospital General de Elda, Alicante, Espan˜a 1699-258X/$ - see front matter &
2009 Elsevier Espan˜ a, S.L.Todos los derechos reservados.
doi:10.1016/j.reuma.2009.12.005 www.reumatologiaclinica.org
REFERENCES

103. How to measure disease activity in axial spondyloarthritis?
Pedro Machadoa,b and De´sire´e van der Heijdea Current Opinion in Rheumatology 2011, 23:339–345
How should we diagnose spondyloarthritis according to the ASAS classification criteria A guide for practicing physicians
Rosaline van den Berg, Désirée M.F.M. van der Heijde University Medical Centre, Leiden, The Netherlands Pol Arch Med Wewn.
2010; 120 (11): 452-458 Copyright by Medycyna Praktyczna, Kraków 2010
How to diagnose axial spondyloarthritis early M Rudwaleit 1 ,Van der Heijde D 2 ,MA Khan 3 ,J Braun 4 , J Sieper 1
Afiliaciones de los autores
1 Reumatología, Departamento de Medicina I, Charité-Campus Benjamin Franklin, Berlín, Alemania 2 Reumatología, Instituto de
Investigación CAPHRI, Universidad de Maastricht, Países Bajos 3 Universidad Case Western Reserve, MetroHealth Medical Center,
Cleveland, Ohio, EE.UU. 4 Rheumazentrum Cuenca del Ruhr, Herne, Alemania Correspondencia a:
Dr. M Rudwaleit
Medizinische Klinik I, Charité-Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlín,
Alemania; martin.rudwaleit@charite.de
Aceptado 17 de octubre 2003
Comparison of statistically derived ASAS improvement criteria for ankylosing spondylitis with clinically relevant improvement
according to an expert panel
A van Tubergen, D van der Heijde, J Anderson, R Landewé, M Dougados, J Braun,
N Bellamy, G Udrea, Sj van der Linden, for the ASAS Working Group
Ann Rheum Dis 2003;62:215–221
Nuevos criterios ASAS para el diagnóstico de espondiloartritis.Diagnóstico de sacroileítis por resonancia magnéticaM.E. Banegas
Illescas∗, C. López Menéndez, M.L. Rozas Rodríguez yR.M. Fernández Quintero Servicio 0033-8338/$ – see front matter © 2013
SERAM. Publicado por Elsevier España, S.L. Todos los derechos reservados. http://dx.doi.org/10.1016/j.rx.2013.05.004
http://www.airemb.es/es/profesionales/investigacion/herramientas/calculadoras/item/72-calculadora-asdas.html
The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis
J Sieper, M Rudwaleit, X Baraliakos, J Brandt, J Braun, R Burgos-Vargas, M Dougados, K-G Hermann, R Landewé, W Maksymowych
and D van der Heijde Ann Rheum Dis 2009;68;ii1-ii44
http://ard.bmj.com/cgi/content/full/68/Suppl_2/ii1
REFERENCES

104. Assessment and treatment of ankylosing spondylitis: current status and future directions Jane Zochling Current Opinion in Rheumatology 2008, 20:398–403
Assessment and treatment of ankylosing spondylitis: current status and future directions. Jane Zochling Current Opinion in Rheumatology 2008, 20:398–403
The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection
M Rudwaleit,1 D van der Heijde,2 R Landewe´,3 J Listing,4 N Akkoc,5 J Brandt,6
J Braun,7 C T Chou,8 E Collantes-Estevez,9 M Dougados,10 F Huang,11 J Gu,12
M A Khan,13 Y Kirazli,14 W P Maksymowych,15 H Mielants,16 I J Sørensen,17
S Ozgocmen,18 E Roussou,19 R Valle-On˜ate,20 U Weber,21 J Wei,22 J Sieper1,23
Ann Rheum Dis 2009;68:777–783. doi:10.1136/ard.2009.108233
http://ard.bmj.com/
MRI in ankylosing spondylitis
Walter P. Maksymowych Current Opinion in Rheumatology 2009,21:313–317
Radiografı´a convencional: BASRI total y SASSS
Isabel Castrejo´n Ferna´ndez a,_ y Jesu´ s Sanz Sanz b a Servicio de Reumatologı´a, Hospital Universitario La Princesa, Madrid, Espan˜a b Servicio de Reumatologı´a, Hospital
Universitario Puerta de Hierro, Majadahonda, Madrid, Espan˜a 1699-258X/$ - see front matter & 2009 Elsevier Espan˜ a, S.L. Todos los derechos reservados.
doi:10.1016/j.reuma.2009.12.003
New therapeutic approaches for spondyloarthritis
Augustine M. Manadana, Neena Jamesb and Joel A. Block Curr Opin Rheumatol 19:259–264. _ 2007 Lippincott Williams & Wilkins.
aJohn H. Stroger Hospital of Cook County and Rush University Medical Center,
Chicago, Illinois, USA, bRush University Medical Center, Chicago, Illinois, USA and
cSection of Rheumatology, Rush University Medical Center, Chicago, Illinois, USA
Management and treatment of ankylosing spondylitis
Jane Zochling and Ju¨ rgen Braun Curr Opin Rheumatol 17:418—425. ª 2005 Lippincott Williams & Wilkins.
Rheumazentrum-Ruhrgebiet, St.Josefs-Krankenhaus, Landgrafenstr. 15, 44652
Herne, Germany
Rehabilitation in ankylosing spondylitis
Francine Ton Nghiem and John Patrick Donohue Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
Correspondence to Francine Ton Nghiem, Beth Israel
Deaconess Medical Center, 330 Brookline Ave.,
Boston, MA 02215, USA
Current Opinion in Rheumatology 2008, 20:203–207
REFERENCES