Brief about Spondylitis

1. SPONDYLITIS
Dr.Pooja Sharda Janardan

2. Spondylitis
• Spondylitis is a form of arthritis that primarily
affects the spine, although other joints can
become involved. It causes inflammation of the
spinal joints (vertebrae) that can lead to severe,
chronic pain and discomfort.
• In more advanced cases this inflammation can
lead to ankylosis -- new bone formation in the
spine, causing sections of the spine to fuse in a
fixed, immobile position.
• Spondylitis affects men more often than women.

4. Types of Spondylitis-
• Pott's Disease/Spine
• Ankylosing Spondylitis
• Spondylodiscitis

5. ETIOPATHOGENESIS
Condition Reasons
Bone spurs These overgrowths of bone are the result of the body trying to grow
extra bone to make the spine stronger. The extra bone can press on
delicate areas of the spine, such as the spinal cord and nerves,
resulting in pain.
Dehydrated
spinal discs
Loss of fluid between the spinal discs cause the friction of bones,
leads to degenerative disease
Herniated discs Single excessive strain or injury may cause a herniated disc. A
herniated disc refers to a problem with one of the rubbery cushions
(discs) that sit between the individual bones (vertebrae) that stack to
make your spine.
Injury An injury to neck can also leads to same condition.
Ligament
stiffness
The tough cords that connect your spinal bones to each other can
become even stiffer over time, which affects your neck movement and
makes the neck feel tight
Overuse Continuously sitting or repetitive weightlifting can leads to
spondylitis.

6. Risk factors Diagnosis
• Neck injuries
• Work-related activities
• Genetic factors
• Smoking
• Obesity
• Physical examination-
 Reflexes
 Sensory deficits
 Neck motion
• Radiology-
 X-ray
 CT scan
 MRI

7. Pott's Disease/Spine
Pott disease, also known as tuberculous
spondylitis, is a classic presentation of
extra pulmonary tuberculosis (TB).
Pott’s disease results from
haematogenous spread of tuberculosis
from other sites, often the lungs.
 Pott’s Disease is a combination of
osteomyelitis and arthritis which involves
multiple vertebrae
The typical site of involvement is the
anterior aspect of the vertebral body
adjacent to the subchondral plate and
occurs most frequently in the lower
thoracic vertebrae.
8-10% worlwide

8. It can cause-
Vertebral collapse,
Kyphotic deformity of the spine,
Compression fractures,
Spinal deformities,
Neurological insults,
 Paraplegia

9. Clinical presentation
• Back pain
• Fever
• Localized Tenderness
• Muscle Spasms
• Restricted Spinal Motion
• Occasional chills
• Wheezing sound during breathing
• Dizziness and fatigue
• Weight loss
• Impaired sensation
• Paresis

10. Clinical Menifestations
• Spinal Involvement
• Neurological deficits
• Cervical Spinal TB
Co-morbidities
• Immunosuppressive
Disorders
• HIV/AIDS
• TB
• Gastrectomy
• Peptic Ulcer
• Drug Addiction
• Alcoholism
• Malnourishment

11. • Diagnosis-
• The Mantoux Test
• Erythrocyte
Sedimentation Rate (ESR)
• Microbiology Studies
• CT scan
• MRI
• Biopsy
• PCR
• Etiology
• Paradiscal
• Anterior Granuloma
• Central Lesions

12. Systemic Menifestations
Involvment Menifestations
Musculoskeletal Vertebral Fractures, Vertebral Collapse, Spinal Ligament
Destruction, Intervertebral Disc Destruction, Paravertebral
Abscess, Muscle Atrophy, Kyphotic Deformity,
Osteoporosis
Neurological Paresthesia, Paralysis, Paresis, Abnormal Muscle Tone,
Abnormal Reflexes, Cauda Equina Syndrome,
Myelomalacia,
Cardiovascular Spinal Artery Infarction, Avascularity of Intervertebral
Discs,Thrombosis
Integumentary Ulcers, Abscess, Cutaneous Fungal Infections
Urogenital Bladder Dysfunction,Bowel dysfunction

13. Pharmacological Treatment
• Anti-TB drugs shall be given to treat
tubercular complications like Pott’s spine.

14. Ankylosing Spondylitis
• AS is a form of arthritis that primarily affects
the spine, although other joints can become
involved. It causes inflammation of the spinal
joints (vertebrae) that can lead to severe,
chronic pain and discomfort.

15. Clinical Presentation
• Stiffness and pain in your lower back in the
early morning.
• Pain in one or both buttocks.
• Neck, shoulder, or thigh pain.
• Chest pain or a tightness.
• Fatigue,

16. Diagnosis
• SLR, 90°
• X-ray
• MRI (Sacroiliac Joint)
Possible complications
• Osteoporosis
• Lumbar fracture
• Cervical spondylosis
• Disc displacement
• Toe/finger swelling
• Uveitis

18. NSAIDs
• Nonsteroidal anti-inflammatory drugs
(NSAIDs)
Ankylosing spondylitis is associated with the
prostaglandin E receptor 4 (PTGER4) gene.
This receptor is associated with bone
absorption; NSAIDs inhibit prostaglandin
production, thus reducing the absorption.

19. • Naproxen 500 mg PO,OD for 7-21 days
• Maximum dose- 1500mg per day, for 1-2
weeks
• Aceclofenac 100mg, OD/BD/TDS PO
• Diclofenac 50-100mg OD/BD/TDS PO
• Side effects- Indigestion, heartburn, stomach
pain, nausea, dizziness, bruising, itching, rash,
tinnitus
• Monitor RFT if taking for longer duration.

20. Opioid analgesic
• Tramadol is widely used, at dose 50-100mg
• It can also given in combination with
diclofenac 25mg, PO

21. • Side effects-
• Somnolence, gastric irritation, headache,
blurred vision, mania, dependence,
• Indication- To be use only when pain score is
more than 7.
• Monitoring- HR, BP, Pain score

22. BIOLOGIC MEDICATIONS

23. TNF Inhibitors
• These medications have been shown to be
highly effective in treating not only the
arthritis of the joints, but also the
inflammation in the gut and eyes, as well as
the spinal arthritis associated with ankylosing
spondylitis and related diseases.
• Improves pain, function and other symptoms
of AS
• Improves spinal inflammation

24. • Adalimumab 40mg/IV
• Etanercept 50mg SC weekly
• Infliximab 5 mg/kg IV 0-6 weeks
• Side effects-
 Headache.
 Abdominal pain
 Nausea, vomiting, or heartburn.
 Weakness.
 Cough.
 Redness, itching, pain, or swelling at the site of
injection.

25. • Monitoring-
• WBC, RBC, hemoglobin, platelets, AST, ALT and
ESR/CRP

26. IL-17 Inhibitor
• Secukinumab 150mg IV per day
• Ixekizumab 80mg IV per day
• Side effects- Injection site reactions, weight gain
Nausea, Rhinitis, Insomnia, Hypersensitivity
• Monitoring parameters- Neutrophil count,
Temperature
• Acts by inhibiting IL-17, involved in inflammation
• Test dose should be given before starting
treatment with biological agents.

27. Corticosteroids
• Corticosteroids have a anti-inflammatory effect
and can be taken as PO or IV for treatment of AS.
• Acts by binding to cellular glucocorticoid
receptors, corticosteroid acts by inhibiting
inflammatory cells and suppresses expression of
inflammatory mediators
• Prednisolone 10mg- 80mg, divided doses. PO
• Hydrocortisone 100-500mg/IV/IM/PO, (slow
dose-10mg-100mg)

28. • Prednisone 8mg-32mg, PO, (less used)
• Contraindications- Vaccines, Psychotropic
agents, NSAIDs
• Side effects- Itching, Insomnia, Increase
appetite, Increase weight
• Type D ADR

29. Antimetabollite
• Methotrexate is an antimetabollite as well as
immunosuppressant.
• In rheumatoid arthritis, methotrexate reduces
inflammation and damage to joints.
• Acts by inhibiting T-cell immune response,
responsible for cell mediated immune
reactions.
• Initial dose- 7.5mg PO once a week
• Maximum dose 25mg PO once a week

30. • Side effects-
• Anemia, stomach pain or upset, diarrhea, hair
loss, tiredness, dizziness, chills, headache,
mouth sores
• Special indication - Add Folic acid PO 5mg
while giving methotrexate.
• Monitoring parameters- Hb, ESR, LFT, RFT,
Vitamin B and Vitamin K
• Interactions- Theophylline, NSAIDs,
Phenytoin, Probenecid, Amoxicillin, Ampicillin

31. Sulfasalazine
• Sulfasalazine has immunomodulatory effect.
• Inhibits AICAR transformylase and, as such,
promotes the accumulation of adenosine and
its anti-inflammatory actions via the
adenosine A2A receptor
• Dose- 500-1000 mg PO, OD/BD
• This drug is used when treatment with
corticosteroid is not working.

32. • Side effects- headache, increased sensitivity to
sunlight, skin rash or itching, vomiting, black
urine, abdominal pain, infections, bruising
• Monitoring parameters- Bleeding time,
clotting time, RF factor, CRP
• Contra-indications- Digoxin, Amoxicillin, PCM,
Naproxen, Etoricoxib, Adalimumab
• Hematologic toxicity,
• G6PD deficiency
• Hemophillia

33. Leflunomide
• Given to the patients failed with MTx
• Anti-inflammatory
• Leflunomide inhibits the reproduction of
rapidly dividing cells- lymphocytes, modifies
immune reactions, inhibits the mitochondrial
enzyme dihydroorotate dehydrogenase
• 100 mg PO OD for 3 days, then maintain dose
at 10-20mg PO OD per day

34. • Side effects- Diarrhea, RTI, UTI, dyspepsia,
pruritis, dry skin.
• Interactions- Adalimumab, Anakinra,
Zetanercept, losartan, phenytoin
• Contraindications-
• Pregnancy,Liver disease, Hepatitis B/C, Active
serious infections, Hypersensitivity
• Monitor LFTs, RF factor, ESR

35. Treatment Drug class Reasoning Examples
1st Line
agents
NSAIDs OR
Opioid
analgesics
2-4 weeks
Treats pain and
reduce inflammation
Naproxen,
Aceclofenac
Tramadol
IF NO/LOW RELIEF
2nd Line
agents
Biologics –
TNF Inhibitors
IL-17 inhibitors
4-8 weeks
Treats spinal
inflammation
Adalimumab,
Infliximab
Secukinumab
Ixekizumab
IF NO/LOW RELIEF OR NOT SO SEVERE STATE
OR DMARDs for 4-8
weeks
Anti- rheumatics Prednisolone.
Methotrexate
Sulfasalazine
With PHYSIOTHERAPY

37. Spondylodiscitis
• Defined as a primary infection (accompanied
by destruction) of the intervertebral disc
(discitis), with secondary infections of the
vertebrae (spondylitis), starting at the
endplates.
• It can lead to osteomyelitis of the spinal
column.
• It has a high morbidity and mortality and is a
rare but serious infection

38. • Spondylodiscitis is the most common
complication of sepsis.
• Pathogens responsible spondylodiscitis are
Staphylococci, Escheria coli and
Mycobacterium tuberculosis.

39. Risk Factors
• Infection
• Diabetes mellitus
• Age
• Cardiovascular diseases
• Obesity
• Chronic steroid intake
• Alcoholism and smoking
• HIV infection
• Serious traumas
• Chemotherapy, human immunodeficiency virus infections, or
chronic alcoholism
• Rheumatic diseases
• Renal failure

40. Clinical Presentation
Back or neck pain,
more worse at night
Radicular pain radiating
to the chest or abdomen
Fever
Spinal deformities,
Neurological deficits:
leg weakness, paralysis,
sensory deficit,
Cervical lesion
Local tenderness
Limb weakness
Epidural abcess
formation
Hip pain
Loss of lower back
movement
Poor bladder control
Spinal tenderness
Paravertebral muscle
spasm

41. Diagnosis
• MRI
• PET(Positron-emission
tomography)
• X-ray
• Biopsy
• Blood Culture
• Leukocyte count
• C-reactive protein
• ESR
Disease Monitoring
• Visual Analogue Scale (VAS)
• Oswestry disability index
(ODI)

42. TREATMENT
Antibiotics and immobilization of the spine.
• Surgery- Posterior decompression and
stabilization of a spondylodiscitis

44. Exercises
• Back streching
• Leg stretching
• Planks
• Cobra’s
• Sun salutation