Unclassified spondylarthritis

Patients in this category seem to be the most frequently encountered in family practice. They clearly have a spondyloarthropathy but fail to meet the criteria for any one of the individual entities within the group. A typical patient is a young male in his third decade with a painful knee or other joint, unilateral (or bilateral) back pain with one of the entheseal problems, e.g. plantar fasciitis. Investigations

Radiological sacroiliitis is central to the diagnosis. Changes include narrowing of SIJs, • X-rays: margin irregularity, sclerosis of periarticular bone and eventually bony fusion. Spondylitis usually follows.

ESR: Most patients have an elevated ESR.

HLA-B27: This test has low specificity and has limited value.

l In patients with a history of reactive arthritis cultures should be obtained from the Microbiology: urethra, faeces, urine and blood. 16

Management principles

• Identify the most active elements of the disease and treat accordingly.

• Provide patient and family education with appropriate reassurance: this is vital. Stress that, although the disease is non-curable, treatment is effective and long-term prognosis generally good.

• Provide regular assessment and support.

• Give genetic counselling: e.g. in ankylosing spondylitis the risk to offspring is significant.

• Give advice regarding work, especially with posture.

• Refer for physiotherapy for exercises, postural exercises and hydrotherapy. Appropriate physiotherapy slows deterioration in spinal function. 17

• Consider referral for occupational therapy.

• Pharmacological agents:

o NSAIDs, e.g. indomethacin 75-200 mg daily to control pain, stiffness and synovitis o sulphasalazine (if NSAIDs ineffective)

o intra-articular corticosteroids for severe monoarthritis and intralesional corticosteroids for enthesopathy.

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