NECK PAIN

FROM RHEUMATOLOGY PERSPECTIVES

Andri Reza Rahmadi

Divisi Reumatologi, Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran Universitas Padjadjaran / RSUP Dr. Hasan Sadikin Bandung
 Riwayat Hidup
Nama : Andri Reza Rahmadi, dr, SpPD-KR, M.Kes, CCD, FINASIM

Pendidikan :
• Dokter Umum lulus 1997 FK UNPAD Bandung
• Magister Kesehatan lulus 2003 Pasca Sarjana UGM Yogyakarta
• Spesialis Penyakit Dalam lulus 2008 FK UNPAD Bandung
• Konsultan Reumatologi lulus 2013 FK UNPAD/RSHS Bandung

Pekerjaan :
• Dosen Fakultas Kedokteran Universitas Padjadjaran
• SpPD Konsultan Reumatologi RS Dr Hasan Sadikin Bandung

Organisasi :
• IDI, PAPDI, IRA, PERALMUNI, PEROSI
Joint of Cervical Spine
Inflammation of Neck Articular

• Arthritis of the joint

• Pain, Warm, Redness, Swollen, Stiffness

• Morning Stiffness

• Spondyloarthritis
 Spondyloarthritis (SPA)
• A group of common inflammatory
rheumatic disorders characterized by:
- Axial and/or peripheral arthritis, enthesitis,
dactylitis
- Potential extra-articular changes such as
uveitis, bowel disease and skin rash
 SPA
• Characterized by:
- Gender Male
- Sacroileitis
- Inflammatory back pain : Neck Pain
- Peripheral arthropathy : Enthesitis
- High ESR / CRP
- Rheumatoid factor (-) / CCP (-)
- Subcutaneous nodules (-)
- Enthesitis
- Extra spinal involvement (eye, heart, lung and skin)
- HLA-B27
• At least 6 other genes associated with ankylosing
spondylitis identified to date
• Combined Environmental factor
 Inflammatory Neck Pain
• Assumed inflammation of spine

• Young age of onset < 45 years old

• Continuous pain > 3 months

• Morning stiffness

• Pain improving on activity

Criteria for Classification of SPA

• ESSG
- (European Spondyloarthropathy Study Group)

• Amor Criteria

• Modified New York Criteria

 Spondyloarthritis (SPA)
• Ankylosing spondylitis (AS)
• Reactive arthritis (REA)
• Psoriatic arthritis (PSA)
• SPA associated with inflammatory
bowel disease (IBD)
• Undifferentiated SPA (USPA)
• Juvenile onset spondyloarthritis
 Ankylosing Spondylitis (AS)
• Most common and most typical

• 0.2-1.2% of Caucasian population

• Lower male to female ratio (2-3:1)

• Higher in HLA-B27 populations

Ankylosing spondylitis
 AS Symptoms
• Early adulthood male
• Dull pain buttock / lower lumbar area
• Morning stiffness worsened on inactivity, relived on
exertion
• Enthesitis : Inflammation at bone insertion sites of
ligaments or tendons
• Arthritis 25-35% involving large joints asymmetrical
• Neck pain with limited ROM
 Diagnosis of AS Delayed
• As long as 8 years

• Longer delays in females

• ESR / CRP

• X-ray not specific

• MRI expensive
Other Clinical Features of AS
• Acute anterior uveitis – 30% with
spondylitis

• Aortal valve diseases, CHF, aortitis,

angina, pericarditis, conduction deficits

• Dyspnea, cough, hemoptysis =

pulmonary fibrosis
 Diagnostic and Classification Criteria

• European spondyloarthropathy study

group (ESSG)

• Assessment in Spondyloarthritis
International Society (ASAS) proposed
new set of diagnostic criteria enabling
identification of SPA before structural
changes occur in the spine
 Conventional Radiography
• Domain in clinical trials of (ASAS)

• Recognition of early bone changes

• Inexpensive, easy to generate

• Widely available and inexpensive

 Radiographic Hallmark
• Fusion of Cervical Bone
Radiographic Hallmarks in SPA
• Erosions – earliest – iliac side

• Periostitis

• Bone proliferation at enthesis

• Normal bone mineralization

Sacroiliac Joint Involvement in (SPA)

• Most common early clinical finding

• First manifestations of disease

 Imaging Role in Sacroilitis
• MRI and CT – high sensitivity and better
detection of early sacroilitis but cost
prohibits use in routine diagnosis

• Plain radiograph initial diagnostic tool

but large inter and intraobserver
variations documented
 Better Imaging
• CT Scan : joint space, ossification of
enthesopathies

• MRI : present disease activity, erosion

of cartilaginous joint facets

• Ultrasound : soft tissue involvement

• Bone Scintigraphy : early sacroileitis

 Arthritis in PSA
• Asymmetric in small and large joints

• Patterns include:
- Mutilans

- Peripheral oligoarthritis / polyarthritis

- Spondylitis

- DIP arthritis (fingers and toes >50%)

 Dactylitis (Sausage Digit)
• PSA

• REA

• Joint and tenosynovial inflammation

 Back Pain in PSA
• Cervical spine disease common (>50%)

• Progresses in severity in parallel with

disease of peripheral joints

• Sacroilitis – 20% of patients

• Spondylitis – 5% of patients
 PSA
• Nails (83%) or skin precede or follow joint
involvement

• Scalp, behind ears, umbilicus or gluteal

folds

• Fatigue, iritis, uveitis

Abnormal Nail in PSA
 Biomarkers to Assess PSA
• ESR / CRP

• Matrix metalloproteinase-3

• Circulating osteoclast precursors

• HLA-B27
 PSA Radiographic Changes
• Entheseal bone formation

• Periostitis

• Entheseal erosions

• Diffuse bone based pathology

 PSA and Sacroilitis
• 25% in two series
• 78% in a third series
• Unilateral
• Axial and peripheral disease cause frequent
and severe lesion
• Cartilaginous and ligamentous joint
involvement
• Bony ankylosis less frequent than AS
• Bone eburnation of sacral and iliac surface
more marked in PSA than AS
 Ultrasound in PSA
• 25% more lesions found than on
clinical exam alone

• Achilles abnormalities in 59.2% of

PSA patients
 Enteropathic ENSPA
• Protzer, et. Al.

• SPA in 10.7% of all CD and 14.4%

of all UC patients

• 26.8% prior to GI symptoms

• 14.4% simultaneous
 ENSPA and Sacroilitis
• Often bilateral

• Radiographically similar to AS

• More dominant involvement of

ligamentous portion of joint than
other forms
 ENSPA and Imaging
• CT entheseal and ligamentous
- Frequent

• MRI inflammation at entheses

 Undifferentiated
Spondyloarthropathy (UPSA)

• Clinical and suggestive of SPA but

not fulfilling diagnostic or
classification criteria

• USPA versus AS lack of grade ≥ 2

bilateral or grade 3 unilateral
sacroilitis on x-ray
 Undifferentiated
Spondyloarthropathy (USPA)

• Patients without criteria for

well-defined SPA

• Fewer extra-articular changes

• Sacroilitis / spondylitis absent, or

very mild after years of active disease

• Good prognosis
 Juvenile Spondyloarthropathy

• Asymmetric

• Lower extremity peripheral

• Boys aged 7-16 years

• Enthesitis and dactylitis prominent

• Systemic manifestations frequent in

juvenile than adult form
 Therapy of SPA
• Basic essential therapy NSAID’s and
Physical Therapy
• Management of AS
- Symptoms
- Signs
- Disease activity (severity)
- Functional status
 NSAIDs
• Responds well to NSAIDs

• Not responds to steroid

• Na Diclofenac
• K Diclofenac
• Ibuprofen
• Ketoprofen
• Ketorolac
• Naproxen
 Sulfasalazine (SZA)
• Control of peripheral joint involvement

• Reduce spinal stiffness

• No effect on enthesitis, spinal mobility

or physical therapy

• Start Low go Slow

• 1x 500 mg up to 3x1000 mg
 Methotrexate
• Modest effect on peripheral joints

• Studies at odds on spine

• Start 7,5 mg / week up to 25 mg / week

• Addition : Folic Acid

 Biphosphonates
• Modest effect
- Osteoporosis

- Inflammatory spinal symptoms

 TNF Inhibitors
• Effective in suppressing
inflammation with joint destruction

• Reduce pain

• Fail to slow new bone formation

• Administered early, drug free

remission is possible
 TNF Inhibitors in AS
• Infliximab

• Etanercept

• Adalimumab

• Golimumab
 TNF Agents
• Dramatic change in therapeutic
strategies in AS

• Improvement of clinical disease activity

correlates with reduction of acute
skeletal change documented by post
Gadolinium and Stir MRI exams
 Take Home Messages
• Radiological study of SIJ in SPA
represents clinical and imaging
challenges

• Integrated use of different imaging

techniques is suggested to avoid
misdiagnosis

• MRI technique of choice for f/u,

given lack of ionizing radiation