Patient Resources

• National Axial Spondyloathritis Society (NASS) Webpage
• Versus Arthritis - Ankylosing Spondylitis Webpage

Clinican Resources

• RefHelp Page - Rheumatology Axial Spondyloarthritis
• Act on Axial SpA Webpage

Definition

Axial Spondyloarthritis is a chronic inflammatory condition targeting the sacroiliac joints and the spine. It typically starts in the late teens and early 20’s but can present in people up to 45 years of age. It has been estimated that AxSpA accounts for <5% of chronic back pain.

History

• Back pain > 3months with onset <45yrs of age
• Does not improve on resting
• Insidious onset
• Pain at night improving on rising
• Early morning stiffness improving with exercise
• Good response to NSAID

Associated features

• History of iritis or uveitis
• History of psoriasis
• History of inflammatory bowel disease
• Positive family history of AxSpA
• Peripheral large joint synovitis
• Heel pain (enthesitis)
• Buttock pain alternating with back pain
• Dactylitis of fingers or toes

Examination

• Reduced range of spine movements
• Peripheral joint examination for synovitis

Additional features of AxSpA

• Good response to NSAID
• Raised CRP or ESR (may be normal)
• Routine bloods otherwise unremarkable
• HLA B27 usually positive 

Other Considerations

• Affects a similar number of women as men
• May be present despite no evidence of sacroiliitis on a plain film X-Ray

Differential Diagnosis

• Non-specific neck pain
• Rheumatoid Arthritis (RA)

Patient resources

Versus arthritis - PMR

NHS Inform - PMR

Definition

PMR is a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips.

Typical signs and symptoms

• Muscle stiffness in the morning that lasts longer than 45 minutes.
• A history of neck, shoulder girdle, and/or hip girdle stiffness and pain, occurring in patients aged >50 years (usually women)
• Patients complain of difficulty rising from seated or prone positions, varying degrees of muscle tenderness, shoulder/hip bursitis, and/or oligoarthritic
• Rapid improvement often occurs within 24 to 48 hours with low-dose prednisolone
• Extreme tiredness
• Loss of appetite
• Weight loss
• Depression

Prevalence

The prevalence of PMR in 2015 was 0.85%.

Risk factors

• Over 65 years old
• Female gender

Prognosis

The prognosis of PMR is good. Response to systemic corticosteroids is often rapid and dramatic, with many symptoms resolving within 24–72 hours.

Other considerations

Temporal arteritis

Up to 1 in 5 people with PMR develop a more serious condition called temporal arteritis (also known as giant cell arteritis), where the arteries in the head and neck become inflamed.

Symptoms include:

• A new or frequent headache that usually develops suddenly
• Pain in the jaw muscles or tongue when eating or talking
• Problems with sights, such as double vision or loss of vision in 1 or both eyes.

Differential diagnosis

Rheumatoid Arthritis

Patient resources

Versus arthritis - RA
EdinRheum.org - RA

Definition

RA is among the most common rheumatic diseases. It is an auto-immune condition that can cause pain, swelling and stiffness in joints.  

Typical signs and symptoms

• Joint pain, which is often worse in the mornings and after a period of inactivity.
• Swollen, hot and tender joints.
• Stiffness, especially in the morning and lasting more than 30minutes.

Other symptoms can include:

• Tiredness and a lack of energy
• High temperature
• Sweating
• Poor appetite
• wWeight loss
• Dry eyes – if the eyes are affected
• Chest pain – if the heart or lungs are affected

Prevalence

The incidence of RA is approximately 3 cases per 10,000 population, and the prevalence rate is approximately 1%, increasing with age and peaking between the ages of 35 and 50 years

Risk factors

• Genetics
• Female gender
• Smoking

Prognosis

Most cases of RA get steadily worse, especially without adequate management. People with RA need long-term treatment to help manage their disease in order to slow it down or stop it from getting worse and causing joint damage, disability, and other complications.

Other considerations

• 90% of patients with RA develop cervical spondylitis
• RA can progress to instability, including atlantoaxial subluxation, subaxial subluxation, and basilar invagination. 
• Occipital headaches can present secondary to the compression of the greater occipital branch of the C2 nerve, which occurs secondary to degeneration of the C1/C2 joint

Differential diagnosis

Axial Spondyloarthritis (AxSpA)

Patient resources

• EdRheum - Giant Cell Arteritis 
• Versus Arthritis - Giant Cell Arteritis

Definition

Giant cell arteritis (GCA) is a condition in which inflammation is present in blood vessels called arteries. The inflammation of a blood vessel is called ‘vasculitis’ or arteritis. GCA commonly affects the medium and larger blood vessels that supply the head and neck.

Typically the temporal artery is affected – there is one under the skin on each side of the forehead (the temple area). For this reason, the condition is sometimes called Temporal Arteritis.

Typical signs and symptoms

History

• New onset of persistent localised headache (usually unilateral and in the temporal area, but can be bilateral) in a patient age >50 years
• Jaw claudication (pain over masseter muscles on chewing)
• Tenderness or pain over scalp
• Visual disturbance
• Constitutional Symptoms: Malaise, weight loss, unexplained fever, night sweats
• There may also be symmetrical pain and stiffness affecting the shoulder and pelvic girdle

Examination

• Often normal
• Occasionally focal tenderness and thickening over temporal artery or pulseless artery
• Visual field defects or reduced visual acuity
• Cranial nerve defects

Investigations

• ESR and CRP- almost always elevated.
• Further investigations including temporal and axillary artery ultrasound may be organised by secondary care following referral

Other considerations

See GCA probability scoring system in RefHelp Rheumatology link below to assess likelyhood of GCA based on clinical features.

Clinical resources

Rheumatology - RefHelp - Giant Cell Arteritis

Neurology - RefHelp - Facial Pain