Morning Stiffness, Dry Eyes, Back Pain in a Fit 58-Year-Old

Kristine M. Lohr, MD, MS; Muhammad Sohail Khan, MD


November 10, 2022

An anteroposterior projection of the pelvis (AP pelvis) is often sufficient to evaluate the inferior aspects of the sacroiliac joints. The Ferguson view (AP with the tube angled 25-40 degrees cephalad) counteracts the overlap of the sacrum with the ilium, enabling a full view of the sacroiliac joint. This view is recognized because the symphysis pubis overlaps the sacrum.

MRI of the pelvis with T1 sequences is used for evaluation of ankylosis, erosions, backfill, and fatty metaplasia, and short T1 inversion recovery sequences are used for evaluation of osteitis/inflammation. Semicoronal views are included to visualize the sacroiliac joints along their full length. Pelvis MRI identifies 95% of patients with axial SpA/ankylosing spondylitis. Only 5% of patients require lumbar spine MRI owing to normal pelvis MRI.

The radiographic changes of axial SpA are predominantly seen in the axial skeleton (sacroiliac, apophyseal, discovertebral, and costovertebral) as well as at sites of enthesopathy ("whiskering" of the iliac crest, greater tuberosities of the humerus, ischial tuberosities, femoral trochanters, calcaneus, and vertebral spinous processes). Sacroiliitis is usually bilateral and symmetric. Initially, it involves the synovial-lined lower two thirds of the sacroiliac joint. The earliest radiographic change is minimal erosion of the iliac side of the sacroiliac joint, where the cartilage is thinner and has clefts, or sclerosis. Progression of the erosive process may result in moderate to significant erosions, sclerosis, widening, narrowing, or partial ankylosis of the sacroiliac joint space, eventually followed by complete bony ankylosis or fusion of the joint

Axial spondyloarthritis has no cure. Treatment focuses on control of inflammatory symptoms and participation in an exercise program to minimize deformity and disability.

For most patients with axial spondyloarthropathy, an NSAID is used as initial therapy rather than a biologic agent. Two weeks of NSAID therapy is considered an adequate trial. For those who do not respond to NSAIDs, tumor necrosis factor (TNF) inhibitors can be considered. For patients who fail to respond to TNF inhibitors, interleukin-17 (IL-17) inhibitors or Janus kinase (JAK) inhibitors can be used.

A TNF inhibitor was prescribed for the patient in this case. Within 6 months, she showed dramatic improvement in her joint pain and range of motion symptoms.


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