Spondyloarthritis

Spondyloarthritis, disease of the posterior section of the spine, i.e., its joints (disease of the bodies of the vertebrae, i.e., disease of the anterior section of the spine, is called spondylitis). The disease most often affects the most mobile and most loaded part of the spine—the lower half of the lumbar region. Based on causative factors, the following are distinguished: 1) static S., 2) rheumatic S.—infectious or toxic, and 3) deformative S. In the dynamic development of each of these forms, with longer duration and progression, phenomena of spondylosis (see) may join them and develop in parallel with them. In this case, deformative osteoarthritis of the spine results. 1. Static S.—one of the most harmless, most benign in terms of course. Large autopsy material shows that spondyloarthritis-type changes after 45 years are almost universal, especially in the lumbar region (Willis). These changes are more often and earlier observed in workers and are explained by strong tensions and loads on the spine during the gradual fading of its elasticity. Examinations of loaders with experience from 7 to 39 years (Novotel'nov) showed that the amount of S. gradually increases after 9 years of experience; transition to deformative S., often with spondylosis, occurs after 17-20 years of experience. In diagnostic terms, it is noteworthy that even pronounced forms of static deformative S. do not create serious back pain, while pain in the legs is rarely observed. From a neurological point of view, it can be said that with these forms of S., there is mild lumbago and almost no sciatica. Therefore, it is not surprising that loaders with static deformative S. and static osteoarthritis of the spine (S.+spondylosis) for years and decades continue their heavy labor without loss of work capacity, not lagging in output (up to 16 tons per day) from completely healthy loaders (Novotel'nov) [see separate table (pp. 371-372), fig. 3]. It is also noteworthy that the lifting strength of loaders with deformative S. and osteoarthritis of the spine on average turned out not only not lower, but even higher than the lifting strength of healthy loaders with a normal spine (Novotel'nov). This fact proves that static deformative S., even with spondylosis, is a beneficial reaction, has a protective character, and increases the strength of the spine. Clinic. Slightly flattened lumbar lordosis and mild limitation of mobility. Loading and palpation are painless. On the X-ray, deforming phenomena in the area of articular processes, usually of the lower lumbar vertebrae, with sclerosis darkening the joint spaces, often with the presence of small hooks on the lateral parts of the bodies (spondylosis), which fuse together (from two adjacent bodies) only in exceptional cases of severity. Pure forms of static S. without spondylosis are sometimes called instead of S. spondyloarthrosis. Similar phenomena of static S. with development of spondylosis occur on the basis of congenital developmental defects of the lumbar spine—spondylolysis, sacralization, lumbarization. But these forms clinically proceed much more severely. In contrast to purely static spondyloarthritis, here not only passive but also active movement causes sharp pain, and therefore movements, especially during exacerbation and progression, are contraindicated. 2. Rheumatic—infectious or toxic spondyloarthritis; its signs do not essentially differ from the signs of rheumatic diseases described for other joints, being part of the general polyarthritis. The joints of the spine in rheumatism are involved in the disease simultaneously with other joints or separately and independently of them, sometimes even preceding them. Angina, influenza, gonorrhea in men and gynecological diseases in women precede a large number of cases of rheumatic S. It is also often preceded by 'cold' and trauma. In some cases, 'cold' apparently is an element localizing rheumatic spondyloarthritis at the site of injury. The disease begins either with sharply acute pains or with a slow and gradual increase in them. The pains are usually localized in the lumbar and gluteal region, spreading to one or the OTHER leg or to both legs. Sometimes, conversely, the pains begin with the leg. Clinic. In contrast to static S., the typical signs of 'rheumatic' S. are the following: sharp flattening of the lumbar lordosis with sharp tension of the long spinal muscles and sharp limitation of mobility of the lumbar spine, with Lasègue's symptom radiating to the back, with a gait of short steps (since a long step causes Lasègue's symptom), without pain on loading, but with pain on jumping and on shaking and with very sharp pain on pressure on the spinous processes of the lumbar vertebrae and especially on their sides (projective pain from the side of the root foramina of the spine). These subjective and objective phenomena from the side of the spine and legs, many even modern neurologists consider from the point of view of purely primary nervous causes, which is reflected in the diagnosis of these phenomena, which still often appear in works and reports under the name of lumboischialgia. The posterior roots, being closer to the diseased joints of the spine, undoubtedly receive irritation from them. With more pronounced manifestations of S. on one side, another typical picture of S. results, which older authors called scoliosis ischiadica. This name also denoted the nervous nature of this phenomenon. Here there is also Lasègue's symptom on the affected side of the spine with radiation of pains not into the leg, but into the lumbar and gluteal region. Pains in the lumbar region have a dual origin—from the side of the diseased joints of the spine and from the side of the back muscles, which have received irritation through the posterior branches from the roots of the diseased joints. Irritation of the roots from the side of diseased and swollen joints of the spine causes pain in the legs corresponding to the segments of the affected joints. Initially it has the character of neuralgia, without changes in sensitivity and without atrophy. However, with the duration of the process, its recurrences, usually frequently repeated, and in progressive forms of S., true root neuritis—sciatica—develops with atrophy of muscles and changes in sensitivity corresponding to the segments of the diseased joints. Due to their thickness, the roots of L5 and S1 are especially vulnerable. On the other hand, rheumatic S. most often affects the lower half of the lumbar spine, as the most loaded and most working. Involvement in the process of the joints of the upper half of the lumbar spine causes neuritic phenomena from the branches of the sacral, not lumbar, plexus. X-ray of initial rheumatic S. adds little in diagnostic terms. In older recurrent and progressive processes, on the X-ray there are 'trophic' phenomena of osteoporosis in the articular parts, especially in the articular processes: initially only narrowing of the joint spaces with loss of subchondral sclerosis, later—with festooning of the borders of the joint spaces and finally with phenomena of joint deformations. Along with the reduction of cartilaginous discs, the deformed ends of the lower articular processes descend and embed themselves into the arch of the underlying vertebra and as if spread out over its concavity until they fuse with it in phenomena of severe progressive S. This section of the spine then becomes completely immobile, and the pain subsides if the process does not spread to neighboring vertebrae. Consequently, progressive 'rheumatic' S. can also reach its final limit—deformative S. If to this is added spondylosis as a secondary phenomenon on the basis of static insufficiency of such a spine, in the end a complex picture of deformative osteoarthritis of the spine results. 3. From what has been stated about static and rheumatic (toxic) S., it follows that deformative S. is not some special form of spondyloarthritis, but arises from other forms, being the highest degree of their dynamic development, especially along with the phenomenon of spondylosis [see separate table (pp. 371-372), fig. 6], when to the deformation of joints is secondarily added the deformation of bodies. Treatment. From the pathology and dynamic development, it is quite clear that each of these forms of S. requires a special approach. In terms of treatment, common to all of them is the elimination of the causing causes: too heavy work, riding or in conditions of shaking, prolonged sitting or standing without movement; healing of the primary foci of infection (angina, chronic gonorrhea, prostatitis, gynecological foci, etc.). Local: application of all kinds of heat, especially mud in summer, warm baths, massage. Strong exercises and passive movements are harmful in all forms of S. In subsiding and subsiding cases, moderate active movements in the form of therapeutic physical exercises, mototherapy, are indicated, except, of course, for those S. that are based on developmental defects of the spine, especially with spondylolysis.

On the contrary, here, as with recurrences and in progressive forms of rheumatic S., support for the spine, even in the form of a soft supporting corset or even a half-corset-belt, is a very effective means. The corset is especially effective when the process is limited to the lumbar spine. But even in a corset, the patient should avoid known movements that cause pain. Prolonged rest on a curved frame to restore lumbar lordosis (important for the elasticity of spinal movement) gives the most effective result. Redressions for this purpose should not be performed, out of danger of causing an exacerbation. To give elasticity, a thick rubber sole and a rubber heel are indicated.