MCQs in Rheumatology:
Spondyloarthropathies
Contributors: These MCQs were written by Dr Roshan Amarasena, and were
reviewed by Dr Adrian Jones, and Dr Ed Roddy. The MCQs were edited by Dr A
Abhishek who also facilitated the review process.
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Question 1
A 77 year old retired joiner had a thoracic spine x-ray following a fall. There was no
fracture; however the x ray was reported as showing extensive ‘flowing’ nonmarginal syndesmophytes, and fusion of several contiguous vertebrae. The patient is
asymptomatic. You think he has diffuse idiopathic skeletal hyperostosis (DISH)
Which one of the following is incorrect regarding DISH?
1.
2.
3.
4.
5.
Common in men > 50 years in age
Associated with diabetes
Enthesopathy is uncommon
Cauda equina syndrome can occur
Dysphagia is a recognised complication
Question 2
A 45 year man with long standing ankylosing spondylitis is reviewed in the
anaesthetic pre-operative assessment clinic prior to a hip replacement. The
anaesthetist is concerned about risk of intubation, and requests a plan film
radiograph of the cervical spine.
What are the normal anterior, and posterior atlanto-dental intervals?
1.
2.
3.
4.
5.
> 3 mm, and > 14.5 mm
< 3 mm, and < 14.5 mm
>3 mm, and < 14.5 mm
< 3 mm, and > 14.5 mm
None of the above
Question 3
A 47 year old man has long standing active Crohn’s disease, manifesting as
intermittent diarrhoea, PR bleed, and weight loss. He has recently had a flare of
bowel symptoms, and over the last 6 months has also developed synovitis in the
right wrist, and in both ankle joints. He is referred for advice on management of his
arthritis.
Which of the following is the most effective treatment for treating the gastro-intestinal
and musculoskeletal manifestations of Crohn’s disease?
1.
2.
3.
4.
5.
Etanercept
Infliximab
Methotrexate
Rituximab
Sulphasalazine
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Question 4
Single nucleotide polymorphisms in which of the following genes are most likely to
associate with ankylosing spondylitis?
1.
2.
3.
4.
5.
ENPP1
IL6
IL23R
NOD 2 (nucleotide binding oligomerisation domain protein 2)
TGF beta1
Question 5
A 69-year-old man is referred by his GP for ‘possible ankylosing spondylitis’ as a
plain X-ray of spine showed flowing ossifications at the antero-lateral region of the
thoracic spine. He has no backache. On examination he has mildly restricted spinal
movements, wall to occiput distance is 1.0cm, and a modified Schobers’ tests are
6.5cm. Chest expansion is normal. The CRP and ESR are normal.
Which one of the following would be the most appropriate treatment?
1. anti-TNF agent
2. hydrotherapy
3. NSAIDs
4. physiotherapy
5. no treatment needed
Question 6
A 24 year man with ankylosing spondylitis who has failed two NSAIDs is considered
for biologic therapy for AS. It is required by NICE to assess the disease activity 12
weeks apart.
Which of the following domains do not form part of BASDAI (Bath Ankylosing
Spondylitis Disease Activity Index)?
1.
2.
3.
4.
5.
Degree of fatigue
Duration of morning stiffness
Duration of spinal pain
Intensity of morning stiffness
Intensity of spinal pain
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Question 7
A twenty-seven year old architect with ankylosing spondylitis (AS) diagnosed three
years ago has active spinal disease despite a trial of several non-steroidal antiinflammatory agents, physiotherapy, and analgesia. He is considered for treatment
with anti-TNF α agent.
Which of the following is incorrect about treating AS with anti-TNF α agent?
1. Patient should have failed at least two NSAIDs at maximum tolerated dose taken
sequentially for 4 weeks.
2. Have spinal disease with a BASDI ≥4 on two occasions 12 weeks apart.
3. Have spinal pain with a VAS ≥4 cm, on two occasions 12 weeks apart.
4. Have a raised CRP and/or ESR.
5. Need to fulfil the modified New York criteria for diagnosis of AS.
Question 8
A 39 year old lawyer with back pain was seen by the extended scope
physiotherapist in a community clinic. A clinical diagnosis of ankylosing spondylitis
(AS) was made. Plain radiographs of the thoraco-lumbar and sacro-illiac joints were
performed.
Which one of the following statements about radiographic features of AS is
incorrect?
1.
2.
3.
4.
Erosions are more likely in upper third of sacroiliac joint.
Pseudo widening of sacroiliac joint is due to erosions.
Spinal osteoporosis may be present in severe long standing AS.
Syndesmophytes result from ossification of the outer layers of annulus
fibrosis.
5. Vertebral fractures can occur through fused vertebral bodies.
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Question 9
A 37 year old man is referred to you for long standing backache. He had intermittent
backache since leaving college, and has seen his GP on many occasions before.
The backache has been attributed to sport injuries and mechanical pain. Over the
last one year, he has tried naproxen and ibuprofen for 6 months each with modest
improvement in symptoms, and is currently on tramadol. In clinic, he gives a history
of low back pain, worse at rest, and in the morning, and also pain following physical
activity. Examination reveals absence of a normal lumbar lordosis, reduced spinal
flexion, and a positive Schobers’ test (3 cm). There is no localised spinal tenderness.
Investigations
Hb
12.5 gm/l
WBC count 10.9 x 103/ml
Platelets
378 x 103/ml
CRP
26 mg/l
ESR
18 mm/hr
Plain radiographs of lumbar spine, and pelvis show syndesmophytes, and sacro-iliac
joint fusion.
What is the most appropriate next step in his management?
1.
2.
3.
4.
5.
Arrange MRI of spine and sacroiliac joints
Assess BASDAI and spinal pain VAS for starting anti-TNF treatment
Refer to pain clinic for pain control
Try alternative NSAID
Try alternative Cox-II inhibitor
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Answers
Q1.
3. Enthesopathy is uncommon
DISH preferentially involves the peri-vertebral and peri-articular ligaments and
tendons. There is 21 MF ratio. It is rare in those younger than 45 years.
Characteristically there is flowing classification of the anterolateral spine of ≥4
consecutive vertebrae (Resnick). There is also no apophyseal joint ankylosis and no
erosions. The metabolic associations of DISH include diabetes, dyslipidaemia and
hyperuricaemia. The primary lesion in DISH is enthesopathy – and peripheral joints,
tendons may be involved as well.
Q2.
4. < 3 mm, and > 14.5 mm
Spinal complications of inflammatory arthritides include atlanto-axial instability,
basilar invagination, and sub-axial disease. Although atlanto-axial subluxation may
be asymptomatic, patients present with occipital headache, or facial pain. Flexionextension views of the lateral cervical spine allow dynamic assessment of atlantoaxial instability. Anterior atlanto-dental interval (AADI) measured from the posterior
aspect of the anterior ring of C1 to the anterior aspect of the dens, and posterior
atlanto-dental interval (PADI) measured from the posterior aspect of the dens to the
anterior aspect of the C1 lamina are measurements for atlanto-axial subluxation.
PADI < 14 mm, and AADI >3mm suggests atlanto-axial subluxation. Migration of the
tip of the odontoid peg > 4.5 mm above the Mac Gregor’s line (an imaginary line
drawn from the occiput to the tip of the hard palate) suggests basilar invagination. It
is important to remember that clinically significant cord compression may occur from
pannus in the presence of a normal AADI/PADI on plain film radiographs.
Q3.
2. Infliximab
Etanercept is not approved by NICE for the treatment of Crohn’s disease, or the
associated arthritis. There is also evidence to suggest that the monoclonal anti-TNF
antibodies (e.g. adalimumab, and infliximab) are more effective in the treatment of
chronic granulomatous diseases than the soluble TNF receptor fusion complex
etanercept.
Q4.
3.IL23R
Polymorphisms in the MHC genes explains only 40-50% of the genetic risk of AS.
Approximately half of this is explained by the HLA B 27 gene. Thus, it is important to
know the non-MHC genetic risk factors of AS. Single nucleotide polymorphisms in
IL23R gene have been associated with AS. There is no reported association
between SNP in IL6, TGF beta, and NOD2 genes and AS. There are no reports of
association between ENPP1 and AS.
Q5.
5. no treatment needed
Diffuse idiopathic skeletal hyperostosis (DISH) usually affects the elderly and is an
incidental finding on radiography. There is usually florid flowing ossifications of the
anterolateral regions of the spine involving four or more contiguous vertebrae. It
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commonly affects the thoracic region. Unlike AS, HLA B27 is no more common than
in the general population, and the sacroiliac joints are not affected. There is no
restriction of the spinal movements and there is usually no history of backache in
adolescence.
Q6.
3. Duration of spinal pain
The BASDAI measures fatigue, spinal pain, joint pain/swelling, areas of localized
tenderness (also called enthesitis, or inflammation of tendons and ligaments), and
duration and severity of morning stiffness.
Q7.
4. Have raised CRP and/or ESR
Patients starting anti-TNF α agents for AS need not have a raised inflammatory
marker.
Q8.
1. Erosions are more likely in upper third of sacroiliac joint.
The lower half to 2/3rd of the sacroiliac joint is lined by synovial tissue. Erosions, and
irregularities due to sacro-ilitis are best seen here. The upper ½ to 1/3 rd of the joint is
held together by ligaments, and lacks a synovial lining.
Q9. 2. Assess BASDAI and spinal pain VAS for starting anti-TNF treatment
This patient has clinical and radiographic signs of AS. If the BASDAI, and spinal pain
VAS are >4 on two occasions 3 months apart he will be eligible for anti-TNF agents
as per the NICE guidelines for AS. NICE guidelines do not require presence of
sacro-ilitis or enthesitis on MRI for starting anti-TNF agents. There is no need to start
him on other anti-inflammatory agents, as he has already tried and failed on two
NSAIDs.
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