A 21-year-old male carpenter presented with a two-year history of low back pain radiating down both buttocks and thighs that was worse with inactivity. Examination revealed reduced forward flexion of the spine and chest expansion. Blood tests showed elevated inflammatory markers. X-rays showed syndesmophyte formation and sacroiliitis. He was ultimately diagnosed with ankylosing spondylitis.

1. SPONDYLOARTHROPATHIES
CASE
BY ABHINAV DOGRA

2. A.E.Y is a 21-year-old carpenter who has a two-
year history of low back pain radiating down
both buttocks and down the posterior aspect
of his thighs.
The pain and stiffness is eased with
movement and exercise but is much worse
at night and with prolonged inactivity.
The patient has significant night pain, which
prevents
him from sleeping properly.

3. WHA
TISTHETYPEOF
THISBACKPAIN??
WHA
TISTHEPOSSIBLE
ETIOLOGY??

4. Causesof low
back pain
• Lumbar spondylosis
• Disk herniation
• Spondylolisthesis
• Spinal stenosis
• Fracture (mostly
osteoporotic)
• Nonspecific (idiopathic)
Mechanic
al
Neoplastic
• Primary
• Metastati
c
Inflammatory
• Spondyloarthriti

5. Causesof low backpain
Infectious
• Vertebral
osteomyeliti
s
• Epidur
al
absces
s
Metabolic
• Osteoporoti
c
compressio
n fractures
• Paget disease
Referred pain
to spine
• From major
viscera,
retroperitonea
l structures,
urogenital
system, aorta,
or hip

7. WHA
TARESIGNSDO
YOUSEARCHFORIN
EXAMINATIONIN
P
A
TIENTSWITH
INFLAMMATORYBACK
PAIN??

8. The patient also has
profound fatigue and
difficulty continuing work
as a carpenter.
Examination revealed a
reduced forward flexion of
the spine.
The patient also had
reduced chest expansion
of 2cm across the fourth
rib space.

9. Modified
Schober
test

10. Tragusto wall
distance

11. WHATARE LABORATORY
INVESTIGATIONS WILLYOU
REQUEST TO AID IN THE
DIAGNOSIS??
1 CRP
2 CBC
3 RHEUMATOID FACTOR
4 ANA
5 SERUM CALCIUM
6 ESR
7 HLAB27

12. The routine bloods (CBC and
biochemistry) were normal .
The inflammatory markers were
elevated
ESR = 41
CRP = 21

16. X-rays of the lumbar sacral spine revealed
syndesmophyte formation.
X-rays of the sacroiliac joints showed sclerosis of
the lower
one-third of the sacroiliac joint, indicating
sacroiliitis &
MRI of sacroiliac joints

17. WHAT IS THE
MOST LIKELY
DIAGNOS
IS
??

20. Then he was referred to a
rheumatologist and was diagnosed as
ankylosing spondylitis.

23. How to manage
this patient?
• csDMARDs
• NSAIDS
• BIOLOGICAL
THERAPY
• CORTICOSTEROI
DS

24. Physicaltherapy
andexercise
All patients
should be
educated
about the
value of
exercise and
the types of
exercise that
are beneficial.

25. 2. Nonsteroidal
anti-
inflammatory
drugs:
NSAIDs are the first-line
pharmacologic therapy.
A good response is seen in 70–
80% with optimal effect by 2
weeks.
With active disease, patients should
take NSAIDs continuously, daily at
the full dose for treatment of
inflammatory disease.
In inactive disease, or once patients
have initiated a biologic, NSAIDs
may be taken as needed

26. 3- Biologics
TNF
inhibitors
• Recommended as
second line therapy
after NSAID therapy
has failed (two
different NSAIDs for
one month each).
• TNF inhibitors have
been shown to be
very effective in the
treatment of AS.