This document defines and describes seronegative spondyloarthropathy, a group of related inflammatory joint diseases that affect the spine. Key points: - It refers to conditions where serological tests are typically negative for rheumatoid factor. The spine is commonly involved, starting in the sacroiliac joints. - It includes ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, arthritis associated with inflammatory bowel disease, and undifferentiated spondyloarthropathies. - Ankylosing spondylitis is the most common type and is associated with the HLA-B27 gene. It typically causes low back pain, morning stiffness, and

1. Seronegative SpondyloArthropathy
DR. BIPUL BORTHAKUR
PROF ORTYHOPAEDICS,SILCHAR,ASSAM,INDIA

2. Definition
• The term seronegative spondyloarthropathy refers to condition in
which serological test are typically negative for rheumatoid factor,a
non specific indicator of other rheumatological disease
• Spondyloarthropathies are a group of related inflammatory joint
diseases that affect spine and are associated with MHC class 1
molecule HLA-B27
• Unlike in RA typically the spine involvement starts in the sacroiliac
joints and involvement of cervical spine occurs less frequently

3. IT INCLUDES THE FOLLOWING
• Ankylosing Spondylitis
• Reiters syndrome
• Psoriatic arthritis
• Arthritis of inflammatory bowel disease
• The undifferentiated spondyloarthropathies

4. Ankylosing Spondylitis
• Ankylosing spondylitis is the third most common form of chronic
arthritis in the united states
• The term ankylosing comes from greek word “angkylos” which
means bent
• Its incidence is 1-3 per 1000 of general population
• Males are more commonly affected ,ratio 4:1
• Approximately 90% are positive for HLA-b27
• The 10% patients who are negative manifest signs and symptoms
of AS
• Bacterial infection with Klebsiella Pneumonia has been proposed
to cause the disorder due to molecular mimicry
• The sacro- iliac joint involvement is the hall mark of the disease

5. Signs and symptoms
• The sacroiliac joint involvement is the hall mark of the disease
• The hip and shoulder are the most commonly affected extra axial joints
and may be the initial symptom in 15% of cases
• Spine involvement usually begins with lumbar stiffness and loss of lordosis
• Cervical involvement is late and rare but typically causes loss of lordosis
and limitation of neck movement and may also present as pathological
fracture
• The inflammation of apophyseal joints and and calcification of ligaments
eventually lead to complete ankyloses of vertebra
• The spine which becomes rigid is prone to pathological fractures
• Patients typically present during 2nd to 4th decade of life with low back
pain, morning stiffness, chest wall, pain and difficulty in activities of life

6. Common symptoms of AS
• Low back pain ,morning stiffness ,chest pain
• Difficulty in doing daily activities
• Enthesopathy,pain in tendo -achilles ,plantar fasciitis
• Non orthopedic manifestations include –anterior uveitis ,ileitis
which may be present in 25% of cases
• Cardiopulmonary manifestation include-aortic and mitral
regurgitation, aortic stenosis,aortitis,restrictive pulmonary disease
• Pain in SI joint with tenderness on palpation
• Amyloid deposition may cause signs and symptoms of renal failure

7. Pathogenesis

8. Clinical Examination
• Hip Pathology i.e FFD is as assessed using Thomas test
• Schober test-Used to asses diminished spinal mobility
A point 10 cm above and 5 cm below the PSIS
is marked in midline with patient fully erect .In
normal cases there should be at least 5 cm
excursion between two points ,
but in AS it is less
 Once fusion of costo -vertebral joints occurs ,chest expansion
measured at fourth intercostal space is limited to less than 2,5
cm between full inspiration and expiration
 The chin brow angle ,gaze angle and occiput to wall distance is
decreased
 The chin brow angle is measured by a vertical line drawn from
chin to elbow

10. Investigations/Labs
• Laboratory tests are mostly done to find out markers of
inflammation
• ESR is elevated
• CRP which is a marker of inflammation is found elevated in
50-70 %of cases
• HlA-B27 is positive in about 90 % of cases and is usually
considered diagnostic
• Xray shows areas of worn out bones
• MRI is the radiological investigation of choce which is
helpful in detection of early sacroiliatis
• Radiological findings are garded from grade 0-4 ,where 4
represents complete ankylosis

11. Radiological grading of sacroiliatis

12. Scoring of ankylosing spondylitis

14. Diagnostic Criteria
• The initial axial SPA manifestation is sacriliatis diagnosed
on radiological examination on the basis of modified New
York criteria of 1984
• Sacroiliatis on x-ray is diagnostic criteria of SPA according
to according to European Spondoarthropathy study Group
criteria(ESSG) and Amor Criteria

15. Modified New York criteria for diagnosis

17. Management
• Medical management-Treatment consists of analgesics
/anti-inflammatory
• Coxcibs are the first line drugs for AS
• Biologics-such as Infliximab which is a chimeric monoclonal
antibody against TNF-α which is administered in a dose of
5mg/kg body weight at two weeks interval followed by once
every 6 wks is the biologic of choice
• Reduction and correction of deformities by traction and halo
vest immobilization
• Surgical treatment id indicated for fractures and nonunions

18. Physiotherapy in AS
• A exercise routine with posture correction can be applied to delay and
possibly stop the progression of the disease
• Spinal extension exrecises are the key component and should be done
twice
• Proper sleeping posture on a flat bed without pillow ewith frequent
sleeping and lying is advocated
• Upper back hyper extensuin exercises
• Breathing exercises to increase or maintain rib cage excursion as well as
instruction in abdomino thoracic breathing
• Range of motion exercises for hip and knee to prevent deformity and
contractures
• Bracing or corseting
• Aerobic exercises
• Hydrotherapy and aqusatic physiotherapy

19. Reiters syndrome
• Reiter's syndrome is reactive arthritis which developes in
response to infection and characterized by triad of Arthritis,
conjunctivitis and bacterial urethritis
• It is an autoimmune disease marked by inflammatory synovitis
and erosion at insertion sites of ligaments and tendons
• Commonly occurs in the presence of an enteric infection
• More commonly seen in males and individuals with HIV
• People with HLA b27 marker positive are more common to
develop the disease
• Conservative treatment along with tetracycline or erythromycin
500mg 4times a day for 10 days is the treatment of choice
• Surgery in the form of synovectomy, fusion and tendon repair
may be needed

20. Clinical features in Reiter’s disease

21. Psoratic arthritis
• Chronic progressive inflammatory joint disease associated with psoriasis
• Condition affects both periphera; joints and axial skeleton causing pain
,stiffness and restriction of movement
• Typically affects 30-50 years old
• Equal prevelance in both males and females
• 80-90% increased chance if a first degree relative has psoriasis
• Diagnosis is made by ruling out other conditions
• X ray shows erosion in DIP joint
• Managents consists of Nsaids,DMARDs
• Otezla which is PDE-4 inbibitor is the biologic of choice approved in 2014
by Fda

22. X-ray finding in psoriatic arthropathy

23. Arthritis associated with inflammatory bowel
disease
• Arthritis is the most common extra intestinal manifestation of
inflammatory bowel disease (IBD)
• IBD-associated arthropathy is considered a subtype of seronegative
spondyloarthropathy, with axial, peripheral, or a combination of both joint
• Peripheral arthritis is generally non-erosive and the oligo articular variant
particularly may correlate with intestinal disease activity
• Axial arthritis may include inflammatory back pain, sacroiliatis, or
ankylosing spondylitis, and is less likely to correlate with gastrointestinal
symptoms.
• Treatment of inflammatory bowel disease is not always sufficient for
control of arthritis

24. • HLA-B27, may contribute to pathogenesis of arthritis in IBD,
through presentation of arthritogenic peptides to T cells
• Diagnosis is largely clinical, based on the presence of peripheral
or axial arthritis in the setting of IBD.
• Inflammatory markers such as CRP, ESR, platelet, or white blood
cell count, can be elevated by IBD alone, without arthritis, and
therefore may be difficult to interpret in the setting of IBD
associated arthropathies
• Plain radiographs of peripheral joints may show effusions or
periarticular osteopenia as is seen in other inflammatory
arthritides. Erosions and joint destruction are rare.
• MRI may also be helpful in predicting and monitoring response
to treatment
• DMARDs may be considered for patients who are refractory to
conservative measures. Sulfasalazine (SSZ) may be effective in
treating peripheral arthritis and has activity for UC bowel
inflammation in UC,

25. • TNF inhibitors(adalimumab) have been found to be highly
effective for IBD patients who are steroid dependent or
refractory to conventional treatment
• Infliximab however is the best

26. सञ्जय उवाच |
तं तथा कृ पयाववष्टमश्रुपूर्ााकु लेक्षर्म ् |
ववषीदन्तममदं वाक्यमुवाच मधुसूदन: || 1||
sañjaya uvācha
taṁ tathā kṛipayāviṣhṭamaśhru pūrṇākulekṣhaṇam
viṣhīdantamidaṁ vākyam uvācha madhusūdanaḥ
meaning-Sanjay said: Seeing Arjun overwhelmed with pity, his
mind grief-stricken, and his eyes full of tears, Shree Krishna
spoke the following words.
THANK YOU