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Inflammatory back pain — SCE Rheumatology MCQ

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EasyMusculoskeletal investigationsInflammatory back painSCE Rheumatology

A 27-year-old woman has an 8-month history of low back pain that wakes her during the second half of the night, is associated with morning stiffness and improves with movement. Examination shows reduced lumbar flexion. CRP is 22 mg/L. Dedicated plain-film radiographs of the sacroiliac joints do not show sacroiliitis meeting modified New York criteria. What is the most appropriate next investigation?

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Correct answer: D — Unenhanced MRI using an inflammatory back pain protocol

The correct answer is D. Her young age, prolonged back pain, nocturnal waking, morning stiffness, improvement with movement and raised CRP support suspected axial spondyloarthritis. NICE recommends unenhanced MRI using an inflammatory back pain protocol when sacroiliac radiographs do not demonstrate sacroiliitis meeting modified New York criteria. The protocol includes STIR and T1-weighted sequences of the sacroiliac joints and whole spine and can demonstrate active inflammation consistent with non-radiographic axial spondyloarthritis. HLA-B27 testing may support the diagnosis but is not the preferred next test after a non-diagnostic radiograph; NICE particularly recommends it if MRI is negative and it has not already been measured. CT exposes the patient to radiation and is not the recommended next investigation. Scintigraphy should not be offered, and repeating radiographs would delay diagnosis.

Reference: National Institute for Health and Care Excellence. Spondyloarthritis in over 16s: diagnosis and management (NG65), recommendations 1.2.4–1.2.10. 2017; reviewed 4 March 2025. https://www.nice.org.uk/guidance/ng65/chapter/Recommendations