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Suspected axial spondyloarthritis — MSRA MCQ

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HardHip and GroinSuspected axial spondyloarthritisMSRA

A 32-year-old woman presents with 5 months of deep bilateral groin discomfort associated with alternating buttock and low back pain. Symptoms began gradually without trauma. She is woken most nights in the second half of the night and reports stiffness for around 75 minutes after waking. Her symptoms improve after walking or swimming, but worsen with prolonged sitting. Naproxen taken for dysmenorrhoea has repeatedly produced marked improvement by the following day. Hip flexion and rotation are full, and do not reproduce the groin discomfort. There is no focal greater-trochanteric tenderness or neurological deficit. CRP is normal. A pelvic radiograph requested 2 months ago was reported as normal, including no sacroiliitis. What is the most appropriate next step in primary care?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Refer to rheumatology for assessment of suspected axial spondyloarthritis

Explanation lettering: E = shown as B · B = shown as C · C = shown as E

This presentation meets NICE referral criteria for suspected axial spondyloarthritis (axSpA). Her low back pain began before age 45 years and has persisted for more than 3 months. She also has at least four additional criteria: onset before age 35 years, waking in the second half of the night, buttock pain, improvement with movement, and rapid improvement with an NSAID. She should therefore be referred directly to rheumatology; HLA-B27 testing is not required as a gatekeeper when four or more additional criteria are present. The normal CRP and normal pelvic radiograph do not exclude axSpA. NICE specifically advises that axSpA may be present despite absent sacroiliitis on plain radiography, and inflammatory markers may be normal. Her full, non-painful hip range of movement makes primary intra-articular hip disease less likely despite the groin symptom. A is inappropriate because further primary-care radiography delays indicated referral and a normal film does not rule out disease. B misapplies the HLA-B27 sequence, which is used when exactly three additional criteria are present. C is initially plausible because hip and buttock pain are commonly mechanical, but the inflammatory pattern and NSAID response are discriminating. E would be appropriate if examination suggested intrinsic hip pathology, such as painful restricted internal rotation.

Reference: NICE NG65: Spondyloarthritis in over 16s: diagnosis and management — Recognition and referral in non-specialist care settings (2017) — https://www.nice.org.uk/guidance/NG65/chapter/Recommendations NICE NG65: Spondyloarthritis in over 16s: diagnosis and management — Recognition and referral in non-specialist care settings (2017) — https://www.nice.org.uk/guidance/NG65/chapter/Recommendations NICE Quality Standard QS170: Spondyloarthritis — Quality statement 1: Referral (2018) — https://www.nice.org.uk/guidance/qs170/chapter/Quality-statement-1-Referral