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Suspected non-radiographic axial spondyloarthritis — MSRA MCQ

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ModerateMRISuspected non-radiographic axial spondyloarthritisMSRA

A 33-year-old woman is assessed in a rheumatology interface clinic for 18 months of low back pain and alternating buttock pain. Symptoms began at age 31. She wakes in the second half of the night because of back pain and has morning stiffness lasting 90 minutes. Pain improves with exercise but not with rest, and improved substantially with a trial of naproxen. She has psoriasis managed with topical treatment. There is no fever, weight loss, trauma, neurological deficit, bladder or bowel disturbance, or history of malignancy. CRP is normal and HLA-B27 is negative. Plain radiographs of the sacroiliac joints do not show sacroiliitis meeting modified New York criteria. What is the most appropriate next imaging investigation?

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

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Correct answer: A — Request an unenhanced MRI using an inflammatory back pain protocol of the whole spine and sacroiliac joints

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

This presentation has several features suggesting axial spondyloarthritis: back pain beginning before age 45 years, prolonged morning stiffness, night waking, improvement with exercise and a good NSAID response. Psoriasis further increases clinical suspicion. Normal CRP and negative HLA-B27 do not exclude axial spondyloarthritis. As sacroiliac radiographs do not demonstrate sacroiliitis meeting modified New York criteria, NICE recommends unenhanced MRI using an inflammatory back pain protocol. This includes STIR and T1-weighted sequences of the whole spine and sacroiliac joints, allowing detection of inflammatory lesions consistent with non-radiographic axial spondyloarthritis. A lumbar MRI alone may identify alternative lumbar pathology but does not provide the required assessment of the sacroiliac joints or whole spine. C is inappropriate because NICE specifies an unenhanced inflammatory back pain protocol, rather than contrast-enhanced imaging limited to the sacroiliac joints. D can show structural change but is not the recommended next test for suspected non-radiographic disease after non-diagnostic radiographs. E is specifically not recommended for suspected axial spondyloarthritis.

Reference: NICE NG65: Spondyloarthritis in over 16s: diagnosis and management — Imaging for suspected axial spondyloarthritis (2017) — https://www.nice.org.uk/guidance/ng65/chapter/Recommendations