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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 a 7-month history of deep bilateral buttock pain, intermittent groin pain and low back stiffness. Symptoms began at age 31 years. She wakes most nights in the second half of the night and feels markedly better after getting up and moving around. Naproxen produces substantial improvement within 24 hours. She has chronic plaque psoriasis managed with topical treatment. Examination shows mildly reduced hip internal rotation bilaterally but no peripheral synovitis, dactylitis or enthesitis. Neurological examination is normal. CRP and ESR are normal. A pelvic radiograph performed 3 months ago for groin pain did not show sacroiliitis. What is the most appropriate next step in primary care?

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

This presentation meets NICE criteria for direct rheumatology referral for suspected axial spondyloarthritis (axSpA). Her back pain began before age 45 years and has persisted for more than 3 months. She has at least four additional referral features: onset before age 35 years, waking in the second half of the night, buttock pain, improvement with movement, rapid response to an NSAID and current psoriasis. HLA-B27 testing is therefore not required before referral; it is used in the NICE pathway only when exactly three additional features are present. Normal inflammatory markers do not exclude axSpA. Likewise, a normal plain pelvic radiograph does not exclude disease, because non-radiographic axSpA may be present without radiographic sacroiliitis. MRI using an inflammatory back-pain protocol is part of specialist diagnostic assessment after appropriate radiography, rather than a test that should delay referral in someone who already meets the primary-care referral threshold. Physiotherapy may have a role after diagnostic assessment and as part of management, but labelling this as mechanical pain would overlook the inflammatory symptom pattern and psoriasis-associated risk.

Reference: Spondyloarthritis in over 16s: diagnosis and management — Recommendations (Published 28 February 2017; last updated 2 June 2017) — https://www.nice.org.uk/guidance/NG65/chapter/Recommendations Spondyloarthritis in over 16s: diagnosis and management — Recommendations (Published 28 February 2017; last updated 2 June 2017) — https://www.nice.org.uk/guidance/NG65/chapter/Recommendations