Inflammatory Back Pain in Adults

Suspected inflammatory back pain: axial Spondyloarthritis (axSpa)

Key message: Early referral improves treatment response and potentially reduces disease progression.

Adults with suspected axial spondyloarthritis (axSpa), with at least 3 of the symptoms or predisposing factors listed below, should be referred for a specialist opinion to the RCHT early inflammatory back pain clinic , please specify this on the referral

If there is no evidence of inflammatory back pain in the history then consider referral to the orthopedic back pain pathway instead for further assessment.

Symptoms of inflammatory back pain include:-

Age at onset <45 years of age.
Insidious onset.
Duration for at least 3 months.
Marked and protracted early morning stiffness (>30 minutes duration).
Pain at night (with improvement on getting up).
Improvement with exercise.
No improvement with rest.
Improvement with NSAID’s.

The diagnosis of axSpa should also be considered in the following patients presenting with back pain:-

History of anterior uveitis.
History of psoriasis.
History of inflammatory bowel disease.
History of peripheral arthritis.
History of dactylitis.
History of enthesitis (plantar fasciitis, Achilles enthesitis).
Family history of ankylosing spondylitis, reactive arthritis, psoriasis, IBD or uveitis.

*Please consider using the Spade tool to aid decision making with referral(www.spadetool.co.uk)

Investigations prior to referral:-

FBC, U&E, LFTS, CRP, HLA -B27

Do not delay referral if investigations are normal.

Nb.CRP can be normal & up to 20% of patients with axSpa are HLA-B27 negative

There is no role for plain X-rays unless suspicion of vertebral fracture (X-rays can take 8-10 years to reveal changes consistent with AxSpa).

Red flags Consider other serious pathology in patients at particular risk:-

Extremes of age

Immunocompromised

Past history of cancer

Constitutional symptoms (weight loss)

History is key in diagnosing inflammatory back pain.

Typically presents as low back pain and stiffness of insidious onset that is worse first thing in the morning or after rest, lasts at least 30 minutes and improves with activity.

Sacroiliitis may present as ill-defined unilateral or bilateral buttock pain, with radiation sometimes into the upper posterior thigh.

Pain may also be felt in the thoracic or cervical region or in the chest. Occasionally, patients present with symptoms of peripheral joint symptoms or enthesitis (Achilles enthesitis or plantar fasciitis).

Examination:-

Clinical findings may be subtle in the early stages.

Examination should include:

Range of movement of the lumbar, thoracic and cervical spine
Examination of the sacroiliac joints
Evidence of synovitis of peripheral joints, dactylitis or enthesitis.
Assess for the presence of extra-articular manifestation of disease, including anterior uveitis, aortic incompetence, cardiac conduction disturbances, pulmonary fibrosis, psoriasis and inflammatory bowel disease.

Details to be included in referral:

Duration of symptoms (at least 3 months).

Age at onset (<45 years of age).

Nature and character of spinal symptoms.

History of peripheral joint symptoms or enthesitis.

History of psoriasis, anterior uveitis, IBD.

Family history of psoriasis, anterior uveitis, IBD, ankylosing spondylitis, reactive arthritis.

Systemic symptoms (weight loss, fever)

Examination findings.

Investigations (HLA-B27, CRP).

References:

www.nice.org.uk (NG65)