A 26-year-old Italian-American man comes to your office for the evaluation of low back pain. He has had this pain for the last eight months, and it is progressively getting worse. The pain is worse in the morning and gets better as the day progresses. He denies any history of trauma in the past. He works as a chef at a local restaurant. His father and uncles also have "back problems." His physical examination reveals a limited range of motion of his lumbosacral spine and markedly reduced chest expansion. The rest of his physical and musculoskeletal examination is unremarkable.
Which of the following is the most appropriate next step in the management of this patient?

Question

A 26-year-old Italian-American man comes to your office for the evaluation of low back pain.  He has had this pain for the last eight months, and it is progressively getting worse.  The pain is worse in the morning and gets better as the day progresses.  He denies any history of trauma in the past.  He works as a chef at a local restaurant.  His father and uncles also have "back problems."  His physical examination reveals a limited range of motion of his lumbosacral spine and markedly reduced chest expansion.  The rest of his physical and musculoskeletal examination is unremarkable. 
Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The patient has typical features of ankylosing spondylitis. These include back pain with morning stiffness which improves with exercise, insidious onset, presence of symptoms for more than three months, reduced range of forward flexion of the lumbar spine on Schober testing, and reduced chest expansion. A diagnosis of ankylosing spondylitis cannot be made unless there is evidence of sacroiliitis, which is the earliest change that is seen radiographically. Therefore, when a patient has typical features of ankylosing spondylitis, a plain x-ray of the sacroiliac joint is the next step to establish the diagnosis. Other radiographic abnormalities suggesting the diagnosis of ankylosing spondylitis include erosions of the ischial tuberosity and iliac crest. Early in the course of disease, squaring of the vertebral bodies on plain x-ray may also suggest the diagnosis. (Choice D) When ankylosing spondylitis is strongly suspected clinically and radiographic findings of plain x-ray are negative or equivocal, a further imaging is indicated to establish the diagnosis. MRI or CT scan may be used for this purpose. (Choice A) HLA-B 27 is frequently (>90% of the patients) present in patients with ankylosing spondylitis and other spondyloarthropathies. Its presence is not specific for the diagnosis of ankylosing spondylitis; however, its absence (negative for HLA B 27) makes the diagnosis of ankylosing spondylitis unlikely. (Choice B) Testing for ANA and rheumatoid factor is not the next appropriate step when a patient has a history typical of ankylosing spondylitis. ANA and rheumatoid factor are absent in ankylosing spondylitis and other seronegative spondyloarthropathies. (Choice C) A bone scan has no role in the diagnosis of ankylosing spondylitis. Educational objective: The three important clinical criteria for the diagnosis of ankylosing spondylitis are: Presence of low back pain and stiffness for more than a three month duration that improves with exercise or activity. Limitation of the range of motion of the lumbar spine. Limitation of chest expansion relative to the normal values. References: Comparison of radiography, computed tomography and magnetic resonance imaging in the detection of sacroiliitis accompanying ankylosing spondylitis. (http://www.ncbi.nlm.nih.gov/pubmed/9677647)

A 26-Year-Old Italian-American Man Comes to Your Office for the Evaluation