A 24-year-old woman comes to the office with several months of low back and buttock pain. Her pain is most severe early in the morning and fades as the day progresses. There is no recent history of significant illness or trauma. Vital signs are normal. On examination, tenderness is present in the lower lumbar spine. Muscle strength and deep tendon reflexes are normal and equal in all extremities. Plain x-ray findings are shown in the image below: Which of the following is the most appropriate next step in management?

Question

A 24-year-old woman comes to the office with several months of low back and buttock pain.  Her pain is most severe early in the morning and fades as the day progresses.  There is no recent history of significant illness or trauma.  Vital signs are normal.  On examination, tenderness is present in the lower lumbar spine.  Muscle strength and deep tendon reflexes are normal and equal in all extremities.  Plain x-ray findings are shown in the image below:  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d116_76c1_bc81_e9f67524a982_MD0003_00 This patient has inflammatory back pain (ie, onset age <40, chronic/insidious onset, worse with rest/better with activity) and spinal tenderness. Her pelvic x-rays show findings of sacroiliitis, including widening of the sacroiliac joint space and sclerosis of the subchondral bone. This is a characteristic presentation of ankylosing spondylitis (AS). widening of the sacroiliac joint space In AS, prostaglandin E2, acting primarily via the EP4 receptor, has a synergistic effect with the inflammatory cytokines (eg, tumor necrosis factor-alpha [TNF-alpha], IL-17) in promoting syndesmophyte formation and ankylosis. Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, naproxen) and cyclooxygenase-2 inhibitors (eg, celecoxib) reduce the formation of prostaglandin E2. These agents often provide substantial relief of symptoms in AS and inhibit progression of the disease. In many patients (70%-80%), NSAIDs are the only agents needed to reduce pain and stiffness. NSAIDs also help the peripheral arthritis often seen in association with AS. (Choice A) Colchicine is a microtubule inhibitor that suppresses mitosis and inflammatory cell migration. It is commonly used in the treatment of gout but is not recommended for AS. (Choice C) Options for pain relief in patients who have persistent symptoms on NSAID therapy include acetaminophen and tramadol. Opioids (eg, oxycodone) are not well studied for AS and, unlike NSAIDs, do not address the underlying inflammatory process. (Choice D) Intraarticular glucocorticoid injections can be used in select patients with AS for treatment of sacroiliitis, peripheral arthritis, or enthesitis (inflammation at tendon insertions). Systemic glucocorticoids (eg, prednisone) are generally not effective. (Choice E) Anti-TNF (eg, etanercept, infliximab) and anti-IL-17 (eg, secukinumab) agents are effective for patients who have progressive disease despite NSAIDs. However, these medications have significant toxicity and are not used as first-line treatment because many patients do extremely well with NSAIDs alone. Educational objective: First-line treatment options for ankylosing spondylitis include nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors, which provide substantial relief of symptoms and may inhibit progression of the disease for long periods.

A 24-Year-Old Woman Comes to the Office with Several Months