Diagnosis and Management of Inflammatory Back Pain

Clinical Presentation and Diagnosis

The clinical presentation of chronic low back pain and stiffness that improves with movement and worsens in the morning is most consistent with inflammatory back pain, specifically early axial spondyloarthritis, according to the European League Against Rheumatism 1
Morning stiffness that improves with movement is a cardinal feature of inflammatory back pain, whereas mechanical pain typically worsens with activity, as noted by the American College of Rheumatology 1
The prevalence of ankylosing spondylitis in primary care patients with chronic low back pain ranges from 0.3% to 5%, as reported by the American College of Physicians 2, 3
Among patients with chronic back pain presenting before age 45, the prevalence of axial spondyloarthritis is estimated at 5% when inflammatory features are present, according to the Spondyloarthritis Research Consortium of Canada 1

The classic triad of improvement with exercise, morning stiffness, and worsening with rest has high specificity for inflammatory causes, as stated by the European League Against Rheumatism 1
Assessing for alternating buttock pain and whether pain awakens the patient during the second part of the night can aid in diagnosis, as recommended by the American College of Physicians 2
MRI of the sacroiliac joints can detect inflammation before radiographic changes appear, as noted by the European League Against Rheumatism 1

Early diagnosis is critical because NSAIDs should be taken regularly once diagnosis is made, and TNF-blocking agents show strong efficacy, particularly in patients with disease duration less than 10 years, as reported by the American College of Rheumatology 1