Question of the Week # 467

A 32-year-old man comes in regularly because his back hurts. You suspect malingering because he continually requests narcotic pain relievers and imaging studies of his spine. He has come 5 times in the last 6 months with the same problem, typically stating that the pain improves with exercise and leaning forward but is worse at night; pain also occurs at times in his buttocks and does not improve with rest. On physical examination you find no abnormalities of the spine besides inflexibility of the lower spine when he leans forward. Neurological examination is normal, including the absence of pain on a straight-leg raise test. X-ray of the spine and sacroiliac joint is normal. All blood tests including rheumatoid factor, ESR, and C-reactive protein are normal. Today, he again claims to have only minimal improvement with ibuprofen. He is requesting narcotics and a “doctor’s note to get out of work.” What is the next best step in management?
A. MRI of the sacroiliac joint
B. Anti-cyclic citrullinated peptide (anti-CCP)
C. HLA-B27 testing
D. Methotrexate
E. Report to employer for malingering

9 Responses

  1. C

  2. A) MRI of the sacroiliac joint.
    Methotrexate is not used in the treatment of ankylosing spondylitis. Patients should exercise. the drug of choice are NSAIDS, if they do not improve the symptoms we should use TNF inhibitors

  3. A

  4. C

  5. answer is A, based on the patients age, 3rd decade, the sequelae of symptoms, in particular stiffness at the lumbar spine and improvement of symptoms with movement, you need to r/o seronegative spondyloarthropathy such as AS; differentials include sciatica, spinal stenosis, possible early onset RA ( low probability), you need MRI to R/O AS and look for features of sacro-illitis, x-ray being normal does not exclude this. hla b27 is not a specific test for AS

  6. C or A first HLA then MRI

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