Skill Checkup: A 44-Year-Old Man With Moderate to Severe Lower Back Pain Despite Treatment

Marina Magrey, MD


April 05, 2023

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 44-year-old man from the US with a history of axial spondyloarthritis (SpA) presents with moderate to severe lower back pain. The patient was diagnosed with axial SpA 2 years ago. First-line treatment consisted of naproxen, titrated up to 1000 mg/d; however, the patient remained symptomatic. For the past 20 months, he has been on second-line treatment with etanercept 50 mg/wk. Although that treatment was originally effective, at today's visit, the patient reports lower back pain of increasing severity over the past 3 months. He states that his back pain is worse in the mornings and frequently wakes him up at night owing to its severity. He also reports morning back/neck stiffness that lasts for approximately 1 hour, as well as significant fatigue throughout the day that is interfering with his ability to function in his job as a construction foreman.

The patient is 5 ft 11 in (1.8 m) and weighs 178 lb (80.74 kg; BMI, 24.8).

No abnormalities are noted upon physical examination. Vital signs are within normal ranges. The patient has an Ankylosing Spondylitis Disease Activity Score (ASDAS) of 2.2. MRI reveals inflammation of the sacroiliac joints.



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