Adults
Suspected axial spondyloarthritis (axSpA)
Chronic back pain beginning before age 45 with inflammatory features. Diagnosis is often delayed by years.
What to look for
- Back pain for 3 months or more that began before age 45
- Inflammatory features: insidious onset, morning stiffness over 30 minutes, improves with exercise but not rest, night pain, alternating buttock pain
- Plus: HLA-B27, uveitis, psoriasis, IBD, dactylitis or enthesitis, family history, a good NSAID response, or a raised CRP
What to do
- Send CRP, ESR and HLA-B27.
- Get an AP pelvis radiograph as the first imaging test. The 2026 ACR guideline prefers it over lumbar spine films or dedicated SI joint views.
- If X-rays are non-diagnostic, SI joint MRI without contrast is the next test. Rheumatology often arranges this.
- Start a continuous NSAID trial and refer to physical therapy while waiting.
Good to know
- A normal X-ray does not rule out axSpA. Non-radiographic disease is common, especially in women.
About this urgency level
Specialist evaluation helps, but these are usually less time-sensitive than new inflammatory arthritis or connective tissue disease.
Timeframes are typical targets. Local pathways, capacity and clinical judgment come first.