What is the treatment approach for a patient with severe cervical pain and a positive Human Leukocyte Antigen B27 (HLA B27) test result?

Treatment Approach for Severe Cervical Pain with Positive HLA-B27

Patients with severe cervical pain and positive HLA-B27 should be referred promptly to a rheumatologist for evaluation of axial spondyloarthritis, as this combination significantly increases the likelihood of inflammatory rather than purely degenerative pathology. 1

Diagnostic Considerations

When evaluating a patient with severe cervical pain and positive HLA-B27, consider:

• HLA-B27 positivity increases the likelihood of axial spondyloarthritis to approximately 32% in patients with chronic back pain 1
• The presence of inflammatory back pain features is crucial for diagnosis:
  • Morning stiffness lasting more than 30 minutes
  • Pain that improves with exercise but not with rest
  • Pain that worsens at night or early morning 1
• Age of symptom onset (before 45 years suggests axSpA) 1

Initial Management

1. First-line treatment: NSAIDs

   • NSAIDs are highly effective for inflammatory pain in axial spondyloarthritis
   • 75% of patients with ankylosing spondylitis show good response to NSAIDs within 48 hours, compared to only 15% with mechanical back pain 2
   • Short-term NSAID use is safe if inflammatory bowel disease (a potential comorbidity) is in remission 2
   • COX-2 selective NSAIDs may be preferred for long-term treatment due to fewer gastric side effects 2

2. Physical therapy and exercise

   • Regular physiotherapy is essential for maintaining function and reducing pain 1
   • Structured exercise program should be initiated early 1

When to Refer and Advanced Treatment Options

Refer to rheumatology when:

• HLA-B27 positive patient has chronic neck pain with inflammatory features
• Patient shows inadequate response to NSAIDs 1

For patients with persistent symptoms despite NSAIDs:

1. For peripheral joint involvement:

   • Local corticosteroid injections may be beneficial 2, 1
   • Sulfasalazine or methotrexate may be considered for peripheral arthropathy 2

2. For axial disease with inadequate NSAID response:

   • TNF inhibitors (infliximab, etanercept) have "surprisingly strong and fast effect on almost all aspects of active disease" 2
   • IL-17 inhibitors are an alternative biologic option 1

Imaging Recommendations

• MRI is more sensitive than radiography for detecting early inflammatory changes 1
• Sacroiliac joint imaging should be performed even in patients with primarily cervical symptoms 1
• X-rays of affected joints should be part of initial assessment 1

Important Considerations

• HLA-B27 testing should only be performed once, as results don't change over time 1
• Inflammatory markers (ESR/CRP) have limited utility with low sensitivity (~50%) in early axial spondyloarthritis 1
• The risk of developing ankylosing spondylitis is significantly higher in HLA-B27 positive individuals with a family history of the condition 3
• HLA-B27 positive patients may also be at risk for aortic regurgitation and conduction system abnormalities, which should be monitored 4

Monitoring and Follow-up

• Regular clinical reassessment is crucial in patients with HLA-B27 positivity 1
• Assess response to NSAIDs within 48 hours, as good response supports inflammatory etiology 2
• Monitor for extra-articular manifestations including uveitis, psoriasis, and inflammatory bowel disease 2