What is the best course of treatment for a patient with chronic back pain, bony ankylosis through the mid and lower thoracic spine, disc space narrowing, prominent thoracic kyphosis, and mild rightward curvature of the lower thoracic spine, with a negative HLA (Human Leukocyte Antigen) B27 test result?

Treatment of Chronic Back Pain with Spinal Ankylosis (HLA-B27 Negative)

Despite the negative HLA-B27, this patient's radiographic findings of bony ankylosis, disc space narrowing, and thoracic kyphosis are consistent with advanced axial spondyloarthropathy, and treatment should follow the same evidence-based approach as HLA-B27 positive ankylosing spondylitis, starting with NSAIDs as first-line therapy, structured exercise programs, and vigilant monitoring for spinal fractures. 1

Critical Safety Consideration: Fracture Risk

Patients with spinal ankylosis have a high incidence of unstable fractures from minor trauma or even without recognizable trauma. 1

• Maintain high clinical suspicion for fracture whenever this patient presents with new or worsening spine pain 1
• Multiplanar CT is required for exclusion of fracture if any trauma is reported or new pain develops 1
• These fractures frequently involve all 3 columns and are unstable with high rates of neurologic injury 1
• If neurologic symptoms develop, MRI without contrast is needed to evaluate spinal cord and nerve root injuries 1

First-Line Pharmacologic Treatment

NSAIDs (including COX-2 inhibitors) are the recommended first-line drug treatment for pain and stiffness. 1

• Continuous NSAID treatment is preferred over on-demand dosing for persistently active, symptomatic disease 1
• Cardiovascular, gastrointestinal, and renal risks must be assessed before prescribing 1
• If NSAIDs fail, are contraindicated, or poorly tolerated, consider analgesics such as acetaminophen or tramadol for residual pain 1, 2

Non-Pharmacologic Treatment (Essential Component)

Structured exercise therapy and physical therapy are fundamental treatments that must be implemented alongside pharmacologic management. 1, 2

• Exercise programs should focus on spinal mobility, postural correction, and core strengthening 1, 2
• Physical therapy provides back pain relief for 2-18 months 3
• Multidisciplinary rehabilitation combining physical, psychological, and educational interventions demonstrates effectiveness 2
• Consider complementary approaches including yoga, tai chi, or mindfulness-based stress reduction based on patient preference 2

Advanced Pharmacologic Options

If inadequate response to NSAIDs and exercise after 4-6 weeks:

• Duloxetine or tramadol as second-line therapy 2
• Tricyclic antidepressants (amitriptyline 10-25mg at bedtime) as part of multimodal strategy 2
• Opioids only as last resort after thorough discussion of risks versus benefits 1, 2

Treatments NOT Recommended

Avoid the following interventions as they lack evidence or may cause harm:

• Systemic glucocorticoids for axial disease (no evidence of efficacy) 1
• Disease-modifying antirheumatic drugs (DMARDs) including sulfasalazine and methotrexate for axial disease (no evidence of efficacy) 1
• Epidural injections, facet injections, or radiofrequency ablation for chronic axial spine pain (do not improve morbidity or quality of life) 3
• Bed rest (contraindicated and worsens outcomes) 2

Biologic Therapy Consideration

Anti-TNF therapy should be considered if persistently high disease activity despite conventional treatments (NSAIDs, exercise, physical therapy). 1

• No requirement for DMARD use before or concurrent with anti-TNF therapy for axial disease 1
• Switching to a second TNF blocker may be beneficial in patients with loss of response 1
• No evidence supports biological agents other than TNF inhibitors for ankylosing spondylitis 1

Surgical Considerations

Spinal corrective osteotomy may be considered for severe disabling deformity given this patient's prominent thoracic kyphosis. 1

• Total hip arthroplasty should be considered if hip involvement develops with refractory pain or disability 1
• Consult spinal surgeon immediately if acute vertebral fracture occurs 1

Disease Monitoring

• Monitor disease activity through patient history, clinical parameters, and laboratory tests at individualized intervals based on symptom course and severity 1
• Spinal radiographs should not be repeated more frequently than every 2 years unless clearly indicated 1
• If significant change in disease course occurs, evaluate for causes other than inflammation, particularly spinal fracture 1

Important Clinical Pitfall

HLA-B27 negativity does not exclude axial spondyloarthropathy or ankylosing spondylitis. 1, 4 The radiographic findings of bony ankylosis and characteristic spinal changes are diagnostic regardless of HLA-B27 status, and treatment recommendations remain identical. 1