Morning Stiffness with Back Pain and Burning Sensation
Your symptoms strongly suggest axial spondyloarthritis (including ankylosing spondylitis) rather than radiculopathy, and you need HLA-B27 testing, inflammatory markers, plain radiographs of sacroiliac joints, and rheumatology referral while starting NSAIDs immediately. 1, 2
Why This is Likely Inflammatory Spondyloarthritis
Your symptom pattern is pathognomonic for inflammatory rather than mechanical back pain:
- Morning stiffness improving with movement is the hallmark feature that distinguishes inflammatory from mechanical causes 2, 3
- Morning stiffness lasting >30 minutes has 70.3% sensitivity and 81.2% specificity for ankylosing spondylitis when combined with other features 4
- Pain worsening with rest and improving with activity is the opposite pattern of radiculopathy or disc herniation, which typically worsen with movement 2, 3
- The burning sensation likely represents enthesitis (inflammation at tendon/ligament insertion sites), which is the primary pathologic process in ankylosing spondylitis 5
Immediate Diagnostic Workup
Order these tests now, before the rheumatology appointment:
- Plain radiographs of sacroiliac joints and lumbar spine as first-line imaging (sensitivity 66%, specificity 68% for established disease) 1, 3
- HLA-B27 testing - positive in 74-89% of patients with axial spondyloarthritis, increases post-test probability to 32% in chronic back pain patients 1, 3
- ESR and CRP - though normal in 50% of cases, so cannot rule out disease if negative 3
- If radiographs are negative but clinical suspicion remains high, MRI of sacroiliac joints detects early inflammatory changes before structural damage appears 2, 3
Start Treatment Immediately
Begin NSAIDs at full anti-inflammatory doses now - do not wait for test results or rheumatology appointment 1, 2:
- Approximately 75% of patients show good or very good response within 48 hours of full-dose NSAID therapy 1
- Use the lowest effective dose initially, then titrate to maximum tolerated doses while weighing cardiovascular, gastrointestinal, and renal risks 1
- A dramatic response to NSAIDs within 48 hours itself supports the diagnosis (sensitivity 75%, post-test probability 14%) 6
Mandatory Rheumatology Referral Criteria
You meet criteria for urgent rheumatology referral based on having chronic back pain (>3 months) plus multiple red flags 1:
- Back pain with morning stiffness >30 minutes
- Improvement with movement but not rest
- Likely onset before age 45 (implied by presentation pattern)
- Burning sensation suggesting enthesitis
The diagnosis is frequently delayed 5-8 years from symptom onset, so early recognition is critical 3
What Rheumatology Will Do
The rheumatologist will:
- Confirm diagnosis using ASAS classification criteria 2
- Assess disease activity using BASDAI score (>4 indicates active disease requiring treatment escalation) 1
- Consider biologic DMARDs or JAK inhibitors if NSAIDs fail to control symptoms after adequate trial (at least 3 months at maximal recommended dose) 6, 2
- Screen for extra-articular manifestations, particularly acute anterior uveitis (occurs in up to 40% of patients and requires prompt ophthalmologic referral to prevent vision loss) 3
Critical Pitfalls to Avoid
Do not dismiss this as simple mechanical back pain - up to 5% of patients with chronic lower back pain in primary care have inflammatory disease, but it is commonly missed 6, 5
Do not wait for radiographic changes - it may take several years of inflammation before radiological damage appears on plain films, but MRI can detect early disease 6, 7
Do not stop NSAIDs prematurely - regular NSAID use may slow radiographic progression in established disease 7
Do not assume normal inflammatory markers rule out disease - ESR and CRP are normal in 50% of cases 3