Ankylosing Spondylitis: The Daily PANCE Blueprint

The answer is E. Ankylosing spondylitis

Back pain in a young man that is worse with rest and better with exercise is inflammatory, and inflammatory back pain plus sacroiliitis is ankylosing spondylitis. Learn the five features of inflammatory back pain and this question answers itself: onset before age 45, insidious start, morning stiffness over 30 minutes, improvement with activity but not with rest, and night pain that wakes the patient in the second half of the night. Mechanical back pain does the exact opposite — it is worse with activity and relieved by lying down — which is why “better with exercise” is the single most useful phrase in the stem. The reduced chest expansion comes from costovertebral joint involvement, and the anterior uveitis is the most common extra-articular manifestation, seen in up to 40% of patients. Diagnosis rests on sacroiliac imaging — plain films may show sacroiliitis, and MRI catches it years earlier — supported by elevated inflammatory markers and HLA-B27, which is present in roughly 90% of patients but is a supporting test rather than a diagnostic one. Treatment is NSAIDs plus a formal, ongoing exercise and posture program, escalating to a TNF inhibitor when NSAIDs fail; conventional DMARDs like methotrexate do little for axial disease. Untreated, syndesmophytes bridge the vertebrae into the classic “bamboo spine,” which is both stiff and brittle — a fused cervical spine fractures with surprisingly minor trauma. The traps: a disk herniation gives radicular leg pain worse with sitting and flexion; spinal stenosis is a disease of older adults with neurogenic claudication relieved by leaning forward; and rheumatoid arthritis attacks small peripheral joints symmetrically and spares the lumbar spine, with a positive RF or anti-CCP.