21/06/2026
The Hidden Inflammatory Back Disease That Often Goes Unrecognized :
By Dr Puneet Srivastava
Senior Consultant Rheumatologist
Back pain is one of the commonest health complaints worldwide and, in most cases, it is attributed to mechanical causes such as poor posture, muscle strain, degenerative disc disease, or sedentary lifestyles. However, there exists a group of patients whose back pain has an entirely different origin—an inflammatory condition known as Non-Radiographic Axial Spondyloarthritis (nr-axSpA).
Unfortunately, awareness of this disease remains limited among both patients and healthcare professionals, resulting in delayed diagnosis and years of unnecessary suffering.
Many patients with nr-axSpA spend years moving from one clinic to another. Some are told they have fibromyalgia, while others are reassured that their investigations are normal. Yet their symptoms persist. They continue to experience pain, stiffness, fatigue, disturbed sleep, and declining quality of life.
One of the major reasons for delayed diagnosis is the misconception that inflammatory arthritis must always be accompanied by abnormal blood tests or visible changes on X-rays.
In reality, patients with Non-Radiographic Axial Spondyloarthritis may have completely normal X-rays, normal inflammatory markers such as ESR and CRP, and even a negative HLA-B27 test.
A normal blood report therefore does not necessarily mean the absence of disease.
The hallmark symptom is inflammatory back pain. Typically, symptoms begin before the age of 45 years and persist for months or years. Unlike mechanical back pain, which often worsens with activity, inflammatory back pain improves with movement and exercise and tends to worsen with prolonged rest. Many patients report significant morning stiffness and night-time pain that wakes them from sleep.
Additional clues may include heel pain, psoriasis, recurrent eye inflammation (uveitis), inflammatory bowel disease, or a family history of similar conditions.
In recent years, magnetic resonance imaging (MRI) has transformed our ability to identify inflammatory spinal disease at an earlier stage. MRI can detect inflammation within the sacroiliac joints long before permanent damage becomes visible on conventional X-rays.
However, MRI interpretation is not always straightforward. The earliest signs of inflammation may appear as subtle areas of subchondral bone marrow edema that can be difficult to appreciate, particularly when the disease is in its infancy. As a result, some patients may receive MRI reports that are described as normal despite symptoms strongly suggestive of inflammatory disease.
This highlights an important principle in medicine: investigations should support clinical judgment, not replace it.
The diagnosis of axial spondyloarthritis is ultimately based on the entire clinical picture. Symptoms, examination findings, family history, associated conditions, laboratory investigations, and imaging studies must all be considered together. No single blood test or imaging report can definitively confirm or exclude the diagnosis in every patient.
As rheumatologists, we are frequently reminded that medicine remains both a science and an art. While modern imaging and laboratory techniques have greatly improved our diagnostic capabilities, careful listening to the patient's history remains equally important.
Early recognition of Non-Radiographic Axial Spondyloarthritis can be life-changing. Effective treatments are now available that can control inflammation, reduce pain, improve mobility, and help patients maintain productive and active lives.
Patients should remember three important facts:
A normal X-ray does not exclude axial spondyloarthritis.
A negative HLA-B27 test does not exclude axial spondyloarthritis.
Normal ESR and CRP levels do not exclude axial spondyloarthritis.
Persistent back pain in a young individual that improves with exercise and worsens with rest deserves careful evaluation. Sometimes the diagnosis is not hidden in the blood test. Sometimes it is not visible on the X-ray. Sometimes it emerges only when the patient's story is heard in full and the imaging is reviewed through the lens of clinical experience.
In rheumatology, as in all of medicine, we must remember a timeless principle: Treat the patient, not merely the test results.
Dr Puneet Srivastava
Senior Consultant Rheumatologist
Srigyan Rheumatology Clinic, Ghaziabad
Call now to connect with business.
