A 28-year-old man presents to the Emergency Department with sudden onset severe lower back pain and urinary retention following heavy lifting at the gym 18 hours ago. He reports bilateral leg paraesthesia and inability to pass urine for 12 hours. On examination, he has reduced perianal sensation, bilateral ankle weakness (4/5), and post-void residual volume of 800ml on bladder scan. MRI shows large L4-L5 central disc prolapse with cauda equina compression. He is listed for emergency decompression. What is the most important prognostic factor for neurological recovery?
Q52
A 76-year-old woman undergoes cemented hemiarthroplasty for a displaced intracapsular neck of femur fracture. She has COPD (FEV1 45% predicted) and ischaemic heart disease. Intraoperatively, immediately after cement insertion, she develops severe hypotension (BP 70/40 mmHg), hypoxia (SpO2 82%), and bradycardia (HR 45/min). What is the underlying pathophysiology of this complication?
Q53
A 67-year-old man with known prostate cancer presents with a 6-week history of progressively worsening thoracic back pain. The pain is constant, worse at night, and unrelieved by analgesia. On examination, there is tenderness over T8-T9 vertebrae, with normal power and sensation in the lower limbs. Plain radiographs show a lytic lesion in T9 vertebra. What is the most appropriate next step in management?
Q54
An 80-year-old woman sustains a Garden II undisplaced intracapsular neck of femur fracture. She is fully mobile pre-injury with a walking stick, living independently. She has atrial fibrillation, hypertension, and chronic kidney disease stage 3. Her abbreviated mental test score is 9/10. What is the most appropriate surgical management?
Q55
A 69-year-old woman with rheumatoid arthritis presents with a 4-week history of worsening lower back pain and progressive bilateral leg weakness. She has been taking prednisolone 15mg daily for the past 10 years. On examination, she has reduced power bilaterally in hip flexion (3/5) and knee extension (3/5), with saddle anaesthesia. What is the most appropriate immediate management?
Q56
A 42-year-old woman presents with a 5-week history of lower back pain that radiates down her right leg to the lateral aspect of her foot. She reports numbness over the dorsum of her foot and difficulty walking on her heels. Straight leg raise is positive at 40 degrees on the right. Which nerve root is most likely affected?
Q57
A 75-year-old man presents to the Emergency Department following a fall. He has pain in his right hip and cannot weight-bear. On examination, the right leg appears shortened and externally rotated. Radiographs confirm a neck of femur fracture. What anatomical landmark distinguishes intracapsular from extracapsular neck of femur fractures?
Q58
A 68-year-old woman sustains an intracapsular neck of femur fracture following a fall. Which artery provides the majority of the blood supply to the femoral head in adults and is most commonly disrupted in displaced intracapsular fractures?
Q59
A 71-year-old man sustains a subtrochanteric femur fracture 3cm below the lesser trochanter following a fall down stairs. Radiographs show a transverse fracture pattern with a medial spike of cortex. He has a history of osteoporosis and has been taking alendronate 70mg weekly for 8 years with good compliance. What is the most likely underlying aetiology of this fracture?
Q60
A 39-year-old woman presents with a 16-week history of lower back pain and significant morning stiffness. She reports the pain alternates between both buttocks and improves throughout the day with activity. Examination shows reduced lumbar spine flexion. Blood tests show ESR 38 mm/hr, CRP 22 mg/L, normal ANA, negative rheumatoid factor, and HLA-B27 positive. MRI pelvis shows bilateral bone marrow oedema in the sacroiliac joints. What is the most appropriate initial pharmacological management?
Orthopaedics & MSK UK Medical PG Practice Questions and MCQs
Question 51: A 28-year-old man presents to the Emergency Department with sudden onset severe lower back pain and urinary retention following heavy lifting at the gym 18 hours ago. He reports bilateral leg paraesthesia and inability to pass urine for 12 hours. On examination, he has reduced perianal sensation, bilateral ankle weakness (4/5), and post-void residual volume of 800ml on bladder scan. MRI shows large L4-L5 central disc prolapse with cauda equina compression. He is listed for emergency decompression. What is the most important prognostic factor for neurological recovery?
A. Age of the patient
B. Size of disc prolapse on MRI
C. Duration of symptoms before surgical decompression (Correct Answer)
D. Severity of motor weakness at presentation
E. Presence of urinary retention versus urinary incontinence
Explanation: ***Duration of symptoms before surgical decompression***
- The **time to surgery** is the most critical prognostic factor, with decompression within **48 hours** (ideally <24 hours) significantly improving outcomes for bladder and bowel function.
- Prolonged compression leads to **irreversible ischemic damage** to the nerve roots, meaning outcomes deteriorate rapidly the longer the surgery is delayed.
*Age of the patient*
- While younger age may assist in general rehabilitation, it is not a primary predictor of **neurological recovery** in acute cauda equina syndrome.
- Surgical urgency remains the priority regardless of age to prevent **permanent neurological deficits**.
*Size of disc prolapse on MRI*
- Although a large canal occupancy is helpful for diagnosis, **radiological severity** of the disc prolapse does not correlate well with the degree of neurological recovery.
- The **clinical presentation** and timing of intervention are far more clinically significant than the physical dimensions of the prolapsed disc.
*Severity of motor weakness at presentation*
- While initial motor deficits guide the urgency of care, even patients with **severe weakness** can experience significant recovery if decompressed quickly.
- **Duration of compression** is a more reliable prognostic marker for long-term function than the baseline motor score.
*Presence of urinary retention versus urinary incontinence*
- Though **urinary retention (CESR)** often signals a more severe prognosis than incomplete symptoms (CESI), the timing of decompression still dictates the final functional outcome.
- Classification into **CESI or CESR** helps categorize severity, but the delay to surgery is the ultimate determinant of whether bladder function returns.
Question 52: A 76-year-old woman undergoes cemented hemiarthroplasty for a displaced intracapsular neck of femur fracture. She has COPD (FEV1 45% predicted) and ischaemic heart disease. Intraoperatively, immediately after cement insertion, she develops severe hypotension (BP 70/40 mmHg), hypoxia (SpO2 82%), and bradycardia (HR 45/min). What is the underlying pathophysiology of this complication?
A. Type 1 hypersensitivity reaction to methyl methacrylate causing anaphylaxis
B. Pulmonary and systemic embolisation of cement, marrow contents, and air causing increased pulmonary vascular resistance (Correct Answer)
C. Direct myocardial toxicity from systemic absorption of cement monomer
D. Massive pulmonary embolism from dislodged deep vein thrombus
E. Haemorrhagic shock from intraoperative bleeding into the surgical site
Explanation: ***Pulmonary and systemic embolisation of cement, marrow contents, and air causing increased pulmonary vascular resistance***
- This clinical scenario describes **Bone Cement Implantation Syndrome (BCIS)**, an acute cardiorespiratory collapse occurring during cemented arthroplasty due to embolization.
- **Pressurization of cement** into the intramedullary canal forces **fat globules, bone marrow, air, and cytotoxic cement monomers** into the venous system, causing **pulmonary vascular obstruction**, right heart strain, and subsequent systemic shock.
*Type 1 hypersensitivity reaction to methyl methacrylate causing anaphylaxis*
- While **methyl methacrylate** can cause allergic reactions, BCIS is primarily an **embolic and inflammatory response**, not a typical IgE-mediated anaphylaxis.
- True **anaphylaxis** often includes cutaneous manifestations (e.g., urticaria, angioedema) or severe bronchospasm, which are not the defining features of this acute presentation.
*Direct myocardial toxicity from systemic absorption of cement monomer*
- Systemic absorption of **methyl methacrylate monomer** can contribute to **vasodilation** and direct myocardial depression, but it is considered a secondary mechanism in BCIS.
- The immediate and dominant cause of severe hypotension and hypoxia in BCIS is the massive **pulmonary microembolism** and its hemodynamic consequences.
*Massive pulmonary embolism from dislodged deep vein thrombus*
- While a **venous thromboembolism (VTE)** is a risk in orthopedic surgery, the *immediate timing* of symptoms **after cement insertion** strongly points to **BCIS**, not a spontaneous DVT dislodgement.
- BCIS is directly linked to the mechanical and biochemical events of the **cementing process**, differentiating it from a randomly dislodged pre-existing DVT.
*Haemorrhagic shock from intraoperative bleeding into the surgical site*
- **Haemorrhagic shock** from blood loss typically presents with hypotension and **compensatory tachycardia**, not the profound bradycardia observed in this case.
- The acute onset of **hypoxia** and **bradycardia** immediately following cement application is inconsistent with typical hemorrhagic shock, which would usually have a more gradual onset and different vital sign patterns.
Question 53: A 67-year-old man with known prostate cancer presents with a 6-week history of progressively worsening thoracic back pain. The pain is constant, worse at night, and unrelieved by analgesia. On examination, there is tenderness over T8-T9 vertebrae, with normal power and sensation in the lower limbs. Plain radiographs show a lytic lesion in T9 vertebra. What is the most appropriate next step in management?
A. Commence oral bisphosphonate therapy and arrange outpatient oncology review
B. Arrange urgent whole spine MRI within 24 hours (Correct Answer)
C. Commence high-dose oral corticosteroids and arrange routine MRI
D. Refer for urgent radiotherapy to thoracic spine
E. Arrange CT-guided biopsy of the lesion
Explanation: ***Arrange urgent whole spine MRI within 24 hours***
- The patient presents with **red flags** for **Metastatic Spinal Cord Compression (MSCC)**, including known **prostate cancer**, progressively worsening back pain (constant, worse at night, unrelieved by analgesia), and a **lytic lesion** on radiograph.
- **Urgent MRI of the whole spine** within 24 hours is the gold standard investigation to identify the degree of compression and check for **synchronous spinal metastases** before irreversible neurological damage occurs.
*Commence oral bisphosphonate therapy and arrange outpatient oncology review*
- While **bisphosphonates** are useful for reducing skeletal-related events and pain in bone metastases, they do nothing to prevent the acute neurological catastrophic risk of **spinal cord compression**.
- An outpatient review results in a dangerous **diagnostic delay**, as suspected MSCC requires immediate emergency assessment and management to preserve motor and sensory function.
*Commence high-dose oral corticosteroids and arrange routine MRI*
- **High-dose oral corticosteroids** (e.g., Dexamethasone) should be initiated immediately upon *suspicion* of MSCC to reduce edema around the spinal cord, but this must be paired with an **urgent MRI**.
- Delaying imaging by arranging a **routine MRI** increases the risk of the patient developing irreversible **neurological deficits** or even **paraplegia** while awaiting the scan.
*Refer for urgent radiotherapy to thoracic spine*
- **Radiotherapy** is a primary treatment modality for confirmed MSCC, but it cannot be safely or effectively prescribed without an **MRI** to precisely define the exact field and identify any other sites of compression.
- Depending on the MRI findings, **surgical decompression** might be the preferred first-line treatment over radiotherapy for some patients, which can only be determined after comprehensive **MRI imaging**.
*Arrange CT-guided biopsy of the lesion*
- **CT-guided biopsy** is unnecessary and causes a delay in management because the patient already has a known primary diagnosis of **prostate cancer**, making the lytic lesion highly likely to be a metastasis.
- The immediate priority is assessing for **thecal sac compression** and potential neurological compromise rather than histological confirmation of a clear metastatic process.
Question 54: An 80-year-old woman sustains a Garden II undisplaced intracapsular neck of femur fracture. She is fully mobile pre-injury with a walking stick, living independently. She has atrial fibrillation, hypertension, and chronic kidney disease stage 3. Her abbreviated mental test score is 9/10. What is the most appropriate surgical management?
A. Cemented hemiarthroplasty
B. Uncemented hemiarthroplasty
C. Total hip replacement
D. Internal fixation with cannulated screws (Correct Answer)
E. Non-operative management with early mobilisation
Explanation: ***Internal fixation with cannulated screws***
- For **Garden I and II undisplaced intracapsular fractures**, **internal fixation** (commonly with cannulated screws) is the preferred treatment to preserve the natural femoral head.
- This procedure is less invasive, with lower **operative time** and **blood loss**, which is advantageous for an 80-year-old patient with significant **comorbidities**.
*Cemented hemiarthroplasty*
- This is primarily indicated for **displaced intracapsular fractures** (Garden III and IV) in elderly patients, especially those with limited mobility or cognitive impairment.
- While suitable for the elderly, it is a more invasive procedure than internal fixation and not the first choice for an **undisplaced fracture**.
*Uncemented hemiarthroplasty*
- Generally avoided in older patients due to a higher risk of **intra-operative fractures** and poor long-term outcomes compared to cemented fixation.
- **NICE guidelines** recommend **cemented implants** when arthroplasty is indicated for hip fractures in the elderly.
*Total hip replacement*
- Reserved for **displaced intracapsular fractures** in active, cognitively intact patients with a good life expectancy, often to prevent future revision.
- Although the patient is fit and cognitively intact, her fracture is **undisplaced**, making joint-preserving **internal fixation** the more appropriate initial option.
*Non-operative management with early mobilisation*
- This approach is typically reserved for patients who are **non-ambulatory** before the injury or those with **terminal illness** and are too medically unstable for any surgical intervention.
- It carries a high risk of **non-union**, malunion, and prolonged pain, which would compromise this patient's **pre-injury independence** and quality of life.
Question 55: A 69-year-old woman with rheumatoid arthritis presents with a 4-week history of worsening lower back pain and progressive bilateral leg weakness. She has been taking prednisolone 15mg daily for the past 10 years. On examination, she has reduced power bilaterally in hip flexion (3/5) and knee extension (3/5), with saddle anaesthesia. What is the most appropriate immediate management?
A. Commence analgesia and physiotherapy referral
B. Arrange urgent MRI spine and immediate neurosurgical referral (Correct Answer)
C. Arrange routine MRI spine within 2 weeks
D. Commence oral bisphosphonate therapy
E. Increase prednisolone dose to 30mg daily
Explanation: ***Arrange urgent MRI spine and immediate neurosurgical referral***
- The patient presents with classic features of **Cauda Equina Syndrome (CES)**, including **saddle anaesthesia**, progressive **bilateral leg weakness**, and worsening back pain.
- This is a **neurosurgical emergency** requiring urgent diagnostic imaging (MRI) and prompt surgical decompression to prevent permanent neurological deficits.
*Commence analgesia and physiotherapy referral*
- **Physiotherapy** is contraindicated in acute **neurological compromise** due to potential spinal cord or cauda equina compression.
- Relying solely on **analgesia** would significantly delay definitive treatment, risking **irreversible nerve damage** and permanent disability.
*Arrange routine MRI spine within 2 weeks*
- A routine MRI is inappropriate for suspected **Cauda Equina Syndrome**, which demands **immediate imaging** to confirm the diagnosis and identify the level of compression.
- Delays beyond **24-48 hours** can significantly worsen prognosis and lead to permanent neurological deficits such as **bowel and bladder dysfunction**.
*Commence oral bisphosphonate therapy*
- While chronic **prednisolone** use increases the risk of **osteoporosis** and vertebral fractures, bisphosphonates do not address the acute neurological emergency of cauda equina compression.
- This therapy is for **long-term bone density management** and offers no immediate benefit for nerve root decompression.
*Increase prednisolone dose to 30mg daily*
- Increasing steroid dosage will not resolve the **mechanical compression** of the cauda equina and could exacerbate existing **osteoporosis** or mask a potential infectious cause like an epidural abscess.
- Steroids are not a treatment for **structural compression** of nerve roots, which requires urgent surgical intervention.
Question 56: A 42-year-old woman presents with a 5-week history of lower back pain that radiates down her right leg to the lateral aspect of her foot. She reports numbness over the dorsum of her foot and difficulty walking on her heels. Straight leg raise is positive at 40 degrees on the right. Which nerve root is most likely affected?
A. L3
B. L4
C. L5 (Correct Answer)
D. S1
E. S2
Explanation: ***L5***- The patient's presentation with **numbness over the dorsum of the foot**, difficulty walking on her **heels** (indicating weakness in foot dorsiflexion), and pain radiating to the **lateral aspect of her foot** are classic symptoms of **L5 radiculopathy**.- A positive **straight leg raise** test further supports nerve root compression, often seen with lumbar disc herniation affecting the L5 root, typically at the **L4-L5 level**.*L3*- L3 radiculopathy typically presents with sensory loss over the **anterior thigh** and the medial aspect of the knee.- Motor weakness primarily involves **hip flexion** and **knee extension**, not foot dorsiflexion.*L4*- L4 nerve root compression is characterized by sensory deficits over the **medial leg** and medial malleolus, not the dorsum of the foot.- It often results in weakness of **knee extension** and a diminished **patellar reflex**.*S1*- S1 radiculopathy is typically associated with weakness in **plantar flexion**, leading to difficulty with **toe walking**.- Sensory loss is primarily over the **lateral aspect of the foot** and small toe, and the **Achilles reflex** is usually diminished.*S2*- S2 nerve root compression is less common and primarily affects sensation over the **posterior thigh** and popliteal fossa.- It does not typically cause the specific motor weakness in **heel walking** or the sensory distribution over the dorsal foot seen in this patient.
Question 57: A 75-year-old man presents to the Emergency Department following a fall. He has pain in his right hip and cannot weight-bear. On examination, the right leg appears shortened and externally rotated. Radiographs confirm a neck of femur fracture. What anatomical landmark distinguishes intracapsular from extracapsular neck of femur fractures?
A. Lesser trochanter
B. Greater trochanter
C. Intertrochanteric line anteriorly and intertrochanteric crest posteriorly (Correct Answer)
D. Femoral shaft
E. Subtrochanteric region
Explanation: ***Intertrochanteric line anteriorly and intertrochanteric crest posteriorly***
- These landmarks represent the **distal attachment** of the **hip joint capsule**; fractures proximal to these lines are considered **intracapsular**.
- This distinction is critical because intracapsular fractures risk disrupting the **medial circumflex femoral artery**, leading to **avascular necrosis**.
*Lesser trochanter*
- This is a site of attachment for the **iliopsoas muscle** and is located distal to the capsule, making it a feature of **extracapsular** fractures.
- Isolated fractures here are rare and usually occur due to **avulsion injuries** in younger patients or metabolic bone disease.
*Greater trochanter*
- The greater trochanter serves as an attachment point for the **gluteus medius** and minimus and is located outside the synovial joint capsule.
- Fractures involving this area are classified as **extracapsular** and generally have a better blood supply for healing compared to neck fractures.
*Femoral shaft*
- This region starts distal to the **subtrochanteric area** and is entirely unrelated to the hip joint capsule boundaries.
- Injuries here are classified as **femoral shaft fractures** and are managed with different surgical techniques like **intramedullary nailing**.
*Subtrochanteric region*
- Defined as the area within **5cm distal** to the lesser trochanter, which is well below the capsular attachment points.
- Fractures in this zone are **extracapsular** and are subjected to high mechanical stresses from surrounding musculature.
Question 58: A 68-year-old woman sustains an intracapsular neck of femur fracture following a fall. Which artery provides the majority of the blood supply to the femoral head in adults and is most commonly disrupted in displaced intracapsular fractures?
A. Lateral circumflex femoral artery
B. Medial circumflex femoral artery (Correct Answer)
C. Artery of ligamentum teres
D. Inferior gluteal artery
E. Obturator artery
Explanation: ***Medial circumflex femoral artery***
- This artery provides the **majority (60-80%)** of the blood supply to the adult femoral head via its **retinacular branches**.
- Because these branches are **intracapsular** and closely applied to the femoral neck, they are frequently torn in **displaced fractures**, leading to high rates of **avascular necrosis**.
*Lateral circumflex femoral artery*
- This artery mainly supplies the **greater trochanter** and the soft tissues of the lateral thigh, contributing minimally to the femoral head.
- While it participates in the **cruciate anastomosis**, its role in maintaining femoral head viability is significantly less than that of the medial circumflex.
*Artery of ligamentum teres*
- This artery is a branch of the **obturator artery** and provides only about **10-20%** of the blood supply to the femoral head in adults.
- It is generally **insufficient** to prevent ischemic death of the femoral head if the main retinacular supply is lost due to a fracture.
*Inferior gluteal artery*
- The inferior gluteal artery primarily supplies the **gluteus maximus** muscle and the posterior pelvic region.
- While it contributes to the **trochanteric anastomosis**, it is not a direct or significant source of blood for the **proximal head of the femur**.
*Obturator artery*
- The obturator artery gives rise to the **artery of the ligamentum teres**, which is only a minor contributor to adult femoral vascularity.
- It primarily supplies the **muscles of the medial compartment** of the thigh and the pelvic wall rather than the bone of the femoral head.
Question 59: A 71-year-old man sustains a subtrochanteric femur fracture 3cm below the lesser trochanter following a fall down stairs. Radiographs show a transverse fracture pattern with a medial spike of cortex. He has a history of osteoporosis and has been taking alendronate 70mg weekly for 8 years with good compliance. What is the most likely underlying aetiology of this fracture?
A. Pathological fracture through metastatic deposit
B. Stress fracture from undiagnosed Paget's disease
C. Atypical femoral fracture related to long-term bisphosphonate therapy (Correct Answer)
D. Typical osteoporotic fragility fracture
E. Insufficiency fracture from vitamin D deficiency
Explanation: ***Atypical femoral fracture related to long-term bisphosphonate therapy***- This patient's fracture exhibits classic **atypical femoral fracture (AFF)** features, including a **subtrochanteric location**, **transverse fracture pattern**, and the characteristic **medial spike** of cortex.- Long-term use of **bisphosphonates** (specifically >5 years) can lead to oversuppression of **bone remodeling**, causing the accumulation of microdamage and specialized stress fractures.*Pathological fracture through metastatic deposit*- While metastases often occur in the proximal femur, they typically present with **lytic or blastic lesions** on imaging rather than a clean transverse fracture with a medial spike.- There is no mention of a primary malignancy or system symptoms that would lead toward a **neoplastic** etiology.*Stress fracture from undiagnosed Paget's disease*- Paget's disease typically causes **cortical thickening**, **coarse trabeculae**, and bone enlargement, which are not described in this radiographic presentation.- While Paget's can result in fractures, they usually occur in bones that show characteristic **osteoblastic and osteoclastic** remodeling abnormalities.*Typical osteoporotic fragility fracture*- Osteoporotic fragility fractures of the hip usually involve the **femoral neck** or **intertrochanteric region** and often have a spiral or oblique configuration.- The **transverse pattern** and specific subtrochanteric location are specifically defining features of **atypical** fractures rather than standard fragility fractures.*Insufficiency fracture from vitamin D deficiency*- While **vitamin D deficiency** (osteomalacia) can lead to Looser's zones or insufficiency fractures, these are typically bilateral and located in the **femoral neck** or pubic rami.- This fracture's morphological features and the strong correlation with **8 years of alendronate** use make AFF the most probable diagnosis.
Question 60: A 39-year-old woman presents with a 16-week history of lower back pain and significant morning stiffness. She reports the pain alternates between both buttocks and improves throughout the day with activity. Examination shows reduced lumbar spine flexion. Blood tests show ESR 38 mm/hr, CRP 22 mg/L, normal ANA, negative rheumatoid factor, and HLA-B27 positive. MRI pelvis shows bilateral bone marrow oedema in the sacroiliac joints. What is the most appropriate initial pharmacological management?
A. High-dose non-steroidal anti-inflammatory drug (NSAID) continuously (Correct Answer)
B. Anti-TNF biologic therapy (adalimumab)
C. Bisphosphonate therapy (alendronate)
D. Oral prednisolone 15mg daily with calcium and vitamin D
E. Disease-modifying antirheumatic drug (methotrexate)
Explanation: ***High-dose non-steroidal anti-inflammatory drug (NSAID) continuously***- **NSAIDs** are the first-line pharmacological treatment for **axial spondyloarthritis** and should be used at the maximum tolerated dose to reduce inflammation and pain.- Unlike other forms of arthritis, **continuous use** of NSAIDs in axial disease is preferred over on-demand use as it may potentially slow **radiographic progression**.*Anti-TNF biologic therapy (adalimumab)*- These are highly effective agents restricted to **second-line therapy** for patients who have failed at least two different **NSAIDs** over a 4-week period.- They are indicated only if disease activity remains high, typically measured by a **BASDAI score** of 4 or more.*Bisphosphonate therapy (alendronate)*- This class of medication is used to treat **osteoporosis** and has no role in managing the primary inflammatory symptoms of **ankylosing spondylitis**.- While patients with chronic inflammation are at higher risk for bone loss, it is not an **initial management** strategy for back pain.*Oral prednisolone 15mg daily with calcium and vitamin D*- **Systemic corticosteroids** are generally avoided in axial spondyloarthritis because they have shown **limited efficacy** for spinal disease.- Long-term use of oral steroids carries significant risks, including **osteoporosis** and metabolic complications, without improving long-term outcomes in this condition.*Disease-modifying antirheumatic drug (methotrexate)*- Conventional **DMARDs** like methotrexate or sulfasalazine are ineffective for **axial (spinal) disease** and are not recommended for isolated sacroiliitis.- These agents are only considered in cases where there is significant **peripheral joint involvement** accompanying the axial symptoms.
