Diagnostic Approach and Management of Right-Sided Sacroiliac Pain

Clinical Presentation and Diagnosis

The American College of Radiology suggests that inflammatory axial spondyloarthropathy (axSpA) is highly unlikely in a 90-year-old patient, as it typically presents in younger adults (20s-40s) 1, 2
Improvement with heat and NSAIDs is consistent with degenerative joint disease, and inflammatory back pain typically improves with exercise and worsens with rest, as noted by the American College of Radiology 2, 3
The American College of Radiology rates X-ray of sacroiliac joints as "usually appropriate" (rating 9) for initial evaluation, to assess for degenerative changes, sclerosis, and joint space narrowing 3, 4

Plain radiographs of the pelvis/sacroiliac joints should be obtained first to evaluate for degenerative changes, sclerosis, and joint space narrowing, as recommended by the American College of Radiology 3, 4
CT without contrast (rating 7) can identify subtle erosions and degenerative changes, especially useful if MRI is contraindicated, according to the American College of Radiology 3, 4
MRI is NOT routinely indicated in this clinical scenario unless inflammatory disease is genuinely suspected, which it should not be given the patient's age and presentation, as stated by the American College of Radiology 3, 4

The American Society of Anesthesiologists and ASRA support SI joint injections for chronic SI joint pain, which serves both diagnostic and therapeutic purposes 5
The American College of Rheumatology conditionally recommends local glucocorticoid injections for stable disease with active symptoms, with an evidence rating of 1 B+ 7
Continue NSAIDs (ibuprofen/Advil) as already providing benefit, and monitor for GI toxicity given age, as recommended by the American College of Rheumatology 6
Consider adding acetaminophen for additional analgesia if NSAIDs alone insufficient, as suggested by the American College of Rheumatology 6