A 33-Year-Old Patient with Persistent Back Pain

Abstract

A 33-year-old male with a past medical history of uveitis and psoriasis presented to the pain clinic for evaluation of bilateral lower back pain. The patient was initially evaluated by his primary care physician (PCP) and was later referred to the pain clinic for suspected bilateral sacroiliac (SI) joint inflammation and pain. After the AP X-ray of the pelvis was inconclusive, MRI of the pelvis was performed and demonstrated SI joint inflammation. Given the medical history of psoriasis, uveitis, and presence of sacroiliac (SI) joint involvement, a diagnosis of sacroiliitis in the presence of ankylosing spondyloarthropathy was made. The diagnosis is usually confirmed in the presence of 4 out of 11 clinical features or the presence of sacroiliitis on the AP X-ray of the pelvis or a pelvic MRI. Sacroiliitis is a multifactorial disease involving a complex interplay of genetic factors, gut microbes, and immune system disturbances. The human leukocyte antigen HLA B-27 gene has been found to be present in 85% of the people affected with the disease. Treatment involves both non-pharmacological and pharmacological options. Among the pharmacological options are NSAIDS, TNF-alpha inhibitors, and glucocorticoids. The role of SI joint corticosteroid injections has also been elucidated in sacroiliitis or spondyloarthropathy due to ankylosing spondylitis. In this chapter, we highlight that the management of SI joint inflammation involves not only carefully titrated pharmacological agents but also use of SI joint steroid injections.