| Back Pain - Sacroiliac Joint Pain: Part 1
Patient B:
A 62 year old woman presented with pain that might have come from the back, the hip or the sacroiliac joint.
She has had back pain on and off over many years; she put this down to her work as a nurse. Twelve months before attending for consultation she developed severe back pain: it came on over a few days. The pain spread from the back into the left buttock and then the back of the left leg to the calf but not the foot. It was made worse by walking, sitting and even lying. That pain had been severe for the first eleven months, but had eased moderately in the previous month.
Additionally, she had also noticed progressively worsening left hip pain for the previous few years. The pain spread from the hip area into the groin and the front of the thigh. It is made worse by walking: she has been limping for about 6 months. There was also a sensation of locking and give way in the hip area, rather than the groin.
By the time she was first seen the worst pains now were the outer hip and groin pain on walking, and the left sacroiliac area on sitting.
Her health is otherwise good. She was sleeping better. There was no history of cancer or night sweats. She had tried anti-inflammatory medications, but had developed some stomach discomfort. These pills relieved the pain to a moderate extent.
EXAMINATION:
She walked with a definite limp. There was moderate irritability of the left hip, with mild movement loss. Movements produced left groin pain and back pain. Femoral nerve stretch was also tight, producing some anterior thigh pain. Straight leg raise ( SLR ) test was painful on the left also, producing some groin pain. Active SLR was more painful than passive, and range was close to full. There were no neurological abnormalities in the lower limbs.
She could touch her toes with ease. Lumbar extension was more painful but the range was good.
INVESTIGATIONS:
CT scan of the lumbar spine taken two months earlier showed severe internal disc disruption of the L5/S1 disc with prominent disc space narrowing and intra-discal gas. The spinal canal dimensions were normal. The far out regions were all normal as high as L1/2
DIAGNOSIS:
- Left outer hip and leg pain.
- Left hip osteoarthritis: It was thought.
- Other potential origin included the sacroiliac joint
- Low back origin pain: it appears that the severe attack was related to the back.
Could it be from the sacroiliac joint?
X-rays reveal no changes in the joint, but this does not help with assessment of that joint.
Could the pain be form a disc rupture?
If it was the disc rupture has resolved.
MANAGEMENT:
1. Left hip operation is a possible necessity as she is having trouble walking. She should see a hip surgeon.
2. The suspicion is that the back problem is secondary to the hip problem and comes from abnormal mechanics associated with the limp.
3. It would be reasonable at the moment to inject the hip, and the left sacroiliac joint. It is however likely that the effects will be short term. It was decided to inject the sacroiliac joint.
RESULTS: REPORT:
Patient B has since underwent a left sacroiliac joint injection with 2 ml of Marcain 0.5% and 1 ampoule Celestone. The joint was first outlined with contrast material. The injection approach required was from the inferior aspect of the joint.
Pain Chart: (score out of 10)
| |
TIME |
HIP |
SIJ Area |
|
HIP |
SIJ Area |
| Before |
|
8 |
5 |
Day 2 |
3 |
1 |
| 5 min |
13:05 |
5 |
1 |
Day 3 |
2 |
1 |
| 30 min |
13:30 |
7 |
0 |
Day 4 |
2 |
2 |
| 60 min |
14:00 |
5 |
0 |
Day 5 |
3 |
1 |
| 90 min |
14:30 |
5 |
0 |
Day 6 |
2 |
0 |
| 2 hrs |
15:00 |
6 |
0 |
Day 7 |
2 |
0 |
| 3 hrs |
16:00 |
5 |
0 |
Day 8 |
1 |
0 |
| 4 hrs |
17:00 |
5 |
0 |
Day 9 |
1 |
0 |
| 5 hrs |
18:00 |
6 |
0 |
Day 10 |
1 |
0 |
| 6 hrs |
19:00 |
6 |
0 |
Day 11 |
2 |
0 |
| 7 hrs |
20:00 |
5 |
0 |
Day 12 |
1 |
0 |
COMMENTS:
The patient reported that at 9 hours pain her pain increased again, and spread from the groin down the front of the thigh to above knee with a score of 7/10. On day 14 she reported that she had not had any pain down left leg from SIJ at all since procedure. She described that as "a huge relief". Also, the back pain was much better; she reported only a slight niggle with a pain score of less than 1/10, only occurring on sitting. |
