|Year : 2021 | Volume
| Issue : 2 | Page : 49-51
Sacroiliac joint arthropathy masquerading as lumbar canal stenosis
Shalina Chandran, Sneha Shreyas, Basavaraj Kanthi, Gautam Das
Daradia Pain Hospital, Kolkata, West Bengal, India
|Date of Submission||21-Apr-2022|
|Date of Acceptance||27-Sep-2022|
|Date of Web Publication||08-Mar-2023|
Artech Kalyani, Vazhuthacaud, Thiruvananthapuram - 695 010, Kerala
Source of Support: None, Conflict of Interest: None
Low back pain (LBP) is one of the most common chronic pain conditions which can arise from any of many potential pain generators. A thorough history, clinical examination, and investigations can give clues about the source, but ultimately, it is clinched by diagnostic interventions. Our case report is of a 70-year-old man who presented with complaints of LBP with symptoms of neurogenic claudication. Examination suggested sacroiliac joint involvement, however, the magnetic resonance imaging pointed to lumbar canal stenosis. Respecting the clinical findings, it was decided to proceed with diagnostic blocks of S1, 2, and 3 followings which the patient had excellent pain relief. We would like this to be a reminder of the importance of diagnostic blocks in identifying the pain generator and also of not relying solely on radiological findings.
Keywords: Low back pain, lumbar canal stenosis, magnetic resonance imaging spine, Sacroiliac joint arthropathy
|How to cite this article:|
Chandran S, Shreyas S, Kanthi B, Das G. Sacroiliac joint arthropathy masquerading as lumbar canal stenosis. J Recent Adv Pain 2021;7:49-51
|How to cite this URL:|
Chandran S, Shreyas S, Kanthi B, Das G. Sacroiliac joint arthropathy masquerading as lumbar canal stenosis. J Recent Adv Pain [serial online] 2021 [cited 2023 Mar 31];7:49-51. Available from: http://www.jorapain.com/text.asp?2021/7/2/49/298670
| Introduction|| |
Of the chronic pain conditions encountered in worldwide clinical practice, low back pain (LBP) is one of the most common. Most individuals will experience LBP at some point of their life. LBP persisting for 12 weeks or more is considered chronic LBP.
Chronic LBP is a complex condition with the pain generator being from any one of disc, facet joint, sacroiliac joint, muscles, ligaments, bursae, or hip joint. One or more pain generators can be involved. Identifying the correct pain generator/s is of utmost importance not only for avoiding unnecessary procedures but also for proper treatment.
The International Association for the Study of Pain defines lumbar spinal pain as pain perceived anywhere within a region bounded by the last thoracic spinous process, the first sacral spinous process, and the lateral border of the erector spinae. LBP is also defined as pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain. The sacroiliac (SI) joint is the third most common pain generator of LBP. It is a diarthrodial synovial joint. SI joint pain typically overlies the low back and buttock with possible referred pain into the leg, usually above knee level. Pain may also be referred to the abdomen or rarely to the foot.
| Case Report|| |
A 70-year-old man presented to our outpatient department with complaints of LBP for 5 years. The pain was gradual in onset and had increased in intensity over the last 6 months. The pain was of a dull aching type, radiating to the right leg, and not associated with numbness, tingling, or burning sensation. The pain increased on standing and was aggravated on walking. He could hardly walk 200 m. The pain was relieved on sitting. There was no history of trauma, falls, or loss of weight. There was no bladder or bowel dysfunction. He had no associated comorbid conditions.
The range of movements was normal. Neurological examination revealed no sensory deficits, normal muscle strength, and deep tendon reflexes. There was tenderness of the right sacroiliac joint on palpation. The flexion, abduction, and external rotation test elicited pain in right SI joint.
Investigations showed an elevated erythrocyte sedimentation rate of 40mm and the magnetic resonance imaging (MRI) revealed that the anteroposterior canal diameter of L4-5 was 5mm [Figure 1].
|Figure 1: MRI Transverse section L4-5 showing canal stenosis. MRI: Magnetic resonance imaging|
Click here to view
Based on the history and radiological findings, the diagnosis pointed toward a diagnosis of lumbar canal stenosis. However, the clinical examination suggested sacroiliac joint involvement. Hence, a decision was made for a diagnostic block of SI joint.
After discussing the risks, benefits, and complications, he was scheduled for the procedure. Using a hybrid technique with fluoroscopy and ultrasonography, the right sacroiliac joint was identified and 2.5 ml of 2% lignocaine with methylprednisolone 40mg made to 5ml with normal saline was injected into the joint after confirming needle placement with dye spread [Figure 2]. The patient was made to walk around for 30 min after the block. He reported excellent pain relief after the diagnostic block, with complete relief of claudication pain. Thus, the diagnostic block uncovered the SI joint as the pain generator. He was suggested to undergo cryoneurolysis of the lateral branches of S1, 2, and 3 of the right SI joint if the pain reappeared. He continued to be satisfied at the 2-month follow-up with a sustained 70% pain relief.
| Discussion|| |
The SI joint is a weight-bearing joint between the sacrum and the ilium and functions as a shock absorber. It is innervated by lateral branches of S1, 2, and 3 and sometimes from L4, 5, and S4. 15–30% of all cases of low back ache have been attributed to SI joint pain. In spite of this, it is still often underdiagnosed and hence undertreated. This is largely due to the fact that there is still no evidence to support any single provocative test or diagnostic imaging modality specific for the SI joint. Intra-articular SI joint injection using local anesthetics with or without steroids has thus evolved as the diagnostic standard.,,
In the presence of conflicting clinical and radiological findings, it becomes more challenging to make the diagnosis. Chronic LBP could have multiple pain generators simultaneously and hence multimodal treatment is required for the relief of pain. LBP has to be considered a complex disease, in which an accurate diagnosis of the pain generator/s is made before any treatment is started. MRI, the gold standard of spinal imaging typically, reveals abnormal findings in both symptomatic and asymptomatic individuals. If ordered indiscriminately and interpreted blindly, the diagnosis may not correspond to the patient's actual condition.
The mistaken idea that 80%–90% of LBP have unknown causes has persisted for decades. This is especially relevant to conditions such as SI joint that is difficult to diagnose based on clinical signs and symptoms. However, studies have now shown that image-guided injection of local anesthetics is the gold standard for diagnosing SI joint pain.,,,,
| Conclusion|| |
LBP can be due to any of various pain generators and to make the right diagnosis, relying only on MRI may be misleading. MRI can help in supporting the clinical diagnosis but should not be used solely to make a diagnosis. Diagnostic local anesthetic injections into the pain generator remain the gold standard of confirmation. Our patient came with typical complaints of lumbar canal stenosis, supported by MRI findings. However, clinical examination and diagnostic block revealed the pain generator to be of sacroiliac joint pathology. This case report is to highlight that something as common as LBP can still be a confusing entity and hence the need for proper clinical examination and diagnostic blocks to clinch the diagnosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Das G. Basics of Pain Management. 2nd
ed. New Delhi: CBS Publishers; 2019.
Khan KJ, Das G, Patel P, Chatha PK, Kumar S. MRI can be misleading. J Recent Adv Pain 2019;5:32-5. [Full text]
Simopoulos TT, Manchikanti L, Singh V, Gupta S, Hameed H, Diwan S, et al.
A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician 2012;15:E305-44.
Gurumoorthi R, Vanathi N. Sacroiliac joint injection. J Recent Adv Pain 2016;2:87-9. [Full text]
Buchanan P, Vodapally S, Lee DW, Hagedorn JM, Bovinet C, Strand N, et al.
Successful diagnosis of sacroiliac joint dysfunction. J Pain Res 2021;14:3135-43.
Falowski S, Sayed D, Pope J, Patterson D, Fishman M, Gupta M, et al.
A review and algorithm in the diagnosis and treatment of sacroiliac joint pain. J Pain Res 2020;13:3337-48.
Allegri M, Montella S, Salici F, Valente A, Marchesini M, Compagnone C, et al.
Mechanisms of low back pain: A guide for diagnosis and therapy. F1000Res 2016;5:v1000-530.
Buijs E, Visser L, Groen G. Sciatica and the sacroiliac joint: A forgotten concept. Br J Anaesth 2007;99:713-6.
Cohen SP. Sacroiliac joint pain: A comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005;101:1440-53.
[Figure 1], [Figure 2]