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Sacroiliitis, a condition commonly seen in ankylosing spondylitis, is well known to be one of the main pain generators of low back pain, which may result in difficulty with walking. A year old male with history of ankylosing spondylitis presented to the University Hospital of the West Indies, Physical Medicine and Rehabilitation Clinic, with a two-year history of right buttock, low back and groin pain. Radiographic evaluation revealed increased sclerosis and erosive changes in bilateral sacroiliac joints, right greater than left.
Right intra-articular sacroiliac joint steroid injection was administered under fluoroscopy guidance. This case report illustrates the effectiveness of intra-articular sacroiliac joint steroid injection in treating sacroiliitis in ankylosing spondylitis.
A fundamental clinical feature of ankylosing spondylitis AS is sacroiliitis, which is inflammation of the sacroiliac joints. It is characterized by back pain and stiffness affecting the sacroiliac joint and axial skeleton 1 — 3. The sacroiliac joint is commonly the first joint involved and may also be the most painful symptomatically. While the aetiology of AS is unknown, genetic and environmental factors play a major role.
The prevalence of AS is approximately 0. However, onset is usually in the second and third decades of life and affects men two to three times more often than women 6 , 7. He was subsequently diagnosed with AS in He was being treated by a rheumatologist and current medication included sulfasalazine and non-steroidal anti-inflammatory medication. He had also been treated with Actemra tocilizumab which controlled the fatigue and generalized inflammatory symptoms. However, his pain persisted.
He was placed on amitriptyline and paroxetine for depression. Physical therapy was also incorporated in his treatment and he was also lifting light weights at the gym a few days per week. On examination, he was found to walk with a normal gait. He was able to heel and toe walk, but heel walking worsened the right low back pain. Straight leg raise was negative. Slump sit test was positive on right but negative on the left side. There was tenderness on palpation over the right sacroiliac joint.
He was assessed as having sacroiliitis on the right greater than on the left, with the right being symptomatic. Fluoroscopy-guided right sacroiliac joint steroid injection was done. The technique used had the patient position prone.
The region overlying the inferior aspect of the right sacroiliac joint was identified using superficial landmarks and fluoroscopy. Under sterile condition, the area over the right sacroiliac joint was cleaned with betadine and draped. Using fluoroscopic guidance, a gauge quinke needle was used to enter the right sacroiliac joint from below. One millimetre of Omnipaque iohexol was used to confirm an intra-articular flow pattern and there was no vascular uptake.
He still had low back pain and also complained of right shoulder pain. He was also prescribed a sacroiliac joint belt to be worn daily and a pelvic stabilizing rehabilitation programme was outlined. Ankylosing spondylitis is a progressive inflammatory seronegative autoimmune disease which causes inflammation of the spine and sacroiliac joints, resulting in axial skeleton rigidity and if left untreated can advance to fusion of the spine ie Bamboo spine 10 , Sacroiliitis is regarded as a hallmark in diagnosing AS 3.
Other clinical presentations include positive HLA-B27 test, radiological findings including sclerosis or erosion of the sacroiliac joint , low back pain, peripheral arthritis and extra-articular involvement — such as uveitis, and costosternal involvement restricting chest expansion — may also occur 2 , 6.
The prevalence of AS is highest in the northern European countries, whereas persons of Afro-Caribbean descent have the least The use of NSAIDs and fluoroscopy-guided steroid injection is widely used to treat sacroiliitis, along with physical therapy 8 , 9. It is to be noted that in the index case, the symptoms of low back pain persisted post IASIJ injection; this is not surprising as the treatment is localized to the site injected.
Further treatment must be incorporated for the alleviation of the lumbosacral spine pain. This is consistent with a study done by Karabacakoglu et al , who found that fluoroscopy-guided intra-articular corticosteroid instillation in the SIJ may be regarded as an effective therapy since there was a National Center for Biotechnology Information , U. West Indian Med J. Published online Nov Copyright Material printed in the West Indian Medical Journal is covered by copyright and may not be reproduced in whole or in part without the written permission of the Editor.
Single photocopies may be made by individuals without obtaining prior permission. Abstract Sacroiliitis, a condition commonly seen in ankylosing spondylitis, is well known to be one of the main pain generators of low back pain, which may result in difficulty with walking.
Ankylosing spondylitis, fluoroscopy-guided, physical medicine and rehabilitation, sacroiliitis, steroid injection.
Introduction A fundamental clinical feature of ankylosing spondylitis AS is sacroiliitis, which is inflammation of the sacroiliac joints. Open in a separate window. Pelvic X-ray showing subchondral sclerosis and marginal erosive changes on the right greater than on the left. Discussion Ankylosing spondylitis is a progressive inflammatory seronegative autoimmune disease which causes inflammation of the spine and sacroiliac joints, resulting in axial skeleton rigidity and if left untreated can advance to fusion of the spine ie Bamboo spine 10 , Enthesopathy of rheumatoid and ankylosing spondylitis.
Assessment of the efficacy of sacroiliac corticosteroid injections in spondylarthropathies. Is disease severity in ankylosing spondylitis genetically determined? Brophy S, Calin A. Comparison of clinical and radiographic severity of juvenile-onset vs. Treatment of ankylosing spondylitis: Am J Med Sci. Fluoroscopy-guided sacroiliac joint injection. The outcome of ankylosing spondylitis: Incidence and prevalence of ankylosing spondylitis in Finland.