Updated: 6/24/2021

Sacroiliitis

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  • summary
    • Sacroiliitis is an inflammatory condition of the sacroiliac joint that can cause persistent low back and posterior pelvic pain.
    • Diagnosis is made with MRI studies with contrast showing fluid/inflammation at the SI joint and possible abscess.
    • Treatment is usually nonoperative with NSAIDs and rest, with IV antibiotics reserved for infections. Surgical debridement is indicated in the presence of an abscess. 
  • Epidemiology
    • Demographics
      • most commonly presents in teen to middle-aged individuals
        • males > females
    • Associated conditions
      • commonly part of ankylosing spodyliitis or Reiter's syndrome
  • Etiology
    • Pathophysiology
      • can stem from traumatic event or infection
      • pregnancy may lead to increased incidence in some females
      • often stems from chronic inflammation of SI joints
      • can lead to fibrosis and ossification within SI joint
    • Associated conditions
      • ankylosing spodyliitis
        • associated with HLA-B27
        • 1-2% of all individuals will have HLA-B27
      • Reiter's syndrome
        • oligoarticular arthritis, conjunctivitis and urethritis
      • joint arthritis
  • Presentation
    • Symptoms
      • pain with prolonged standing
      • difficulty climbing stairs
      • generalized low back pain
      • weakness from hip musculature on affected side
      • morning stiffness
    • Physical exam
      • FABER test
        • pain with flexion, abduction, and external rotation of hip
      • ankylosing spondylitis associated with
        • spinal flexion deformities
        • starting in T and L spines
  • Imaging
    • Radiographs
      • may show some erosive changes in the bone, but it’s not specific
      • may show calcifications or sclerosis within SI joint
    • MRI is study of choice
      • use gadolinium
      • T2’s show fluid/inflammation at the SI joint and maybe an abscess
  • Studies
    • Labs
      • WBC
        • usually normal
        • can be elevated with infection
      • ESR/CRP
        • usually elevated
      • blood cultures
        • are positive in 50%
      • HLA-B27
        • check for rheumatoid factor (should be negative for true Ankylosing spondylitis)
  • Treatment
    • Depends on cause
      • infection
        • IV antibiotics
          • until symptoms and the CRP resolve
          • then put on orals antibiotic
        • surgery
          • may be necessary if this fails or if there is a large abscess
      • trauma or overuse
        • rest, activity modification, NSAIDS, corticosteroid injections
          • indications
            • most resolve with soft tissue rest and activity modification
      • pregnancy
        • observation
          • typically resolves after childbirth
      • part of larger spondylopathy
        • aggressive PT, NSAIDs, TNF inhibitors
          • severe symptoms may require TNF inhibitors or other similar medications
  • Prognosis
    • Depends on cause but most patients will eventually resolve the episode and continue without issues
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