Updated: 10/6/2016

Sacroiliitis

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Introduction
  •  Epidemiology
    • commonly part of ankylosing spodyliitis or Reiter's syndrome
    • most commonly presents in teen to middle aged individuals
      • males > females
  • 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
  • Prognosis
    • depends on cause but most patients will eventually resolve the episode and continue without issues
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
 

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(SAE07PE.95) A 15-year-old boy reports a 2-day history of progressive left buttock pain and severe limping. He denies any history of trauma or radiation of the pain. He has an oral temperature of 100.4 degrees F (38 degrees C). Examination reveals that the lumbar spine and left hip have unguarded motion. The abdomen is nontender. There is moderate tenderness of the left sacroiliac region with no palpable swelling. Pain is elicited when the left lower extremity is placed in the figure-4 position (FABER test). Laboratory studies show a peripheral WBC count of 11,500/mmP3P (normal to 10,500/mmP3P) and an erythrocyte sedimentation rate of 38 mm/h (normal up to 20 mm/h). Radiographs of the pelvis, hips, and lumbar spine are normal. A nucleotide bone scan (posterior view) is shown in Figure 44. Initial management should consist of Review Topic

QID: 6155
FIGURES:
1

oral nonsteroidal anti-inflammatory drugs.

25%

(78/310)

2

intravenous antistaphylococcal antibiotics.

44%

(136/310)

3

incision and debridement of the retroperitoneal abscess.

6%

(19/310)

4

incision and debridement of the left sacroiliac joint.

24%

(74/310)

5

arthrotomy and irrigation of the left hip joint.

0%

(1/310)

L 4

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