SI joint pain

[facets]

Update on this case, the internist found pos HLA B27 and a very high C reactive protein, dx, ankylosing spondylitis, (no crazy uncle involved) and has sent the patient to rhemuatology for possible disease modifying agents. Any of you familiar? She is very worried about being disabled from this dz. I remember back is the 1980's this diagnosis was one of the "your screwed" types. You know you have MS, you're screwed, you have ALS your screwed too. Now I think they can stop it before she looks like a pretzel.

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[lobelsteve]

I have a patient, 55 year old female with severe SI joint pain on the left side. No specific trauma except perhaps being bumped on the thigh by a large dog running by. This has been going on for 6 months and steadily gotten worse. Plain films, MRIs show moderate arthritis of the facets and SI joints, hips clear, right side is just is bad on x ray but no pain there. Moving from sitting to standing is excruciating, as is getting out of bed. She is ordinarily athletic, no interest in disability and this has totally devestated her quality of life and she is desperate for relief. "Sucking it up" is not an option, this is a US Army veteran who can take a needle without a flinch. Physical therapy, chiropractic, every topical agent, stretching, lyrica, has been tried. NSAID are contraindicated due to a GI bleed. SI joint injections, facet injections, radiofrequency at L4 L5 S1 S2 S3 has not helped. The pain is in the buttock and lateral thigh, severe gripping vise like with a severe stabbing pain when motion is attempted. PRP is planned next. Small doses of opoids do work, no addiction history but she does not like the feeling that she gets from narcotics, does not like the "high" feeling and is asking about a pump her reasoning being that this should deliver pain relief without making her feel like she is drugged. She has also asked about a SCS but this does not appear to be radicular. She will do anything to be relieved of this and is and is willing to pay cash if the insurance company will not cover the treatment. She is really desperate. Any suggestions?

Post the MRI report from before you started poking her all over the place....Then post your findings on initial exam and your review of the SIJ on her lumbar MRI. You can see enough there that if it was negative at that time, it was not going to be seen. AS is way less common in females and usually shows plain film findings way before they get stuck with a bunch of useless needles.

 

[clubdeac]

Update on this case, the internist found pos HLA B27 and a very high C reactive protein, dx, ankylosing spondylitis, (no crazy uncle involved) and has sent the patient to rhemuatology for possible disease modifying agents. Any of you familiar? She is very worried about being disabled from this dz. I remember back is the 1980's this diagnosis was one of the "your screwed" types. You know you have MS, you're screwed, you have ALS your screwed too. Now I think they can stop it before she looks like a pretzel.

You can treat this very well with biologics these days I.e. enbrel, if it truly is AS

 

[facets]

Thanks yes, I thought that AS was usually men, age below 40, not 55 y/o females and mostly stiffness not severe pain, she is stiff but pain is the primary problem, terrible in the am. The SI Joints are arthritic but didn't look like AS, according to the 3 pain docs who looked at them besides me. she did get a little better with the PRP and choke, chiropractic using a very wierd technique I can't begin to understand.It may have been coincidental with the PRP. Who knows. She is grieving a very actice lifestyle so hopefully humira or embral will help.Will it help with the disease modification or the pain also? She is devested from the pain and as stated before does not want to be on strong narcotics. That's why she asked about the pump, she wants pain relief but no drugs in her head.Oh BTW the MRI showed moderate facet arthropathy, big deal, I know but facet syndrome does not show up on MRI.
So Steve, are you saying that none of our procedures are going to help with this ladies pain, please don't tell me she has a diagnosis of "you're screwed". She is a very nice lady, always doing volunteer work at the church etc, This pain has her pretty down and cons
idering early retirement which she DOES not want. Her profession, of course, she is a fellow physician. They always get the weird stuff. Her CRP was I believe 16 or so and a positive HLA B27.Are you saying that the diagnosis was wrong? What else could cause these blood results. The internist was determined to find something all the pain docs missed esp since she is a physician. Thanks for the embral advice clubdeac. So do we shoot one of our own or what?

 

[jonnylingo]

I do my PRP for free, right after a trigger point or nerve block.

Do yo only bill for the TPI or nerve block? If so, are you covering the cost of the kit?

 

[lobelsteve]

Thanks yes, I thought that AS was usually men, age below 40, not 55 y/o females and mostly stiffness not severe pain, she is stiff but pain is the primary problem, terrible in the am. The SI Joints are arthritic but didn't look like AS, according to the 3 pain docs who looked at them besides me. she did get a little better with the PRP and choke, chiropractic using a very wierd technique I can't begin to understand.It may have been coincidental with the PRP. Who knows. She is grieving a very actice lifestyle so hopefully humira or embral will help.Will it help with the disease modification or the pain also? She is devested from the pain and as stated before does not want to be on strong narcotics. That's why she asked about the pump, she wants pain relief but no drugs in her head.Oh BTW the MRI showed moderate facet arthropathy, big deal, I know but facet syndrome does not show up on MRI.
So Steve, are you saying that none of our procedures are going to help with this ladies pain, please don't tell me she has a diagnosis of "you're screwed". She is a very nice lady, always doing volunteer work at the church etc, This pain has her pretty down and cons
idering early retirement which she DOES not want. Her profession, of course, she is a fellow physician. They always get the weird stuff. Her CRP was I believe 16 or so and a positive HLA B27.Are you saying that the diagnosis was wrong? What else could cause these blood results. The internist was determined to find something all the pain docs missed esp since she is a physician. Thanks for the embral advice clubdeac. So do we shoot one of our own or what?

If she has AS, then none of our procedures are that useful, but AS would have been tough to miss on the MRI.

http://www.spondylitis.org/about/as_diag.aspx

I'm not convinced her history is c/w AS.

The only female with AS I have treated had an SIJ that looked like this at time of Dx:

She did not respond as well as Rheum would have liked to DMARDs.

 

[lobelsteve]

Do yo only bill for the TPI or nerve block? If so, are you covering the cost of the kit?

I don't use a kit. I draw 20cc blood and put it in purple tops, centrifuge in the lab for 10 minutes. I draw out of the vials with a Tuohy to get the buffy coat and enough plasma/red cells for 2-3cc injection.

Then I inject as TPI or tendon injection.

Until adequate data exists, I refuse to spend my $$$ or my patient's insurance $$$ on unproven treatments.

 

[facets]

Holy Cra*, I can't post her films but they didn't look like that. The rheum just wants new standing pelvis X rays with attention to the SI joints. If she did not do well with the DMARD what did they do. Oh wait they said "you're screwed you are a female with AS" Oy

 

[Ducttape]

Holy Cra*, I can't post her films but they didn't look like that. The rheum just wants new standing pelvis X rays with attention to the SI joints. If she did not do well with the DMARD what did they do. Oh wait they said "you're screwed you are a female with AS" Oy

i would take exception to the "you're screwed" idea.

if you truly believe that, then the patient is screwed.

med trials, injections, etc. not helping? focus on functionality, bmed, cognitive therapies, etc like was discussed previously.

if you dont believe in them, and you have nothing else to offer, then you and she are screwed, and maybe it would be best if you refer her to someone else for a second opinion.

ps i wouldnt consider fusion an option, but there are some surgeons who aggressively treat. its a questionable way to treat pain and a great way to reduce functionality.

 

[facets]

Thank you, I appreciate your sensitivity, really. I was being sarcastic, it would have been in orchid if I knew how to do that. I hope she is not screwed, she is another physician and a friend and for that reason is under the care of 3 other pain docs and an internist and now a rheumatologist. I know I cannot be objective. I didn't bring that up in my initial post to avoid muddy water. I am really frustrated for her. I don't know what else would cause her CRP to jump to 16. I would love to post images but don't know how to upload them but they don't look like the one Steve showed, just arthritis left being equal to right. Hopefully she will get some relief from DMARD drugs, she does get relief from low dose opoids but does not want to stay on them, and cannot take NSAID due to esophageal erosions and gastropathy. It does not sound like anyone thinks that an SCS trial would work and a pump is a bit out there. Injections really did not help much.

 

[Ducttape]

if this person is a friend...

then maybe what would be most helpful is to just be her friend, help her out emotionally during this rough time.

listen to her, do things with her, support her emotionally, hug her, etc. do what friends do.


course, im just quoting things off the internet - im a pain doc, i dont have friends...

 

[Ducttape]

if this person is a friend...

then maybe what would be most helpful is to just be her friend, help her out emotionally during this rough time.

listen to her, do things with her, support her emotionally, hug her, etc. do what friends do.


course, im just quoting things off the internet - im a pain doc, i dont have friends...