Sacroilitis

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ED50

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20 yo female just gave birth to first child and developed low back pain. MRI showed some L5/S1 disc space disease but to my surprise XR showed sacroilitis in the joint. Rhem panel negative. Has anyone seen this? I was planning on sending to rheum but the negative panel surprised me too. Normal BMI and no IVDU
 
Is it triangular? It may also be osteitis condensans illi.

Can you see the SI joint on the MR? Given recent baby, I’d bet it’s benign sclerosis and unrelated. There should be marrow edema for true sacroiliitis.
 
Did the xray for sacroiliitis or the MRI?

Either was, just inject it. When there is active sij inflammation, its usually a home run
 
ED50 said:
20 yo female just gave birth to first child and developed low back pain. MRI showed some L5/S1 disc space disease but to my surprise XR showed sacroilitis in the joint. Rhem panel negative. Has anyone seen this? I was planning on sending to rheum but the negative panel surprised me too. Normal BMI and no IVDU
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Rheum panel include HLA-B27?
H/o psoriasis? It likes the SIJ. Sacroiliac joint pain as an important element of psoriatic arthritis diagnosis
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Still more likely related to relaxin hormone and pushing out a baby. How far out from childbirth? C-section or vag delivery?
 
She just gave birth people. All her ligaments and tendons are loosey goosey from her progesterone and relaxin then she forced a watermelon through a lemon sized hole. Pelvic/back pain is completely normal.

What was the physical exam like? Treat patients not pictures.

If she's in a ton of pain, I'd be willing to treat her SI joints, facets, disc, whatever. But honestly this will improve over the next 3 months or so on it's own.
 
Thanks for the thoughts. To answer some questions - She is approximately 9 + months out from childbirth vag delivery. No hx of rheum disease. Did PT x2 without benefit. Panel I ran included ANA, RF, HLA-B27, ESR, CRP - all normal. MRI was for lumbar spine as her pain localizes to lumbosacral junction. I read about how the first rheumatic flare for many patients occurs during and after childbirth but I have never seen it. Radiologist read XR as sacroilitis. Exam is pretty benign other then pain around the lumbosacral junction - pain to palpation of the SI joints but provocative testing is not positive.
 
maxxor said:
Is it triangular? It may also be osteitis condensans illi.

Can you see the SI joint on the MR? Given recent baby, I’d bet it’s benign sclerosis and unrelated. There should be marrow edema for true sacroiliitis.
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Have to admit I've never heard of this. I'll double check the imaging on Monday.
 
9 mo later……

Do SIJ and triple cream + sij stretches.

If MRI Lspine normal and rheum workup neg, then nothing else to do. Would not offer MBB without correlation with hx and if disc pain and normL mri there is nothing else to do.
 
ED50 said:
Thanks for the thoughts. To answer some questions - She is approximately 9 + months out from childbirth vag delivery. No hx of rheum disease. Did PT x2 without benefit. Panel I ran included ANA, RF, HLA-B27, ESR, CRP - all normal. MRI was for lumbar spine as her pain localizes to lumbosacral junction. I read about how the first rheumatic flare for many patients occurs during and after childbirth but I have never seen it. Radiologist read XR as sacroilitis. Exam is pretty benign other then pain around the lumbosacral junction - pain to palpation of the SI joints but provocative testing is not positive.
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I think you meant to say, "FABER and Gaenslen positive. Sacral compression positive. Fortin finger positive. Tender to palpation at the SIJ."

Right?

Isn't that what you meant to say?
 
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lobelsteve said:
9 mo later……

Do SIJ and triple cream + sij stretches.

If MRI Lspine normal and rheum workup neg, then nothing else to do. Would not offer MBB without correlation with hx and if disc pain and normL mri there is nothing else to do.
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what is the third thing in your cream? I do a reasonable number of ketoprofen/lidocaine topical creams
 
Agree likely related to laxity. If they're breastfeeding, those hormonal effects will continue.

Sacroilitis can be a soft call on x-ray. What grade is it?

Agree with following the exam over the imaging
 
only way to truly see "sacroilitis" is with a sacral MRI. If you're concerned get the sacral MRI. I suspect it will be negative and the sacroilitis on X-ray is a false read due to recent pregnancy
 
clubdeac said:
only way to truly see "sacroilitis" is with a sacral MRI. If you're concerned get the sacral MRI. I suspect it will be negative and the sacroilitis on X-ray is a false read due to recent pregnancy
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I wouldn't. Likely self resolving process unless clinically you think she has an inflammatory Spondyloarthropathy or infection. MRI only helpful if it affects your management.
 
Baron S said:
I wouldn't. Likely self resolving process unless clinically you think she has an inflammatory Spondyloarthropathy or infection. MRI only helpful if it affects your management.
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Resolving process this many months after delivery? No.
MRI to assess for disease process and possible need for Rheum to Rx Plaquenil.
Inject it.
 
lobelsteve said:
Resolving process this many months after delivery? No.
MRI to assess for disease process and possible need for Rheum to Rx Plaquenil.
Inject it.
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Why wait for the mri? Is it gonna chance ur management?
 
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nvrsumr said:
still gonna poke it if it lights up on MRI
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Maybe. Maybe not. Clearing out this lady but I’ve had a lady in the past with cancer on the SIJ. CT scan is posted in the picture forum somewhere
 
nvrsumr said:
still gonna poke it if it lights up on MRI
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Wouldn’t poke it if it lights up. True sacroilitis on mri will show inflammation/edema throughout periarticular bone. I don’t think a local injection will help much
 
I find SI injections very effective in MRI-positive spondyloarthropathies. Not super durable but usually high percent relief.
 
RoloTomassi said:
I find SI injections very effective in MRI-positive spondyloarthropathies. Not super durable but usually high percent relief.
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I have seen 2 in last 16 years. I work with 2 Rheumatologists. How many you seeing?
 
SIJ injections work exceptionally well when there is active inflammation. just like in any other joint (facet, knee, etc). it is a good stopgap measure until a DMARD starts to work. ive had idiopathic sacroiliitis help for >1 year at a time. dont ask me how
 
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