Journal of Back and Musculoskeletal Rehabilitation 22 (2009) 9197 DOI 10.

3233/BMR-2009-0221 IOS Press

91

Sacroiliac joint pathologies in low back pain

Anupam Datta Gupta
Department of Aged and Extended Care/Rehabilitation Medicine, The Queen Elizabeth Hospital, SA, Australia

Abstract. Objective: The study describes the clinical spectrum of patients with low back pain due to sacroiliac joint (SIJ) involvement with the proposition of a diagnostic scheme. Methods: In this retrospective review, 61 patients with SIJ pain (unilateral or bilateral) greater than six weeks duration were evaluated by pain history, clinical examination including SIJ provocative tests, laboratory investigations and skeletal imaging. Results: Fifty two patients (M: F, 31:21) were diagnosed to have specic SIJ pathologies amongst 61 patients presenting between 2002 to 2004. Forty patients (65%) were diagnosed with rheumatic conditions ankylosing spondylitis (AS) 21, undifferentiated spondyloarthropathy (UspA) 11, psoriatic arthropathy (PS) 5, reactive arthropathy (ReA) 1 and juvenile spondyloarthropathy (JS)-2. Non rheumatic conditions were involved in 12 patients (20%) osteitis condensus ilii (OCI) 4, osteomalacia 2, tuberculosis 2, pyogenic arthritis 1, pregnancy related sacroiliac joint pain 2 and malignancy in 1 patient. The diagnosis could not be conrmed in 9 patients (15%). Conclusions: Medical history, clinical examination including SIJ tests, plain radiography and laboratory investigations were helpful in diagnosing SIJ pathology in 39% cases (n = 24), 46% (n = 28) needed CT or MRI. A diagnostic scheme of dividing the SIJ pathologies into rheumatic and non-rheumatic conditions was helpful in evaluating patients with suspected SIJ pathologies. Keywords: Sacroiliac joint pain, sacroiliac tests, sacroiliitis, algorithm

1. Introduction Low back pain affects two thirds of adults and is a very common reason for visits to a physician [13]. The pain can arise from lumber strain or sprain, intervertebral disc disease, fracture, spinal canal stenosis, spondylolysis or listhesis, spinal instability or deformity, ligaments and facet joints. The other conditions could be inammatory, infective, neoplastic, metabolic and visceral conditions arising from pelvic organs, renal, gastrointestinal disease and aortic aneurysm. Sacroiliac joint (SIJ) was widely considered as a major source in causing low back pain until Mixter and Barr described disc herniation as a source of pain in the lumbosacral spine in 1934 [22]. There is renewed interest in SIJ pain which has been implicated in 15% to 25% of the patients presenting with axial low back pain [10]. The spondyloarthropathies affecting the SIJ
Address for correspondence: Anupam Datta Gupta, 34C Tutt Avenue, Kingswood, SA 5062, Australia. Tel.: +61 08 81720420, Fax: +61 08 8222 8563; E-mail: anupamduttagupta@yahoo.com.

have a prevalence of 0.5% to 1.9% [26] and comprise ankylosing spondylitis, psoriatic arthropathy, reactive arthropathy, enteropathic arthropathy and undifferentiated spondyloarthropathy. SIJ can also be involved with mechanical, infective, degenerative, metabolic, traumatic and neoplastic conditions. Case reports of SIJ involvement secondary to tuberculosis, pyogenic arthritis, osteitis condensus ilii, osteomalacia and malignancy are available in the literature. The causes of SIJ involvement are diverse and the diagnosis is often challenging. Clinically it is important to screen the patients for early referral pathways to the respective specialties so that appropriate management can be instituted. The differential diagnosis of sacroiliac joint pain can be divided broadly in to rheumatic and nonrheumatic conditions. Hitherto there has been no diagnostic scheme available in primary care for differentiating the various SIJ conditions. In this paper I report a case series of 61 patients who had sacroiliac joint involvement along with the diagnosis and frequency of different conditions. This study was undertaken to analyze the clinical spectrum of patients with features of SIJ involvement causing low back pain and to investi-

ISSN 1053-8127/09/$17.00 2009 IOS Press and the authors. All rights reserved

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A.D. Gupta / Sacroiliac joint pathologies in low back pain

gate the causes with a view to developing a diagnostic scheme for SIJ conditions.

2.4. Laboratory tests Blood tests included complete blood examination (CBE), erythrocyte sedimentation rate (ESR) and C reactive protein (CRP), liver function tests, creatine kinase, calcium, phosphorus, rheumatoid factor, antinuclear factor and HLA B27. 2.5. Radiology Routine pelvic X- rays with sacroiliac joints were taken, symmetry of SIJ involvement was noted and sacroiliitis was graded from 0 to 4 (grades 0, normal, 1 possible, 2 minimal, 3 moderate, 4 completely fused or ankylosed) [21]. For cases where the diagnosis was unclear but clinically SIJ pathology was suspected, CT scan or MRI was done. The radiologists reporting the images were not involved with the study. European Spondyloarthropathy Study Group criteria for spondyloarthropathies and Modied New York Criteria for ankylosing spondylitis were used [14,21]. Undifferentiated spondyloarthropathy was diagnosed when the patient had characteristic features of spondyloarthropathy but did not fulll the criteria of its dened subtypes. Characteristic skin/nail changes or history of antecedent genitourinary infection followed by oligoarthritis and back pain were helpful in the diagnosis of psoriatic and reactive spondyloarthropathy.

2. Methods 2.1. Study population A retrospective review of 600 patients presenting with low back pain was done during the period from 2002 to 2004 in an outpatient musculoskeletal clinic of a public hospital in India after the ethical committee approval. Patients with clinical symptoms of unilateral or bilateral gluteal pain around the sacral sulcus or posterior superior iliac spine, greater than six weeks duration with or without leg pain were recruited. The exclusion criteria were patients with recent history of trauma, diskogenic pain with positive nerve root compression signs, hip pathology, and the patients with previous spinal surgery, vertebral body pathologies and visceral disease such as liver and kidney failures. 2.2. History Routine clinical history was taken regarding pain including history of inammatory back pain (4) featuring the following: age of onset < 40 years, duration more than three months, insidious onset, presence of morning stiffness and improvement with exercise. Antecedent history of gastrointestinal or genitourinary infection, eye involvement and peripheral arthritis were also taken along with usual red and yellow ag signs. 2.3. Clinical examination Clinical examination included: examination of the lumbar spine including Schobers test L5 vertebrae was marked, one nger 5 cm below this level and another nger 10 cm above were placed, patient was asked to bend forward and touch his/her toes. Distance between two ngers if increased by < 20 cm- restriction in the lumber exion was noted. Straight leg raising test, neurological examination of the lower limbs, chest expansion, skin and nail examination, signs of enthesitis and arthritis, limb length discrepancy and gait examination were also carried out. The provocative tests for SIJ such as Patrick or Flexion Abduction and External Rotation Extension (FABERE) test, Posterior Shear or POSH test and Gaenslens tests were performed to elicit tenderness around SIJ [16,19].

3. Results Total number of patients 600 Number of patients who did not meet the inclusion criteria 539 Number of patients with suspected SIJ problem 61 9 patients had pain around SIJ but no abnormality was detected in blood tests or routine radiologywere not followed up by interventions such as radiologically guided SIJ injection 52 patients were diagnosed to have specic SIJ conditions. Forty (40) patients with rheumatic conditions AS-21, UspA-11, PS-5, ReA-1 and JS2. Twelve patients (12) were diagnosed with non rheumatic conditions: OCI 4, osteomalacia 2,

A.D. Gupta / Sacroiliac joint pathologies in low back pain Table 1 SIJ pain diagnosis in the series Diagnosis Ankylosing spondylitis (AS) Undifferentiated spondyloarthropathy(UspA) Psoriatic arthropathy (PsA) Reactive arthropathy (ReA) Juvenile spondyloarthropathy (JRA) Osteitis condensus ilii (OCI) Osteomalacia (OM) Pregnancy related SIJ pain Tuberculosis (TB) Pyogenic arthritis Chondrosarcoma(CS) Total No of cases 21 11 5 1 2 4 2 2 2 1 1 52 Sex ratio (M:F) 16:5 8:3 3.2 1:0 2:0 0:4 0:2 0:2 1:1 0.1 0.1 31:21

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tuberculosis 2, pyogenic arthritis 1, pregnancy related sacroiliac joint pain 2 and malignancy in 1 patient. On the basis of history, clinical examination and radiological ndings, 52 subjects (85%) were diagnosed to have specic pathologies in the SIJ. The age ranging from 17 to 56 years, 31 men and 21 women with 65% (40 patients) having rheumatic conditions and 20% (12 patients) having non-rheumatic conditions. In the rheumatic group, patients were diagnosed as ankylosing spondylitis (21), undifferentiated spondyloarthropathy (11), psoriatic arthropathy (5), reactive arthropathy (1) and juvenile spondyloarthropathy (2). The non-rheumatic group consisted of osteitis condensus ilii (4), osteomalacia (2), tubercular infection (2), pyogenic infection (1), pregnancy related SIJ pain (2) and malignancy (1) (Table 1). Two young patients (age 16 and 17) in this series had back pain associated with knee arthritis and the plain AP view X-ray showed sacroiliitis. The patients were referred to rheumatologist due to the possibility of juvenile spondyloarthropathy. A 24-year-old woman who presented with right sided gluteal pain, not responding to analgesics and later on developed systemic symptoms such as fever. She had normal lumber spinal and hip movements without any neurological decit. Routine X-ray did not reveal any abnormality however the CT scan revealed erosion of the right SIJ with abscess formation in the iliacus muscle. Another 28-year-old young male with low back and gluteal pain was treated for diskogenic pain since MRI of the lumber spine revealed lumbar disk prolapse (L5/S1). There was no relief following treatment for disk prolapse and the patient subsequently developed malaise and fever. The ESR was elevated (60 mm/hr) and erosion of sacrum and ilium was seen on the MRI of the SIJ. Acid fast bacilli were detected in the pus

aspirated from the sacroiliac joint and the histopathology showed chronic granulomatous inammation. The patients responded well with initial period of rest and antitubercular chemotherapy. Osteitis condensus ilii was diagnosed in four middle aged women with a history of multiple pregnancies who developed aching type of buttock pain without morning stiffness. The lumbar spinal and hip movements were normal, the SIJ provocative tests were positive. The X-rays revealed bilateral sclerosis around the sacroiliac joints but the ESR was normal. Two patients presented with low back pain, weakness in pelvic girdle muscles and generalized body ache and were diagnosed with osteomalacia. The x-ray revealed sclerosis around the SIJ, Loosers zone and fractures of the pubic bone. These patients had a normal ESR, low serum calcium, elevated alkaline phosphates level and were treated with vitamin D and calcium supplementation. Two patients developed SIJ pain following pregnancy. There was tenderness around SIJ but the X-ray or blood tests did not show any abnormality. They responded to treatment with NSAID and sacroiliac orthosis (corset). A 15-year-old girl presented with pain and swelling around right sacroiliac joint was diagnosed to have a neoplastic condition. The follow up period for the patients in this study was 2 years. Nine patients (15%) had pain around the sacroiliac region but the clinical picture or the radiology did not conrm any of the conditions enumerated before. Controlled local anaesthetic blocks were not performed to conrm the SIJ pain in this group of patients. Thirty patients from the rheumatic group had inammatory back pain (IBP) and forty patients reported pain on provocative SIJ tests. Plain X-ray showed SIJ changes in 24 patients where as 28 patients needed CT scan (3 patients with infection, 7 patients with AS, 11 patients with UspA, and patients with PsA, ReA) and MRI

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A.D. Gupta / Sacroiliac joint pathologies in low back pain Table 2 Grades of sacroiliitis in the rheumatic group Spondyloarthropathies Psoriatic arthropathy, Reactive arthropathy Juvenile spondyloarthropathy Ankylosing spondylitis, Undifferentiated spondyloarthropathy Grades of sacroilitis 2 3 4

Table 3 Radiographic involvement of sacroiliac joints in different conditions Bilateral, symmetric Ankylosing spondylitis Psoriatic arthropathy Juvenile spondyloarthropathy Osteitis condensus ilii Osteomalacia Post partum strain Bilateral, asymmetric Unilateral Tuberculosis Malignancy

Reactive arthropathy

was done in two patients with tuberculosis. Advanced sacroiliitis (grade 4) was noted in AS, UspA and in JS whereas sacroiliitis was less advanced (grade 2) in PsA in ReA (Table 2). Fusion of the SIJ (Grade 3/4 sacroiliitis) was noted in AS but erosion and sclerosis were prevalent in PsA and ReA. The SIJ involvements were symmetric in AS, UspA, JS, Osteitis condensus ilii and in Osteomalacia. Bilateral SIJ involvement was noted in rheumatic, metabolic conditions and in osteitis condensus ilii whereas in infective and neoplastic conditions, the SIJ involvement was unilateral (Table 3). Elevated ESR and CRP were noted in 20 patients with SpA, JS and in patients with infection. Blood tests were normal in osteitis condensus ilii but elevated serum alkaline phosphatase and lowered serum calcium were noted in patients with Osteomalacia. The histopathology revealed myxoid chondrosarcoma in the patient with malignancy and the patient died after one year.

4. Discussion Besides spondyloarthropathies, the non rheumaic SIJ conditions are important causes SIJ pain. Triaging back pain due to SIJ involvement is a medical model of diagnosis involving detailed history, careful clinical examination and laboratory tests and radiological investigation [23]. SIJ pain is medial buttock pain around the sacral sulcus (usually below L5) with referral patterns in lower lumbar region, lower extremity or groin [15] and can herald a range of diseases. In this study 52 patients were diagnosed with history, clinical examination and radiological investigation. Multiple tests have been described to aid the diagnosis of SIJ pain, but there are limitations with SIJ provocative maneuvers [6]. How-

ever, the predictive values of these tests are maximized when multiple tests are used together [9,29]. Routine radiography revealed SIJ changes in 24 patients in this series and aided the diagnosis but CT and MRI were needed in diagnosing early sacroiliitis in cases of SpA and infective conditions of SIJ. Plain radiograph is not effective in diagnosing early sacroiliitis or SIJ dysfunction. A bone scan has value in conrming low-grade inammatory change, infection, tumor or sacral fracture. CT scan is more accurate than plain radiography, but MRI has more specicity and sensitivity in detecting sacroiliitis at an early stage [7,20]. The value of inammatory markers such as ESR or CRP may be limited in early cases of spondyloarthropathies. In recent literature, inammatory backache has been cited as the key symptom of axial spondyloarthropathy with low to moderate sensitivity and specicity of the Schober test [26]. SIJ tuberculosis (TB) can occur in 10% of all skeletal tuberculosis without evidence of TB elsewhere [25]. Skeletal TB has an insidious onset, follows a chronic course and red ag signs are often absent during the initial presentation. One should have a high index of suspicion in cases of unilateral destructive sacroiliac joint lesion with the history of persistent SIJ pain and other symptoms such as fever. At the initial stage, infective condition could be a differential diagnosis along with Psoriatic or Reiters arthropathy [17]. Reports of cases with osteomalacia and sacroiliitis are available in the literature [2,11]. Tuberculosis and osteomalacia should be kept in mind in the setting of developing countries. Osteitis condensus ilii is a benign and self limiting condition which is differentiated from Ankylosing Spondylitis by preserved joint space, intact articular margins and sclerotic changes mostly in the ilium on

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Sacroiliac joint pathologies

Inflammatory backache, reduced spinal mobility, features of SpA, radiological sacroiliitis (bilateral involvement), normal/raised CRP/ESR, HLA B27

Non inflammatory backache, normal spinal movement, no features of SpA normal/raised CRP, ESR (Infection) Unilateral/bilateral involvement

Rheumatic

Non-rheumatic

Adults) AS/UspA/PsA/ReA EA/RA/Others Red flag signs Raised CRP/ESR/ Ca/ALP etc +CT/MRI

(Children) Juvenile SpA

Blood tests normal and +/-imaging

History of trauma +imaging

Miscellaneous History, normal blood tests +/- imaging

SIJ dysfunction Degenerative

Stress/insufficiency fracture

Osteitis condensus illi Peripartum SIJ

Infective (Unilateral) Pyogenic, Tubercular Fungal

Neoplastic (Unilateral) Primary, Secondary

Metabolic (Bilateral) Osteomalacia, Osteoporosis Paget s disease, Gout, Hyperparathyroidism

SpA- spondyloarthropathy, AS- ankylosing spondylitis, UspA-undifferentiated spondyloarthropathy, PsA-psoriatic arthropathy, ReA- reactive arthropathy, EA- enteropathic arthropathy, RA- rheumatoid arthritis, CRP- c reactive protein, ESR-erythrocyte sedimentation rate, SIJ- sacroiliac joint, Ca- calcium, ALP -alkaline phosphatase, HLA- human leukocyte antigen, +/imaging- positive or negative X-ray/CT or MRI findings.
Fig. 1. Diagnostic scheme.

X-ray with normal ESR and non-inammatory nature of back pain [12,28]. During pregnancy, SIJ pain can occur from increased weight, excessive lordotic posture and hormone related laxity of ligaments [4,5]. Malignancy, though rare can masquerade as sacroiliitis [1,3,24]. Diagnostic scheme, decision tree or clinical algorithms are known and useful methods in the clinical medicine for diagnosis or treatment. The aim of the study was to design a diagnostic scheme which can help the clinicians in diagnosing different SIJ prob-

lems. An extensive literature review regarding different causes of SIJ pain and multitude of conditions involving SIJ was undertaken. Earlier workers proposed diagnostic algorithms for different subtypes of spondyloarthropathies [27] and chronic low back pain for general practice management [8]. Another algorithm was described on the basis of MRI and quantitative scintigraphy [20]. Looking at the different causes it was apparent that those SIJ conditions could be broadly subdivided into rheumatic causes such as spondyloarthropathies i.e. ankylosing spondylitis, undifferen-

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A.D. Gupta / Sacroiliac joint pathologies in low back pain [2] S. Akkus, M.N. Tamar and H. Yorgancigil, A case of osteomalacia mimicking ankylosing spondylitis, Rheumatoid Int 20(6) (Aug 2001), 239242. A. Al-Adsani, M.N. Niazy and M. Mohd, Ewings Sarcoma of the ilium mimicking sacroiliitis, Rheumatology 38 (1999), 792793. H. Albert, M. Godskesen and J. Westergaard, Prognosis in four syndromes of pregnancy-related pelvic pain, Acta Obstet Gynaecol Scand 80 (2001), 505510. G. Berg, M. Hammar, J. Moller-Nielsen, U. Linden and J. Thorblad, Low back pain during pregnancy, Obstet Gynecol 71 (1988), 7175. J.M. Berthelot, J.J. Labat, B. Goff, F. Gouin and Y. Maugars, Sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain, Joint Bone Spine 73 (2006), 1723. U. Blum, C. Buitrago-Tellez, A. Mundinger et al., Magnetic resonance imaging (MRI) for detection of active Sacroiliitisa prospective study comparing conventional radiography, scintigraphy, and contrast enhanced MRI, J Rheumatol 23(12) (Dec 1996), 21072115. N. Bogduk, Management of chronic low back pain, Med J Aust 180(2) (2004), 7983. N.A. Broadhurst and M.J. Bond, Pain provocation tests for the assessment of sacroiliac joint dysfunction, J Spinal Disord 11(4) (1998), 341345. S.P. Cohen, Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis and treatment, Anesth Analg 101 (2005), 14401453. B. Cortet, L. Berniere, E. Solau-Gervais, A. Hacene et al., Axial osteomalacia with sacroiliitis and moderate phosphate diabetes: Report of a case, Clinical Exp Rheumatol 18 (2000), 625628. P. de Bosset, D.A. Gordon, H.A. Smythe, M.B. Urowitz, B.E. Koehler and D.P. Singal, Comparison of osteitis condensus ilii and ankylosing spondylitis in female patients: Clinical, radiological and HLA typing characteristics, J Chronic Dis 31 (1978), 171181. R.A. Deyo and J.N. Weinstein, Low Back Pain, N Eng J Med 344 (2001), 363370. M. Douglas, S. Van der Linden, R. Juhlin, B. Huitfeldt, B. Amor, A. Colin et al., The European Spondyloarthropathy Study Group preliminary criteria for the classication spondyloarthropathy, Arthritis Rheum 34 (1991), 12181227. P. Dreyfuss, S.J. Dreyer, A. Cole and A. Mayo, Sacroiliac Joint Pain, J. Am Acad Ortho Surg 12(40) (2004), 255265. J.K. Freburger and D.L. Riddle, Using published evidence to guide the examination of the sacroiliac joint region, Phys Ther 81(5) (2001), 11351143. F. Gelal, D. Sabah, R. Dogan and A. Avci, Multi focal skeletal tuberculosis involving the lumber spine and a sacroiliac joint: MRI imaging ndings, Diagn Interv Radiol 12 (2006), 139 141. H.C. Hansen, A.M. Mckenzie-Brown, S.P. Cohen, J.R. Swicegood, J.D. Colson and L. Manchikanti, Sacroiliac Joint Interventions: systematic review, Pain Physician 10 (2007), 165 184. P. Huijbregts, Sacroiliac joint dysfunction: Evidence-based diagnosis, Orthopaedic Division Review (2004), 1844. J.C. Jarvik and R.A. Deyo, Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging, Ann Intern Med 137 (2002), 586597. M.A. Khan, Update on Spondyloarthropathies, Ann Intern Med 136 (2000), 896907.

tiated spondyloarthropathy, psoriatic arthropathy, reactive arthritis and enteropathic arthropathy. The non rheumatic conditions were mechanical or SIJ dysfunction, degenerative, pregnancy related, infective, osteitis condensus, traumatic, malignancy, metabolic and other conditions. During examination of a patient presented with low back pain with suspected SIJ pathology, it was good rst step to determine whether the condition is rheumatic or non rheumatic depending on history, clinical examination and routine tests. The next step was to nd out which subgroup the patient belonged to under those headings. The diagnostic scheme (Fig. 1) was derived keeping in mind both the rheumatic and various other non rheumatic conditions involving the SIJ. This could potentially help clinicians to diagnose patients presenting with low back pain with suspected SIJ pathology. The limitations of the study were i) Radiologically guided injection was not performed to conrm the SIJ pain in the patients who had suspected mechanical SIJ dysfunction. There is moderate evidence for intraarticular injection for diagnosing SIJ pain [18]. Similarly patients with pain around the SIJ due to zygapophyseal (facet) joint pathology were not evaluated by intervention such as injection or nerve block. ii) The number of patients from this retrospective study is not great enough to allow valid epidemiological conclusions. A prospective study is under way to conrm the clinical usefulness of the proposed diagnostic scheme. 5. Conclusions Medical history, clinical examination including sacroiliac joint tests, plain radiography and laboratory investigations were helpful in diagnosing sacroiliac joint pathology in 39% cases (n = 24), the remaining 46% (n = 28) needed CT or MRI. Diagnosis could not be conrmed in nine patients [15%]. Besides rheumatic causes, conditions such as tuberculosis, pyogenic infection, osteitis condensus ilii, osteomalacia, pregnancy related changes and neoplasm were the other causes of SIJ pathology. A diagnostic scheme of dividing the SIJ pathologies into rheumatic and non- rheumatic conditions was helpful in evaluating patients with suspected SIJ pathologies. References
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