LETTERS TO EDITOR Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 147-148  

Sacroiliac joint pain - A diagnostic dilemma

Vinod Krishnagopal1, Sharanya Krishnakumar2, R Purushotham1, R Sudhakaran1
1 Department of Anesthesiology, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
2 Department of Microbiology, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India

Date of Submission27-Jan-2022Date of Decision12-Apr-2022Date of Acceptance02-May-2022Date of Web Publication10-Jun-2022

Correspondence Address:
Dr. Vinod Krishnagopal
Departments of Anesthesiology, Sree Balaji Medical College and Hospital, Chennai - 600 044, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/TheIAForum.TheIAForum_14_22

How to cite this article:
Krishnagopal V, Krishnakumar S, Purushotham R, Sudhakaran R. Sacroiliac joint pain - A diagnostic dilemma. Indian Anaesth Forum 2022;23:147-8

Sir,

Sacroiliac (SI) joint pain accounts for 15%–30% of all low backache (LBA) patients.[1] Accurate clinical diagnosis of SI joint pain is often difficult as it is compounded by the presence of vague pain distribution in the lower back and absence of specific clinical tests. Narrowing down the cause of LBA can be made difficult by the presence of other pathologies which may coexist in the imaging tests but may not be the pain generator. The gold standard technique of diagnosis is fluoroscopy-guided injection of the suspected pain generator. When the clinical and radiological tests used for diagnosing the cause of LBA are contradictory in a patient, it is difficult for the clinician to choose which pain generator to block first. Here, we discuss a case of successful pain relief to a person with LBA by fluoroscopy-guided SI joint injection.

A 62-year-old woman presented with severe pain with Numeric Rating Scale (NRS) score of 8–9/10 in the right gluteal and lower lumbar region.[2] The pain radiated to the right lower limb up to the knee and worsened on sitting down. On examination, there was tenderness in the right gluteal region below the posterior superior iliac spine. Motor and sensory examination was normal. Provocative tests such as distraction test and thigh thrust test were all negative.[3] Straight leg raising (SLR) test was positive on the right side. Magnetic resonance imaging (MRI) revealed L4 and L5 disc bulge with compression of exiting nerve root on the right side. The patient was a known case of coronary artery disease with ejection fraction of 25%. The patient was on tablet (T.) clopidogrel which was stopped 7 days before the procedure and was started on T. aspirin 75 mg. Following evaluation of the patient, we concluded that the pain generator could be either right SI joint or the L4–L5 disc. The site of pain and tenderness along with aggravation of pain on sitting were in favor of SI joint pathology. However, positive SLR test, absence of provocative tests, and MRI findings were in favor of disc pathology. We planned to take up the patient for right SI joint injection on the 1st day, and if the patient still had pain (NRS score not reduced by 50%), the patient would be subjected to nerve root block on the next day.

On the day of the block, a 20-gauge intravenous cannula was secured on the right hand, and the heart rate, noninvasive blood pressure, and peripheral oxygen saturation were attached. The patient was placed in the prone position. The fluoroscope was positioned over the lumbosacral region, and a check image was taken. On visualizing the pelvis, the fluoroscope was rotated 5°–15° in the craniocaudal direction to square the vertebrae. The fluoroscope was then rotated contra-laterally in the oblique plane to visualize the inferior and widest part of the joint. Under local infiltration, a 22-gauge Quincke needle was advanced under fluoroscopic guidance to enter into the inferior part of the joint [Figure 1]. 1ml of nonionic contrast agent was injected to confirm the intra-articular position and exclude intravascular placement [Figure 2], following which 2ml of 2% plain lignocaine and 40mg of depomethyl prednisolone were injected incrementally after repeated aspiration. The patient was shifted to the recovery room, and her pain intensity was assessed 1 h after the block and it was 1–2/10. This was a positive response, and the patient was discharged on the next day. Six months follow-up revealed that the patient was comfortable and the pain intensity was reduced to 0/10.

We feel that more importance could be given to the history and site of pain than imaging techniques to decide the pain generator to be blocked first as it may reduce the undue stress, anxiety, time delay, and expense to our patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Chuang CW, Hung SK, Pan PT, Kao MC. Diagnosis and interventional pain management options for sacroiliac joint pain. Ci Ji Yi Xue Za Zhi 2019;31:207-10.  
    2.Pathak A, Sharma S, Jensen MP. The utility and validity of pain intensity rating scales for use in developing countries. Pain Rep 2018;3:e672.  
    3.Barros G, McGrath L, Gelfenbeyn M. Sacroiliac joint dysfunction in patients with low back pain. Fed Pract 2019;36:370-5.  
    
  [Figure 1], [Figure 2]