Sacrodyny- Pain in the iliosacral jointcauses and therapy procedure

Transcription

1 Sacrodyny- Pain in the iliosacral jointcauses and therapy procedure The problem Perhaps, you have heard about the following clinical history: A patient, who had got a slipped disc and was treated successfully by minimal invasive therapy (for example by the periduralcatheter-therapy according to Salim), is still complaining about pseudoradicular pain radiating from the lower back to the thigh. No paresis is detectable. In the last MRI neither a slipped disc nor a protrusion can be proved. No medical treatment, no physiotherapeutic measure is able to bring an improvement for the patient. What can be done with those patients? Off, into the psychosomatic category?! I ve noticed this syndrome in about 80 % of my patients with successfully treated slipped disc. In my opinion, we do wrong to this patients declaring them a malingerer or people who want to retire or claim on a pension. The causes of back pain often aren t as obviously as it seems and many times the therapy is frustrating for both, the patient and the therapist. Now, what means sacrodyny and what kind of path morphological alterations can be seen behind this clinical picture? The cause The sacrodyny means pain in the iliosacral joint (=ISJ). The latter is the connection between the ilium and the sacrum in the dorsal part of the bony pelvis. Nerve supply of the ISJ comes from the roots of L 2 to L5 of the plexus lumbalis as well as from S1 to S3 of the plexus sacralis. Main supply comes from S 2 nerve route. There are two characteristic forms of sacrodyny: the functional and the degenerative one. 1. The functional sacrodyny It is very often associated with slipped disc because of spine malposition caused by pain. It comes forward after having carefully treated the slipped

2 disc by minimal invasive method, like Periduralcatheter-therapy according to Salim, or by operation. The predisposing factors are congenital or acquired spine malposition, e.g. different leg lengths, unilateral sports stress by football, gulf, etc. 2. The degenerative sacrodyny You can find it associated with general osteoarthritis or with acute attack of rheumatic disease. Further forms are the post traumatic and the postpartum sacrodyny. Clinical history and symptoms As already indicated in the beginning, the patient complains about the persistence of pseudoradicular pain radiating from the lower back to the thigh. Mostly the patient describes the pain radiating from the back to the dorsal side of thigh or seldom radiating into the inguinal region. Over and above that there is a strong tenderness in one or both iliosacral joints. No motor or sensitive paralysis can be detected. Characteristically the patient makes no recovery by common therapy as well as medical and physiotherapeutic treatment or periradiculary therapy. The diagnostic process For getting the right diagnosis clinical examination is most important, as already described. But sometimes, there are no impressions with the exception of the strong tenderness in the iliosacral region. By means of a lumbar MRI a slipped disc can be excluded. A szintiscan can detect an active arthrosis of the iliosacral joints.

3 The procedure Corresponding to all the other minimal invasive methods, the infiltration of the ISJ will be done in local anaesthesia. The patient will lie in prone position on the CT-examination table. Under CT control, the height of the nerve root S2 will be marked. Fig.1: The right measurement of the height of the ISJ Fig.2: the injection point is marked on the patients back After careful disinfection, the special injection needle will be inserted forward into the ISJ and a small quantity of contrast medium will be given. The next CT scan will show the distribution of the contrast medium. With right positioning of the injection needle contrast medium will be seen in the ISJ and along S2 nerve root. If not, the position will have to be corrected. Thereupon, local anaesthetic and crystalline cortisone suspension will be given. Fig.3: the exact positioning of the injection needles and the right contrast medium distribution Fig.4: after CT control the patient is given the medication

4 After removing the needle a sterile bandage will form the end. The patient will be free of pain. After first injection the pain can return so a treatment course of three interventions with regular interval of two weeks each should be performed. Results Two groups each with 600 patients had an aftercare. Group 1: These patients were treated by the CT controlled ISJ-injection with S2- blocking according to Salim. Group 2: The patients of the control group had a conservative treatment with medication combined with physiotherapy. The pain intensity was represented in the visual analogue scale (=VAS). The pain before treatment was fixed on 10 of the VAS for all patients. The success rates were described in two therapy periods: First period: Second period: after two months of treatment after 4, 5 months, all patients with persisting pain had got another therapy cycle after ISJ injection control group 0 after 2 months after 4,5 months Fig.5: Pain intensity represented on VAS in comparison of both therapy groups Already after first treatment the group after ISJ-injection shows a decrease of pain on 10 % of the starting value. That means a success rate of 90 % in the group of CT controlled ISJ injection. In the control group with conservative therapy the success rate was measured with only 15 %. The relapse incidence in the second group amounts 60 % in comparison to this in the first group the incidence of recurrent pain amounts to 10%. These facts show a significant reduction of recurrence incidence.

5 These results are similar to those, when sacrodyny occurs with woman after delivery. The posttraumatic sacrodyny is accompanied with recurrent pain in approx. 35%, but the success rate does not differ significantly from that of the functional sacrodyny. But there are important differences to the degenerative form. The success rate is around 76% after the first therapy cycle. The relapse quote amounts to approx. 60%. After the second therapy period a success of 80% could be achieved. The importance of sacrodyny treatment shows in complain reducing during after periduralcatheter-therapy according to Salim Group 1: After periduralcatheter-therapy the average pain intensity was reduced from 10 to 2on the VAS. That means a success rate of 80 %. Group 2: After conventional treatment, periradiculary therapy or operation the average pain intensity was declared with 5, 7 on the VAS. In this group a pain reduction of only 43% was obtained. Group PDK + ISG: After the iliosacral injections the success rate in the first group increased upon 90%. These data show the importance of the iliosacral treatment following periduralcatheter-therapy by Salim before control group after PDK after PDK+ ISG 0 before control PDK PDK+ ISG Fig.6: the average pain intensity of the patients before and after therapy represented on the VAS

6 Summary The functional sacrodyny is a widespread clinical picture. In 80% of cases it is seen after successful treatment of slipped disc. Whereas the conservative treatment with medication and physiotherapeutic therapy only shows small success, the CT controlled iliosacral injection with S2 blocking according to Salim is able to achieve a success rate of 90%. In my opinion the iliosacral injection should be the primary therapy method in this clinical picture. At once, the patient is immediately free of pain. When getting again a muscle tension, followed by shifting the spine-pelvis-axis as well as the beginning of a new vicious circle, will be counteracted therewith. If the iliosacral pain should occur again, the treatment can be repeated unproblematically. Complications, as infection or bleeding, are rare when acting carefully. The therapy can well be executed with outpatient treatment. Author: Dr. med. Elias Salim, Dr. med. Jana Salim Practice: Winterhuder Marktplatz 17 D Hamburg Germany Tel.: ++49 (0) Fax: ++49 (0) [email protected] Internet: