What is sacroiliitis: symptoms, treatment, prognosis

Brucellosis sacroiliitis
Brucellosis is characterized by a transient nature of tissue damage, which indicates the possible appearance of volatile arthralgias. In a number of clinical cases, persistent, long-term and, at the same time, difficult to stop inflammatory processes, expressed as synovitis or arthritis, can be observed.

Tandem with brucellosis can have different forms. Patients with this type of diagnosis complain of pain concentrated in the joint area, which can significantly intensify when performing various types of movements.

A conservative approach is required, involving a combination of specific therapy with the use of a complex of antibiotics, vaccination and the prescription of a number of medications.

Aseptic sacroiliitis

This is quite common for rheumatic diseases, in particular psoriatic arthritis.

X-ray examination makes it possible to make a diagnosis in the first stages of progression, which guarantees successful prognosis for recovery.

The primary stages involve a moderate widening of the joint gap, with unclear contours of the articulation.

The second stage involves a pronounced symptomatic picture, accompanied by a narrowing of the joint space and the formation of single erosions.

The third and fourth stages involve partial and complete ankylosis, respectively.

Symptoms of sacroiliitis of the presented type are mild. The pain can be of slight or moderate intensity, radiating to the thigh, increasing during a state of rest, and decreasing only with increased physical activity.

Diagnostic testing may require additional specific methods, which include laboratory testing.

Non-infectious sacroiliitis

Lesions of the sacroiliac joint of non-infectious origin do not belong to the concept of “sacroiliitis”, however, medical practice allows such a diagnosis.

Changes of this type may have a number of preconditions, the exact list of which is not easy to determine. Most likely, the pathologies are caused by previous injuries or systematic overload.

Among the complaints, spontaneous painful attacks are noted, localized in the sacral area. When performing movements, an increase in discomfort may be observed.

The main direction of treatment is the elimination of inflammation and pain. Physiotherapeutic procedures, taking a complex of medications and other solutions that can speed up recovery can be used as therapeutic methods.

General information

What is sacroiliitis?
This is an inflammatory process of the sacroiliac (ileosacral) joint, which can be unilateral or bilateral. The paired sacroiliac joints connect the sacrum (a section of the spine made up of five vertebrae fused into one bone) and the ilium, forming the pelvic ring. This is a synovial joint, the articular surface of the sacrum has hyaline cartilage, and the surface of the ilium has fibrocartilage. The articular surface of the sacrum is uneven and it connects with the same irregularities of the ilium. The joint is held in place by strong interosseous sacrolumbar ligaments, which are attached to the sacrum and ilium.

The joint is physiologically adapted to the load, since its main function is support. It supports the body, reducing the strain when walking. The range of motion in the joint when walking is limited due to ligaments.

Most often, sacroiliitis is a symptom of various diseases of an infectious or autoimmune nature.
In this regard, the classification of diseases indicates the underlying disease ( Bechterew's disease , psoriatic arthritis , rheumatoid arthritis , various spondylopathies and dorsopathies ), in which unilateral or bilateral inflammation of the joint occurs. Sacroiliitis , which is not classified elsewhere, has an ICD-10 code of M46.1.
The anatomical structure of the joint contributes to low-symptomatic manifestations in the initial stages of the disease. Over time, the pain in the joint area intensifies, radiating to the buttock and groin. Subsequently, changes occur in the joint in the form of arthrosis and ankylosis , and the joint becomes a source of constant pain. Pain in the sacrum in women or men is most often associated with neurological manifestations of degenerative changes in this part of the spine, and patients do not receive the necessary treatment for a long time if there is a specific inflammation (tuberculosis, syphilitic, brucellosis) or autoimmune ( Bechterew's disease , Reiter's , psoriasis ). In this regard, you need to know how to make a diagnosis, signs of sacroiliitis of the iliosacral joint. In this short review we will look at all these questions. And also, which doctor treats sacroiliitis? Depending on the cause, this may be a rheumatologist or a traumatologist. However, initially you need to see a therapist and undergo a minimum of examinations, based on the results of which the doctor will give a referral to a specialist.

Pathogenesis

The sacroiliac joint is complex, partly a synovial joint and partly a fixed synostosis. Considering the presence of powerful ligaments that support it, it is more correct to speak of a complex. There are pain receptors in the joint capsule, ligaments, and even in the subchondral bone, but there are fewer of them. Damage to any of the structures becomes a source of pain. The most common causes are spondyloarthropathy and arthrosis-arthritis , which develop against the background of specific factors - autoimmune, infectious or septic inflammation. Damage to the joint develops from a combination of two factors - pronounced axial load and rotation.

Reviews

Almost all patients who have encountered sacroyelitis claim that this pathology needs to be treated for a long time and with high quality. Only complex therapy will help overcome the disease.

Elena, 38 years old: “I had pain in the lower back that radiated to my hip, which appeared 6 years ago. I went to the doctor, who diagnosed me with sacroyelitis due to arthritis. I was prescribed anti-inflammatory drugs, electrophoresis, and magnetic therapy. In addition, I started visiting an osteopath, who turned out to be an excellent specialist, doing exercise therapy (first under the supervision of an instructor, and then on my own at home), and going to the pool. All these procedures together helped get rid of lower back pain.”

Anna, 35 years old: “I was diagnosed with left-sided sacroyelitis after childbirth. The pain was severe, treatment took place in a hospital. For about a month I went to physiotherapy, received NSAID injections, as well as vitamins. A therapeutic blockade helped with severe pain. Then I wore a corset for about 6 months and did gymnastics. After the course of therapy, the pain went away and didn’t bother me anymore.”

Andrey, 39 years old: “My sacroiliac joint became inflamed on the right, and then on the left. Pain appears on one side, then on the other, then on both sides. The pain gradually became stronger and stronger. I went to doctors for a long time, they prescribed a bunch of tests, but they couldn’t find the reason. Then I found a good specialist on the advice of friends, who found out that I have bilateral sacroyelitis of an autoimmune nature. I prescribed a bunch of medications and physical therapy, I hope it gets better. Although the doctor immediately warned that the treatment would be long.”

Classification

Depending on the prevalence of the process in the joint, the following are distinguished:

synovitis (only the synovial membrane is affected);
panarthritis (all joint tissues);
osteoarthritis (degenerative changes in joint surfaces).

According to the nature of inflammation and changes in the joint:

specific (syphilitic, tuberculosis, brucellosis, yersinia);
nonspecific (purulent) arises from a focus of osteomyelitis ;
autoimmune (aseptic),
degenerative-dystrophic.

Purulent damage to the joint is always one-sided - right-sided sacroiliitis or left-sided sacroiliitis develops. The onset is acute, there is a rapid course with high fever and chills, sharp pain in the back on the right (if right-sided sacroiliitis occurs) or on the left (left-sided). The patient's condition quickly deteriorates, and severe intoxication develops. The causes of purulent inflammation are osteomyelitis , a breakthrough of the abscess in the surrounding tissues, or infection of the joint due to an open injury to the pelvis and back.

Unilateral damage is also caused by:

bone tumors;
metastases of tumors of various localizations;
infections ( tuberculosis , brucellosis , chlamydia , gonorrhea , syphilis );
septic arthritis.

Bilateral sacroiliitis accompanies systemic diseases that occur with arthritis. What it is? Bilateral means damage to the joints on both sides, which can be symmetrical (on both sides in the same places) or asymmetrical (on both sides, but in different places of the joint).

Bilateral and symmetrical lesions are observed when:

inflammatory bowel disease ( ulcerative colitis , Crohn's disease );
ankylosing spondylitis ( ankylosing );
condensing osteitis ( osteosclerosis ) of the ilium;
multicentric reticulohistiocytosis (systemic disease with infiltration of organs by giant cells and histiocytes);
Whipple's disease.

Bilateral lesions are of particular diagnostic importance in ankylosing spondylitis - sometimes this is an early sign of an incipient disease.

Bilateral but asymmetrical lesions are observed when:

psoriatic arthritis;
Reiter's disease;
rheumatoid arthritis;
osteoarthritis;
relapsing polychondritis (systemic immune-inflammatory with gradual destruction of cartilaginous structures);
Behçet's disease (systemic vasculitis).

Causes of pain in the sacrum

Primary inflammation of the sacroiliac joint can be caused by:

traumatic injuries to bones, ligaments and muscles in this area;
repeated excessive loads;
local infection of the joint in open injuries;
tumors and metastases (most often from the genital organs, intestines and lungs);
pregnancy and childbirth.

Secondary inflammation occurs in the following diseases:

Ankylosing spondylitis . Ankylosing spondylitis is a chronic inflammatory disease of the spine. The main symptom is damage to the sacroiliac joints. In the peripheral form of ankylosing spondylitis, damage to the sacroiliac joints occurs without significant pain, and therefore can only be detected by x-ray. The X-ray picture makes it possible to make an early diagnosis. In the initial stages, foci of subchondral osteoporosis appear, the contours of the joints become unclear and a false impression appears that the joint space is widened. Then erosion of the subchondral bone appears - the edges of the joint become uneven. Gradually, the joint space narrows and even disappears (ankylosis). The diagnosis of ankylosing spondylitis is considered reliable in the presence of a unilateral lesion of stage III-IV or bilateral lesion of stage II-IV, as well as one clinical manifestation. A potential causative agent of ankylosing spondylitis is Klebsiella pneumoniae.
Inflammatory bowel diseases ( ulcerative colitis and Crohn's disease ). Sacroiliitis, usually symmetrical, is found in 25% of patients with ulcerative colitis and 15% with Crohn's disease. It may be a precursor to these diseases and the only localization on the joint side, but in 90% of patients it is asymptomatic. Its presence does not correlate with the severity of the inflammatory process in the intestine. Treatment of intestinal syndrome does not improve the clinical course of sacroiliitis. In parallel with inflammation of the sacroiliac joint, eye damage ( episcleritis , corneal ulcer ) is detected. Some patients experience transient sacroiliitis.
Whipple's disease . Signs of this disease are articular syndrome, gastrointestinal damage ( diarrhea and steatorrhea ), paroxysmal abdominal pain, malabsorption and progressive weight loss. Unilateral or bilateral damage to the sacrococcygeal joint is found in 14% of patients.
Psoriasis . With this disease, damage to the joints, including the sacroiliac joints, is common. Characterized by asymmetric arthritis , damage to the fingers and toes, distal interphalangeal joints, as well as asymmetric bilateral sacroiliitis. X-ray examination reveals periarticular osteoporosis , bone erosion, narrowing of the gap, bone ankylosis, and destruction of the vertebrae.

Infectious lesions of the sacroiliac joint are not so common; they are caused by:

Tuberculosis . Tuberculosis of the joint is observed in 1-4% of patients. The primary focus is located in the ilium or sacrum. The defeat is one-sided. X-ray shows massive destruction of the sacrum and ilium. Sequestra occupy one third of the bone, the contours of the joint are not clear, and the edges are corroded. Sometimes there is a disappearance of the joint space (partial or complete).
Yersiniosis . With this infectious disease there is an enteral phase, and then the disease passes into the generalized, allergic and secondary focal stages, which occur with exacerbations.
Brucellosis . Brucellosis lesions are bilateral in nature and mask dystrophic diseases of the joint. Patients experience pain in the lumbosacral region when walking, stiffness of movement, and pain when going down stairs. An epidemiological history helps to establish a diagnosis.
Syphilis . Syphilitic lesion occurs at the tertiary stage of the disease. It manifests itself as night pain, which is diffuse in nature. X-rays reveal minor changes that become pronounced over time.

If we consider this pathology in men, then it occurs with Reiter's disease , which affects mainly men. This is an autoimmune disease that affects the eyes ( conjunctivitis ), joints ( arthritis , including the sacroiliac joint) and the genitourinary system ( urethritis ). Ankylosing spondylitis is also more common (2-3 times) in men. Considering that men are more susceptible to significant physical activity and intense sports activities, this factor plays a big role in the occurrence of sacroiliitis .

The causes of pain in the sacrum in women, in general, do not differ from those in men. But there are still specific reasons, one of which is pregnancy . This is due to the fact that weight increases during pregnancy, and changes in hormonal levels cause stretching and weakening of ligaments and increased lordosis (excessive curvature of the lumbar spine with a convexity forward). The pelvis becomes “less rigid”, and this is favorable for childbirth. About 50% of women experience pain in the lower back and their source is the sacroiliac joints.

Pain in the sacrum in women can provoke difficult childbirth, during which pelvic tissues are damaged, ligaments, muscles and the pelvis are further stretched. In such cases, a course of nonsteroidal anti-inflammatory drugs and wearing a sacroiliac belt are recommended. It fixes tissue, stabilizes joints, and helps reduce inflammation. The recovery process can be lengthy and take from several months to a year. Complaints often recur during subsequent pregnancies and after childbirth.

Pain in the sacral region in women can cause malformations of the pelvis, disturbances in the formation of the sacroiliac joints, injuries to the pelvic bones, and pelvic distortion due to shortening of the leg. A difference in leg length of more than 5 mm already causes pain due to the increased load on the joint. It should be taken into account that in case of gynecological diseases, the sacroiliac joint is an area of referred pain. Also, pain in the sacral spine in women can be associated with a sedentary lifestyle, carrying heavy objects, prolonged static loads, running and jumping. Thus, if pain appears in the sacral spine in women, then this condition requires further examination to clarify the cause.

Contraindications

Magnetic resonance imaging does not harm the body, but only if you have no contraindications to the procedure. The main contraindication is the presence of metal objects in the body (pins, knitting needles, implants, pacemakers) because under the influence of the magnetic field of the tomograph, they can heat up and move.

Other contraindications include the following factors:

Presence of pregnancy. During the first 2 months of pregnancy, it is not recommended to do an MRI without good reason.
Patients weighing more than 250 kg are not allowed to participate in the study.
Claustrophobia. Fear of closed spaces is included in the list of contraindications, since it will be difficult for the patient to spend half an hour motionless in a closed tomograph.
Allergic reaction. This contraindication is relevant if magnetic resonance imaging is performed with contrast agents.

The specialist also has the right to refuse to allow a patient to undergo magnetic resonance imaging of the iliosacral joints in case of epilepsy or convulsive syndrome.

Symptoms of sacroiliitis

The main symptoms of sacroiliitis are pain in the sacrum at night, after waking up, and when moving. The pain radiates to the buttocks and back of the thighs. All these symptoms resemble lumbosacral radiculitis. In addition, patients complain of morning stiffness.

For systemic diseases, the following are characteristic:

bilateral lesion;
widespread pain, covering the entire lumbosacral region and spreading to the thigh and buttocks;
the pain intensifies at night and with prolonged stay in one position;
reduction of pain when moving;
stiffness in the morning.

In the chronic course of the disease, the pain is moderate and intensifies with prolonged stay in one position (sitting or standing).

Symptoms for injuries, infections and tumors:

predominantly unilateral lesion;
pain in the lower back and spreading to the leg;
intensifies with abduction of the leg, pressure and movements;
subsides at rest.

The most pronounced symptoms are observed with purulent lesions of the joint. With the infectious nature of the disease, the temperature rises, severe pain develops, which is why the patient takes a forced position (legs bent at the knee and hip joints). The pain intensifies when straightening the legs, turning, and when pressing on the wing of the ilium. On examination, sharp pain is noted in the sacroiliac joint. A positive test for the presence of sacroiliitis is painful extension of the hip while simultaneously fixing the pelvis in the prone position. Due to pain, patients require pain relief and assistance.

As we have found out, pain in the sacrum in men is often associated with ankylosing spondylitis. It is characterized by intensification at rest and in one position. The pain is especially disturbing in the second half of the night. Patients feel better when they move or exercise regularly. With this disease, planned activity is important, which prevents irreversible changes in the joint in the form of ankylosis .

Stretching exercises

To achieve the effect, you must perform individual exercises for at least one minute. While holding your body in a certain position, you need to relax and feel how the muscles stretch. Types of exercises:

While standing, lunge forward with your right leg and bend your knee. Place your hands on your right limb, and try to bring the knee of your left leg closer to the floor. Slowly perform several forward bends. Then do the same with your other leg forward.
Lunge again, but keep your leg straight, as if doing a split. Point your hands towards the floor. In this way, stretch both legs.
“Butterfly” - in a sitting position, point your feet towards each other and connect. Watch your posture, bend your elbows. With your hands, grab your knees and press on them, trying to lower your knees to the floor. As you inhale, bend your body forward until you feel a stretch. Spend about a minute in this position, then stop putting pressure on your legs and straighten your back.
Lie on the floor with your back, place your right lower limb on your left, and turn your body in the same direction. Return to the starting position, in a mirror position, do the same with the other leg.
“Cat” - standing on all fours, bend your back down, and then you need to bend it in the opposite direction.

Tests and diagnostics

Radiography. True sacroiliitis in ankylosing spondylitis has characteristic radiological signs: unevenness of the joint space, subchondral sclerosis, widening of the joint space, and at a later date - narrowing. Radiologically there are 4 stages:

Stage I - areas of erosion and changes in the joint space are absent;
Stage II - narrowing of the joint space;
Stage III - erosion, narrowing of the gap, severe sclerosis , bone “bridges” between the two surfaces of the joint and partial ankylosis ;
Stage IV—overgrowth of the gap and complete ankylosis .

MRI is the most informative method that allows you to detect changes very early, when they are not yet detected radiographically. In the early stages, swelling of the articular surfaces is detected, there are still no changes in the surface of the cartilage, and the joint space is not changed.

CT scan. Detects changes in the second stage - narrowing or widening of the gap, cartilage defects in the form of small points. Later, foci of destruction are detected in the ilium.

For rheumatic diseases, additional tests are prescribed to identify specific antibodies (rheumatoid factor class IgA and IgM, antibodies to cyclic citrullinated peptide), HLA-B27 antigen in ankylosing spondylitis .

To diagnose sacroiliitis, special tests are used (Kushelevsky’s symptoms), which are performed by the doctor when examining the patient:

When sharp pressure is applied to the crests of the iliac bones while the patient is lying on his back on a hard surface, pain occurs in the sacral area.
Sharp pressure on the area of the ilium with the patient lying on his side also causes pain in the sacrum. The symptom is checked on both sides.
The patient is positioned on his back, the leg is bent at the knee and laid to the side. The doctor rests his hand on the bent knee joint, while with the other hand he presses on the ilium on the opposite side. When performing a test in the presence of sacroiliitis, pain appears. The symptom is checked on both sides.

Treatment

In the early stages of treatment, heat, cold, or a combination of both may be prescribed.
NSAIDs may be prescribed during the acute phase of the disease. As it becomes chronic, their effectiveness decreases.
Intra-articular anesthetic/steroid injections can be performed for diagnostic and therapeutic purposes. If symptoms persist (6 to 8 weeks) without at least 50% improvement, the drug can be repeated.
Physical therapy is an effective tool for working with SIJ dysfunction - if the pain is caused by joint hypermobility, then physical therapy can stabilize and strengthen the lumbopelvic muscles, if the pain is caused by immobility, then physical therapy can help increase the range of motion in the SIJ.
If previous treatments do not provide adequate relief, radiofrequency ablation is recommended in some cases.
If these measures are ineffective, surgery can be performed (fixation of the SIJ).

In children

Pathology of the sacroiliac joint occurs in adults, but in children it is an insufficiently studied pathology. Due to the complex anatomical structure of the joint, children rarely localize pain in this particular area, and this makes diagnosis difficult. The inflammatory process in the joint is preceded by injuries, hypothermia and acute respiratory viral infections.

During X-ray examination, in case of primary sacroiliitis, the process is localized in the middle and lower third of the joint (which corresponds to the synovial part of the joint), and in case of secondary sacroiliitis, it is localized in the upper third (this is the fibrous part). Most often, children experience purulent sacroiliitis , the clinical picture of which is dominated by abdominal, infectious-toxic and ischioradicular syndrome.

Infectious-toxic syndrome includes fever and intoxication (weakness, headache, nausea, disturbances in appetite and sleep, disturbance of consciousness, lethargy). With abdominal syndrome, abdominal pain, loose stools, intestinal paresis, tension in the muscles of the anterior abdominal wall and its soreness appear.

Ischioradicular syndrome is manifested by a forced position (lying on the back with straight legs). Minor movements of the body and legs cause severe pain. Due to the pelvic distortion, the leg is shortened by 1-1.5 cm on the affected side, and a curvature of the spine towards the inflamed joint is also detected. Children cannot lift their leg - only slight bending of the leg at the knee and hip joint.

In newborns and infants, inflammation of the iliosacral joint occurs with a severe general condition and a predominance of infectious-toxic syndrome with high fever.

In children 1-3 years old with this pathology, the condition is moderate or also severe. There is an infectious-toxic syndrome, and the abdominal syndrome occurs with periodic abdominal pain, muscle tension in the abdomen on the affected side. If the children still walk for the first two days, leaning on the front of the foot, and then refuse to walk. They experience minor paresis of the foot. In older children, ischioradicular syndrome predominates, and they can clearly localize pain.

If there is a purulent focus (phlegmon), surgical treatment is performed and antibiotics are prescribed (taking into account sensitivity to antibiotics). The duration of antibiotic treatment is 4-6 weeks. Sometimes after surgery, special immobilization or adhesive traction of the leg on the affected side is performed. Bed rest is observed for 1-3 weeks (depending on the severity and volume of the operation). After this, children begin to stand up and walk with crutches, protecting the leg on the affected side. Wearing the leg is allowed after 3-4 weeks, but it must be dosed.

If we consider ankylosing spondylitis, then 20% of all cases of the disease occur under the age of 15-16 years. 25% of sick children have a family history of seronegative spondyloarthritis . The disease usually begins at age 10, and patients begin to be examined at age 15, when the diagnosis of ankylosing spondylitis is made.

It is eligible in the presence of three syndromes:

arthritis of peripheral joints;
enthesopathies;
spinal damage.

Enthesopathy is a pathological process at the sites of attachment of tendons, ligaments or joint capsules to the bone. The ends of tendons ( tendinitis ) and adjacent joint capsules may also be affected. In adolescents, the peripheral form of ankylosing spondylitis mostly occurs - initial damage to the sacroiliac joints, and then the addition of lesions to the knee and ankle joints, in which deforming arthrosis .

Thus, the first symptom is pain in the sacrum. Pain in the lumbosacral spine is accompanied by changes in posture and even swelling in the sacroiliac area. Involvement of the sacroiliac joints is observed at the age of 11-14 years, and then the large and medium joints of the legs are affected. Particularly characteristic of the juvenile form of ankylosing spondylitis is the involvement of the hip (in the first place), knee, ankle and tarsal joints. It is very important to suspect and identify the disease at an early age in order to carry out timely treatment and prevent the progression of the disease.

List of sources

Bunchuk N.V., Badokin V.V., Korotaeva T.V. Psoriatic arthritis. In the book: Rheumatology. National leadership. Ed. Nasonova E. L., Nasonova V. A. M.: GEOTAR-Media, 2008. 720 p.
Silantieva T.S. Seronegative spondyloarthritis and ankylosing spondylitis: how to establish a diagnosis and not be late with treatment / Health of Ukraine. — 2021.— No. 7, pp. 37-38.
 Ostanina T.G., Evstigneev I.V., Cherny V.I., M.A. Beresten. Tuberculous sacroiliitis / Clinical immunology. Allergology. Infectology. — 2021.— No. 5, pp. 39-43.
Slobodin T.N. Damage to the sacroiliac joint: diagnostic difficulties / Health of Ukraine. - 2021. - No. 5, p. 25.
Badokin V.V. Psoriatic sacroiliitis and psoriatic ankylosing spondylitis // Consilium Medicum. 2008. No. 2.

Is a contrast agent required?

The use of contrast agents when performing magnetic resonance imaging of the iliosacral joints is required if the purpose of diagnosis is to search for a neoplasm, clarify its origin and location. In some cases, contrast imaging may also be recommended for inflammatory processes. After the administration of a contrast agent, an increase in signal intensity is observed from the pathologically altered articular cartilage, capsule and periarticular tissues.

The use of contrast agents is absolutely safe for the body. Modern drugs do not cause side effects and are well tolerated. In rare cases, you may experience slight dizziness, but it quickly goes away on its own and does not require treatment.