Document 6476532

ACUTE
POSTPARTUM
A REPORT
OF
YIZHAR
FOUR
FLOMAN,
MEIR
LIEBERGALL
From
Hadassah
INFLAMMATORY
SACROILIITIS
CASES
CHARLES
MILGROM,
University
JOHN
Hospital,
M.
Jerusalem,
GOMORI,
SHMUEL
KENAN,
a septic
Received
[Br]
30 March
1994;
1994;
76-B:887-90.
Accepted
26 May
aetiology,
CASE
All four
previous
Pain
in the region
of the sacroiliacjoint
is not uncommon,
bral
ping
discs (Macnab
and McCulloch
innervation
of these structures
the sacroiliac
(SI)joint
to the
tion difficult
and this has led
existence
of ‘real’
SI joint
1991).
In pregnancy,
however,
mon (Fast et al 1987; Ostgaard
SI joint
and the pelvis
the early
postpartum
may occur are sacroiliac
We
which
report
started
four
The
joints
pain is usually
or interverte-
1990).
The overlapand the proximity
of
hip make clinical
examinamany clinicians
to doubt the
pain (Bernard
and Cassidy
SI joint pain is not uncomand Andersson
1988).
The
undergo
considerable
changes
in
period
and two conditions
which
strain and septic
sacroiliitis.
patients
as agonising
with
postpartum
unilateral
subsided
gradually
of our patients
were
young
history
of low back pain (Table
was
unilateral,
by
intense
the smallest
Pain
was
bed.
compression
(Hoppenfeld
but thejoint
itself is seldom
the source.
referred
from the neighbouring
facet
the pain
and
of the pelvis
1976).
All four
mild
elevation
a positive
bone
radiographs
of the SI joints
up films
including
yielding
only
(case
and
had
of
scan
4)
drops
MRI
anterior
capsule
(Fig. 2).
1 was given a course
metronidazole.
right
and
drugs
acute
of gentamicin,
were
(indomethacin
followtests,
2 and
control,
episode
with
test
mild
blood
Cases
fluid.
2 received
All four patients
anti-inflammatory
as were
sterile
and
phosphatase
The
initial
fluoroscopic
SI joint
case
bed,
by tapping
side-to-side
1).
normal,
the
fluid
metronidazole,
alkaline
(Fig.
under
showed
Case
in
even
by
of clear
during
in the
rest
Rheumatological
were all normal.
of the Sljoint
a few
at
with
no
sacroiliac
by the Gaenslen
an elevated
ESR,
were
taken
at one year.
HLA-B27
typing,
3 had aspiration
patient
even
women
I). The
movement,
exacerbated
leucocytosis,
levels,
and
and
of
REPORTS
aggravated
on the
1994
and
completely
after treatment
by non-steroidal
anti-inflammatory
drugs.
Our
cases
illustrate
the difficulties
diagnosis
and treatment
of this dramatic
condition.
pain
Surg
EZRA,
Israel
We report
four patients
with unilateral
postpartum
sacroililtis
presenting
with agonising
unilateral
pain,
an elevated
ESR, elevated
alkaline
phosphatase
levels,
leucocytosis
and positive
bone scans. The diagnosis
of
a non-infectious
inflammatory
cause was supported
by
the postpartum
onset,
the response
to non-steroidal
anti-inflammatory
drugs, negative
aspiration
cultures
in two cases and the lack of changes
in the sacroiliac
joints on long-term
follow-up
radiographs.
J BoneJoint
YOSSEF
In one
of
bulging
pain
of its
ampicillin
ampicillin
given
and
non-steroidal
25 mg three
times
sacroiliitis
sacroiliac
pain
days after delivery
accompanied
by significant
matory’
features.
In none of the cases was there
a few
‘inflamproof of
Y. Floman,
MD, Professor
C. Milgrom,
MD, Associate
Professor
S. Kenan,
MD, Attending
Physician
M. Liebergall,
MD, Senior
Lecturer
Department
of Orthopaedic
Surgery
J. M. Gomori,
MD, Associate
Professor
Department
of Diagnostic
Radiology
Y. Ezra, MD, Lecturer
Department
of Obstetrics
and Gynaecology
Hadassah
University
Hospital,
Em Kerem,
91120,
Israel.
Correspondence
©1994
British
0301-620X/94/6893
VOL.
should
Editorial
be sent
Society
$2.00
76-B, No. 6, NOVEMBER
P0
Box
12000,
Jerusalem
to Dr M. Liebergall.
of Bone
and Joint
Fig.
Surgery
Case
1994
4. Bone
scan
showing
increased
1
activity
in the right
SI joint
(arrow).
887
Y. FLOMAN,
888
C. MILGROM,
J. M. GOMORI,
ET
AL
Case 4. Figure
2a - Ti-weighted
axial image showing
a fluid collection
at the anterior
margin
(arrow).
Figure
2b - T2-weighted
axial image showing
increased
signal density
from fluid
and from the bulging
anterior
capsule
(arrows).
daily
for
cases
daily
for
case
three
months
living
without
Follow-up
1 to 3 and
4).
they
Radiographs
could
pain.
has
all four women
recurrence
of
naproxen
In all cases
500
recovery
all perform
continued
for
mg
was
bid
slow,
the activities
four
remained
by
of daily
to ten
years,
have had subsequent
pregnancies
any symptoms
referable
to the
have
twice
but
and
without
SI joint.
normal.
four
cases
which
we
describe
period
among
approximately
incidence
of about
1 in 10 000.
but has the unique
features
ESR and mild leucocytosis.
signs
of infection,
and
sequelae.
The
(Frigerio,
downward
normal
Stowe
and
SI joint
occurred
in a 15-year
40 000 births,
The condition
of agonising
There were
all the cases
has only
and
pregnancy,
Cassidy
1991).
hormonal
In
changes
SI joint
SI joint
the
cause
relax.
The
hormone
relaxin
ligaments
of the SI joint (Weiss
last
the
trimester
pelvic
of
joints
to
causes
softening
of
et al 1977),
preparing
the
the
pelvis
for the passage
of the fetus
through
the pelvic
outlet.
Trousseau
(1873)
gave
the first description
of SI
joint strain during
pregnancy
and after delivery,
describing
severe
pain
in the sacroiliac
region
during
the last
trimester
of pregnancy,
and relating
it to the increased
motion
in the SI joint.
His patients
had no accompanying
fever
and the pain disappeared
after rest. Young
(1940)
DISCUSSION
The
(Bernard
of the right
in the right
a small
giving
is very
an
rare
SI pain, elevated
never any definite
settled
with
no
range
of motion
and Howe
1974),
consisting
of upwardslight
anteroposterior
gliding
motion
gave
the
syndrome
seventh
name
‘sacroiliac
but described
month
soon
after
describing
studies,
delivery
trimester
of pregnancy.
the SI joint
was loose
separate
the
manual
traction.
to this
in the
clinical
sixth or
of pregnancy.
Sashin
(1930),
SI joint in postmortem
died
arthropathy’
its onset
usually
joint
and
in the
last
of
to
ThE
also
two
by
about
noted
JOURNAL
who
that
OF BONE
died
of the
who
In these four cases,
the capsule
and thin and it was possible
surfaces
Sashin
the normal
anatomy
included
two women
1 cm
with
slight
separation
AND JOINT
light
SURGERY
ACUTE
Table
I.
Details
of four
patients
POSTPARTUM
with
postpartum
INFLAMMATORY
inflammatory
SACROILIITIS
889
sacroiliitis
Case
1
2
3
4
Age (yr)
24
24
27
30
Parity
1
1
1
1
Delivery
Normal
Caesarean
Normal
Normal
8
11
10
3
Left
Left
Left
Right
8 to 43
1 1 to 95
10 to 38
3 to 44
2 to 12
2 to 16
None
None
13 500
10 200
12 800
9 70()
60
80
90
120
155
140
120
13t)
None
None
None
1 1 to 25
5 to 10
None
None
14 to 50
1 1 to 95
10 to 38
3 to 44
Scintigraphy
Left positive
Left positive
Left positive
Right
Radiography
Loss
Normal
Loss of lumbar
Sterile
Sterile
Onset
of SI pain (days
postpartum)
Side of pain
Duration
of pain (days
Duration
of pyrexia
WBC*
ESR
postpartum)
(days)
(per mm3)
1st hour*
Alkaline
phosphatase
Possible
infection
(IU)
focus
Endometritis
(Proteus
Antibiotic
treatment
NSAID
(days
treatment
(days
postpartum)
postpartum)
SI aspiration
*
at the
pubis
which
are
Macnab
ligaments
normal
could
thin,
mirabi/is)
of lumbar
Not done
values:
tear
weak
WBC,
the
4 to 10 000/mm’;
anterior
structures.
ESR,
sacroiliac
This
0 to 20 1st hour;
ligaments,
was
and
even
tearing
during
et al (1989)
performed
CT
of delivery,
and found
gas
women,
bilaterally
in 33%.
undergoes
vacuum
stretching
during
effect.
It may also
effusion
dramatic
into
the joint
clinical
picture
parturition.
by
the
to
which
observed
which
bleeding
may create
or synovial
could
give
in our four
rise
to
patients.
the
onset
of severe
movement
pain
made
at the sacroiliacjoint,
systemic
signs
worse
by weight-bearing
or
but it is accompanied
by
more
definite
logical
these
bone,
changes
become
apparent
after
a short
period;
include
joint
erosions,
sclerosis
of the adjacent
and sometimes
bony ankylosis
(Gordon
and Kabins
of infection.
Resnik
and Resnick
1985).
Postpartum
sacroiliac
pain,
termed
sacroiliitis’,
has
been
well
described
Typical
radio-
1980;
VOL.
76-B, No. 6, NOVEMBER
1994
‘inflammatory
in the
French
and a raised
Not done
et al 1968;
capsule
infection
1940)
was
ESR.
Girodias
An infectious
in the body
(urinary
but not in the Sljoint
1970;
Etienne,
that
the
softened,
focus
tract,
itself.
is often
vagina,
Etienne
found
uterus
and
et al (1972)
oedematous
postpartum
and ligaments
of the SI joint were susceptible
to
through
the lymphatics,
the bloodstream
(Batson
or
questioned
female
patients
it is usually
secondary
to pelvic
such as chorioamnionitis,
postpartum
endomean infected
abortion.
The
clinical
picture
is
that of non-infectious
sacroiliitis,
with an acute
Normal
30 to 1 10 IU
(Gaucher
considered
a
lordosis
Vaudrey
and Gougeon
1972),
but is rarely
mentioned
in
the English
papers.
The condition
occurs
a few days after
delivery,
and is usually
associated
with pyrexia,
leucocyelsewhere
adnexae),
The most important
differential
diagnosis
is pyogenic
sacroiliitis.
This
is rare, but may affect
young
men or
women
(Delbarre
et al 1975;
Sabato,
Porat
and Floman
1983).
In
infections
tritis,
or
similar
to
phosphatase,
tosis
Garagiola
of the pelvis
within
24 hours
in the SI joint
in 42% of the
This implies
that the SI joint
delivery
cause
alkaline
literature
confirmed
and McCulloch
(1990),
who
stated
that
and capsule
of the SI joints
are susceptible
stretching
lordosis
positive
by
direct
whether
actually
extension.
postpartum
an infectious
Gaucher
et
inflammatory
al
(1968)
sacroiliitis
process.
Our
review
of the literature
found
17 cases
postpartum
sacroiliitis
reported
since 1968 (Gaucher
et
1968;
Girodias
1970;
Etienne
et al 1972)
only
one
which
was shown
to be due to infection.
This was in
drug
was
addict
at one day postpartum;
cultured
from
the SI joint.
patients
were
after the pain
positive
cultures.
treated
with
had persisted
antibiotics,
for several
the erosive
on follow-
possible
differential
cases
but usually
only
days and without
showed
condensans
ilii (Thompson
seen in young
multiparous
pregnancy
and sacroiliac
of these
aureus
other
16
changes
in the SI joint that would
be expected
up radiographs
after septic sacroiliitis.
Another
None
Staphylococcus
Many
of the
of
al
of
a
diagnosis
is
osteitis
1954). This is most commonly
women,
and is often related
to
pain. This radiographic
finding
Y. FLOMAN,
890
is present
have
in 1% of the general
experienced
(Numaguchi
1971).
bilateral
joints
pregnancy
The
increased
(Resnik
The
have
radiographic
Resnick
cases
population;
83%
radiodensity
and
four
female
and
C. MILGROM,
92%
born
children
appearance
on the
iliac
of the
SI
we
report
had
all the
clinical
features
of postpartum
inflammatory
sacroiliitis,
with
severe
unilateral
pain. Their bone scans showed
increased
sacroiliac
activity
on the affected
side, although
Ayres
et
al (1981)
point out that false-positive
scintigraphy
of the
SI joint
is possible.
The MRI in case
the joint,
with
bulging
of the anterior
evidence
image
of a stress
was
very
fracture
different
or bone
from
that
4 showed
capsule,
fluid
but
infection.
This
described
and
cases
in
no
MR
by Wilbur,
ET
AL
Spigos
Our
(1988)
two
recovered
but
of changes
in a case
of postpartum
cultures,
and
antibiotic
non-infectious
septic
the fact
treatment,
that
as
follow-up
sequelae
or risk
No benefits
commercial
in any form have been received
party related
directly
or indirectly
an
does
the
radiographs.
of postpartum
inflammatory
differential
diagnosis
difficult.
pain may lead the clinician
as in the first two cases
seems
to be self-limiting,
two
suggest
aetiology,
in the long-term
The infrequency
iliitis
makes
its
agonising
treatment,
condition
sterile
without
inflammatory
lack
1985).
which
Langer
sacroiliitis.
is of
side
J. M. GOMORI,
sacroThe
to start antibiotic
in our series.
The
however,
with
no
of recurrence.
or will be received
from
to the subject
of this article.
a
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OF BONE AND
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Imaging
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SURGERY