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 REFERENCES i, Hilson AJ, Maisey MN, et at. An improved method iliacjoint imaging: a study of normal subjects, patients with and patients with low back pain. C/in Radio/ 1981; 32:442-5. Ayres Batson OV. The of metastases. function of the vertebral veins Ann Surg 1940; 112:138-49. and their role for sacrosacroiliitis in the spread Bernard TN, Cassidy iD. The sacroiliacjoint syndrome. In Frymoyer ed. The adu/t spine. New York, etc: Raven Press, 1991; 2:2107-30. Delbarre F, Rondier iliac joint: report S7-A:819-2S. J, Etienne JC, partum C, Gougeon abortum. Ann Fast A, Shapiro Vaudrey Ct du post Delrieu of thirteen F, et at. Pyogenic cases. J Bone D, Ducommun El, infection Joint Surg Y. Les sacrocoxites Med de Reims 1972; et al. Low-back JW, of the sacro[Am] 1975; aigues du Macnab I, McCulloch 1990:104, 107, 294. Numaguchi Y. Osteitis J. Backache. condensans Baltimore: Williams ilii, including and Wilkins, its resolution. Radio/ogy 1971; 98:1-8. Ostgaard Trans Resnik HC, Andersson 1988; 12:76-7. CS, JAMA Low Resnick D. Radiology 1985; 253:2863-6. Sabato S, Porat 7:552. Sashin D. A critical the sacro-iliacjoints. post GBJ. S, Floman back pain of disorders Y. Pyogenic in pregnancy. of the sacroiliitis. Orthop sacroiliac Orthop joints. Trans 1983; 9:5-12. pain in pregnancy. analysis of the anatomy J BoneJoint Surg of the pathologic 1930; 12:891-910. changes of Spine 1987; 12:368-71. Frigeno NA, Stowe RR, Howe Orthop 1974; 100:370-7. iW. Movement ofthe sacroiliacjoint. Garagiola DM, Tarver 1W, Gibson L, Rogers RE, changes in the pelvis after uncomplicated vaginal on l4women.AJR 1989; 153:123941. Wass iL delivery: C/in Anatomic a CT study Trousseau A. Sur le relachement 4:810-8. Thompson M. Osteitis ankylosing spondylitis. Weiss G, Gaucher A, Louyot P, Manivit P, Pourel J, Montet Y. Les osteoarthritis pelviennes du post partum.Ann MedNancy 1968; 7:1092-105. Girodias No E. Les arthrites 18, 1970. Gordon G, Kabins Hoppenfeld York: SA. sacro-iliaques Pyogenic S. Physica/ examination Appelton-Century-Crofts, du post partum. sacroiliitis. of the 1976:261. These Mcd, Am J Med 1980; spine extremities. and relaxin Obstet Lyon, 69:50-6. New condensans Ann Rheum du bassin. C/in ilii and its differentiation Dis 1954; 13: 147-56. Med 1873; from O’Byrne M, Hochman JA, et al. Secretion of progesterone and by the human corpus luteum at mid pregnancy and at term. Gyneco/ 1977; 50:679-81. WilburAC, Langer BG, Spigos in pregnancy by magnetic 1988; 6:341-3. Young des symphyses DG. Diagnosis ofsacroiliacjoint resonance imaging. Magn Reson i. Relaxation of the pelvic joints of pregnancy. J Obst Gynec Br Emp ThE JOURNAL in pregnancy: pelvic 1940; 47:493-524. OF BONE AND JOINT infection Imaging arthropathy SURGERY