Sacroileite

The sacrum is located at the base of the spinal column which transmits to it all the longitudinal forces acting above it. Bilaterally the sacrum articulates with the iliac bones of the pelvis via the sacroiliac joints, through which it distributes and transmits the descending forces, received through the spinal column, to the two hemipelvises e, consequently, to the coxofemoral joints (between femur and pelvis) and the lower limbs. Likewise, in reverse, the ascending forces coming from the lower limbs are transmitted to the pelvis, to the sacrum and the spinal column.

.THE SACROILIAC JOINTS^[1]Levangie, Pamela K., and Cynthia C. Norkin. Joint structure and function: a comprehensive analysis. F. A. Davis, 2011.

The articular surfaces of the sacrum have an auricular shape (a ”C”) and are covered with a layer of hyaline cartilage. The iliac articular surfaces also have an auricular shape. The layer of cartilage that covers them is thinner than that of the articular surfaces of the sacrum and is often described as being made of fibrocartilage but Gray's Anatomy^[2]Horan, F. Gray’s Anatomy. The anatomical basis of clinical practice. Edited by Susan Standring Pp. 1551. Illinois. Churchill Livingstone Elsevier, 2008. ISBN: 978-0-443-06684-9.£ 99. 2009 983-983., extremely authoritative source, claims it is hyaline cartilage. The debate is still ongoing.

The ASIs are stabilized by a complex and powerful ligament system:

The sacroiliac ligaments front, interosseous and posterior, directly associated with the ASI
The iliolumbar ligaments, sacrospinous and sacrotuberous, indirectly associated with the ASI

The sacroiliac ligaments are strengthened by fibrous expansions of the following muscles, che contribute to the stability of the joint:

quadrate of the loins
column erector
gluteus maximus and minimus
piriform
iliac

The anterior sacroiliac ligaments are considered, dal Gray’s Anatomy, capsular ligaments , due to their intimate connections with the anteroinferior margins of the joint capsule^[3]Horan, F. Gray’s Anatomy. The anatomical basis of clinical practice. Edited by Susan Standring Pp. 1551. Illinois. Churchill Livingstone Elsevier, 2008. ISBN: 978-0-443-06684-9.£ 99. 2009 983-983.. The interosseous sacroiliac ligaments are the major structural link of the ASI.

The joint capsule, strengthened by the anterior sacroiliac ligaments, efficiently protects the ventral portion ventral part of the ASI. In the dorsal areas of the ASI But, where these reinforcing elements are absent, continuity of the capsular structure may occur which allow intra-articular fluid substances to escape from the joint and thus come into contact with the surrounding extra-articular structures.^[4]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856.

The sacroiliac joint causes pain in the lower back and gluteal area in approximately the 15% Parkinson's disease is a progressive neurological disorder. The differential diagnosis is not simple because lower back pain can have various underlying causes (you see low back pain). ^[5]Dreyfuss, Paul, et al. Sacroiliac joint pain. JAAOS-Journal of the American Academy of Orthopaedic Surgeons 12.4 2004 255-265..

CAUSES OF SACROILEITIS^[6]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856.

Mechanics, of postural origin, which create excessive stress on the sacroiliac joint.
Direct and indirect traumas (injuries, falls, etc.);
Arthrosis
Pregnancy: sacroilite piogena(Almoujahed, Mohammad O., Riad Khatib, and Joseph Baran. Pregnancy-associated pyogenic sacroiliitis. Case report and review. Infectious diseases in obstetrics and gynecology 11.1 2003 53-57.))a posture.
Infectious type
Arthritis (ankylosing spondylitis, rheumatoid arthritis, gotta, systemic lupus erythematosus, Reiter's disease);
Chronic intestinal diseases (such as Crohn's disease and ulcerative colitis);
Visceral problems: irritable colon, ovarian problems, pelvic pain
Drug abuse^[7]Guyot, Daniel R., A. Manoli 2nd, and G. A. Kling. Pyogenic sacroiliitis in IV drug abusers. American Journal of Roentgenology 149.6 1987 1209-1211.

Physiotherapy deals with treating sacroiliitis due to mechanical causes of postural origin, to direct and indirect trauma and arthrosis.

DIFFERENTIAL DIAGNOSIS^[8]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856.

Architecture anatomy of the capsular structure of the ASI, due to its susceptibility to loss of firmness in the dorsal areas, can be a vehicle for transmission of any intra-articular pathologies to the outside, contributing to the spread of pain of sacroiliac origin also to other areas:

ai muscles that provide their fibrous expansions to support the sacroiliac ligaments
to the muscles hamstring and psoas

This dynamic can also involve nervous structures, as the lumbosacral plexus (fibers coming from the L4-L5 roots) where he dorsal sacral plexus, causing acute irritative processes. Furthermore i dorsal lumbosacral branches that innervate the sacroiliac joint itself, can contribute to exacerbate sacroiliac pain^[9]Vleeming A, Schuenke MD, Masi AT, JE Career, Danneels L, Willard FH 2012 The sacroiliac joint. An overview of its anatomy function and potential clinical implications. J Anat 221 6 537–67^[10]Egund N, Jurik AG 2014 Anatomy and histology of the sacroiliac joints. Semin Musculoskelet Radiol 18 3 332–9.

For these reasons, in acute sacroiliitis can mimic other pathological conditions such as:

acute low back pain with or without root involvement
acute arthritis of the hip
trochanteric borsitis
acute abdomen

The physical exam with direct palpation of the ASIs and the execution of prompt maneuvers (FABER test) are essential for diagnosis. In cases where the clinical picture and physical examination are doubtful, the doctor may resort to diagnostic imaging^[11]Braun J, Sieper J, Bollow M 2000 Imaging of sacroiliitis. Clin Rheumatol 19 51–7 :

Technetium bone scan to investigate the localization of the pathological process at the ASI level
TAC e, in particular, the magnetic resonance imaging (RM) of the ASI can be used to evaluate the degree of extension of the pathological process, to evaluate the presence of complications and to exclude other possible diagnoses such as sacral stress fractures. MRI appears to be a reliable test in particular in the visualization of joint erosions in early seronegative spondyloarthropathy and allows the differentiation of active sacroiliitis from chronic sacroiliitis.^[12]Puhakka, K. Books, et al. Imaging of sacroiliitis in early seronegative spondylarthropathy. Assessment of abnormalities by MR in comparison with radiography and CT. Acta Radiologica 44.2 2003 … Continue reading.

ACUTE SACROILEITIS^[13]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856.

SACROILEITE PIOGENICA^[14]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856.

Pyogenic sacroiliitis (pyogenico: which causes a purulent phlogistic reaction), is’ by far the most frequent cause of acute sacroiliitis. It can occur in any age group but is more common among 20 e 30 years. In 2/3 of patients has an onset “espolosive” and unilateral. Typically includes high fever, but in some cases it can also be moderate. The fever, during acute sacroiliitis, should always raise suspicions of pyogenic sacroiliitis but the absence of fever actually does not exclude the possibility of septic sacroiliitis, particularly in the presence of significantly high ESR and CRP values (C-reactive protein). The pain, strong and continuous, original from the affected sacroiliac joint and is felt most often in the buttock area, of the back and/or hip. Sometimes it can radiate up to the gamba. In 10% of patients is present with acute abdominal pain, located in the lower quadrants.

In the serious cases, the patient may not be able to walk and in a supine position tends to keep the limb extra-rotated due to spasm of the piriformis muscle. In less serious cases the patient usually walks with a limp to escape the load on the affected hemisphere.

The FABER test can it can trigger excruciating pain. Hip mobilization usually has no limitations and this allows us to exclude acute pathologies affecting the coxofemoral joint.

Laboratory tests generally show elevated ESR and protein values C-reactive (CRP). Leukocytosis is less typical and is seen in only about half of cases.

Sacroiliitis from BRUCELLOSIS^[15]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856.

In the BRUCELLOSIS^[16]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856., Sacroiliitis is the most frequently occurring osteoarticular localization found in over the 10% of patients. It can be of type septic or reactive.

INFLAMMATORY SACROILEITIS^[17]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856.:

from reactive arthritis
post-partum

Sacroileite nell’reactive arthritis it is a finding frequently highlighted by x-rays and bone scans but is usually asymptomatic. Only rarely have cases of Acute sacroiliitis during reactive arthritis. The painful syndrome of acute sacroiliitis, from inflammatory, it can be very difficult to distinguish from that of sacroiliitis piogenica, even if the fever in the former is less high than in the latter, the same thing happens for PCR (C-reactive protein) and you see it (erythrocyte sedimentation rate) and the inflammation does not involve adjacent soft tissue structures. They knowbone igraphy it is useful for demonstrating the distribution of the inflammatory process to the sacroiliac joint and the rest of the skeleton. LCT can highlight irregularities/erosions of the sacroiliac joint and swelling of the joint capsule while bone marrow edema, the entity, synovitis and capsulitis of the ASI are visible on MRI. Not only both sacroiliac joints but also other joints may be affected, and entheses are frequently involved. History of a recent gastrointestinal infection or genitourinary and/or extra-articular manifestations characteristic of arthritis reactive, such as conjunctivitis or keratoderma may be critical to the diagnosis.

Acute postpartum inflammatory sacroiliitis. It occurs a few days after giving birth and is associated with fever, leukocytosis, VES elevata

GOUTY SACROILEITIS AND CPPD^[18]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856.

They are also called metabolic arthropathies “from crystal deposits”. In gout the crystals are of urate and in CPPD of calcium pyrophosphate. Their deposition inside the joints is at the origin of the joint pathological process.

SACROILEITIS ASSOCIATED WITH NEOPLASIES.

Acute sacroiliitis is one of the rheumatic syndromes associated with some types of hematological neoplasms^[19]Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856..

Note[+]

Note
↑1	Levangie, Pamela K., and Cynthia C. Norkin. Joint structure and function: a comprehensive analysis. F. A. Davis, 2011.
↑2, ↑3	Horan, F. Gray’s Anatomy. The anatomical basis of clinical practice. Edited by Susan Standring Pp. 1551. Illinois. Churchill Livingstone Elsevier, 2008. ISBN: 978-0-443-06684-9.£ 99. 2009 983-983.
↑4, ↑6, ↑8, ↑13, ↑14, ↑15, ↑16, ↑17, ↑18, ↑19	Slobodin, Gleb, et al. Acute sacroiliitis. Clinical rheumatology 35 2016 851-856.
↑5	Dreyfuss, Paul, et al. Sacroiliac joint pain. JAAOS-Journal of the American Academy of Orthopaedic Surgeons 12.4 2004 255-265.
↑7	Guyot, Daniel R., A. Manoli 2nd, and G. A. Kling. Pyogenic sacroiliitis in IV drug abusers. American Journal of Roentgenology 149.6 1987 1209-1211.
↑9	Vleeming A, Schuenke MD, Masi AT, JE Career, Danneels L, Willard FH 2012 The sacroiliac joint. An overview of its anatomy function and potential clinical implications. J Anat 221 6 537–67
↑10	Egund N, Jurik AG 2014 Anatomy and histology of the sacroiliac joints. Semin Musculoskelet Radiol 18 3 332–9
↑11	Braun J, Sieper J, Bollow M 2000 Imaging of sacroiliitis. Clin Rheumatol 19 51–7
↑12	Puhakka, K. Books, et al. Imaging of sacroiliitis in early seronegative spondylarthropathy. Assessment of abnormalities by MR in comparison with radiography and CT. Acta Radiologica 44.2 2003 218-229.