An undiagnosed case of sacroiliac joint dysfunction spelled the beginning of a nightmare for a 40-year-old telecommunications manager.
ANIZAWATI Yaacob knew pain like a bosom friend. A fall she took one evening after work had landed the 40-year-old telecommunications manager in its cruel and relentless company.
It all began when she was unexpectedly hit by sudden dizziness, a common symptom of Takayasu’s arteritis (a rare disorder that causes blood vessel inflammation), and she abruptly lost balance.
“I was getting off a chair. Next thing I knew, I was lying on the floor. My head had slammed against the bathroom skirting,” she recalls.
Fortunately for Anizawati, it wasn’t long before her husband returned from work to their apartment.
“He found me lying on the floor half-conscious,” she shares.
The event marked the beginning of numerous episodes of sharp and intense pain.
A “splitting pain” that surfaced at her lower back region days afterwards spelled the first sign of Anizawati’s impending nightmare.
She was diagnosed with having a minor slipped disc, from which the mother-of-one took time off work to undergo rehabilitation.
But the pain only got steadily worse over the following month.
At one point, she was so badly affected by it that even basic activities such as standing and sitting became a challenge.
undiagnosed sacroiliac joint dysfunction.
“At night, I could hardly sleep. It was so painful, I didn’t know what to do. I was crying on the inside,” she shares.
She hit rock bottom when she had to move back in with her parents in her hometown of Ipoh, Perak.
Mobility had become an issue, and the pain was prohibiting her from commuting up and down the stairs of their second-floor apartment.
“My husband was working all the time and he couldn’t take care of me. I had no choice but to be dependant on my parents,” she says.
The debilitating pain also prevented her from taking care of her five-year-old son.
“At that time, I was feeling really annoyed with everybody around me. I wasn’t myself. I was in constant pain.
“My mum would come in and try to rub the pain away with hot oil, but it didn’t work at all,” she recalls.
Finally, unable to put up with the torment any longer, Anizawati sought a second medical opinion.
A MRI scan carried out by consultant spine surgeon Dr Eugene Wong revealed that a sacroiliac (SI) joint dysfunction had been the source of her distress.
SI joint pain
The SI joints are weight-bearing joints that are located between the hips and the spine. They allow torsional or twisting movements when we move our legs.
SI joint dysfunction is thought to result in low back and/or leg pain. The leg pain can be particularly difficult, and may feel similar to sciatica or pain caused by a lumbar disc herniation.
While it is still unclear what causes the pain, it is thought that an alteration in the normal joint motion may be the culprit behind sacroiliac pain.
According to Dr Wong, the SI joint may also fail due to congenital malformation, increased stresses due to lower back fusion surgery, direct trauma or overuse.
Other causes of SI joint pain include infection, limb length discrepancy, scoliosis, rheumatoid arthritis, gout, psoriasis and osteoarthritis.
Multiple pregnancies may also increase the risk of arthritis in the joint later in life.
For decades, the SI joints have been suspected to be a common cause of lower back pain. However, difficulty in proving it with standard diagnostic tests has left many in the medical professional sceptical.
Sometimes, the cause of the pain is unknown, even after extensive investigations.
However, it is now acknowledged that the SI joints are a more common source of back pain than most people realise.
The SI joint is also a contributing factor in failed back surgery syndrome in 29-40% of cases, says Dr Wong.
While ageing and weight problems can contribute to the SI pain, he points out that the deviation could happen to anyone at any age.
The lack of awareness of the joint as a source of pain has contributed to diagnostic uncertainty and few available treatment options to address the pain coming from this joint.
Treatment for SI joint pain
Initial treatment recommendations usually include the use of ice or cold packs, to be applied in 15-to-20 minute intervals to reduce inflammation in the afflicted area, along with rest to reduce irritation.
Ice can be continued anywhere between two days to two weeks, depending on the duration and intensity of these painful episodes.
Once the inflammation subsides, a gradual return to normal activities may be possible.
If the pain persists, first-line treatment involving pain and anti-inflammatory medications to reduce the swelling is usually recommended.
Some patients may benefit from wearing a sacroiliac belt, an “orthotic” or a brace that can be wrapped around the waist to stabilise a loose or “hypermobile” SI joint. The orthotic can be “weaned” away as the pain subsides.
Rehabilitation exercises may be helpful to strengthen the muscles around the SI joint and to appropriately increase range of motion.
Radiofrequency ablation can be done to ablate pain fibres to the SI joint. This destroys any sensation coming from the joint, and its effect can last for up to two years, says Dr Wong.
For severe cases of pain that do not go away after several weeks or months of non-operative pain management, surgery may be a viable option. In SI joint fusion surgery, one or both of the SI joints may be fused with the goal of eliminating any abnormal motion.
In the new Distraction Interference Arthrodesis, Neurovascular Anticipating (DIANA) procedure, an implant is inserted via a small incision (3-5cm) using special instruments to realign the SI joint. This is inserted via a posterior midline approach to avoid the neurovascular structures. This process is called “ligamentotaxis”.
Bone is then added, which aims to ensure a solid, permanent immobilisation of the joint after the healing phase is complete.
“In layman terms, we basically put in a screw to distract the surfaces, and to keep them from rubbing together,” the doctor explains.
“So far, DIANA has proven to be a very safe procedure,” he adds.
Following the surgery, patients can walk around with crutches, though activity is limited to partial weight-bearing on the affected side for the first six weeks.
Patients do not suffer from stiffness in the traditional sense, or increased stress in the untreated SI joint.
New lease on life
For Anizawati, recovery from the DIANA procedure has been smooth. She says she is surprised by the absence of pain following the surgery.
“By the fourth week, I could start walking without crutches. Now, I can go back to climbing the stairs of my apartment,” she says with a smile, two months after operation.
A straight, thin scar roughly the length of a ball-point pen currently sits atop her lower back. She says she is happy to feel like herself again.
The experience, she shares, has given her a new lease on life.
Anizawati, who was previously largely sedentary, says she has been making better lifestyle choices since, and now goes for brisk-walking for about 20 minutes every morning.
“When you get sick, and then you recover, you value your health more,” she says.
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