천장관절질환 최신지견

성 덕현 Duk Hyun Sung

성균관대학교 의과대학, 삼성서울병원 재활의학과 Department Physical Medicine and Rehabilitation Sungkyunkwan University School of Medicine Samsung Medical Center Introduction

Sacroiliac joint and Low back pain Introduction

Classification of low back pain

• Mechanical pain • (Mechanical) + Neuropathic pain • Inflammatory pain • Muscular pain

• Non-specific pain Introduction

History – Mechanical low back pain

• Sacroiliac joint = Primary source of low back pain (early 20th century)

• Radiculopathy due to HIVD (1934 Mixter and Barr)

• Recrudescence of Sacroiliac joint as a source of chronic low back pain (sacroiliac joint syndrome) Introduction

History – Inflammatory low back pain

• Sacroiliac joint in Ankylosing spondylitis (1934 : Characteristic obliteration of sacroiliac joints (W. Krebs))

• Sacroiliitis in Seronegative spondyloarthropathy Anatomy

• True diarthroidal joint - undulating joint surface - fibrocartilage - rudimentary posterior joint capsule strong interosseous ligamnent

• Interlocking mechanism despite of vertical alignment • “C” shape Anatomy

• Motion - less than 2- 3 degrees in all planes - negligible displacement

• Stability - “keystone in an arch” effect - interosseous ligament - posterior sacroiliac, sacrotuberous, sacrospinal ligaments Anatomy

• Innervation - no mention in “Gray’s Anatomy” - L2 ~ S3 nerve roots/ Lumbosacral plexus Anatomy

• Plain radiograph - standard AP view : anterosuperior portion and posteroinferior portion - oblique sacroiliac joint view : no additional benefit Problems of the Sacroiliac joint

• Low back pain with Red flag - infection, malignancy

• Mechanical pain - fracture, sacroiliac joint syndrome

• Inflammatory pain – spondyloarthropathy (SpA) Sacroiliac joint – Red flag

• Sacroiliitis - tuberculosis - chronic unilateral buttock and/or low back pain

• Malignancy - primary tumor : chordoma - metastatic tumor with lumbosacral plexopathy : breast, prostate Inflammatory Spondyloarthropathy

• Ankylosing spondylitis Psoriatic arthopathy Arthropathy associated with inflammatory bowel disease Reactive arthritis

• Inflammatory back pain Sacroiliitis HLA B27 Inflammatory Spondyloarthropathy

• “Back pain with an inflammatory nature” 1977 Calin et al. - insidious in onset - younger than 40 years (45 years in ESSG) - persisting for at least three months - associated with morning stiffness - improving with exercise

4 or 5 features as a screening method for diagnosis of AS Inflammatory Spondyloarthropathy Inflammatory Spondyloarthropathy

• Patrick’s test, Gaenslen’s test, etc. - regional provoking test : lumbosacral spine ~ hip joint : little value in making the specific diagnosis Inflammatory Spondyloarthropathy

• Plain radiography - modified New York criteria - poor inter-rater reliability for grade I or II

• CT - more sensitive for detection of erosion

• MRI - subchodral marrow edema in early stage saroiliitis - synovial enhancement Inflammatory Spondyloarthropathy Inflammatory Spondyloarthropathy

• Low sensitivity - wider clinical spectrum of SpA - non-simultaneous expression of various clinical features - long-term F/U and high index of suspicion - decision to treat or not to treat should be based upon the presence of clinical symptom and signs and not depend on the formal fulfillment of criteria Inflammatory Spondyloarthropathy HLA B27

HLA typing : first independent variable to discriminate SpA from control To specify a clinical presentation than diagnosis (problem >> disease) Inflammatory low back pain

• CPPD, Gout • Bechet’s disease • SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome

• Osteitis condensans ilii • DISH (diffuse idiopathic skeletal hyperostosis) • Osteoarthritis Chronic low back pain

• Mechanical pain - instability or abnormal load transmission

• Sacroiliac joint dysfunction (SJD) Sacroiliac Joint Dysfunction

• Sacroiliac joint pain Sacroiliac Joint Dysfunction

• Diagnostic sacroiliac joint block Sacroiliac Joint Dysfunction

• Chronic low back pain (LBP) - worker’s compensation, cases under litigation - non-organic pain

• Sacroiliac joint syndrome - no characteristic history, no valuable physical exam. - no abnormality in imaging study - depend solely on “diagnostic sacroiliac joint block” Sacroiliac Joint Dysfunction

• Other suggested disorders for patients with chronic LBP - discogenic pain : internal disc disruption (IDD) degenerative disc disease (DDD) - facet joint pain

• IDD, DDD, facet joint syndrome - diagnosis depends on “diagnostic block” Sacroiliac Joint Dysfunction

• No theoretical base for treatment in SJD - fusion of sacroiliac joint - intraarticular steroid injection - mechanical management : manipulation

• SJD - “disgnosis of exclusion” - “man-made syndrome” Summary

• Sacroiliac joint - low back and/or buttock pain - inflammatory pain > mechanical pain - spondyloathropathy - imaging studies for sacroilitis

- sacroiliac joint dysfunction for chronic low back pain : “disgnosis of exclusion”, “man-made syndrome”