NOR200188.qxd 3/8/11 9:53 PM Page 126 Sacroiliac Joint Dysfunction A Case Study CPT William Murray Pain is a widespread issue in the United States. Nine of physical therapist. She was evaluated and her treatment 10 Americans regularly suffer from pain, and nearly every consisted of a transcutaneous electrical nerve stimula- person will experience low back pain at one point in their lives. tion unit while in the PT clinic, aqua therapy, and ice Undertreated or unrelieved pain costs more than and heat application. $60 billion a year from decreased productivity, lost income, After several weeks, Ms. T returned to the primary care and medical expenses. The ability to diagnose and provide ap- provider and informed her that the pain has not decreased and “feels like that it is getting worse.” She also informed propriate medical treatment is imperative. This case study ex- the provider that she was having difficulty sleeping and amines a 23-year-old Active Duty woman who is preparing to constantly feeling tired secondary to pain. Throughout the be involuntarily released from military duty for an easily cor- next several months, the primary care provider tried nu- rectable medical condition. She has complained of chronic low merous medication trials with no relief for the patient. Ms. back pain that radiates into her hip and down her leg since ex- T gives a history of being prescribed numerous medica- periencing a work-related injury. She has been seen by numer- tions within several drug classifications. She stated vari- ous providers for the previous 11 months before being referred ous side effects that are related to the medications and to the chronic pain clinic. Upon the first appointment to the some complaints that she associates with a medication. chronic pain clinic, she has been diagnosed with sacroiliac See Table 1 for complete medication list and symptoms. joint dysfunction. This case study will demonstrate the impor- In addition, Ms. T had several radiologic studies in- tance of a quality lower back pain assessment. cluding plain x-ray and magnetic resonance imaging (MRI). The MRI on March 5, 2009, found an L5–S1 de- generative disc with a right annular fissure and shallow Chief Complaint and a disc extrusion and mild facet arthropathy; an L4–L5 Comprehensive Assessment shallow central disc extrusion and mild facet arthropa- thy; and an L3–L4 shallow central disc protrusion. In Ms. T is a 23-year-old single woman who is an active duty comparing the L-spine x-rays on April 21, 2009, to a service member. She functions as a medical technician. prior x-ray taken on January 9, 2009, there was worsen- Ms. T presents with complaints of chronic low back pain. ing of intervertebral disc degeneration at L4–L5. Ms. T was referred to the chronic pain clinic by a nurse Ms. T now describes the character of her pain as a “dull practitioner who requested that she have a Medical constant ache” with “intermittent stabbing, shooting, and Evaluation Board (MEB) for retainability. burning pain” that radiates bilaterally to the lower extrem- ities with the right leg pain greater than left. She also notes MEDICAL HISTORY chronic bilateral metatarsal paresthesia and chronic bilat- Ms. T states that she has a sudden constant low back pain eral posterior lower extremity dysesthesia. Ms. T rates her that started 10–11 months ago when she was moving a pa- pain scores with the visual analog scale, quantifying her tient up in the bed. She states that she “heard an audible pop pain from the last week at best as 3/10 to the worst as and felt a sharp pain.” After the event she was unable to con- 10/10. The current pain level of 5/10 is in her lower back at tinue working and reported to the emergency room that L4. She states that “sitting or standing for prolonged peri- evening. During the emergency room visit, she received a ods of time” increases her pain and “swimming, the heat- lumbosacral radiologic examination, with two views, and ing pad, lying on back, and medications” all help her pain. received ketorolac 30 mg IV, cyclobenzaprine 10 mg by Her Modified Beck Depression Inventory (Rodin, Craven, mouth (PO) with a prescription for one tablet twice a day, & Littlefield, 1991) is 22, which indicates a moderate-se- and a prescription for meloxicam 15 mg PO once a day. vere (19–29) depression; however, she expresses no suici- Ms. T followed up after 1 week with the primary care dal ideation. Her Oswestry Disability Index (ODI) is 26 out clinic and informed the provider that she had no “real of 50. (Note: The number or percentage of the ODI is not relief” with the medications. She was informed that she should wait for three additional weeks and then have a CPT William Murray, MSN, RN, ACNS-BC, RN-BC, US Army, Nurse follow-up appointment. One month after the initial in- Corps, Kailua, HI. jury she had another follow-up with her primary care The author has disclosed that he has no financial interests to any com- provider who recommended physical therapy (PT). mercial company related to this educational activity. Ms. T waited two and a half weeks to be seen by the DOI:10.1097/NOR.0b013e31820f513e 126 Orthopaedic Nursing • March/April 2011 • Volume 30 • Number 2 Copyright © 2011 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. NOR200188.qxd 3/8/11 9:53 PM Page 127 TABLE 1. MEDICATION HISTORY Classification Medication Effect Opioid Darvocet N-100 Made her sleepy Percocet 5/500 Made her have muscle weakness Tylenol #3 Caused gastrointestinal upset Tramadol Worked with no side effects Nonsteroidal anti-inflammatory drug Mobic Worked somewhat with no side effects Naprosyn Made her “sleepy” Ibuprofen Worked the best for her with no side effects Benzodiazepine Valium Worked somewhat but always made her feel “cloudy and tired” Muscle Relaxant Flexeril Worked somewhat but always made her feel “cloudy and tired” Anti-epileptic Topamax Worked well but also made her feel “tired” Antidepressant Elavil She does not remember any effects she may have had significant at any one point; however, looking at the trends parallel to the floor without any abnormal positioning; in the score over time will demonstrate the measurement there are no abnormal curvatures of the cervical, tho- of the disabling effects of lumbar spinal disorder.) racic, or lumbar spine; and the iliac crests are parallel. Ms. T’s current medication regimen includes tra- Ms. T is able to maneuver onto the examination table madol 50 mg PO one tablet every 6 hr with an average without difficulty and any facial grimacing. daily dose of two to three tablets, ibuprofen 800 mg PO one tablet every 8 hr with an average daily dose of three SPINE AND NERVOUS SYSTEM tablets daily, and acetaminophen 500 mg PO two tablets Range of motion for the flexion of the spinal column re- every 6–8 hr with an average daily dose of four to six sults in 75Њ of range with minimal persistence of lumbar tablets not exceeding 4 g/day. She denies any food or concavity (lumbar lordosis), suggesting possible muscle drug allergies, tobacco use, or any personal or family spasms. This movement causes some pain but does not history of alcohol/drug abuse. reproduce the exact chief complaint pain. Extension of Ms. T denies any childhood illness and has no surgical the spinal column results in 30Њ of range. This move- history. She is a gravida 0 para 0 and denies any psychiatric ment causes some pain but does not reproduce the exact problems or a past psychiatric diagnosis. She reports a lower back and leg pain. Lateral flexion results in 45Њ of medical history of irritable bowel syndrome with no current range bilaterally and the movement causes some pain. problems or a flare-up at present and denies loss of bowel or Rotation results in varying findings: right-side rotation bladder control. Her current immunizations are up-to-date equals 30Њ whereas left-side rotation equals 45Њ (facet and she is waiting for the H1N1 vaccine to arrive. load) and rotation to the right causes pain into lower Ms. T reports no known family history of illnesses. right paraspinal area at S1; Gillet’s test is undiagnostic Her review of systems is unremarkable with the excep- because of the inability to evaluate S2 and the posterior tion of reports of headaches starting approximately superior iliac spine. 5 months ago occurring after she has been standing or Ms. T has intact sensation to light touch; however, walking for any prolonged periods of time lasting she has a right-sided deficit to pin prick following the greater than 30 min. She reports the headache as a L4 dermatome level. This has not been noted by the sharp stabbing pain at a 7/10 pain rating that starts at patient on previous examination. See Table 2 for more approximately the level C5 and radiates up into the oc- diagnostic data. cipital and temporal region. The patient reports the Upon lying supine, the assessment of the lower extrem- headaches lasting approximately “one or two hours and ities reveals a leg length discrepancy of 2 cm. Gaenslen’s only goes away when I can lie down and take some test is positive for right sacroiliac joint (SIJ) dysfunction; Tylenol [acetaminophen].” In addition, she notes that Faber/Patrick test is positive for right SIJ dysfunction; occasionally the headaches have caused her to become straight leg raise is positive at 25Њ for nerve root irritation.