Sacroilitis/ Inflammatory Back Ache

SACROILITIS/ INFLAMMATORY BACK ACHE

Sacroiliitis is a medical condition caused by the inflammation in the sacroiliac joint that connects the lower spine and pelvis causing pain in the buttocks and lowers back and extending down to one or both legs. It is most frequently confused for Sacroiliac ligament enthesitis which is micro-inflammation at the attachment of the sacroiliac and pelvic ligaments. The condition can be extremely painful after prolonged standing, climbing stairs, taking large strides or when bearing more weight on one leg.

The severity of inflammatory back ache and its symptoms vary in each individual and ranges from mild to extreme pain and stiffness causing a restriction in daily activities.  Sacroiliitis occurs after a traumatic injury, arthritis, pregnancy or rarely an infection of the joints. The condition can worsen over prolonged standing or climbing stairs. At Daystar we tailor customized treatment plan to treat patients suffering from mild to severe conditions of back pain and joint inflammation including Sacroilitis and Sacroiliac enthesitis. The doctor conducts clinical examination to understand the root cause of the condition and may order imaging tests to produce detailed cross-sectional images of both spinal bone and soft tissues surrounding the spine and pelvis area.

Alternative treatment methods at Beth Yehuwdah Arthritis Centre, Pullad & Daystar Clinic, Alappuzha:
Treatment methods for sacroiliac inflammation depend on the severity of the symptoms and the cause of the condition.

PRP Prolotherapy for Sacroilitis/ Sacroiliac Enthesitis/ Inflammatory Back Pain  PRP prolotherapy is a combination treatment where PRP is injected into the Sacroiliac joint and dextrose prolotherapy is given to the ligaments of the joint. This treatment may help a patient who does not want to take lifelong painkillers and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.

How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Table 1: Various biological growth factors released by PRP when activated

 PRP injection delivers a high concentration of autologous (patient’s own) platelets to the joints and soft tissues in the lower back. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the joint using PRP injection stimulates the healing process and faster recovery from the joint condition.
        
Prolotherapy for Sacroilitis/ Sacroiliac Enthesitis/ Inflammatory Back Pain
Back pain due to Sacroilitis is one of the leading causes of disability, yet most of the people suffering from it do not know that sacroilitis and sacroiliac enthesitis is most likely the real cause of the problem! We see, most patients take pain tablets and muscle relaxers to cover the pain, which only masks further degeneration and leads to an endless “pain management” cycle. This is like treating the symptoms versus correcting underlying spinal instability. Comprehensive Dextrose Prolotherapy can break this cycle by assisting the regeneration of weakened and stretched-out soft tissue structures of the cervical/ lumbar spine, alleviating pain and instability. Using Prolotherapy, these conditions can be treated properly and safely to give a more desirable symptomatic outcome.

Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the osteoarthritic joint/ entheses (sites of tendon and ligament attachment to bone). Prolotherapy works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. In Dr Tejaz John’s experience, Prolotherapy is an effective non surgical treatment method used successfully in Sacroilitis/ Sacroiliac Enthesitis. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous attachments in the Spine.

Patient Benefits of PRP Prolotherapy and Prolotherapy:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who wish to avoid if not delay Surgery
• Significantly reduces the symptoms associated with Backache
• Reduced risk of adverse events
• Repairs and tightens ligaments improving sacroiliac joint stability and ease of standing, sitting & walking
• Safe and effective treatment method
• Faster healing and recovery
• PRP Prolotherapy results in safe, significant, effective, progressive improvement of back pain, function and reduction of stiffness.

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Avoid if not delay Surgery.
• Significantly reduces the symptoms associated with Inflammation in cases of Sacroilitis.
• Reduced risk of adverse events compared to oral steroid tablets which are taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
  Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces stiffness.
• More effective treatment method in inflammatory joint diseases.
• Faster recovery.
• NESTIT treatment usually results in significant, effective, progressive improvement of pain, function and reduction of stiffness if given in series.
  
  At Beth Yehudah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Sacroilitis joint/ Inflammatory Back Ache pain conditions. To know more about Sacroilitis/ Inflammatory Back Ache book an appointment now.