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Background Radiographic sacroiliitis is an important outcome in SpA and is mandatory to establish a diagnosis of ankylosing spondylitis (AS). However, few data are available on the factors associated with radiographic sacroiliitis and even less on the predictors of progression from nonradiographic SpA to AS. Objectives To identify factors associated with radiographic sacroiliitis in a cross-sectional study and predictors of progression to AS in a longitudinal study of SpA patients with positive family history. Methods The studied cohort consisted of 1,358 patients fulfilling the ASAS criteria for SpA and having at least one first- or second-degree SpA-affected relative, who were recruited by the Groupe Francais d9Etude Genetique des Spondylarthrites (GFEGS) and followed longitudinally. Anteroposterior radiographs of the pelvis were examined blindly and independently by 2 qualified examiners (RSN, MB), using the modified New York grading system. Definite radiographic sacroiliitis corresponded to a grade ≥2 bilateral, or grade ≥3 unilateral. Association between definite radiographic sacroiliitis at inclusion and demographic and clinical variables was examined using univariate and multivariate regression analysis. Of the 448 cases without definite sacroiliitis at inclusion, 160 patients were followed-up (with new pelvic X-ray) for 2 to 15 years. Factors associated with progression to definite sacro-iliitis were only assessed by univariate regression analysis because of the smaller study sample. Results In multivariate analysis, factors positively associated with definite sacroiliitis at inclusion were male sex (p=7x10–8), younger age at disease onset (p=0.04), longer disease duration (p=0.0005), HLA-B27 positivity (p=0.02), inflammatory back pain (p=0.02) and uveitis (p=9.8x10–5). The only negatively associated factor was enthesitis (p=0.002). In longitudinal study, 38 of the 160 patients (23.75%) developed definite sacroiliitis after a mean follow-up duration of 8.8±3.0 years. The only baseline factor associated with progression to definite sacroiliitis throughout follow-up was a low grade radiographic sacroiliitis at inclusion (p=0.002). Uveitis and buttock pain occurring during the follow-up period were also associated with progression to definite sacro-iliitis (p=0.04 and p=0.05, respectively). Conclusions After an average follow-up duration of almost 9 years, 23.75% of the patients with non-radiographic SpA had developed definitive sacroiliitis (i.e. AS). Factors associated with definitive radiographic sacroiliitis were male sex, younger age at disease, longer disease duration, HLA-B27 positivity, inflammatory back pain, uveitis and lack of enthesitis in the baseline cross-sectional analysis, and low grade radiographic sacroiliitis at inclusion, uveitis and buttock pain during the follow-up in the longitudinal follow-up study. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2661

Introduction Lumbar disc degeneration (LDD) is among the most common causes of low back pain. Typical symptoms include axial low back pain, buttock pain, with or without radiation to posterior thighs or legs, and intolerance to upright positions. Several surgical treatment options are available, including intradiscal injections, intradiscal electrothermal therapy, discectomy, total disc arthroplasty, and fusion. Recently, implantation of interspinous process devices has been shown to decrease low back pain, and provide morphological alterations of the degenerative discs, resulting in satisfactory clinical outcomes. This study was conducted to review our results of using stand-alone DIAM implantation as the treatment for symptomatic LDD. Materials and Methods A total of 24 selected cases of LDD were treated surgically with stand-alone DIAM implantation. In 20 patients, the presenting symptoms were predominantly axial low back/buttock pain with little leg pain, while in 4 patients there was only axial pain. Motor weakness and sensory disturbance involving the corresponding nerve roots were present in eight cases. Three patients had undergone previous lumbar discectomy of the afflicted discs. Typical MRI findings included loss of height, signal changes, and/or annular tear of the discs. On the basis of Pfirrmann grading scale for disc degeneration, three cases were categorized as Grade II, and 21 cases as Grade III. Our exclusion criteria included intermittent claudication due to lumbar spinal stenosis, severe disc space collapse with Modic changes, greater than Grade II spondylolisthesis, facet ankylosis, and L5-S1 pathology. Provocative test with intradiscal injection of normal saline-induced concordant pain in all cases. Results All patients reported significant symptom relief after surgery, as reflected by VAS and ODI improvements. The final outcomes were excellent in 19, good in 2, fair in 2, and poor in 1 cases. Segmental flexion/extension mobility was maintained in 20, and restricted or lost in 2, of 22 cases with preoperative mobility. In the other two cases with no preoperative mobility, DIAM implantation did not change the status. MRI was repeated in the two cases showing fair, and the one case showing poor outcomes. In all of them, enlargement of neuroforamens at the implanted levels were found. In one fair case, disappearance of annular tear was observed. In the other fair case (L4-5 implantation), L5-S1 disc herniation was disclosed, and removed in a second operation. The case with poor outcome was diagnosed with depression, having concomitant multiple joint pain, dysmenorrhea, sleep disorder, despite normal findings on different exams ordered by different specialists. Conclusion In highly selected cases with symptomatic LDD, stand-alone interspinous DIAM implantation is effective for alleviation of symptoms, and stabilization of disc status. Disclosure of Interest None declared References Sandu N, Schaller B, Arasho B, Orabi M. Wallis interspinous implantation to treat degenerative spinal disease: description of the method and case series. Expert Rev Neurother 2011;11(6):799–807 Buric J, Pulidori M, Sinan T, Mehraj S. DIAM device for low back pain in degenerative disc disease : 24 months follow-up. Acta Neurochir Suppl (Wien) 2011;108:177–182 Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine 2001;26(17):1873–1878

A 57-year-old man was referred to the surgical unit following the discovery by his osteopath of a mass in the left buttock. The patient had complained of left-sided sciatica radiating to the foot for 18 months. He gave a 1 month history of buttock pain and there was a noticeable buttock lump. There was no history of trauma. The past medical history was non-contributory. The only abnormality on physical examination was a 7 cm mass in the left buttock, bimanually palpable on rectal examination. Proctoscopy was normal. MRI was performed and the coronal view through the buttocks is shown in Figure 1. Pelvic angiography was then performed (Figure 2). What is the diagnosis?

Background Greater trochanteric pain syndrome consists of a common clinical syndrome including ?classical? trochanteric bursitis but also gluteus medius pathology, with main clinical features being pain and tenderness over the lateral aspect of hip. Objectives To assess the prevalence of trochanteric bursitis and gluteus medius tendonitis by ultrasound examination, together or in isolation, in patients with greater trochanteric pain syndrome and to investigate whether different clinical features could be related to ultrasound findings. Methods 36 (34F/2M) patients with greater trochanteric pain syndrome were studied retrospectively. A coxofemoral or lumbar origin of pain was ruled out in all these patients. The following variables were used: age, disease duration, presence of obesity or leg length inequity, pain type (use-related/at rest) and location (trochanter, buttock or both), Trendelemburg sign and ressted hip abduction or internal rotation, and also the existence of calcifications or significant osteoarthritis changes on X-ray examination. Results Acute or chronic signs of gluteus medius tendinitis were found in 22 patients (61%), and inflammatory changes suggesting both trochanteric bursitis and gluteus medius pathology were detected in 12 (33%); isolated trochanteric bursitis was found in only 2 cases (6%). Disease duration was longer in patients with inflammatory changes at both locations (14 mo vs 6 mo, p = 0.018), but there were no differences relating age. No significant clinical features allowed differentiation of the ultrasound findings, although a tendency towards pain location defining the underlying pathology could be observed (p = 0.062 for trochanteric pain, p = 0.09 for buttock pain). Patients showing inflammatory changes in both gluteus and trochanteric bursa on ultrasound tended to be more obese than those without bursitis (p = 0.073) and calcications on X-ray tended to be found more frequently in those with only gluteus medius tendonitis (p = 0.082). Conclusion Isolated trochanteric bursitis was rarely found on ultrasound examination in patients with greater trochanteric pain syndrome, but gluteus medius tendon inflammatory changes could be found in the vast majority of cases, most of them without associated trochanteric bursitis. No reliable clinical features could be used to distinguish between ultrasound changes.

Background Back pain is a common symptom. It is one the first manifestations of ankylosing spondylitis (AS), which is also included in many sets of diagnostic criteria for spondylarthropathies (SPA). Definitive diagnosis of AS requires the presence of radiologic sacroiliitis, but its appearance lasts many years, so isolation of AS related back pain among patients with inflammatory back pain (IBP) is difficult and needs complete clinical examination with regard to specific signs and symptoms of AS. Objectives The objective of this study is to assess the prevalence of SPA and AS in patients with IBP and to predict the diagnosis of AS on the basis of clinical findings. Methods The study patients were seen in Shaheed Beheshti hospital clinic since 1994–1998. All patients presented with IBP which was confirmed clinically according to the criteria proposed by Clain et al. Patients assessment included, taking history, complete clinical examination for clinical sacroiliitis, buttock pain, arthritis, enthesitis, spinal mobility and chest expansion. Limitation of spine mobility and chest expansion was measured by standard tests. Pelvic radiograph was performed for all patients and appropriate diagnostic tests were requested as needed. Diagnosis of SPA and AS was confirmed by European Spondylarthropathy study Group (ESSG) criteria and the modified New York criteria respectively. Patients with history of spinal trauma, surgery, infectious, degenerative and neoplastic diseases of the spine were excluded from the study. Results Variables analysed for association of IBP with AS, reduction of chest expansion and limitation of the lumbar spin During the study period. 103 patients (52 males, 51 females) entered the study. the mean age of onset of IBP was 29 ± 7 (range 12–54) years, and the mean of the disease duration was 6 ± 5 (range, 0,5–20) years. Clinical examination revealed, arthritis in 20%, clinical sacroiliitis 35%, buttock pain 32%, enthesitis 58%, limitation of motion of the lumbar spine 54%, limited chest expansion 53%, radiographic sacroiliitis 60%, and HLA- B27 positive in 18 of 27(67%). 83% of patients met the ESSG criteria for SPA and 58% met the modified New York criteria for definite AS. Limitation of motion of lumbar spine and reduced chest expansion observed in 54% and 53% of patients respectively. 14 of 18 patients with AS carried HLA – B27(78%). Among the many e motions were the best predictors of the diagnosis of AS, by odds ratio of 3 and 4 respectively. Conclusion The results of the present study show that, the majority of IBP beginning at the third or forth decades of the life are due to SPA, and limitation of motions of spine and reduced chest wall expansion heralds the occurrence of AS. References van der Linden S, van der HeijdeDM. Ankylosing spondylitis and other B27 related spondylarthropathies. Balliers Clin Rheumatol. 1995;9:355–71 Clain A, Fries JF. Clinical history as a screening test for ankylosing spondylitis. JAMA 1977;237:2613–14 Clain A. Spondylarthropathy, undifferentiated spondylarthritis and overlap. In: Madison PJ, et al., eds. Oxford textbook of rheumatology. Oxford University Press, 1998: 1037–48

Piriformis syndrome (PS) is an unusual cause of sciatica that, because of the lack of strict diagnostic criteria, remains a controversial clinical entity. The diagnosis of PS is still primarily clinical because no diagnostic tests have proven to be definitive. We report the case of a 30-year-old woman, affected by a severe scoliosis, who developed a persistent buttock pain resembling that of PS. The clinical suspicion was confirmed by magnetic resonance imaging (MRI) of the pelvis, which showed an enlargement of the left piriformis muscle with an anterior isplacement of the sciatic nerve. The role of MRI in the diagnosis, clinical definition, and therapeutic approach to PS is discussed.

Stress fractures of the sacrum during pregnancy or the postpartum seem uncommon. We report a new case of nontrauma-related postpartal sacral fracture. Only four similar cases have been reported to date. The patient was 36 years of age and her fracture was diagnosed four weeks after her first delivery. Vitamin D levels were low, but there was no osteomalacia. Other standard laboratory tests were normal, as were absorptiometry measurements at the lumbar spine and femur. Rheumatologists should consider sacral fracture in pregnant or nursing patients with buttock pain. Magnetic resonance imaging is the diagnostic investigation of choice.

Conventional spinal surgery is confined to patients with physical compression of nerves within the spinal canal and foramen or is only used for the treatment of back pain by means of tissue immobilisation by fusion.

Piriformis muscle syndrome (PMS) is a cause of sciatica, leg or buttock pain and disability. The pain is usually increased by muscular contraction, palpation or prolonged sitting. The aim of our paper was to evaluate the feasibility of CT-guided percutaneous botulinic toxin (BTX) injection for the purpose of PMS treatment. Thirty patients suffering from PMS, suspected with clinical and electrophysiological criteria, after imaging examinations excluding other causes of sciatic pain, resulted positive at the lidocaine test and were treated by intramuscular injection of BTX type A under CT guidance. The follow-up (12 months) was performed with clinical examination in all cases and with MR 3 months after the procedure in 9 patients to evaluate the denervative process entity of the treated muscle. In 26 cases relief of symptoms was obtained after 5–7 days. In 4 patients an insufficient relief of pain justified a second percutaneous treatment which was clinically successful. No complications or side effects were recorded after BTX injection. The MR examination showed a signal intensity change of the treated muscle in 7 patients due to the denervative process of PM, whereas in the remaining 2 cases only an atrophy of the treated muscle was detected. Larger series are necessary to confirm these MRI preliminary results. The CT-guided BTX injection in the PMS is an emergent and feasible technique that obtains an excellent local therapeutic effect without risk of imprecise inoculation.

Osteoporosis of pregnancy, usually responsible for spinal or femoral fracture,1 is rare as is insufficiency fracture of the sacrum, usually occurring in the elderly.2Magnetic resonance imaging (MRI) permitted during pregnancy, led us to diagnose an insufficiency fracture of the sacrum revealing a pregnancy associated osteoporosis, never previously reported to the best of our knowledge. Rheumatologists need to be aware of this new cause of pelvic pain during pregnancy. A 29 year old pregnant (seventh month) woman presented with a spontaneous acute claudication in conjunction with a left hyperalgesic buttock pain. Her past medical history showed: low back pain, since the second month of her pregnancy, relieved by rest and paracetamol; smoking (10 packet years) stopped at the sixth month of pregnancy; one spontaneous miscarriage at six months responsible for …

Case A 60-year-old lady, who had been on conventional haemodialysis for 27 years and high flux haemodialysis for 4 years, presented with bilateral buttock pain on sitting. The cause of renal failure was medullary cystic disease and she also suffered from Caroli’s disease, hepatitis C, hyperparathyroidism necessitating parathyroidectomy, and ischaemic heart disease. On examination, there were hard, indurated and tender swellings of both buttocks without lymphadenopathy. There were no masses palpable elsewhere. A computed tomography (CT) scan demonstrated ill defined high attenuation signals in both buttocks, greater on the left than the right (Figure 1). Histological analysis of a percutaneous needle biopsy of the region revealed widespread deposition of amyloid (Figure 2). Given the large size of the deposits and their proximity to critical neurological structures, she was managed conservatively with analgesics.

Background Ankylosing sponylitis (AS) is an under-recognised inflammatory condition affecting 200 000 young men and women in the UK. It mostly affects young men before the age of 40 years. Current evidence indicates an average delay in diagnosis of 10 years from symptom onset. One-third of patients are not reviewed in secondary care. Recent UK studies (1) show approximately 8.57 years in delay of diagnosis. The decreased awareness of this condition amongst the general public and primary care physicians could be a key factor in the delay. As the symptoms improve with physical activity, few patients among this age group present to their GP at an early stage, which further delay the diagnosis and management. Objectives –To explore the Primary care physicians knowledge in evaluating Back pain (BP) particularly inflammatory back pain (IBP) –To identify the current practice in diagnosing and managing inflammatory back pain in community –To explore the interest in Primary care about further education on IBP Methods This is a prospective questionnaire based study. The questionnaire has been developed addressing the key factors in the diagnosis of Mechanical back pain (MBP) and inflammatory back pain (IBP), which was piloted locally. The redesigned questionnaire was electronically circulated to GPs practicing across the Leicestershire County. The results were then analysed using excel spreadsheet. Results The total number of respondents N= 151. Most of the GPs (58%) were with more than 15years of clinical experience. As shown in previous studies BP is the common symptom for primary care consultation and most of the Gps (57%) see more than 10 patients with BP symptom It is interesting to note the gender distribution which is equal both men and women Among BP patients they see 85%are due to MBP and 15% due to IBP. (76%) respondents observedIBP in less than 40 yrs of age group and MBP in older age group. 56% Gps are very confident in diagnosing MBP and only 35% are confident in diagnosing IBP.when explore the knowledge further we asked to rate the symptom suggestive of IBP in a scale of 1-10 Early morning stiffness rated 7.8 and improvement with exercise6.8 alternating buttock pain 5.47. While asking the most important investigations they perform for IBP Inflammatory marker came on top as97% comparing MRI of sacroiliac Joint is requested only by 33%. Average 3 visit by a patient to GP before a referral to Secondary care is made and the average delay is 9 months noted. It is observed GPs are very keen to get further education on IBP and prefer practical sessions and web based teaching. Conclusions This is the first study of its kind conducted in our county exploring the Primary Care knowledge in comparing IBP and BP. With a good number (n=151) we can derive a meaningful conclusion locally about the understanding and current practice. Gps are confident in diagnosing and managing MP however less confident in IBP. Though some diagnosing IBP they delay referral to specialist due to lack of knowledge. Further education is essential in raising the awareness among GP in diagnosing IBP early and prompt specialist referral for appropriate management. References Services for people with ankylosing spondylitis in the UK—a survey of rheumatologists and patientsLouise Hamilton et al Rheumatology (2011) 50(11): 1991-1998 Disclosure of Interest A. Moorthy Grant/research support from: ABBOTT, C. Joseph: None Declared

Background It is unclear whether location of inflammatory lesions (presence of bone marrow edema (BME)) is linked to site of pain symptoms Objectives To evaluate if localisation of back pain, as indicated by patients (pts), is related to location of BME lesions seen on MRI (in spine (MRI-spine) or sacroiliac joints (SIJ) (MRI-SI)) Methods Chronic back pain pts (≥3 months, ≤2 years, onset 1 lesion was present on 1 slice. Presence of ankylosis of the SIJ on ≥ 1 slice was scored. MRIs were scored independently by 3 blinded, well calibrated readers. Agreement of 2/3 readers was used. Location of MRI BME lesions was divided in spine (cervical, thoracic, lumbar) and SIJ. Association between pain site and BME location was assessed by logistic regression analysis adjusted for gender, HLA-B27 and age at onset of back pain resulting in adjusted Odds Ratios (OR) Results In 296 pts, data of the location of pain, MRI-spine (n=293) and MRI-SI (n=288) was available. Mean age at pain onset was 28.9 years, 35.1% male, 38.5% HLA-B27+, 36.5% thoracic pain, 82.4% lumbar pain, 33.8% buttock pain and 3.4% total spinal pain. Among all pts, 32.1% showed BME lesions somewhere in the spine (1.7% in cervical part, 17.6% in thoracic part, 22% in lumbar part) and 22.6% in SIJ. Any structural lesions somewhere in the spine were present in 34.1% (5.4% in cervical part, 27% in thoracic part and 19.9% in lumbar part) and fatty lesions in 25% (3% cervical, 15.2% thoracic and 11.1% lumbar) of the pts. OR of having pain and corresponding BME lesions was 2.07 (CI:1.08–3.95;p Conclusions The location of pain in the spine (thoracic, lumbar, buttock or total spine), as indicated by the patient, is only significantly related to the location of BME lesions in thoracic site in all patients with chronic back pain. In addition, in the subgroup with axSpA pts there is a significant relation between buttock pain and any structural lesions seen on MRI-SI Disclosure of Interest None Declared

Here, we report on a rare case of a giant invasive sacral schwannoma. The patient was a 58-year-old woman who had a 6-year history of non-specific buttock pain. Histological investigation confirmed the diagnosis of cellular schwannoma. The following numerical aberration was detected using the GTG-banding method for karyotypes: 47,XX,-14,+18,+22. Cytogenetic studies of schwannomas have indicated a complete or partial loss of chromosome 22 as the most common abnormality, but this case is cytogenetically rare because of the recurrence of trisomy 22.

Aim: The aim of this study was to find out the prevalence and causes of piriformis syndrome in patients with complain of low back pain/buttock pain with sciatica attending Regional Institute of Medical Sciences (RIMS), Imphal. Materials and Methods: All the patients in the study group attending Orthopedic and Physical Medicine and Rehabilitation Out-patient Department in RIMS, Imphal were examined. Those with increased symptoms on sitting, localized significant tenderness on palpation of the muscle, presence of one or more of the following tests: Freiberg, pace, beatty, and FAIR (Flexion , Adduction and Internal Rotation) maneuvers with negative X-ray, ultrasound, computed tomography and magnetic resonance imaging findings were subjected to piriformis muscle injection of lidocaine (2%) 2 ml and methyl prednisolone 2 ml (40 mg) for confirmation of diagnosis. Result: Out of 2910 patients, 182 cases (M: 28, F: 154) in the age range of 19-75 years with a mean age of 43 years were clinically diagnosed as piriformis syndrome. Prevalence of piriformis syndrome was 6.25%. Conclusion: Piriformis syndrome is one of the differential diagnoses of low back/buttock pain with Sciatica. Individuals of all activity levels can be affected. Females are more affected than males. Causes are overuse, prolonged sitting, trauma, and vigorous massage. Diagnosis is by exclusion of other causes. Simple injection with local anesthetic and steroid in the piriformis muscle is both therapeutic and confirmatory of diagnosis. Early diagnosis and treatment with injection of piriformis muscle can prevent further complications and risks of surgery, which is also not 100% curative. With proper care, piriformis injection can be carried out without any complication. Long-term study is needed to evaluate the recurrence after injection treatment.

Background Sacrospinous colpopexy requires the placement of a suture through the sacrospinous ligament, under which lies the pudendal nerve. Entrapment of this nerve may result in perineal or buttock pain. This report analyzes a case of pudendal nerve entrapment and studies the management of the resultant neuropathy. Case A 62-year-old patient experienced a chronic pudendal neuropathy with perineal and buttock pain following a sacrospinous colpopexy. Removal of the suture, 2 years after it was originally placed, resulted in immediate relief of her pain. She has been asymptomatic for 1 year following surgery. Conclusion Pudendal nerve entrapment should be considered in the differential diagnosis of perineal or buttock pain after sacrospinous colpopexy. Relief of pain can be achieved even 2 years after initial surgery.

The relative roles of spinal cord stimulation and the spinal infusion of opioids in the treatment of chronic, non-cancer lower body pain remains unclear. This report contains a retrospective analysis of patients with chronic lower body, neuropathic pain and treated over a 5 year period. Unilateral leg and (insert slash) or buttock pain was treated initially with spinal stimulation and bilateral leg or mainly low back pain was treated initially with spinal infusions. 26 patients received spinal stimulation. Pain relief was ≥ 50% in 16 (62%) with increased activity levels. Stimulator coverage was most difficult or failed in patients with buttock pain. 16 patients received long-term spinal infusions. Pain relief was ≥ 50% in 2 (13%) but 25–49% in another 8 (50%) with stable infusion doses and was best in patients requiring low-dose (< 1 mg (insert slash) h morphine intrathecal) infusions in the trial period. The review indicates that spinal infusions may be best for bilateral or axial pain that has not responded to spinal stimulation. Clonidine appears to be an alternative in high-dose morphine patients. New diamond-shaped electrode and dual quadripolar arrays appear to be very helpful for back, buttock, and (insert slash) or bilateral leg pain patterns.

A 13-year-old school boy presented with right-sided buttock pain, features of sepsis and Staphylococcus aureus positive blood cultures. On examination, he was febrile and in severe pain, with limited hip rotation and positive sacroiliac stress tests. Initial imaging with pelvic x-ray, hip ultrasound and MRI were normal. Despite this, a diagnosis of septic arthritis of the hip was presumed, and the patient underwent a washout of the right hip. When the imaging was reviewed in more detail, it was noted that a section of the sacroiliac joint was abnormal. Subsequent pelvic MRI confirmed that this was, in fact, septic sacroiliitis. The patient made a good recovery following washout of the right sacroiliac joint and 6 weeks of antibiotics.

Purpose To determine the prevalence of inflammatory back pain in an anterior uveitis cohort. Design Retrospective cohort study. Methods Patients with anterior uveitis were recruited from the clinic of an ophthalmologist to complete a survey between March and December 2008. Patients were classified with inflammatory back pain if they had ≥2 positive responses to 4 validated inflammatory back pain questions: presence of morning stiffness >30 minutes in duration; improvement in back pain with exercise but not with rest; awakening from back pain during the second half of the night only; and presence of alternating buttock pain. Disease activity was assessed using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The impact of disease on quality of life was measured using the EuroQOL (EQ-5D) questionnaire. Twenty-five patients underwent further rheumatologic examination. Results One hundred forty-one of 167 patients (84.4%) completed the survey. Sixty-six of 141 patients (46.8%) were classified to have inflammatory back pain. Mean BASDAI (4.2, SD 2.41) and EQ-5D scores (0.73, SD 0.21) were lower than patients with no inflammatory back pain (0.82, SD 0.16, P = .0048). In the subgroup that underwent rheumatologic assessment, a classification of inflammatory back pain was 92% sensitive and 67% specific for a diagnosis of inflammatory back pain. Conclusions The prevalence of inflammatory back pain in a cohort of anterior uveitis patients was found to be 46.8%. Patients with inflammatory back pain had worse quality of life than those without. Ophthalmologists may use these questions on back pain to select patients classified to have inflammatory back pain to refer for early rheumatologic assessment.

Aim Offering insight on pyogenic sacroilitis presenting as a limping child, a rare diagnosis of a common presenting complaint, affecting a mere 1.5% of all septic arthritis in childhood. Methods Case report of a 3 year old girl with pyogenic sacroilitis presenting with an acute onset febrile illness limp and abdominal pain. Review of the current literature on pathogenesis, diagnosis, and treatment of pyogenic sacroilitis. Results Sacroillitis is a rare condition with non-specific clinical features, creating a challenging diagnosis for the clinician, often delaying appropriate management and potentially leading to avoidable complications. Based on the literature review biochemical and plain radiography make the condition hard to distinguish from other septic arthritis. Patients have an elevated temperature with an average of 38.5°C. The ESR is elevated with a mean ranging from 51-75 mm/h, as is the CRP with a mean of 4.7-30 mg/dL. There is also mild leucocytosis. The main pathogen is Staphylococcus aureus. Infections with E.coli, Staphylococcus epidermidis, Salmonella and Mycobacterium tuberculosis have been noted. Plain radiographs are nonspecific. Delayed diagnosis can show sclerosis, lytic destruction and synostosis. Ultrasonography of the joint is helpful in excluding a joint effusion. Clinical suspicion and examination of the sacroiliac joint followed by MR imaging is the best route to diagnosis. Mainstay of treatment is intravenous antibiotics followed by a prolonged course of oral antibiotics. Rarely surgical intervention is needed. Conclusion Sacroillitis is an uncommon clinical presentation in paediatric practice. Children present with fever, buttock pain and a limp. Diagnosis is missed as patients are often examined supine and SI joints are not examined routinely. Misdiagnosis of Appendicitis is also common. The situation is further obscured by the normal findings on plain radiograph and ultrasound. Therefore patients who present with evidence of infection, buttock pain and a gait abnormality should have there SI joint thoroughly examined, including the FABERE test and a referral for detailed imaging. These patients respond well to antimicrobial therapy and make a full asymptomatic recovery.

65-year-old man with a history of chronic myeloid leukemia (CML) presented with fatigue, a 9-kg weight loss, and increasing low back and buttock pain. He had received an allogeneic stem cell transplant 11 months previously. His medications on admission included cyclosporine and prednisone. On arrival, he noted difficulty initiating urination and complained of the inability to completely void. Presenting vital signs were normal except for temperature up to 39.48C. Back and extremity examination revealed exquisite tenderness over the lumbosacral spine and associated leg pain with straight leg testing. Motor examination revealed 4/5 normal strength of the hip flexors. Sensation to light touch and vibration was absent below the ankles bilaterally, and reflexes were diminished or absent at the knees and ankles. Laboratory data revealed a white blood cell count of 9700/mL, hematocrit of 0.29, and platelet count of 126 000/mL. The patient’s lactate dehydrogenase level

First, I would like to commend the authors on describing a well-thought-out diagnostic approach when examining a patient with complex low back pain (LBP).1 I believe this article clearly shows how difficult the diagnostic process can be in patients with LBP. A critical question brought up by the authors of this case report is: should we move away from identifying specific tissue pathology or pain generators when trying to make a diagnosis in patients with LBP? I think this article gives us a clear reason why we should probably not . Although definitely …

Objective : Iliac screw fixation has been used to prevent premature loosening of sacral fixation and to provide more rigid fixation of the sacropelvic unit. We describe our technique for iliac screw placement and review our experience with this technique. Methods : Thirteen consecutive patients who underwent spinopelvic fixation using iliac screws were enrolled. The indications for spinopelvic fixation included long segment fusions for spinal deformity and post-operative flat-back syndrome, symptomatic pseudoarthrosis of previous lumbosacral fusions, high-grade lumbosacral spondylolisthesis, lumbosacral tumors, and sacral fractures. Radiographic outcomes were assessed using plain radiographs, and computed tomographic scans. Clinical outcomes were assessed using the Oswestry Disability Index (ODI) and questionnaire about buttock pain. Results : The median follow-up period was 33 months (range, 13-54 months). Radiographic fusion across the lumbosacral junction was obtained in all 13 patients. The average pre- and post-operative ODI scores were 40.0 and 17.5, respectively. The questionnaire for buttock pain revealed the following: 9 patients (69%) perceived improvement; 3 patients (23%) reported no change; and 1 patient (7.6%) had aggravation of pain. Two patients complained of prominence of the iliac hardware. The complications included one violation of the greater sciatic notch and one deep wound infection. Conclusion : Iliac screw fixation is a safe and valuable technique that provides added structural support to S1 screws in long-segment spinal fusions. Iliac screw fixation is an extensive surgical procedure with potential complications, but high success rates can be achieved when it is performed systematically and in appropriately selected patients.

Rheumatic manifestations are common and varied in infective endocarditis. We performed a retrospective case analysis on 87 patients with 93 episodes of infective endocarditis admitted to Flinders Medical Centre over an 11 year period (1980-1990). Disabling musculoskeletal symptoms and signs were documented in 22 (25%) of the patients. Thirteen patients developed severe or moderately severe low back pain during their illness, two with radiological evidence of a septic discitis or vertebral osteomyelitis. Two patients developed polyarthralgia/arthritis, four had septic arthritis (all with acute Staphylococcus aureus endocarditis), three developed severe loin pain, two acute gout, two had severe buttock pain and sacroiliac joint tenderness and two each developed disabling jaw/facial pain, neck/scapular pain and flank pain respectively. Five patients presented initially to the orthopaedic or rheumatological unit for management of their musculoskeletal symptoms. Four of seven patients with Streptococcus bovis endocarditis demonstrated prominent low back pain supporting a previously noted association between this organism and back symptoms. Furthermore, in one patient who had three separate episodes of endocarditis involving three different organisms, florid back symptoms were only seen in the infective episode involving Streptococcus bovis.

Insufficiency fractures of the sacrum are relatively common and cause severe low back and buttock pain. Percutaneous vertebroplasty is effective for treating vertebral compression fractures. We present a case of percutaneous sacroplasty for the treatment of low back and buttock pain in a sacral insufficiency fracture. A 79-year-old male with non-small lung cancer presented with seve re low back and buttock pain after series of radiation treatments. Preoperative MRI showed both a sacral ala and S2 metastatic insufficiency fracture. An epidural port was inserted for continuous morphine infusion and sacral nerve root blocks were performed. However, his pain did not diminish and we attempted percutaneou s sacroplasty. Both sides of the sacroplasty were done with a fluoroscopy-guided technique with 1.7 ml and 2.3 ml of bone cement injected into the right and left sacral ala. Pain relief was significant and the patient was able to sit down 1 day after the procedure. (Korean J Pain 2008; 21: 229-232)

Congenital scoliosis due to a sacral malformation is quite rare. To the best of our knowledge, most wedge resection osteotomies have been performed to correct a kyphotic deformity in ankylosing spondylitis. However, there is no report of a trapezoidal lumbar wedge resection osteotomy of the vertebral body in the surgical treatment of congenital scoliosis due to a sacral malformation. This paper reports a 41-year-old female with a 25-year history of lower back and buttock pain combined with radiating pain to the lower extremities. The coronal imbalance was 3.8 cm and the scoliosis angle using the Cobb method was 22˚. A trapezoidal wedge resection osteotomy of the L5 body was performed, and the scoliosis was corrected. We detail this modification of a vertebral osteotomy technique and show that a fixed coronal deformity could be corrected effectively using this technique.

Purpose : To evaluate the clinical findings and effective management of thoracic myelopathy combined with degenerative lumbar scoliosis. Material and Methods : Seven cases with degenerative lumbar scoliosis of more than 10 degrees and underwent surgery on the thoracic spine were retrospectively studied through a chart review and the radiological findings. The mean follow-up period was 32.3 months. The average age was 65.3 years (range, 61-82 years), and there were 4 males and 3 females. 5 cases underwent a lumbar laminectomy with or without fusion prior to admission. The patients were evaluated through their history, physical examination, period of symptoms, MRI findings and surgical methods. A clinical evaluation was carried out using the Oswestry Disability Index (ODI). Results : All cases had decreased hip flexion and a spastic gait, along with various degrees of radiating pain and buttock pain. No case had pathological reflexes but various degrees of motor and sensory disturbances were observed. The preoperative MRI findings showed herniated discs at the level of T5-6 (1 case), T6-7 (1 case), T8-9 (2 cases), T9-10 (1 case), T9-12 (1 case) and T10-12 (1 case). Decompression through the anterior approach was carried out on 4 cases, and decompression and posterior fusion was carried out on 3 cases. The average preoperative ODI was 28.6 points (range, 25-34) and improved to 12.3 points (range, 10-15), respectively at the final follow-up. Conclusion : Although thoracic myelopathy combined with degenerative lumbar scoliosis is a rare disease, pathognomonic symptoms such as gait disturbances highlight the need for considering the appropriate management and surgical level through a differential diagnosis with simple degenerative lumbar scoliosis.

A case in which radiotherapy was requested for bone metastases from prostate carcinoma after hormonal and radiation therapy and diagnosed as insufficiency fracture of the sacrum on bone scan was reported. A 78-year-old man underwent endocrine therapy with luteinizing hormone releasing hormone agonists and radical radiotherapy toward pelvis for prostate cancer. The onset of buttock pain started from the nine-month after the beginning of radiotherapy, and was diagnosed as sacrum metastasis by MRI, and radiotherapy was requested again for pain control. However, on bone scan, butterfly-like changed accumulation was noted, therefore sacrum insufficiency fracture was suspected. Addition of CT inspection and reconfirmation of MRI were performed, and bone metastases became negative, and serial observation was performed of the painkilling effect after that. No tumor marker rise was seen after five months without sigh of new bone metastases and the final diagnosis became insufficient fracture. In order to avoid unnecessary treatment, we think that the view of bone scintigram for diagnosis of sacrum insufficient fracture should be known.

Two cases were presented with initial symptoms of inflammatory low back pain and alternate buttock pain. They developed a progressive dyspnea with bilateral mediastinal and hiliar lymphadenopathy and pulmonary interstitial disease as visualized with chest CT scan. Sarcoidosis diagnosis was confirmed by biopsy in both cases--in one case by skin biopsy and in the other by open lung biopsy. These clinical forms of spondyloarthropathy and sarcoidosis were unusual and were compared with similar cases present in the literature.

BACKGROUND: Pain radiating below the knee is typically thought to originate from the lumbosacral spine rather than degenerative hip pathology. We investigated the lower limb distribution of pain using body image maps in 60 patients awaiting primary hip arthroplasty and in 60 patients awaiting spinal decompression for confirmed spinal stenosis. The perception of 33 orthopaedic registrars regarding distribution of hip pain was also assessed. RESULTS: Groin and buttock pain are significantly more common in hip osteoarthritis. The presence of groin pain is 84.3% of those sensitive for hip dysfunction with a specificity of 70.3%. Patients with hip osteoarthritis had pain below the knee in 47% of cases whereas 88.5% of orthopaedic trainees believed hip pain did not radiate below the knee. Radiographic features of osteoarthritis within the hip joint, visual analogue pain score or Oxford Hip Score have no significant association with a patient's distribution of hip pain. CONCLUSIONS: Hip pain referred below the knee is common with a degenerate hip joint and follows the distribution of the saphenous nerve, which branches from the femoral nerve. Radiographic deterioration of a hip joint does not correlate with pain distribution or patient dysfunction as measured by the Oxford Hip Score.

Figure 1. Radiograph showing that the fracture was in the non-weight-bearing portion and extended into the obturator fossa. reaching out and down to play a low ball he felt and heard a crack in his right hip and fell on to the floor. Initially he was thought to have a hamstring injury for which he was referred to the physiotherapist, who put him on crutches, not bearing weight. About I week later he was referred to the fracture clinic because of persisting hip pain. On clinical examination he had pain and spasm on hip flexion to 70". He had pain on rotation of the hip together with some limitation of its rotation. There was no gap palpable in the hamstrings. He was not able to bear weight on the right leg. He did not mention any leg or buttock pain in the preceding history. Radiographs taken at this stage revealed an isolated, undisplaced fracture of the right OS ischium. The fracture was in the

Background: Sacroiliitis is a rare infection and an unusual cause of back pain during pregnancy. Because pregnancy and infections commonly associated with pregnancy are risk factors, this diagnosis should be considered in the gravida with sacroiliac pain. Case: A 17-year-old woman at 24 weeks' gestation, with a history of illicit drug use, presented to a local emergency room with back and buttock pain. Bacteriuria and pyuria were diagnosed, and cefazolin was initiated. Blood cultures grew Staphylococcus aureus and Escherichia coli. Despite prolonged antibiotic therapy for possible endocarditis, she had persistent debilitating lower back and buttock pain. Radiographic studies detected sacroiliitis, and broadened antibiotic therapy effected cure. Conclusion: When sacroiliitis is suspected, diagnostic imaging with either computed axial tomography, or, preferably, magnetic resonance imaging may be helpful. Antibiotic therapy should be tailored to the specific organism involved and continued for 3–6 weeks.

STUDY DESIGN Experimental disc injections in subjects with no history of low back symptoms. OBJECTIVE To determine in an experimental model the reliability of patients' subjective interpretation of pain concordancy during provocative disc injection. BACKGROUND Discography in the evaluation of low back pain relies on a patient's subjective assessment of pain magnitude and quality during disc injection. Reproduction of significant pain on disc injection, which is similar to patients' usual pain, is believed to prove that the disc injected is the source of the patient's low back pain. In the current study, this hypothesis was tested in a controlled setting on patients with known nonspinal pain in a common referral area of discogenic pain. METHODS Patients with no history of low back pain were recruited to participate in a study of discography. Patients scheduled to undergo posterior iliac crest bone graft harvesting for nonthoracolumbar procedures were evaluated with lumbar radiography, magnetic resonance imaging, and psychometric testing. Two to 4 months after bone graft harvesting, patients underwent lumbar discography by strict blinded protocol. Patients were asked to compare the sensations elicited at discography to their usual back/buttock pain since bone graft harvesting. Pain was rated as 0-5 on a pain thermometer and concordancy was rated as none, dissimilar, similar, or exact. RESULTS Eight subjects completed the study, and 24 discs were injected. Of the 14 disc injections causing some pain response, 5 were believed to be "different" (nonconcordant) pains (35.7%); 7 were "similar" (50.0%), and 2 were "exact" pain reproductions (14.3%). The presence of anular disruption predicted concordant pain reproduction (P < 0.05). Of 10 discs with anular tears, injection of 5 elicited pain that was similar to or an exact reproduction of pain at the iliac crest bone graft harvest sites. By the usual criteria for positive discography, 4 of the 8 patients (50%) would have been classified as positive. In these patients, the pain on a single disc injection was very painful, and the pain quality was noted to be exact or similar to the usual discomfort. All subjects had a negative control disc. CONCLUSIONS The findings of this study demonstrate that patients with no history of low back pain who had undergone posterior iliac bone graft harvesting for nonlumbar procedures often experienced a concordant painful sensation on lumbar discography with their usual gluteal area pain. Thus, the ability of a patient to separate spinal from nonspinal sources of pain on discography is questioned, and a response of concordant pain on discography may be less meaningful than often assumed.