Chronic LBP with left sided unilateral lumbarization/sacralization, 15mm left pelvic tilt & SIJ pain

by Lily
(Brisbane, Australia)

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Chronic LBP with left sided unilateral lumbarization/sacralization, 15mm left pelvic tilt & SIJ pain.

I am a 28yo female currently struggling with the second of two severe episodes of low back pain. The first commenced 06/14 and I finally returned to work part time in 03/15 prior to the second episode commencing 07/15. Both episodes had me on complete bed rest and a cocktail of pain medications - I leave the house only for appointments, using crutches for support & limiting weight through my lower back.

Sitting, standing, bending and walking all exacerbate my pain, and I am most comfortable lying on my right side supported by many pillows and a wedge. Ice packs also help relieve some of my pain, and it is predominantly around the left lower lumbar area and SIJ, extending down to the outer left buttock and often the outer/back of my thigh & groin (but never below the knee).

I have had innumerable scans and procedures (but no surgery), epidurals and injections as well as several RF nerve ablations at the left L4, L5 and S1.

Summarised findings on my many reports include -
1. Xray: left sided pelvic tilt of 15mm with partial sacralization of the L5 on the left
2. MRI: mild broadbased bulging of posterior disc annulus at L5/S1 (which contacts the forming S1 nerve roots), and mild facet joint arthropathy on the right (with a 5mm synovial cyst emanating from the lateral aspect of the facet joint).
3. CT: a lumbarized S1 vertebral body
4. MRI: transitional S1 with rudimentary S1/S2 disc and hypoplastic right lateral mass of the S1 (left transverse process articulates with the sacrum and pelvis)
5. Xray: transitional S1 with anomalous articulation between the left transverse process of S1 and the sacrum.

The first episode seemed to be relieved by one of the RF ablations at L4, L5 and S1 after two medial branch blocks. With the understanding that this was not a permanent fix, I was prepared for the pain to return and followed this treatment path again when the second episode commenced. However, this time around it has been unsuccessful and I have come to learn of my transitional vertebra (which I currently believe is a Castellvi type IIIa) - however, whether this is my L5 or S1 I am unsure. Some scans say L5, others S1, and my specialist also believed it to be a pseudoarticulation (based on several scan reports) although after sending me for an injection into this area, the CT radiologist said it is predominantly fused, thus the pseudoarticulation was unable to be injected.

I am beginning to lose hope that my pain will ever be relieved - most recently the SIJ was suggested as a culprit and I had a CT guided anesthetic block which did seem to assist the pain in that immediate vicinity, however I was still left with the pain above the SIJ and referred down my buttock/thigh area. Are you able to provide any further suggestions on treatment paths? I have read much about SIJ dysfunction, and transitional vertebrae (especially regarding the contentiousness of Bertolotti's syndrome) but haven't come across many stories of people with both SIJ dysfunction and a transitional vertebra. I expect this would be quite common due to the biomechanical changes a transitional vertebra may cause, but I don't know what to do next and I can't accept I will just have to learn to live with this pain and remain on so many pain medications at such a young age.

Hello Lily,
Thank you for a comprehensive history. Neither should you accept that this is your lot.

I have a few questions.

1. Have you ever been to a chiropractor?

2. You make no mention of exercises.

3. You had "complete" bed rest? Research suggests that is not helpful, so I have come up with I call massaging bed rest. Bed rest with massage, half hourly exercises, and getting up routinely every hour for a short walk around the house.

4. Has any explanation been given for the groin pain; that's unusual.
5. With no medication for 24 hours, sitting in a normal chair, ask a friend to raise your lower leg parallel to the ground. Repeat with the naughty leg. What happens? If nothing happens repeat with your head flexed on your chest.

6. Do you know if any of the orthopaedic tests for the SIJ were positive?

7. Was the anterior to posterior xray taken with you standing? Have someone stand behind you, place their hands on your iliac crests whilst they are kneeling, and judge whether you have a short leg. Is one crest significantly lower than the other? A simple insert worn every day in the shoe can make a colossal difference. That "pelvic tilt" of 15mm may be very significant.

Bertolotti points to the fact that often the disc above the anomalous joint is the trouble maker; that fits with the fact you had pain on the side of your leg.

Give me some answers, keeping to this thread, and we'll take this further.

Dr B



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