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

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

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I have left alone. After seven treatments his pain and stiffness is 50 percent better, and he is happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti-inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He is doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost pain-free. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he is well pleased; sixty-five percent better after three treatments.

5. Mr T is a wise man; he has taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily stroll has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift; he has a short leg.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. X-rays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65-year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88-year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done. 

10. Mr X is a 71-year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a few months ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It is a non-complicated upper cervical facet syndrome, and she is doing well.

12. Mr D is a 38-year old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he could not sleep on that shoulder.

13. Mr D, a 71-year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors should not be treating the elderly most medical sites state but that is so much bunkum.

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