Sacroiliitis vs. Herniated Disc: A Patient's Journey

Sacroiliitis or herniated disc?

About six years ago, I fell while playing badminton and sat on the ground.
At that time, I did not seek medical attention, thinking that resting would resolve the issue.
In the following years, I experienced lower back pain whenever I was overly fatigued, under significant stress, sat for extended periods, or during cold winters.
At its worst, I was unable to stand or sit, and my entire right leg felt weak; every step I took was painful, and I could only lie flat in bed.
Sometimes I felt normal during the day, but discomfort would appear at night.
Occasionally, resting for a week would improve my condition, while other times I needed to take muscle relaxants.
This summer, my condition worsened, and on April 22 and June 1, I had to take sick leave from work due to severe pain in my right leg, requiring muscle relaxants and rest, which had never happened so frequently before.
Therefore, on April 25, I had an X-ray taken, and the rehabilitation physician diagnosed me with "lumbar stenosis at the L4-L5 levels and mild disc herniation." I underwent physical therapy three times a week for a month (including heat therapy, lumbar stretching, and electrical stimulation) and, upon the physician's recommendation, I self-paid to join a core rehabilitation class for lower back pain at the hospital (which also lasted a month), but my condition fluctuated.
In early June, I visited a traditional Chinese medicine clinic for massage based on a colleague's recommendation, which improved my daily activities, and I did not experience any discomfort symptoms afterward.
On June 13, my original rehabilitation physician scheduled an MRI, and on June 18, I reviewed the report with another rehabilitation physician who stated that the MRI results were normal.
Upon reviewing the X-ray taken in April, he suggested that I likely had right-sided sacroiliitis, mentioned that lumbar stretching was ineffective, and recommended a nuclear scan and shortwave therapy (which I have not yet undergone).
It is confusing to receive two different conclusions from the same X-ray! Currently, my right leg feels normal; I experience no discomfort when getting out of bed or bending over, and I pay close attention to maintaining proper posture in my daily activities.
I have placed a lumbar support cushion on my office chair and make it a point to stand up and move around or perform gentle stretches every 30 minutes.

Miss Su, 30~39 year old female. Ask Date: 2007/06/20

Dr. Lin Yijun reply Orthopedics

Hello Ms.
Su,
Without having seen you in person or reviewed your imaging studies, the following explanation can only serve as a reference.
Given your history of injury and the symptoms you have described, it is reasonable for the rehabilitation physician to consider the possibility of a herniated disc.
Injuries can also frequently lead to dysfunction or inflammation of the sacroiliac joint, so careful differential diagnosis is essential.
Regarding radiological diagnosis, X-rays of the sacroiliac joint are inherently difficult to interpret and are highly influenced by the reader's expertise, unless there is clear evidence of inflammation.
As for lumbar MRI, more than half of individuals may show signs of disc herniation, but most do not experience symptoms; therefore, MRI findings alone cannot be used for definitive diagnosis.
In general, if manipulation therapy leads to improvement, it is more indicative of issues such as sacroiliac joint dysfunction or herniated discs.
However, if the condition is ankylosing spondylitis-related sacroiliitis, it is unlikely to be completely resolved through manipulation alone.
Your physician has arranged for a nuclear medicine scan likely to assess the status of sacroiliitis, as some patients with sacroiliitis may have ankylosing spondylitis, which requires additional pharmacological treatment.
Core rehabilitation for lower back pain, focusing on strength and flexibility training, is beneficial regardless of whether the underlying issue is a herniated disc, sacroiliitis, or ankylosing spondylitis-related sacroiliitis.
I hope this information is helpful to you.
Wishing you good health,
Lin Yi-Jun
Department of Internal Medicine, Taipei Veterans General Hospital

Reply Date: 2007/06/20

More Info

Understanding the differences between sacroiliitis and a herniated disc is crucial for patients experiencing lower back pain, especially when symptoms can overlap. Your journey, marked by a significant injury and subsequent pain episodes, highlights the complexity of diagnosing and managing back pain.

Sacroiliitis is an inflammation of one or both of the sacroiliac joints, which connect the lower spine to the pelvis. This condition can cause pain in the lower back, buttocks, and legs, and is often exacerbated by prolonged sitting, standing, or certain movements. Common causes include injury, arthritis, or infections. Symptoms may include stiffness, pain that worsens with movement, and discomfort that can radiate down the legs.

On the other hand, a herniated disc occurs when the soft inner material of a spinal disc bulges out through a tear in the tougher exterior. This can compress nearby nerves, leading to pain, numbness, or weakness in the legs. Herniated discs are often associated with specific movements or activities that put stress on the spine, such as heavy lifting or sudden twisting motions. Symptoms typically include sharp pain that may radiate down the leg (sciatica), weakness, and sometimes tingling sensations.

Your history of a fall while playing badminton, followed by recurrent episodes of pain, suggests a potential link to either condition. The initial injury could have led to a herniated disc or contributed to the development of sacroiliitis. The fact that your pain worsens with certain activities and improves with rest aligns with both conditions, making it challenging to pinpoint the exact cause without further diagnostic imaging.

The X-ray findings of lumbar stenosis and mild disc protrusion indicate structural changes in the spine that could contribute to your symptoms. However, the subsequent MRI results showing normal findings suggest that the herniated disc may not be the primary issue at this time. The conflicting interpretations of your X-ray by different physicians can understandably lead to confusion. It’s not uncommon for imaging studies to yield varying conclusions based on the interpreting physician's experience and focus.

Given that your symptoms have improved with physical therapy and attention to posture, it’s possible that your pain may be more related to sacroiliitis, especially if you experience discomfort in the pelvic region or buttocks. The recommendation for a nuclear scan and shortwave therapy could provide further insights into the inflammatory processes at play.

Management Strategies:
1. Physical Therapy: Continuing with physical therapy focused on core strengthening and flexibility can help alleviate symptoms and prevent future episodes.

2. Pain Management: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help manage inflammation and pain associated with sacroiliitis.

3. Activity Modification: It’s great to hear that you are mindful of your posture and take breaks during prolonged sitting. Continuing these practices is essential.

4. Follow-Up Imaging: If symptoms persist or worsen, consider discussing further imaging studies, such as a CT scan or repeat MRI, to evaluate for any changes in your condition.

5. Consultation with Specialists: If there is ongoing uncertainty, seeking a second opinion from a spine specialist or rheumatologist may provide clarity on your diagnosis and treatment options.

In conclusion, while both sacroiliitis and a herniated disc can cause significant discomfort, understanding the nuances of each condition is vital for effective management. Your proactive approach to treatment and symptom monitoring will be key in navigating this journey. Always feel empowered to ask your healthcare providers for clarification on your diagnosis and treatment plan, ensuring you are an active participant in your care.

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