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CT appearance of sacroiliac joint trauma in children.
Subchondral fractures in association with an intact joint space and narrowing of the joint space have not previously been reported with sacroiliac joint trauma in children. The subchondral fractures are thought to occur through the zones of cartilage proliferation and provisional calcification in the growing cartilage of the opposing sacroiliac joint surfaces and the zone of cambium layer of the periosteum in the areas of ligamental insertion, as these may represent structurally weak areas. This type of injury may explain the good long-term results in children with trauma to this region. Widening of the sacroiliac joint space in association with trauma as suggested on plain radiographs may thus not be as common as was previously thought.
Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test.
STUDY DESIGN: An experimental study of respiratory function and kinematics of the diaphragm and pelvic floor in subjects with a clinical diagnosis of sacroiliac joint pain and in a comparable pain-free subject group was conducted. OBJECTIVE: To gain insight into the motor control strategies of subjects with sacroiliac joint pain and the resultant effect on breathing pattern. SUMMARY OF BACKGROUND DATA: The active straight-leg-raise test has been proposed as a clinical test for the assessment of load transfer through the pelvis. Clinical observations show that patients with sacroiliac joint pain have suboptimal motor control strategies and alterations in respiratory function when performing low-load tasks such as an active straight leg raise. METHODS: In this study, 13 participants with a clinical diagnosis of sacroiliac joint pain and 13 matched control subjects in the supine resting position were tested with the active straight leg raise and the active straight leg raise with manual compression through the ilia. Respiratory patterns were recorded using spirometry, and minute ventilation was calculated. Diaphragmatic excursion and pelvic floor descent were measured using ultrasonography. RESULTS: The participants with sacroiliac joint pain exhibited increased minute ventilation, decreased diaphragmatic excursion, and increased pelvic floor descent, as compared with pain-free subjects. Considerable variation was observed in respiratory patterns. Enhancement of pelvis stability via manual compression through the ilia reversed these differences. CONCLUSIONS: The study findings formally identified altered motor control strategies and alterations of respiratory function in subjects with sacroiliac joint pain. The changes observed appear to represent a compensatory strategy of the neuromuscular system to enhance force closure of the pelvis where stability has been compromised by injury.
Pain provocation tests for the assessment of sacroiliac joint dysfunction.
A double-blind trial was carried out to determine the sensitivity and specificity of three commonly used pain provocation tests for sacroiliac joint dysfunction. The trial involved 40 patients, all of whom reported pain when they were subjected to each of the three tests. Half of the patients (20) had the symptomatic sacroiliac joint injected with 4 ml of 1% lignocaine, whereas the other 20 patients received 4 ml of normal saline to the painful joint. The level of pain produced by each of the three tests was assessed pre- and posttest injection using a visual analogue scale of 0-100. If the pain could be suppressed by 70% with injection of either normal saline or 1% lignocaine into the symptomatic sacroiliac joint under image intensification, the test was considered to be positive for pain arising from the sacroiliac joint. None of the patients receiving normal saline had their pain suppressed to any significant degree, whereas those patients receiving 1% lignocaine had their pain suppressed sufficiently for the three pain provocation tests to have a specificity of 100% for each test and a sensitivity range of 77-87%. This study indicates that the three tests, when used in combination, have a high predictive value for pain arising from the sacroiliac joint.
[Quantitative scintigraphy of the sacroiliac joints].
Effects of gender and age on quantitative sacroiliac joint imaging are discussed controversially. In most investigations the number of controls has been small and might not exactly reflect the change of sacroiliac/sacral (SI/S) ratios related to different age and gender. The aim of our study was to evaluate the changes SI/S ratios according to age and gender. In 125 patients without any history of either diseases or complaints of the sacroiliac joints a bone scintigraphy was obtained and the SI/S ratios were calculated. We observed a significant negative correlation of SI/S index with age. After separation into 4 different age groups a significant decline of the ratios could be shown. There were no significant differences between male and female patients. We conclude that the influence of age on SI/S ratios is substantial. But also many other factors like patient position, algorithm of SI/S ratio calculation, the time interval between application of the radiopharmaceutical and data acquisition may exert effects on SI/S ratios. It seems necessary for each department to evaluate their own age related reference values of SI/S ratios.
[Histopathological study of the aging process in the human sacroiliac joint].
It has not been well defined the morphologic characteristics of the aging process of the sacroiliac joints in man. We have, therefore, studied the sacroiliac joints of human subjects by light and scanning electron microscopy. The joints were collected from 55 Japanese fetuses and adult cadavers. The articular cartilages on both sacral and iliac sides were composed of hyaline cartilage in the fetuses and adults. In fetuses, loose fibrous strands were found in the articular space and appeared to represent a residue of the intermediate layer during formation of the articular space. In adults who were older than 30, the joints showed definite degeneration which was more severe on the cartilage at the iliac side than that of sacral side. Scanning electron microscopic observations supported the light microscopic findings. Fusion of the two articular surfaces was observed in 24% of the adult joints. These findings strongly suggest that the buffering capacity of the sacroiliac joints decreases with aging which appears to relate to the clinical symptom of low back pain.
[CT-guided percutaneous needle biopsy and intra-articular injection of sacroiliac joint].
OBJECTIVE: To investigate the clinical value of CT-guided percutaneous needle biopsy and intra-articular injection of sacroiliac joint. METHODS: CT-guided percutaneous puncture was conducted to the bilateral sacroiliac joints of 3 specimens of adult pelvis, 18 patients with ankylosing spondylitis (AS), and 10 patients with undifferentiated spondyloarthropathy (uSpA) suspected as early AS clinically. All 28 patients had taken non-steroidal anti-inflammatory agents without adequate control of symptoms or with serious side effects. Biopsy of synovium with 16G or 18G needles and intra-articular injection of steroid were made to the 28 patients. RESULTS: The general success rate of puncture was 4/6 among the specimens of pelvis and was 96.4% (54/56) among the 28 patients. The level of needle insertion was 1.69 cm +/- 0.63 cm up the lower edge of the joint. The obtainment rate of biopsy specimen was 88.5% (46/54) for the cases punctured successfully. The positive rate of pathological examination was 91.7% (22/24). Marked inflammatory changes were found in the biopsy specimens from AS patients and early inflammatory changes were found in the biopsy specimens from uSpA patients. The immediate effective rate of intra-articular steroid injection was 78.6% (22/28). No complication and side effect was found. CONCLUSION: CT-guided percutaneous puncture is an effective and safe guided method for biopsy and intra-articular injection of sacroiliac joint. The proper level of puncture is by the juncture of the middle 1/3 and lower 1/3 of sacroiliac joint. Needle biopsy helps early diagnosis of AS for patients with uSpA. Intra-articular injection is an effective supplementary therapy for AS and uSpA patients.
MRI of the sacroiliac joints in patients with moderate to severe ankylosing spondylitis.
OBJECTIVE: The objectives of our study were to evaluate whether MRI findings of the sacroiliac joints are able to distinguish between active and inactive disease in patients with established ankylosing spondylitis and to determine whether these findings correlate with markers of clinical activity, disease duration, severity, and degree of radiographic damage. MATERIALS AND METHODS: Eighteen patients with symptomatic moderate to severe ankylosing spondylitis were evaluated. MRI of the sacroiliac joint (1.5 T) was performed using fat-saturated T2-weighted, T1-weighted, STIR, and fat-saturated contrast-enhanced T1-weighted sequences. The sacroiliac joints were evaluated by two radiologists for enhancement, subchondral bone marrow edema, erosions, and subchondral fatty marrow infiltration. Findings on MRI were analyzed for correlation with multiple clinical characteristics and measures of disease activity, including radiographic scoring. RESULTS: In 17 patients, MRI showed abnormal findings of the sacroiliac joint. Ten patients showed active disease on MRI as measured by abnormal enhancement and subchondral bone marrow edema. Disease activity detected using MRI correlated in a positive fashion with only C-reactive protein (CRP) level. There was no correlation with the other measures of disease activity or with disease duration. In 14 patients, fatty subchondral bone marrow was detected on MRI. These changes were seen in patients with active and chronic disease and correlated with higher radiographic scores but not with disease duration or markers of disease activity. CONCLUSION: Contrast-enhanced MRI of the sacroiliac joint is sensitive in depicting sacroiliitis in patients with established ankylosing spondylitis. Subchondral edema and enhancement correlate with high CRP levels. Subchondral fatty bone marrow changes were seen in both active and chronic sacroiliitis and are correlated with higher radiographic scores; these changes may be a marker of more advanced disease.
Is the acquisition of a separate view of the sacroiliac joints in the prone position justified in patients with back pain?
One hundred consecutive patients in whom radiographs of the sacroiliac joints had been requested concurrently with radiographs of the lumbar spine and/or pelvis were reviewed to ascertain the diagnostic value of the sacroiliac radiograph. In 92 patients, radiographs of the lumbar spine or pelvis provided complete visualization of the sacroiliac joints, 81 of which were judged normal, six abnormal, and five equivocal. Review of the specific sacroiliac radiographs confirmed the six abnormal cases, and resulted in one equivocal case being judged abnormal. In no case did the sacroiliac joint radiograph result in a normal diagnosis being changed to abnormal. Where the sacroiliac joints appear normal on a lumbar spine or pelvic radiograph, there is no diagnostic benefit, and a considerable radiation penalty, from the performance of additional radiographs specific to those joints.
Which morphology of dry bone articular surfaces suggests so-called fibrous ankylosis in the elderly human sacroiliac joint?
Usually, joint degeneration with aging results in articular cartilage defects, which results in bony ankylosis. However, the sacroiliac articular cartilage is maintained even in the elderly and the fibrous tissues make so-called 'fibrous ankylosis'. Macroscopically and histologically, we observed two sacroiliac joints obtained from one young cadaver as well as 23 sacroiliac joints from 23 elderly cadavers. Each joint was divided into two pieces along the long axis: one half was processed for routine histology after decalcification, whereas the other half was macerated to provide a dry bone specimen. The articular cartilage consistently contained abundant fibers and some of the fibers connected to tight intra-articular fiber bands. Fiber insertion into the thin subchondral bone displayed a tidemark in a spotty manner. Thus, the calcified fibrocartilage seemed to be present and seemed to provide fine granularity on the dry bone specimen. The joint cavity was sometimes closed with fibrocartilage-like tissues: we termed this complete fibrous ankylosis. The dry bone specimen corresponding to complete fibrous ankylosis exhibited significant microporosity and granularity because of fragmented subchondral bone. Moreover, bony ankylosis along the sacroiliac joint margin also contained fibrocartilage-like tissues. Therefore, complete fibrous ankylosis is also likely to be the preliminary step to bony ankylosis in the entire joint area. Consequently, microporosity with granularity seemed to be the most critical anthropological characteristic for estimation of sacroiliac joint movability.
Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part I: Asymptomatic volunteers.
STUDY DESIGN: Pain pattern mapping of the sacroiliac joint in asymptomatic volunteers was investigated. Prospective evaluation of 10 volunteers who received sacroiliac joint injections was performed. The injections consisted of contrast material followed by Xylocaine. OBJECTIVES: To determine the pain referral pattern of the sacroiliac joint in asymptomatic individuals. SUMMARY OF BACKGROUND DATA: All 10 individuals experienced discomfort upon initial injection, with the most significant sensation felt directly around the injection site. Subsequent sensory examination revealed an area of hypesthesia running caudally from the posterior superior iliac spine. METHODS: Volunteers were asked to describe the nature and location of the sensation upon sacroiliac injection. Sensory examination immediately followed the injection to determine referral patterns. RESULTS: Sensory examination immediately after sacroiliac injection revealed an area of buttock hypesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This area of hypesthesia corresponded to the area of maximal pain noted upon injection. CONCLUSION: A pain referral map was successfully generated using provocative injections into the right sacroiliac joint in asymptomatic volunteers.
Origin and pathway of sensory nerve fibers to the ventral and dorsal sides of the sacroiliac joint in rats.
The purpose of this study is to clarify sensory innervation in the ventral and dorsal sides of the sacroiliac joint. Fluoro-gold, a neural tracer, was injected into the left sacroiliac joint of adult rats from the dorsal side after denervation of the dorsal side, and the bilateral dorsal root ganglia (DRGs) from T13 to S4 were examined by fluorescence microscopy five days after injection. In another rat group, the DRGs were examined using the same methods after injection of fluoro-gold from the ventral side. In the case of dorsal denervation (ventral nerve supply), labeled neurons were mainly located in the ipsilateral DRGs from L1 to S2. On the other hand, in the case of ventral denervation (dorsal nerve supply), labeled neurons were noted in the ipsilateral DRGs from L4 to S2. The sacroiliac joint in rats is innervated differently on the ventral and dorsal sides: the sensory nerve fibers to the dorsal side of the sacroiliac joint were derived from the DRGs of lower lumbar and sacral levels (from L4 to S2); and those to the ventral side from the DRGs of upper lumbar, lower lumbar, and sacral levels (from L1 to S2).
The accessory sacroiliac joint: a common anatomic variant.
We identified the accessory sacroiliac joint on 13 (13%) of 100 CT scans of the pelvis and in nine (16%) of 56 dried skeletons. The joint is situated between the medial aspect of the posterior superior iliac spine and a rudimentary transverse tuberosity just lateral to the second sacral foramen. Some joints are true diarthrodial joints and are present at birth, but more commonly they are acquired fibrocartilaginous joints that result from the stress of weight-bearing. Our experience suggests that the accessory sacroiliac joint is not rare and that it is visible on CT scans in many patients.
Role of abdominal CT, when available in patients' records, in the evaluation of degenerative changes of the sacroiliac joints.
To determine the role of abdominal computed tomography (CT) that had been performed for other reasons, in the evaluation of degenerative changes of the sacroiliac joints, the authors performed a retrospective review of the sacroiliac joints of 100 patients, all of whom had an abdominal CT scan and a plain abdominal and/or pelvic roentgenogram in their files. The results indicate that, when available in the patient's record, abdominal CT scans provide substantial additional information in the evaluation of degenerative changes of the sacroiliac joints at no extra cost. The authors' results also suggest that after the age of 55, the patient's age does not seem to influence the extent of sacroiliac joint narrowing, which does appear to be affected by the presence of coexisting diffuse idiopathic skeletal hyperostosis.
A posterior approach for inspection of reduction of sacroiliac joint disruption.
This anatomic study was undertaken to describe a new posterior approach enabling direct inspection of reduction of sacroiliac joint disruption (SIJD), and guidance of iliosacral screw placement. The reduction of SIJD is usually monitored by inspection of the opposing sacrum and ilium at the posterior margin of the greater sciatic notch and there is a relative lack of information concerning inspection of reduction of SIJD from the posterosuperior aspect of the sacroiliac joint surface. Ten cadavers were dissected to determine the possibility of inspecting reduction of SIJD from the posterosuperior aspect of the sacroiliac joint by means of a posterior approach which passed immediately lateral to the deep back muscles and the fifth lumbar transverse process. The results indicated that the posterosuperior aspect of the sacroiliac joint surface and sacral ala can be directly palpated or visualised. This approach facilitates improved access for inspection of reduction of SIJD and guidance of iliosacral screw placement.
Value of quantitative radionuclide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain.
A prospective study was performed to compare the results of quantitative radionuclide bone scanning with those of sacroiliac joint anesthetic block in patients with unilateral low back pain. Thirty-four subjects, forming the control group, underwent quantitative radionuclide bone scanning of the sacroiliac joints. The normal values in sacroiliac uptake difference were taken to be between -1.7% and +6.2%. Thirty-two patients with chronic unilateral low back pain underwent sacroiliac bone scanning and sacroiliac joint block. Six of the seven patients with increased uptake > 6.2% on the painful side had at least 75% pain reduction in response to the block. The sensitivity, specificity, and positive and negative predictive values of the quantitative bone scanning in the unilateral mechanical sacroiliac joint syndrome were 46.1%, 89.5%, 85.7%, and 72%, respectively.
Sacroiliac joint manipulation decreases the H-reflex.
Joint manipulation is widely utilized clinically to decrease pain and increase the range of motion of joints displaying limited mobility. Evidence of efficacy is based on subjective reports of symptom improvement as well as on the results of clinical trials. Experiments were designed to determine whether or not sacroiliac joint manipulation affects the amplitude of the Hoffman (H) reflex. Surface EMG recordings of the reflex response to electrical stimulation of the tibial nerve in the popliteal fossa were made from the soleus muscle. The averaged amplitudes of H-reflexes were compared on both legs before and after either sacroiliac joint manipulation or a sham procedure. H-reflex amplitude was significantly decreased (12.9%) in the ipsilateral leg (p < 0.001) following a sacroiliac joint manipulation while there was no significant alteration following the sham intervention. There was no significant alteration in reflex excitability in the contralateral leg to the sacroiliac joint manipulation. To further investigate the mechanism of these reflex alterations, the local anaesthetic cream EMLA (Astra Pharmaceuticals) was applied to the skin overlying the sacroiliac joint and the experiments were repeated on a different group of subjects. This was intended to determine if excitation of cutaneous afferents was responsible for the reflex excitability changes. There was still a significant decrease in reflex excitability (10.6%) following sacroiliac joint manipulation (p < 0.001). These findings indicate that joint manipulation exerts physiological effects on the central nervous system, probably at the segmental level. The fact that the changes persisted in the presence of cutaneous anaesthesia suggests that the reflex changes are likely to be mediated by joint and/or muscle afferents.
[Effect of oblique needling after equal division and positioning of anatomic points on acute sacroiliac joint injury assessed with infrared thermography].
OBJECTIVE: To evaluate the clinical therapeutic effect of oblique needling after equal division and positioning of anatomic points on acute sacroiliac joint injury assessed with infrared thermography. METHODS: A total of 150 patients with acute sacroiliac joint injury were randomly divided into an oblique needling group, a perpendicular needling group, and an acupressure+tuina group, with 50 cases in each group. After equal division and positioning of anatomic points at sacroiliac joints, the oblique needling, perpendicular needling and acupressure+tuina techniques of acupuncture were operated in three groups, respectively. The treatment was administered once daily, 5 sessions per week; 10 sessions constituted one treatment course, with a total of one course required in the trial. Before and after treatment, the scores of Japanese Orthopaedic Association (JOA), visual analogue scale (VAS) of pain, and World Health Organization quality of life-BREF (WHO QOL-BREF), as well as the average temperature of the lumbosacral region were observed in each group. Additionally, the correlation between the average lumbosacral temperature and efficacy indicators was explored. RESULTS: After treatment, the scores of JOA, WHO QOL-BREF in the oblique needling group were higher (P<0.01, P<0.001), and the VAS score was lower (P<0.01, P<0.001) than those in the perpendicular needling group and the acupressure+tuina group; and the average temperature of the affected lumbosacral region in the oblique needling group was lower compared with that in the other two groups (P<0.001). After treatment, the average lumbosacral temperature of the affected side showed a negative correlation with the JOA score in each group (r=-0.645, -0.482, -0.809, P<0.001). CONCLUSION: Following equal division and positioning of anatomic points, the therapeutic effect of acupuncture with oblique needling is superior to the perpendicular needling and acupressure+tuina on acute sacroiliac joint injury. The average temperature of the affected lumbosacral region is correlated with the severity of lumbosacral dysfunction after treatment.