Bilateral Sacroiliac Research Articles

Evaluation of the true lateral fluoroscopic projection for the relation of the S1 recess/foramen to safe corridors in transiliac-transsacral screw placement in human cadaveric pelves

IntroductionPercutaneous screw fixation is a widely used treatment for posterior pelvic ring injuries. Transiliac-transsacral screw fixation has demonstrated superior biomechanical properties over bilateral sacroiliac screws, particularly in the minimally displaced bilateral sacral fractures. Screw placement under fluoroscopic control is still common, while CT navigation is gaining popularity. However, the accurate placement of screws within a safe zone is essential to avoid neurovascular complications.MethodsAn anatomical study using human cadaveric pelves was conducted to assess radiological landmarks and determine a safe zone in relation to the S1 recess/foramen for transiliac-transsacral screw placement.ResultsFourteen pelves were evaluated. Ten pelves were classified as having a satisfactory corridor for screw placement, while four were deemed to have an impossible or high-risk corridor. A safe zone was defined based on the diagonal bisector of the S1 vertebral body, ICD and anterior cortex.DiscussionThe study findings suggest that lateral fluoroscopic projection can determine a safe entry point for screw placement. Understanding the anatomy and landmarks on lateral fluoroscopic images is crucial for successful screw placement and avoiding complications.ConclusionThe S1 body diagonal is consistently located anterior to the S1 recess in lateral fluoroscopic projections, providing a potential safe corridor for transiliac-transsacral screw placement at the S1 level in nondysmorphic pelves. Further research is needed to confirm these findings with CT imaging and evaluate the technical feasibility of screw placement.

Diabetic Patients with Chronic Pain After Lumbar Surgery Experienced Fewer Analgesic Effects of Laser Therapy

Background: Recent studies indicate that several factors are associated with different responses to pain relief and alteration in reactions to non-pharmacological modalities and pharmacological medications. Biological processes appear to be contributory factors to these outcomes. Objectives: The purpose of this study is to examine how laser therapy can help as a conservative approach for chronic pain after back surgery in patients with diabetes mellitus (DM). Methods: This research included 22 diabetic patients and 26 non-diabetic patients with chronic pain after back surgery. Points of laser irradiation were determined by an ultrasound examination, specifically targeting bilateral sacroiliac joints, L2 - L3 through L5 - S1 facet joints, and the area of cluneal nerves. The duration of laser therapy was three weeks, with treatment sessions using an 808 nm diode laser at a power of 0.5W, performed every other day. Individuals were evaluated using the Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) before and after treatment, and again six months later. Results: Oswestry Disability Index and Numeric Rating Scale scores decreased significantly after treatment and six months later. Furthermore, analysis of the data showed that diabetic patients experienced less therapeutic effect during and after laser therapy sessions. Conclusions: Although laser therapy can reduce pain, diabetic patients reported a lower level of effectiveness compared to non-diabetic patients.

Biomechanical assessment and comparison of fixation methods for bilateral sacroiliac joint luxation in 3D-printed feline pelvic bone models.

Bilateral sacroiliac joint luxation, a condition primarily observed in cats, can significantly impact their quality of life. This study aimed to compare a control with three distinct fixation methods to identify the most robust fixation method capable of withstanding significant tensile stress. Twenty pelvic bone models of cats were made using a 3D printer with polylactic acid plastic. Each model was assembled by cutting the sacroiliac joints and pelvic girdle symphysis with a handsaw, then bonded with cyanoacrylate glue. 3D feline pelvic bone models were categorized into four significant groups, each consisting of five models. The study discovered that the three groups used distinct fixation methods: Two lag screws (DS), K-wires at the ilium wing and sacroiliac joints (TK), and K-wires at the sacroiliac joints (DK). The final group, not fixed, was the control. The results were characterized further through a mechanical compression force test using a universal testing machine. The most robust method at the sacroiliac joints, the DK technique, sustained a maximum force of up to 183.86 N while maintaining the correct bone alignment. The fixation method is more accessible and faster to implement in comparison to the DS method. The DK group exhibited the greatest maximum load capacity among all groups. Sacroiliac joint luxation treatment can effectively be addressed using the K-wires fixation method. However, the DK need space of sacral body same as DS for fixation. Further clinical study should be performed.

Brucellosis (Malta Fever) In Pregnancy and Childbirth: A Case Report

Background: Brucellosis is a multi-organ infectious disease that can affect people of all ages. Systemic symptoms of brucellosis include back pain, headache, fatigue, weakness, general body pain, fever and chills, anorexia, muscle pain, sweating, weight loss, joint pain, cough, neurological symptoms, abdominal pain, diarrhea, and constipation. In this report, the case of a pregnant woman suffering from Malta fever with severe signs that she could not walk is reported. Case Presentation: In this paper, the case of a 28-year-old G3P2 female patient (third pregnancy, two normal deliveries) with 37 weeks of pregnancy and a history of brucellosis in the last two months, being under painkiller treatment, and who has been unable to walk (sacroiliitis) for two weeks, has been reported. Previously, treatment with gentamicin 2 times a day for 6 days was started, and in May 2022, the patient was admitted to Imam Reza Hospital in Mashhad by ambulance. After consultation with an infectious disease specialist, the patient received gentamicin IV QID at a dose of 5 mg/kg, ceftriaxone BID at a dose of 1 mg and IV, and rifampin QID at a dose of 600 mg and PO. She was subjected to CBC differential test twice a week, and BUN and CR assessments were performed every other day. She has received acetaminophen 500 mg PO and Q 6 hrs in the hospital during hospitalization. Radiography of the pelvis was done to check the bilateral sacroiliac joint; it has been found to be normal and no evidence of joint effusion has been seen. After a week of hospitalization and observation in the hospital, vaginal delivery was performed without any problems and she gave birth to a baby boy with an Apgar score of 9-10. Conclusion: Clinical manifestations of brucellosis in pregnant women are weakness, arthralgia, fever, fatigue, excessive night sweats, anorexia, muscle pain, chills, depression, weight loss, headache, and back pain. The most common symptoms are fever, hepatomegaly, spleen involvement, joint complications, and obstetric symptoms, including vaginal bleeding, postpartum endometritis, pelvic or groin pain, premature rupture of membranes, and chorioamnionitis. Rifampicin and trimethoprim- sulfamethoxazole for 6 to 8 weeks constitute the most common and recommended treatment.

Disseminated staphylococcal infection (involving bilateral sacroiliac joints and sternoclavicular joint) in a hemodialysis patient

Pyogenic sacroiliitis is a rare infection and has not been reported in a hemodialysis patient. We report a case of disseminated staphylococcal infection with bilateral sacroiliitis, sternoclavicular arthritis and right sternocleidomastoid abscess in a dialysis patient. Prompt diagnosis and institution of antibiotics resulted in complete recovery.

Sacroiliitis in inflammatory bowel disease on abdominal computed tomography: prevalence, misses, and associated factors

Objective To evaluate the prevalence and rate of a missed diagnosis of sacroiliitis on abdominal computed tomography (CT) in patients with inflammatory bowel disease (IBD). Factors associated with sacroiliitis were also assessed. Method This retrospective study included 210 patients with IBD (mean age 31.1 years) who underwent abdominal CT. Based on a validated abdominal CT scoring tool, bilateral sacroiliac (SI) joints on abdominal CT in the whole study population were retrospectively reviewed. Subsequently, patients were classified into the ‘patients with sacroiliitis’ group and the ‘patients without sacroiliitis’ group. Univariate and multivariate regression analyses were used to clarify the factors associated with sacroiliitis. Results Sacroiliitis was identified in 26 out of 210 patients (12.4%). However, sacroiliitis was recognized on the primary reading in only five of these 26 patients (19.2%) and was missed on the initial report in the remaining 21 patients (80.8%). Among the 21 patients, 20 (95.2%) were finally diagnosed with axial spondyloarthritis (axSpA). There was a higher prevalence of female sex (p = 0.04), upper gastrointestinal involvement (p = 0.04), and back pain (p < 0.01) in patients with sacroiliitis than in those without sacroiliitis. However, on multivariate analysis, back pain was the only factor associated with sacroiliitis (p = 0.01). Conclusion Physicians should carefully evaluate SI joints on abdominal CT in patients with IBD to enable early detection of sacroiliitis, potentially leading to an early diagnosis of axSpA. In addition, if patients with IBD present with back pain, the possibility of sacroiliitis should be considered.

E033 Beyond the surface: artful imitation of Hodgkin’s lymphoma as axial spondyloarthritis

Abstract Background/Aims Rheumatic conditions may be associated with different neoplastic-diseases. Sacroiliitis is not defined as a paraneoplastic syndrome in the literature and considered as the direct involvement of the sacral/iliac bones or sacroiliac joints. There are only few reported cases of back pain and sacroiliac bones/joint involvement as an initial presentation of Hodgkin’s lymphoma. Methods An 18 year boy presented with low back pain of 18 months duration. He had significant morning stiffness and reported good response with non-steroidal anti-inflammatory drugs. He also complained of intermittent fever, insignificant weight loss and occasional dry cough. He denied peripheral joint pain, skin lesions, urethritis, conjunctivitis, uveitis and gastrointestinal disease. The family history was negative for spondyloarthritis (SpA) and neoplastic diseases. He was given empirical anti-tubercular drugs for 6 months with no significant improvement. He was evaluated by physician and rheumatologist elsewhere and treated as SpA in view of inflammatory low back pain, very high inflammatory markers and sacroiliac bones/joint involvement on MRI. The patient tested negative for HLA-B27 (PCR). He was initially started on sulfasalazine, however there was no induction of remission and later switched to tofacitinib since last 4 months. General examination was unremarkable. Bilateral sacroiliac compression and FABER tests were the only positive findings on systemic examination. Results There was leukocytosis (14,100/mm3) with predominant polymorphs, hemoglobin was 9.8g/dl, thrombocytosis (5.4 lakhs/mm3), serum CRP was markedly raised (123mg/L) and ESR was 57mm/hr. His workup for infectious diseases and rheumatic diseases were unremarkable. Repeat MRI according to SpA protocol showed altered marrow signal intensity in lumbar and sacral vertebral bodies and enhancing lytic lesion in right iliac bone till sacroiliac joint. PET-CT revealed multifocal FDG avid mixed lytic sclerotic lesions disseminated in the axial as well as appendicular skeleton with FDG avid sub-centimetric bilateral neck, supraclavicular, axillary, mediastinal and bilateral external/internal iliac and inguinal lymph nodes. Excision biopsy of right supra-clavicular node showed classical Hodgkin lymphoma (CD15 and CD30+ve). He was referred to the haematology clinic for further management. Bone marrow examination was suggestive of tumour infiltration. He received chemotherapy according to the protocol. He is under haematologist care and on a regular follow up with significant improvement in symptoms along with normal inflammatory markers. Conclusion There may be involvement of sacral/ iliac bones and sacroiliac joints by various malignancies including Hodgkin’s lymphoma. Morning stiffness, good response to NSAIDs and MRI findings may delay the diagnosis of primary malignancy, however we should keep a differential of lymphoproliferative disorders as in the aforementioned case and perform other diagnostic modalities. When the expected clinical response is not achieved, the physician must think of a malignancy in cases with persistently high inflammatory markers and marked constitutional symptoms. Disclosure P. Khatri: None. J. Yadavalli: None. K. Shivam: None. R. Gupta: None.

Bilateral Sacroiliac Joint Dislocation, Discussion and Surgical Strategies: A Case Report.

A 16-year-old male patient presented with isolated bilateral sacroiliac (SI) joint dislocation. In this report, we discuss the presentation and focus on strategies for operative reduction and fixation for this rare injury. In conclusion, we present a case of a bilateral ligamentous SI joint dislocation in an adolescent. The patient was reduced in the supine position with a sacral bump and bilateral traction with direct and indirect reduction aids inserted through a lateral window. Bilateral SI screws stabilized the pelvis, facilitating uncomplicated healing.

Outcomes for 15 cats with bilateral sacroiliac luxation treated with transiliosacral toggle suture repair.

To report a surgical technique and outcomes of transiliosacral toggle suture repair to treat feline bilateral sacroiliac luxation/fracture (SILF). Retrospective study. Fifteen client-owned cats. The medical records of cats with bilateral SILF treated using a transiliosacral toggle suture repair were reviewed. Short- and medium-term outcomes were assessed through standard postoperative clinical evaluation and radiographs, including measurements of angle of deviation (AoD), percentage of reduction (PoR), and pelvic canal width ratio (PCWR). Long-term functional follow up was obtained from a questionnaire derived from the Feline Musculoskeletal Pain Index (FMPI). Fifteen cats were enrolled retrospectively, among which 13 survived to discharge. One minor wound complication, treated by secondary intention healing, was encountered. No major complication was reported. Immediately postoperatively, the mean absolute PoR values were 88.1 ± 11.2% and 91 ± 11.6% on the right and left side, respectively. The mean absolute AoD was 3.1 ± 2.8°, and the mean PCWR was 1.24 ± 0.08. The medium-term radiographic follow up at a median of 205 (71-682) days postsurgery revealed the good stability of the repair. Excellent functional outcomes were identified upon the analysis of 12 long-term questionnaires at a median of 365 (119-798) days postsurgery. Anatomic reduction was satisfactory and comparable with previously described techniques with good implant placement documented. Functional outcomes based on FMPI-derived questionnaires were good to excellent in our population. Transiliosacral toggle suture stabilization of bilateral SILF was associated with good outcomes in cats. Further studies are required to compare biomechanical properties and outcomes between this technique and previously described transiliosacral stabilization.

Bilateral sacroiliac joint fusion in long constructs using self-harvesting porous S2-alar iliac screws with an integrated tulip: technical considerations and early clinical and radiographic experience.

The incidence of sacroiliac joint (SIJ) dysfunction after lumbosacral fusion is high. Upfront bilateral SIJ fusion using novel fenestrated self-harvesting porous S2-alar iliac (S2AI) screws could reduce the incidence of SIJ dysfunction and need for subsequent SIJ fusion. In this study, the authors report their early clinical and radiographic results of SIJ fusion using this novel screw. The authors began using self-harvesting porous screws in July 2022. This is a retrospective review of consecutive patients at a single institution who underwent long thoracolumbar surgery with extension to the pelvis using this porous screw. Radiographic parameters of regional and global alignment were collected preoperatively and at the time of last follow-up. The incidence of intraoperative complications and need for revision were collected. The incidences of mechanical complications, including screw breakage, implant loosening/pullout, and screw cap dislocation at the time of last follow-up were also collected. Ten patients with a mean age of 67 years were included, 6 of whom were male. Seven patients had a thoracolumbar construct with extension to the pelvis. Three patients had upper instrumented vertebrae at the proximal lumbar spine. Intraoperative breach was not encountered in any of the patients (0%). Postoperatively, 1 patient (10%) had screw breakage at the neck of the tulip of the modified iliac screw discovered at routine follow-up without clinical sequalae. Use of self-harvesting porous S2AI screws incorporated into long thoracolumbar constructs was safe and feasible, demanding unique technical considerations. Long-term clinical and radiographic follow-up with a large patient cohort is necessary to determine their durability and efficacy to achieve SIJ arthrodesis and prevent SIJ dysfunction.

Successful Management of a Polytrauma with Open Complex Pelvic Fracture

Abstract Pelvic fractures frequently result from powerful external forces and carry a high risk of concurrent injuries. In these patients, fatalities are often caused by associated injuries. Pelvic fractures cause substantial morbidity and can lead to long-term impairment in physical functioning, as well as difficulties with daily activities and negative psychological health. Surgical intervention is necessary for treating unstable pelvic fractures, which may involve isolated posterior or combined posterior and anterior fixation utilizing screws and plates to restore anatomical alignment and promote natural healing. A 19-year-old female road traffic accident victim in hemorrhagic shock was hemodynamically stabilized and investigated for associated injuries. She was diagnosed with bilateral sacroiliac joint dislocations, bilateral superior and inferior pubic rami fractures and crescent fracture of the right iliac wing, Grade III liver injury, Grade III splenic infarction and hemoperitoneum, lung contusion, and bilateral hemothorax with multiple rib fractures, fracture of the transverse process of L4 and L5 vertebrae. A secondary survey revealed a right sciatic nerve injury, admitted to intensive care and managed by a multidisciplinary approach. Abdomen and thorax injuries were managed conservatively, and meanwhile, the pelvic fracture was stabilized by a damage control protocol, and definitive surgical intervention includes iliac crest wound debridement and pelvic ring open reduction and internal fixation by the Modified Stoppa approach. Abdomen and chest injuries were managed conservatively. Monthly regular follow-up was the first 6 months, was able to walk and sit comfortably at the end of 4 months, and was able to resume her normal routine work and job at 6 months without any pain and limitation of movements. It is essential to promptly identify and assess the injuries and implement appropriate perioperative management by a multidisciplinary team. Temporary stabilization of fracture followed by the management of associated injuries and delayed definite fixation yields the best result in polytrauma patients with pelvic fracture.

Tuberculosis of bilateral sacroiliac joints with bilateral psoas abscess: an unusual presentation

Infectious diseases usually affect the sacroiliac joint unilaterally. Out of all tuberculosis cases, bone tuberculosis is reported in 3-5% of cases. The purpose of this case report is to draw attention to the diagnostic challenge of bilateral tuberculous sacroiliitis with psoas abscess, as this clinical picture is very rare. Tuberculosis of the sacroiliac joint is often missed due to vague symptoms. More often, patients are examined in the supine position, thereby overlooking the sacroiliac joint. Involvement of the sacroiliac joint is rare, but exact numbers are not available. Our case report shows a complication of skeletal Tb that a psoas abscess may develop, causing nonspecific symptoms.

ID: 218213 Successful Spinal Cord Stimulator Trial in the Visually Impaired

A 72-year-old gentleman was referred to the chronic pain clinic after being deemed a non-surgical candidate for a multilevel lumbar fusion per orthopedic spine surgery. His past medical history is notable for coronary artery disease, diabetes mellitus, obstructive sleep apnea, and blindness in bilateral eyes. The patient has been suffering for years from lower back pain, without red flag symptoms, and had failed multiple treatment modalities, including bilateral sacroiliac joint injections, L3-4, L4-5, and L5-S1 facet blocks. Although he is capable of performing most of his activities of daily living, his blindness unfortunately has been a barrier to both surgical interventions and pain management therapy. After consultation with a chronic pain physician, he was offered a spinal cord stimulator trial. With direct communication between the patient and the spinal cord stimulator company representative, a remote-less algorithm was able to be programmed that allowed for successful mapping of target nerves generating 80% efficacy in pain therapy. A thorough literature review demonstrated a lack of research focus in neuromodulation for patients with disabilities. With tailored guidance this patient achieved adequate pain relief which significantly improved his quality of life during the trial phase. The patient is determined to undergo a permanent spinal cord stimulator placement soon. This case report outlines a successful neuromodulation trial in a visually impaired patient. Ultimately, there is still work to be done to ensure advancements in pain medicine are accessible to all patients regardless of disabilities.

Success of the pain relief drug injections in management of the bertolloti syndrome: case report and review of the literature

Introduction: Low back pain accompanied by the lumbosacral transitional vertebra (LSTV) is called the Bertolotti syndrome. This report discussed a case treated with combined corticosteroid and local anesthetic injections based on the literature. Case report: A 35-year-old female patient was admitted to the hospital suffering from low back pain. On neurological exam, her left sacroiliac joint was painful on palpation. Her muscle strength was full, but the left patella reflex was hypoactive. X-ray images revealed “Castellvi Type IIa” LSTV on the left side; therefore, it was considered that the patient might have Bertolotti Syndrome. Because şhedid not accept surgical intervention, “betamethasone dipropionate+betamethasone sodium” and “bupivacaine hydrochloride” were injected into her bilateral sacroiliac joints, bilateral L3-4, and L4-5 facets, and left LSVT joint under fluoroscopy. Her low back pain vanished immediately after the procedure, and she was discharged from the hospital with a full recovery. With an interval of about six months, she was hospitalized 5 more times with complaints of recurrent low back pain, and at each hospitalization, "local anesthetic" (LA) alone or "local anesthetic+corticosteroid" (LA+S) combination was injected into the primary trigger zones. During long-term follow-up, she continued his daily life without any problems. Discussion: This case report showed that sequential LA and LA+S administrations could be curative for patients with Bertolotti syndrome who do not accept surgical treatment, or who cannot undergo surgical intervention. Thus, it was concluded that it would be beneficial to conduct studies with larger samples to obtain more precise information about this method.

Rare case of paget’s disease with co-existing features of ankylosing spondylitis

Introduction: Paget’s disease is an uncommon metabolic skeletal disorder characterized by increased osteoclast-mediated bone resorption & compensatory excessive osteoblastic activation. It is often an incidental finding & can also rarely co-exist with other disorders like ankylosing spondylitis.Materials & Methods: Observational type of case study using computed tomography (CT) and X-Ray. 80 years old male came with complaints of giddiness & fall & decreased speech output. CT scans showed intraventricular hemorrhage & patient was treated for the same. However, CT scans revealed features suggesting Paget’s disease with co-existing ankylosing spondylitis & a bone survey for whole body was done. Increased S. Alkaline Phosphatase (187 U/L) & low Calcium (7.5 mg/dl) was noted.Results: CT Brain showed mixed lytic sclerotic changes with widened diploic space & coarse trabeculae involving calvarium fully giving a cotton wool appearance. Spine imaging revealed, picture framing of some vertebrae, anterior & lateral syndesmophytic fusion giving a bamboo spine appearance & diffuse osteopenia with multiple sclerotic areas. X-Ray pelvis showed of Kohler tear drop & sclerosis with near complete fusion of bilateral sacroiliac joints. Conclusion: Paget disease of bone shows an abundance of patterns on imaging that are related to pathologic stage of disease. Recognition of imaging spectrum usually allows early diagnosis & differentiation of its complications, which helps guide therapy & improve patient management.

P32 Therapeutic dilemma due to gut complications with spondyloarthritis

Introduction/BackgroundTumor necrosis factor (TNF) inhibitor therapy is one of the primary modalities of treating spondyloarthritis. However, infections secondary to biologic use is a common complication. Clostridium difficile is a gut colonizer which may become pathogenic in the presence of dysbiosis and antibiotic use. Symptomatic clostridium difficile infection(CDI) due to adalimumab(ADA) use causing lymphocytic colitis(LC) is rarely reported. We present a case of axial plus peripheral spondyloarthritis on adalimumab who developed CDI and presented a therapy related dilemma.Description/MethodWe present a case of a 52-year-old lady who was diagnosed as HLAB27 positive axial spondyloarthritis with bilateral sacroiliitis on MRI bilateral sacroiliac joint in 2016. She failed two non-steroidal antinflammatory drugs (NSAID) with high disease activity scores(BASDAI 8.6, BASFI 6.2, Spinal VAS 9). She was eventually initiated on injection adalimumab in 2017. There was clinical improvement after 6 months of initiating ADA. Repeat MRI spine and SI joint showed resolution of inflammatory changes with adalimumab. Sulfasalazine was added in the treatment protocol due to peripheral arthralgia, however she developed a drug rash to it and it was stopped. In September 2021, she developed recurrent non-bloody watery diarrhoeal episodes. Adalimumab was stopped and she tested positive for Clostridium difficile on three occasions. She received multiple courses of vancomycin, fidoxamycin and metronidazole with partial resolution of diarrhoea. Adalimumab was rechallended in January 2022 since her disease activity was worsening in the absence of NSAID and biologic use. However, it was paused again due to worsening of diarrhoea. Gastroenterology conducted a Colonoscopy and biopsy of colonic polyps which showed increased number of intraepithelial lymphocytes with no thickening of subepithelial collagen plate suggestive of lymphocytic colitis (LC). It was postulated that CDI may have been the trigger for her LC. She has been started on local corticosteroid therapy(budesonide) for her LC. At this junction, we were faced with the decision of restarting adalimumab for her which may have been the original cause of her CDI.Discussion/ResultsWe present this case in view of a dilemma regarding which problem occurred first Did immunosuppression due to adalimumab lead to CDI? Literature is not suggestive of increased risk of CDI with adalimumab, especially in a non-inflammatory bowel disease (IBD) background. Was the lymphocytic colitis triggered by the CDI or was clostridium difficile just incidentally detected on a background of LC? There is a well documented associated of LC with autoimmune conditions and use of NSAIDs along with proton pump inhibitor is another trigger for it. TNF alpha inhibitor is one of the treatment modalities of refractory LC. Would it be appropriate to restart ADA for her since she responded well despite there being a risk of recurrence of a CDI? Finally, what is the role of gut dysbiosis in the role of CDI and LC in this situation. Presently, she is planned to be treated with local steroid therapy for her LC. ADA will be rechallenged once her gut has responded to the steroid course. In the event of her gut worsening on a rechallenge, she will be given a trial of Infliximab.Key learning points/ConclusionThe case highlights the crucial point of thinking of causes of diarrhea apart from well documented conditions of ulcerative colitis/Crohn’s disease in an immunosuppressed spondyloarthritis patient. A detailed stool examination including bacterial and parasitic examination is crucial in recurrent diarrhea. The threshold for colonoscopy should be low when episodes are refractory to treatment. The case-based conference gives us an opportunity to receive feedback regarding further management approaches in this case.

Can Bone Erosion in Axial Spondyloarthropathy be Detected by Ultrashort Echo Time Imaging? A Comparison With Computed Tomography in the Sacroiliac Joint.

Structural lesion evaluation in axial spondyloarthropathy (SpA) can improve accuracy of diagnosis. However, structural lesions (bone erosions) are difficult to be assessed using conventional MRI compared to computed tomography (CT). To evaluate the diagnostic performance of ultrashort echo time (UTE) for detecting bone erosion in axial SpA compared to T1WI and three-dimensional double-echo steady-state (3D DESS) imaging using CT as the reference standard. Retrospective. Fourteen patients (eight females, 57.1%) and 14 healthy controls (seven females, 50.0%) who underwent sacroiliac (SI) joint MRI and CT. 3 T; TSE T1WI, 3D DESS, 2D UTE. The bilateral SI joints were assessed for bone erosion. Three observers scored bone erosion for all three sequences of MRI. CT was used as the gold standard. Diagnostic confidence in axial SpA was measured based on a four-point confidence score. Correlation of erosion scores between CT and MRI were evaluated using Spearman's correlation test. Sensitivity, specificity, and positive-negative predictive values were calculated. Confidence scores were compared using the Wilcoxon sum rank test. Statistical significance was set at P < 0.05. Compared with erosion scores of CT, the correlation coefficients for each MRI sequence showed significant low-to-high positive correlations (0.39-0.72). UTE imaging showed the highest correlation coefficients for all observers (0.70, 0.72, and 0.67, respectively). The specificity of UTE imaging was equal or higher than those of T1WI and 3D DESS for all observers (0.86 vs. 0.71 vs. 0.57; 0.93 vs. 0.71 vs. 0.57; 0.79 vs. 0.79 vs. 0.43). All observers had the highest confidence in interpreting UTE imaging for detecting bone erosion among the three sequences (3.5, 3.4, and 3.3 for UTE; 3.1, 3.0, and 2.6 for T1WI; and 3.2, 2.7, and 2.4 for DESS). UTE imaging can detect bone erosions in patients with axial SpA and show higher specificity than conventional T1WI and 3D DESS. 4 TECHNICAL EFFICACY: Stage 2.

Bilateral open sacroiliac joint fusion during adult spinal deformity surgery using triangular titanium implants: technique description and presentation of 21 cases.

Pelvic fixation enhances long constructs during deformity surgery. Subsequent loosening of iliac screws and pain at the pelvis occur in as many as 29% of patients. Concomitant sacroiliac (SI) fusion may prevent potential pain and failure. The objective of this study was to describe a novel surgical technique and a single institution's experience using bilateral SI fusion during adult deformity surgery with S2-alar-iliac (S2AI) screws and triangular titanium rods (TTRs) placed with navigation. The authors reviewed open SI joint fusions with TTR performed between August 2019 and March 2020. All patients underwent lumbosacral fusion through a midline approach and bilateral S2AI pelvic fixation in the caudal teardrop, followed by TTR placement just proximal and cephalad to the S2AI screws using intraoperative CT imaging guidance. Twenty-one patients were identified who received 42 TTRs, ranging in size from 7.0 × 65 mm to 7.0 × 90 mm. Three TTRs (7%) were malpositioned intraoperatively, and each was successfully repositioned during index surgery without negative sequelae. All breaches occurred in a medial and cephalad direction into the pelvis. Incremental operative time for adding TTR averaged 8 minutes and 33 seconds per implant. Image-guided open SI joint fusion with TTR during lumbosacral fusion is technically feasible. The bony corridor for implant placement is narrower cephalad, and implants tend to deviate medially into the pelvis. Detection of malpositioned implant is aided with intraoperative CT, but this can be salvaged. A prospective randomized clinical trial is underway that will better inform the impact of this technique on patient outcomes.

CLINICAL RELEVANCE OF HETEROTOPIC OSSIFICATION OF HIP AND PELVIC BONES MUSCLES AND LIGAMENTS

Objectives: Heterotopic ossification is a formation of bone at unusual sites. The present study is aimed to observe the ossification of transverse acetabular ligament, obturator membrane and gluteus maximus muscle in hip bones and fibrous capsule of hip joints and ossification of sacrotuberous and sacrospinous ligaments, erector spinae aponeurosis in pelves, and bilateral ankylosis of sacroiliac joints. Methods: The study was performed on 128 dried human hip bones and six pelves of unidentified sex and age, in the Department of Anatomy. An ossified muscles and ligaments of hip and pelvic bones were observed and their measurements were recorded using Vernier calipers. Results: The present study showed the incidence of completely ossified transverse acetabular ligament in four hip bones, that is, 3.12% with completely ossified fibrous capsule of hip joint on the left side. The incidence of bony spurs along the margin of Obturator Foramen in four left hip bones is 6.25% along with the ossification of the gluteus maximus muscle on dorsal aspect of ilium. Out of six pelves, one pelvis presented complete ossification of erector spinae aponeurosis bilaterally on the dorsal surface of the sacrum along with complete ossification of sacrotuberous ligament of the right side and sacrospinous ligament of the left side along with bilateral ankylosed sacroiliac joint of pelvis. Conclusions: The knowledge of these abnormal ossifications of hip bones and pelvis may be of immense help to orthopedicians, surgeons, neurosurgeons, and radiologists to come to differential diagnosis and plan treatment accordingly.

The evaluation of bone marrow edema in sacroiliac joint in patients with ankylosing spondylitis using magnetic resonance imaging Dixon sequence

BackgroundBone marrow edema of the sacroiliac joint is the early imaging manifestation, an indicator of inflammatory activity of ankylosing spondylitis (AS) (Yang R, et. al. Medicine (Baltimore) 98:e14620, 2019).ObjectiveThe aim of the study was to investigate the value of magnetic resonance imaging (MRI) Dixon sequence in the diagnosis of marrow edema of the sacroiliac joint in patients with AS.MethodsForty-five patients with AS admitted in our hospital between November 2016 and February 2019 were selected retrospectively as the case group. Forty-five healthy subjects recruited between November 2016 and February 2019 served as the control group. Bath ankylosing spondylitis disease activity index (BASDAI), Bath ankylosing spondylitis functional index (BASFI), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were recorded after admission to the hospital. The Dixon sequence water-fat ratio of the iliac and sacral surfaces of the bilateral sacroiliac joints in the study group were compared with indicators above in order to find the correlation.ResultsThe water-fat ratio under the bilateral sacroiliac joints on Dixon sequence images in the case group was significantly higher than that in the healthy control group (P<0.05). The Dixon sequence water-fat ratio of the iliac and sacral surfaces of the bilateral sacroiliac joints in the study group were positively correlated with spinal arthritis research (SPARCC), BASFI and BASDAI score (all P < 0.05), but did not correlate with ESR and CRP.ConclusionThe water-fat ratio of magnetic resonance Dixon sequence can be used as a reference index to evaluate the degree of bone marrow edema in active stage of sacroiliac arthritis.