Left Sacroiliac Joint Research Articles

Myoepithelioma of soft tissue

Myoepitheliomas and mixed tumors involving deep subcutaneous and subfascial soft tissues of limb or limb girdle are rare lesions as against salivary lesions that are well established conditions. Here, we report a 22-year-old female who presented with painful hard swelling in the left gluteal region of 1(1/2) year duration. MRI showed a large ill-defined heterogeneous mass lesion measuring about 7-8 cm. in the left sacral region eroding the left sacroiliac region and left sacroiliac joint. With a clinical diagnosis of chondrosarcoma, the tumor with the surrounding tissue was resected in segments at surgery. Histomorphology revealed nests, sheets and cords of round to spindled cells with extensive squamous metaplasia in a myxoid to fibrous stroma. These cells extensively infiltrated muscle and bone. The tumor cells expressed immunoreactivity for cytokeratin (AE1/AE3) and S-100.

Iliac Stress Fracture in a Male Collegiate Track Athlete

Iliac Stress Fracture in a Male Collegiate Track Athlete

Ultrasound-Guided Sacroiliac Joint Injection Technique

We describe a case report and technique for using a portable ultrasound scanner and a curvilinear transducer (4-5MHz) (SonoSite Micromaxx SonoSite, Inc. 21919 30th Drive SE Bothwell W. A.) to guide sacroiliac joint (SIJ) injection. A 42-year-old male presented with chronic lower back pain centered on his left SIJ. His pain averaged 7 out of 10 (numerical rating scale). For the ultrasound-guided SIJ injection the patient was placed in the prone position. The ultrasound transducer was oriented in a transverse orientation at the level of the sacral hiatus. Here the sacral cornuae were identified. Moving the transducer laterally from here, the lateral edge of the sacrum was identified. This bony edge was followed in a cephalad direction with the transducer maintained in a transverse orientation. A second bony contour, the ileum, was identified. The cleft between both bony contours represented the sacroiliac joint. This was found at 4.5 cm depth. Real-time imaging was used to direct a 22G spinal needle into the SIJ, where solution was injected under direct vision. The patient's pain intensity decreased to a 2 out of 10 (numerical rating scale). Function improved and the patient was able to return to work. These improvements were maintained at 16 weeks. Ultrasound guidance does not expose patients and personnel to radiation and is readily accessible. Ultrasound-guided SIJ injections may have particular applications in the management of chronic lower back pain in certain clinical scenarios (e.g. pregnancy). Future studies to demonstrate efficacy and reproducibility are needed.

Primary multifocal osseous Hodgkin's lymphoma

BackgroundHodgkin's disease (HD) most commonly presents with progressive painless enlargement of peripheral lymph nodes, especially around the cervical region. A few children have systemic symptoms and weight loss. At the time of diagnosis, osseous involvement is uncommonCase presentationA case is described of Primary Multifocal Osseous Hodgkin's Lymphoma in a seven-year-old boy. He presented with a painful swelling in the sternum, and further investigations revealed deposits in his L1 vertebra, the left sacro-iliac joint and the right acetabulum.ConclusionThe clinical, radiological and histological features of this disease can mimic other medical conditions, including Tuberculosis, making the diagnosis difficult and often leading to delays in treatment. This is a very rare condition and we believe this to be the youngest reported case in the literature.

Erdheim‐Chester Disease With Cutaneous Features in an Indian Patient

A 60-year-old Indian woman presented with multiple asymptomatic, firm swellings over the face that had been progressively increasing for the past 3.5 years. She complained of dry cough and dyspnea of 2 years' duration, which was diagnosed as interstitial lung disease (ILD) based on chest radiography and high-resolution computed tomography. Apart from occasional backaches, the patient had no other systemic complaints. The results of the general physical examination was normal, with no lymphadenopathy. Cutaneous examination revealed multiple (5) firm, yellowish to skin-colored well-defined nodules with irregular margins ranging in size from 1 x 1 cm to 4 x 8 cm present over the left periorbital region and right jawline, with overlying telangiectasias on the skin (Figure 1). On examination of the chest, she had generalized rhonchi and crepts; the remainder of the systemic examination results were normal. Fine needle aspiration cytology from the nodule in the periorbital area revealed a dispersed population of spindle cells, numerous foam cells, and giant cells suggestive of xanthogranuloma. Histopathology from the nodule on the jawline showed abundant foamy histiocytes in the dermis with few multinucleated giant cells and lymphocytes (Figure 2). The foamy histiocytes were periodic acid-Schiff-positive. On immunohistochemistry, histiocytes were CD68-positive. Findings of routine investigations including hemogram, peripheral blood smear, and blood chemistry were normal. Radiography of the lumbosacral spine showed mixed osteolytic and osteosclerotic lesions involving L5-S1, the left sacroiliac joint, and the left iliac blade. Findings from radiography of the long bones and skull were normal. Contrast-enhanced computed tomographic scan of the abdomen and pelvis showed areas of osteolysis, with marginal sclerosis present bilaterally that involved the iliac blades and the right half of the sacrum. A methylene diphosphate bone scan revealed increased tracer uptake seen at the fifth lumbar vertebrae, bilateral sacroiliac bone, and left iliac bone and areas of photopenia in sacrum. Bone marrow aspiration from the sternum showed normal cells with a normal erythroid-to-myeloid ratio. Ultrasonographic B scanning of the eyes showed no retro-orbital involvement. Erdheim-Chester disease was diagnosed in this patient on the basis of diagnostic histopathology, radiologic features involving bones, and ILD and treatment with 40 mg oral prednisolone daily was started. Surgical debulking of her skin lesions was planned, but the patient refused due to her worsening ILD.

Open reduction and internal fixation of an unstable pelvic ring injury during pregnancy

We report a case of an unstable vertical shear injury of the pelvis in a pregnant patient with a viable foetus. The combination of skeletal traction and pelvic external fixation failed to achieve satisfactory reduction. Open reduction and internal fixation of the pubic symphysis and the left sacro-iliac joint were performed without affecting the pregnancy. At the one-year follow-up, the patient was completely asymptomatic. We feel that surgical treatment of pelvic fractures can be offered to pregnant patients after thoroughly considering the potential benefits and dangers of surgery to the patient and the foetus.

Acute Bacterial Sacroiliitis in an Adult: A Case Report and Review of the Literature

Bindal M, Krabak B. Acute bacterial sacroiliitis in an adult: a case report and review of the literature. Bacterial septic sacroiliitis is an uncommon diagnosis that occurs most frequently in children and young adults. Nonspecific physical examination findings often make it difficult to diagnose the condition, thus delaying appropriate treatment. We review the case of middle-aged woman with sacroiliac joint (SIJ) pain after a torsional injury. Radiographic films showed the pelvis and left lower extremity to be normal. Despite anti-inflammatory medications, analgesics, a corticosteroid injection, and physical therapy, her pain persisted. Laboratory data showed an elevated erythrocyte sedimentation rate and C-reactive protein; otherwise, tests were normal, including negative blood cultures. Magnetic resonance imaging (MRI) revealed a left posteroinferior SIJ effusion and computed tomography (CT) showed an effusion and irregularity in the left SIJ. An SIJ biopsy revealed inflammation suggestive of osteomyelitis. After a course of intravenous antibiotics, the symptoms completely resolved, thus supporting our diagnosis of bacterial sacroiliitis. Repeat MRI and CT confirmed the complete resolution of the sacroiliitis.

The Clinical Usefulness of Multidetector Computed Tomography of the Sacroiliac Joint for Evaluating Spondyloarthropathies

BackgroundsDue to the low sensitivity of plain radiography, the diagnosis of early stage ankylosing spondylitis (AS) is often difficult since many patients do not meet the radiographic criteria. The objective of our study was to investigate the diagnostic value of performing multidetector computed tomography (MDCT) of the sacroiliac (SI) joint in the evaluation of AS patients.MethodsThirty seven patients with definite or probable AS were evaluated. Plain radiography and MDCT imaging of the pelvis were performed for evaluating the SI joints. Two radiologists analyzed the images, and they graded the sacroiliitis on a scale of 0-4 according to the modified NY criteria. The clinical variables we analyzed included the disease duration, the treatment duration, the prescribed drugs, peripheral joint involvement, enthesopathy, the functional limitations and the BASDAI..ResultsMDCT detected more bilateral sacroiliitis as compared to the plain radiography (86.5% vs. 75.7%, respectively), and MDCT yielded a higher grade of disease in 32.4% (right SI joint) and 24.3% (left SI joint) of the patients. More patients satisfied the modified NY criteria with using MDCT as compared with that when using the plain radiography (81.1% vs. 54.1%, respectively, p=0.002).ConclusionsVisualization of the sacroiliac joint by MDCT provided a better diagnosis of AS, and especially during the early stage of the disease.

Lung Collapse After Induction of Anesthesia

A 27-YEAR-OLD black man was brought to the emergency department by ambulance after a motor vehicle accident. On arrival he was alert, responding appropriately, and had stable vital signs. Further investigations revealed left sacroiliac joint diastases and L2-5 transverse process fractures. He had a history of bronchial asthma for which he used an albuterol inhaler, and he had smoked for 9 years. He was admitted to the hospital, and an orthopedic consultation was obtained. The patient was treated with parenteral and oral opioids for pain, nebulized albuterol, and enoxaparin for deep vein thrombosis prophylaxis. He was scheduled for closed reduction and fixation of the left sacroiliac joint for the following day.

Acute Osteomyelitis Presenting As Cholestatic Jaundice

Cholestatic jaundice is a well recognised complication of late sepsis. However, cholestatic liver injury preceding sepsis is less well known and appreciated. This leads to delays in diagnosis in clinical practice and may result in significant morbidity and mortality. The development of a cholestatic blood picture should be considered as an early warning sign of an underlying infection, even in the absence of signs or symptoms of sepsis. This report describes the case of a previously healthy patient who presented with cholestatic jaundice. Staphylococcal osteomyelitis involving the left sacroiliac joint was diagnosed. Literature relating to cholestatic jaundice in sepsis is reviewed.

Magnetic resonance imaging changes of sacroiliac joints in patients with recent-onset inflammatory back pain: inter-reader reliability and prevalence of abnormalities

To study the inter-reader reliability of detecting abnormalities of sacroiliac (SI) joints in patients with recent-onset inflammatory back pain by magnetic resonance imaging (MRI), and to study the prevalence of inflammation and structural changes at various sites of the SI joints.Sixty-eight patients with inflammatory back pain (at least four of the five following criteria: symptom onset before age 40, insidious onset, morning stiffness, duration >3 months, improvement with exercise — or three out of five of these plus night pain) were included (38% male; mean age, 34.9 years [standard deviation 10.3]; 46% HLA-B27-positive; mean symptom duration, 18 months), with symptom duration <2 years. A MRI scan of the SI joints was made in the coronal plane with the following sequences: T1-weighted spin echo, short-tau inversion recovery, T2-weighted fast-spin echo with fat saturation, and T1-spin echo with fat saturation after the administration of gadolinium. Both SI joints were scored for inflammation (separately for subchondral bone and bone marrow, joint space, joint capsule, ligaments) as well as for structural changes (erosions, sclerosis, ankylosis), by two observers independently. Agreement between the two readers was analysed by concordance and discordance rates and by kappa statistics.Inflammation was present in 32 SI joints of 22 patients, most frequently located in bone marrow and/or subchondral bone (29 joints in 21 patients). Readers agreed on the presence of inflammation in 85% of the cases in the right SI joint and in 78% of the cases in the left SI joint. Structural changes on MRI were present in 11 patients. Ten of these 11 patients also showed signs of inflammation.Agreement on the presence or absence of inflammation and structural changes of SI joints by MRI was acceptable, and was sufficiently high to be useful in ascertaining inflammatory and structural changes due to sacroiliitis. About one-third of patients with recent-onset inflammatory back pain show inflammation, and about one-sixth show structural changes in at least one SI joint.

Anatomical consequences of “open-book” pelvic ring disruption. A cadaver experimental study

"Open-book" pelvic fractures associate a diastasis and/or a fracture of the pubic rami with a posterior pelvic disruption of the sacro-iliac joint. These uni or bilateral lesions are potentially lethal mainly due to associated injuries and massive pelvic hemorrhage. The most frequently injured arteries are parietal branch of the commune, internal or external arteries because of their proximity to the bone, the sacro-iliac joint and the inferior ligaments of the pelvis. The pelvic bone dislocation and the increase of pelvic volume facilitate blood effusion. The aim of this study was to determine, on a cadaver fracture model, the direct anatomical consequences of "open-book" pelvic fracture on the ilio-lumbar pedicle and the pelvic cavity volume. Bilateral open-book pelvic ring injuries were created in ten non-embalmed cadaver specimens by directly disrupting the pubic symphysis, the right and the left sacro-iliac joints. Pelvic volume was determined after total pelvic exenteration. Consequences of this fracture on vascular parietal network, nervous pelvic trunk and pelvic cavity volume were studied. The mean volume of the pelvic cavity after complete visceral exenteration was 872.5 cm(3) (extremes 580-756 cm(3)). The average increase of pelvic volume was 20.8% after 5 cm of pubic diastasis. In all cases, because of a transversal disposition of the ilio-lumbar pedicle with regard to the sacro-iliac joint, reproduction of the open-book fracture caused a venous dilaceration of the ilio-lumbar vein in 12 cases after 5 cm of pubic diastasis (12/20=60%). No arterial dilaceration was observed on the ilio-lumbar artery, but this artery was put in tension. Open-book fractures create an increase of pelvic volume that facilitates blood diffusion from parietal pelvic vascular network. Ilio-lumbar pedicle seems to be very vulnerable in this type of fracture because of its relations to the sacro-iliac joint and its transversal disposition with regard to this joint.

Multifocal metastases of recurrent renal cell carcinoma successfully treated with a combination of low dose interleukin‐2, α‐interferon and radiotherapy

A 59-year-old man presented with a 2-month history of left flank pain and a possibility of gross hematuria. Left renal cell carcinoma stage II was diagnosed and radical left nephrectomy was performed. Twenty-two months postoperatively, lung metastases were demonstrated and 6 x 10(6) units of alpha-interferon (IFN-alpha) were administered for 9 months, only to keep the sizes of the metastases unchanged. Thirty-four months after the operation, liver metastases and bone metastasis in the left sacroiliac joint were revealed. The combination cytokine therapy was performed with 1.4 x 10(6) U of interleukin-2 (IL-2) and 3 x 10(6) U of IFN-alpha for 16 weeks, and the left sacroiliac joint metastasis was treated with radiation therapy of 4 Gy per day for 7 days. Six months after the 16 weeks of immunotherapy, computed tomography and bone scintigraphy revealed that the metastases of the lung, liver and bone substantially disappeared and this complete response is still kept after 16 months.

Metastatic prostate cancer presenting as diplopia with regression of signs with hormone manipulation

A 73-year-old man presented with sudden onset diplopia. He was referred to the ophthalmology team who thought he had a VIth nerve palsy. He subsequently underwent computed tomography (CT) (Figure 1) and magnetic resonance imaging (Figure 2). These images revealed a mass occupying and expanding the sella with extension inferiorly to the sphenoid sinus. The clivus was almost completely replaced by tumour. The cavernous sinuses were involved bilaterally but the optic chiasm was not involved. It was thought that these finding were consistent with an unusual invasive pituitary tumour and surgical excision biopsy was undertaken. The histology was consistent with metastatic carcinoma of the prostate. His prostate-specific antigen (PSA) taken post-histology was 382 μg/litre and a bone scan confirmed metastases in the ribs, thoracic and lumbar spine, sacrum, left sacroiliac joint, ilium, ischium and pubis. He was subsequently started on luteinizing hormone-releasing hormone analogues which brought about a resolution of his diplopia. Follow-up CT of the head revealed regression of the skull base mass. At 18-month follow-up he remains well with no visual impairment, the PSA having decreased to &gt;0.2 μg/litre.

Metastatic prostate cancer presenting as diplopia with regression of signs with hormone manipulation

A 73-year-old man presented with sudden onset diplopia. He was referred to the ophthalmology team who thought he had a VIth nerve palsy. He subsequently underwent computed tomography (CT) (Figure 1) and magnetic resonance imaging (Figure 2). These images revealed a mass occupying and expanding the sella with extension inferiorly to the sphenoid sinus. The clivus was almost completely replaced by tumour. The cavernous sinuses were involved bilaterally but the optic chiasm was not involved. It was thought that these finding were consistent with an unusual invasive pituitary tumour and surgical excision biopsy was undertaken. The histology was consistent with metastatic carcinoma of the prostate. His prostate-specific antigen (PSA) taken post-histology was 382 μg/litre and a bone scan confirmed metastases in the ribs, thoracic and lumbar spine, sacrum, left sacroiliac joint, ilium, ischium and pubis. He was subsequently started on luteinizing hormone-releasing hormone analogues which brought about a resoluti...

The Classic: Streptomycin in Tuberculous Bone and Joint Lesions with Mixed Infection and Sinuses

The Classic: Streptomycin in Tuberculous Bone and Joint Lesions with Mixed Infection and Sinuses

Pelvic Injury from Weight Machine

HISTORY A 67yo osteoporotic female sustained a left pelvic injury while using a hip adductor weight machine at her gym. Patient was s/p right total hip replacement on April 21, 2003, and had been transitioned from outpatient physical therapy to outpatient gym acitivities during October 2003. At the gym, she developed acute onset of excruciating pain in her left hip. No lower extremity numbness, tingling or muscle weakness. Initial xrays were negative; however, pain progressed with continued mild exercise. PHYSICAL EXAMINATION Full left hip external/internal range of motion without pain. No lower extremity numbness or tingling. Palpation over the pubic rami and left sacroiliac joint elicited moderate tenderness. Gait was antalgic with a left pelvic tilt. DIFFERENTIAL DIAGNOSIS Adductor Magnus strain Avulsion fracture of pelvis Pelvic fracture TEST AND RESULTS Initial xray of pelvis: negative for fracture Bone scan: increased uptake at insertion of adductor magnus on pubic ramus Bone mineral density scan: Z-score −2.32 (i.e., osteoportic level) Blood work: CBC, ESR negative for any elevation Second xray of pelvis: fracture in superior and inferior rami on the left side of pelvis FINAL/WORKING DIAGNOSIS Acute, yet stable, left superior and inferior pubic rami fractures TREATMENT AND OUTCOMES Weight-bearing as tolerated. Adequate pain control to increase function. Resume physical therapy for controlled mobility and appropriate lower extremity strengthening exercises. Straight cane in right upper extremity to off-load left pelvic muscles and bones.

Pelvic Injury from Weight Machine

HISTORY A 67yo osteoporotic female sustained a left pelvic injury while using a hip adductor weight machine at her gym. Patient was s/p right total hip replacement on April 21, 2003, and had been transitioned from outpatient physical therapy to outpatient gym acitivities during October 2003. At the gym, she developed acute onset of excruciating pain in her left hip. No lower extremity numbness, tingling or muscle weakness. Initial xrays were negative; however, pain progressed with continued mild exercise. PHYSICAL EXAMINATION Full left hip external/internal range of motion without pain. No lower extremity numbness or tingling. Palpation over the pubic rami and left sacroiliac joint elicited moderate tenderness. Gait was antalgic with a left pelvic tilt. DIFFERENTIAL DIAGNOSIS Adductor Magnus strain Avulsion fracture of pelvis Pelvic fracture TEST AND RESULTS Initial xray of pelvis: negative for fracture Bone scan: increased uptake at insertion of adductor magnus on pubic ramus Bone mineral density scan: Z-score −2.32 (i.e., osteoportic level) Blood work: CBC, ESR negative for any elevation Second xray of pelvis: fracture in superior and inferior rami on the left side of pelvis FINAL/WORKING DIAGNOSIS Acute, yet stable, left superior and inferior pubic rami fractures TREATMENT AND OUTCOMES Weight-bearing as tolerated. Adequate pain control to increase function. Resume physical therapy for controlled mobility and appropriate lower extremity strengthening exercises. Straight cane in right upper extremity to off-load left pelvic muscles and bones.

Pyrexia due to pyogenic sacroiliitis with iliopsoas abscess after spinal cord injury

Single case report. To present an unusual cause of fever in a patient with spinal cord injury (SCI). University Hospital, Belgium. A 52-year-old man with a complete T9 paraplegia was admitted to hospital with a 7 day history of fever above 39 degrees C without pain and without gastrointestinal, urinary, or respiratory complaints. The patient had had a flap coverage for a sacral pressure ulcer 6 months prior to admission. Bone scintigraphy demonstrated markedly increased activity in the left sacroiliac joint. Computed tomography (CT) revealed an infection of the left sacroiliac joint with a large abscess involving the iliopsoas muscle. The responsible organism, Pseudomonas aeruginosa, was isolated from abscess liquid obtained by CT-guided aspiration. We postulated that P. aeruginosa had colonized the eschar and, due to the proximity, infected the sacroiliac joint and the adjacent iliopsoas muscle. Prompt intravenous antibiotic therapy ensured clinical improvement and radiological regression. Pyogenic sacroiliitis is a relatively rare condition that may be difficult to diagnose in patients with normal sensation, and even more so in SCI patients. As far as we know, psoas abscess associated with pyogenic sacroiliitis has never been described in SCI patients. This infectious pathology must be kept in mind in SCI patients with fever of unknown origin and with a history of sacral eschar.

A case of pityriasis rubra pilaris associated with rapidly progressive finger joint destruction

A 40-year-old female noticed edema of the lower limbs in March 1995. Nephrotic syndrome due to membranous nephropathy was diagnosed and administration of high-dose corticosteroids resulted in incomplete remission. Progressively enlarging, red scaling skin lesions developed concomitantly from the scalp to the extremities. Pityriasis rubra pilaris (PRP) was diagnosed in 1996 in the Department of Dermatology at Sapporo Medical University hospital. Various treatments proved ineffective. Arthritis of the finger joints developed in July 1999, and proteinuria recurred in April 2000. She was admitted to our department in August 2000. Physical examination on admission revealed marked swelling of both distal interphalangeal (DIP) joints and the right fourth proximal interphalangeal (PIP) joint. Results of testing for antinuclear antibody, rheumatoid factor, and HLA-B27 were all negative. Radiography of the hands revealed destruction of the DIP and PIP joints where MRI indicated the presence of synovitis. Bone scintigraphy demonstrated accumulation in bilateral metatarso-phalangeal joints and the left sacroiliac joint. Arthritis associated with PRP was diagnosed, as both PRP and psoriasis represent keratinizing disorders of the skin and clinical features in the present case resembled those of psoriatic arthritis. Despite administration of high-dose corticosteroids, destruction of finger joints progressed rapidly. Administration of cyclosporine in April 2002 improved arthritic symptoms. Cases of PRP accompanied by arthritis need to be accumulated to allow analysis of the pathogenesis and clinical picture of this association.