Sacroiliac Region Research Articles

Ultrasonographic examination of the equine sacroiliac region

Little information exists about the normal ultrasonographic appearance of the equine sacroiliac region, but knowledge of the ultrasonographic anatomy is necessary to understand the possible pathological changes in sacroiliac diseases. The normal ultrasonographic appearance of soft tissues and bony structures of the sacroiliac region in horses was studied in order to establish clinically relevant reference parameters. Thirteen cadaver specimens were examined using a transcutaneous approach above the tubera sacrale to image the dorsal sacroiliac ligament and the tendon of the longissimus dorsi muscle. A rectal approach was used to outline the sacroiliac joint and its adjacent structures. Thirteen sound horses with no history of back pain were examined following the same protocol as for the post mortem examinations. The tendon of the longissimus dorsi muscle can clearly be distinguished from the dorsal sacroiliac ligament, especially in longitudinal images. Transrectal examination of the sacroiliac joint consists of evaluation of the bony surfaces of the sacrum and ilium in comparison with the contralateral side. Ultrasonographic examination of the sacroiliac region provided clear images of the caudomedial border of the sacroiliac joint and its adjacent structures and is a useful aid in the diagnosis of sacroiliac joint diseases and adjacent lesions. The study has shown ultrasonography to be a useful method for examining and differentiating the longissimus dorsi muscle and the dorsal sacroiliac ligament at the level of the tubera sacrale. Diagnostic ultrasound is available to most practitioners. These reference ultrasound parameters may help to improve the diagnosis of sacroiliac diseases.

Résultats des arthrodèses vertébrales postérieures dans les scolioses secondaires à une ostéogenèse imparfaite

Purpose of the study A survey was conducted at the Necker-Enfants-Malades Hospital in Paris and the Roscoff Helio-Marin Center in Roscoff, France to document results of posterior spinal fusion for scoliosis associated with osteogenesis imperfecta. Material and methods The cases of 27 patients who underwent posterior spinal fusion and Harrington (n = 2) or CD (n = 23) instrumentation performed by one senior orthopedic surgeon were reviewed. Two patients had posterior arthrodesis without instrumentation and were left in halo-traction together with a plaster cast until bone healing was achieved. Results The series included eleven males and sixteen females. Mean age at fusion was 13 y 4 m. The average curvature before surgery was 77̊ and the average correction was 37̊. Mean follow-up was six years. Minor complications due to halo pin infection or migration were observed in two patients and loss of correction with rod fracture in four. Discussion Because of the risk of physical and respiratory incapacity, we believe that spinal surgery and arthrodesis for spinal deformity should be considered after a preparation period by halo-traction with exceptional precautions to correct major curves and prevent complications that could occur in patients with osteogenesis imperfecta. Correction and stabilization of the scoliotic spine in osteogenesis imperecta has yet to be definitively described since we have noticed that the site of deformation is transferred to the sacroiliac region once spinal fusion is achieved.

The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain

Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. Arch Phys Med Rehabil 2003;84:1057-60. ObjectiveTo determine the relationship between an audible pop and symptomatic improvement with spinal manipulation in patients with low back pain (LBP). Design:A prospective cohort study. Setting:Two outpatient physical therapy clinics located in military medical centers. Participants:A cohort of 71 patients with nonradicular LBP referred to physical therapy. Interventions:Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac (SI) region manipulative technique and the presence or absence of an audible pop was noted. Main Outcome Measures:Subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), numeric pain rating scale (PRS) scores, and modified Oswestry Disability Questionnaire (ODQ) scores. Results:An audible pop occurred in 50 of the 71 subjects during the manipulative procedure. Both groups—those who had an audible pop and those who did not—improved over time in flexion ROM, PRS scores, and modified ODQ scores; however, there were no differences between groups (P>.05). Nineteen of the 71 (27%) patients improved dramatically (mean drop in modified ODQ, 67.6%). In 14 of the 19 dramatic responders, an audible pop occurred. However, the odds ratio (1.2; 95% confidence interval, 0.38–4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms after the manipulation. Conclusion:There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with nonradicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.

The sacroiliac joints: evaluation using nuclear scintigraphy. Part 1: The normal horse.

Sacroiliac (SI) disease is recognised as a cause of poor hindlimb action but differential diagnosis is often difficult. That in clinically normal horses there would be a significant difference in the ratio of radiopharmaceutical uptake (RU) between the fifth lumbar vertebra (L5) and each tuber sacrale (TS) and between L5 and each SI joint; and that these ratios would alter with age, but ratios would be bilaterally symmetrical. Dorsal scintigraphic images of the SI region of 15 horses, selected randomly from the clinic database, were analysed by 2 of the authors, comparing noncorrected and motion-corrected images. To determine scintigraphic anatomy, the scintigraphic images of 10 Thoroughbred horses were superimposed over a ventrodorsal radiographic image of an isolated pelvis. Dorsal scintigraphic images of 40 clinically normal horses age 3-16 years were evaluated using subjective examination, profile analysis and quantification using regions of interest. The tubera sacrale were seen as 2 well-defined oval regions immediately to the left and right of the midline, abaxial to which were larger, approximately oval areas with less RU, representing uptake in the SI joints. The definition between the SI region and the TS was more obvious in younger horses. Nonmotion-corrected images were often not of diagnostic quality or could be misinterpreted as abnormal. There were significant differences in RU between the TS and SI joints compared to L5, and decreased RU in the tubera sacrale with increasing age, but no change of uptake in the SI joint region and no effect of gender on RU. There was a high degree of left-right symmetry of the TS and SI joint regions. The scintigraphic images of horses with suspected sacroiliac joint disease should be compared with images of normal horses of comparable age. In normal horses, there was a high degree of symmetry; therefore, marked left-right asymmetry is likely to be abnormal.

The sacroiliac joints: evaluation using nuclear scintigraphy. Part 2: Lame horses.

Sacroiliac (SI) joint disease is difficult to diagnose definitively on clinical grounds. Lameness not attributable to SI joint pain may result in asymmetrical uptake of radiopharmaceutical in the tubera sacrale and SI joints; and that horses with clinical signs suggestive of sacroiliac joint disease would have differences in the ratios of radiopharmaceutical uptake between the fifth lumbar vertebra (L5) and either the tubera sacrale or SI joints compared with normal horses. To determine whether differences in radiopharmaceutical activity could identify individuals with presumed SI joint region pain. The scintigraphic appearance of the pelvic region of 234 horses (Group I) with lameness unrelated to the SI joints was compared with that for 40 normal horses (Group N) in full work and that for 41 horses with suspected SI joint disease (Group II). The effect of age, sex, lame limb and discipline were assessed in Group I. Motion-corrected scintigraphic images were assessed grossly, using profile analysis and by comparing ratios of uptake of mean count per pixel between L5 and each of the left (L) tuber sacrale (TS), right (R) TS, LSI and RSI joints. Left-right symmetry was compared. Lame horses (Group I) had greater asymmetry of radiopharmaceutical uptake in the tubera sacrale compared with normal horses. Horses with right hindlimb lameness had a larger RSI/LSI ratio compared to normal horses. In Group I L5/LTS, L5/RTS and L5/RSI increased with age, and there was a trend for L5/LSI to increase with age. In horses with presumed sacroiliac joint disease (Group II), L5/LTS, L5/RTS and L5/RSI were all greater compared with normal horses. Detection of marked left-right asymmetry by quantitative analysis or profile analysis was helpful in discriminating between those horses with clinical signs compatible with SI joint disease and either normal horses or those lame due to another cause. Scintigraphic evaluation of the SI region is useful to identify SI joint disease in combination with other clinical signs supportive of the diagnosis. However, diagnosis should not be based on this alone because of some degree of overlap in the range of radiopharmaceutical uptake between horses with SI joint disease and both normal horses and those with other causes of lameness.

Percutaneous computed tomographic stabilization of the pathologic sacroiliac joint.

Metastases to the sacroiliac joint region can be a source of significant pain in many patients who are terminally ill. Six patients with metastatic lesions in the sacroiliac region who presented with significant posterior pelvic pain were treated with computed tomography-guided insertion of iliosacral screws. All patients reported excellent pain control in the early postoperative period. Computed tomography-guided insertion of iliosacral screws in an area of relatively preserved bone stock provides good purchase of the screws. It is a safe percutaneous procedure and it helps alleviate pain in patients with sacroiliac metastases.

Hematogenous sacroiliac infection following body piercing

Musculoskeletal infection following body piercing occurs rarely and has not been previously described in the orthopaedic literature. We report on a 17-year-old boy who developed hematogenous Staphylococcus aureus infection of the sacroiliac region following piercing of his eyebrow. Diagnosis was confirmed by bone scintigraphy and he responded well to antibiotic therapy. With the growing popularity of body piercing, the orthopedic community worldwide needs to be aware of the significant musculoskeletal sepsis that may complicate this fashion.

The swing procedure for pelvic ring reconstruction following tumour excision

Aim: High grade periacetabular osteosarcomas extending to the sacro-iliac region present a difficult management problem. We describe our experience of the swing procedure as a method of limb salvage.Method:The procedure was performed on three patients with stage II B osteosarcoma.Results: Functional outcome was poor in all three with a mean Musculoskeletal Tumor Society score of 29% (27–30) at last review. All three developed local recurrence and one developed pulmonary metastases. The mean disease free interval post-operatively was 4.7 months (4–6) and they died of their disease at a mean of 10 months (5–16).Conclusions: This form of limb salvage is technically demanding and carries a high morbidity. Functional outcome is poor and the prognosis for this group of patients is not improved by surgery. Alternative treatment options are discussed.

Ultrasonographic abnormalities detected in the sacroiliac area in twenty cases of upper hindlimb lameness.

The pelvis is covered with extensive musculature and often presents a challenge in diagnostic imaging. Ultrasonography provides diagnostic information about soft tissue, articular cartilage and bone surfaces, although little information exists about the normal ultrasonographic appearance of the equine sacroiliac region. To determine the clinical applicability of ultrasonographic examination in horses with sacroiliac pain. Horses presented to the University of Minnesota Veterinary Teaching Hospital for hindlimb lameness were evaluated and lower limb lameness was ruled out with examination and local anaesthesia. Twenty cases were diagnosed with sacroiliac pain, characterised by response to palpation over the tuber sacrale. Seven of the 20 had visible asymmetry of the tuber sacrale. Ultrasonography was performed percutaneously and per rectum. Structures imaged were measured and compared to normal reference measurements. Other methods used to confirm diagnoses included thermography, scintigraphy and radiology. All 20 cases with sacroiliac pain showed ultrasonographic abnormalities of the sacroiliac area. Abnormalities were detected in the dorsal sacroiliac ligaments. Ligament size was significantly different from the normal ranges (P < 0.01). Malalignment of the sacroiliac area and sacral fractures were also imaged. Ultrasonography of the sacroiliac region aided diagnosis of ligament damage and displacement of bone surfaces; and may aid in monitoring the progression of healing. Diagnostic ultrasound is readily available to most practitioners. Therefore the findings of this study show that diagnosis of sacroiliac injuries is possible in the field.

“Skilled Mentors” and Reliability

To the Editor: I am writing in response to the article by Riddle et al titled “Evaluation of the Presence of Sacroiliac Joint Region Dysfunction Using a Combination of Tests: A Multicenter Intertester Reliability Study” in the August 2002 issue of the Journal. The research design and statistical analysis used in this multi-center reliability study on examination of the sacroiliac region was impressive. The authors attempted to replicate an earlier study by Cibulka and colleagues,1 but they greatly increased the number of clinical sites and therapists involved, in an attempt to make the results more generalizable to therapists who might use the examination scheme advocated by Cibulka and colleagues. However, the results of the study by Riddle et al demonstrated poor reliability, whereas Cibulka et al had reported an excellent level of reliability. In comparing the 2 studies, it seems that one likely explanation for the disparity in results is the training process used in the studies. Cibulka et al1 developed the examination scheme and likely mentored their coworkers to perform the procedures exactly as they advocated in an attempt to maximize the consistency and reliability. In contrast, Riddle et al sent a written description of the examination procedures with illustrations to the participating physical therapists and asked them to practice the techniques on each other until they felt ready to participate in the study. Manual examination procedures are motor skills that must be practiced under the guidance of a mentor in order to be learned properly. The motor learning literature, I believe, suggests that practice of a motor skill is necessary for the skill to be learned. Petty2 contended that physical therapists in an advanced manual therapy residency program provided inaccurate and unreliable feedback to classmates when practicing manual therapy techniques. Watson and Radman3 showed …

Impairment-Based Examination and Disability Management of an Elderly Woman With Sacroiliac Region Pain

The purpose of this case report is to describe the use of a cluster of sacroiliac tests in conjunction with an impairment-based model of examination, diagnosis, and management of sacroiliac region pain. The patient was a 74-year-old woman with an 18-month history of low back, left buttock, and groin pain following a misstep. The initial symptoms were intermittent. The symptoms became constant and limited her walking tolerance to 5 minutes, which affected her ability to care for her grandchildren. She was examined using a cluster of sacroiliac tests that examined: (1) innominate active mobility, (2) innominate positional symmetry, and (3) sacroiliac ligament tenderness. Following 4 treatments for identified impairments, the patient had unlimited walking tolerance and she resumed an active caregiving role for her grandchildren. This case illustrates the use of an impairment-based model for examination and management of an elderly patient with what appeared to be sacroiliac joint dysfunction.

MR Findings of Tuberculous Arthritis: Significance of Tuberculoma

Purpose: To determine the magnetic resonance (MR) imaging findings of tuberculous arthritis, and the frequency-in such cases-with which tuberculoma occurs. Materials and Methods: MR images of 26 patients (M:F, 14:12; mean age, 46.2 years) with pathologically proven tuberculous arthritis were retrospectively reviewed. The presence of joint effusion, subchondral erosion, synovial proliferation and soft tissue abscess, and whether the inner wall of this abscess was smooth,were assessed. In particular, we determined whether a nodular lesion which showed low SI on T1WI, central low SI with peripheral high SI on T2WI, and rim enhancement on contrast study, was a tuberculoma. Results: The joints involved were those of the knee (n=7), hip (n=7), shoulder (n=4), sacroiliac region (n=3), elbow (n=3), and ankle (n=2). Joint effusion was noted in 15 cases (58%), and subchondral erosion in 24(92%). synovial proliferation was found in 23 cases (88%), and soft tissue abscess in 24 (92%). The inner wall of this abscess was irregular in 17 cases (71%). A tuberculoma was present in intra- or extra-articular soft tissue in 18 cases (69%). Conclusion: The MR findings of tuberculous arthritis were subchondral erosion, synovial proliferation, and soft tissue abscess. The presence of a tuberculoma in intra- or extra-articular soft tissue, a specific finding in tuberculous arthritis, was noted in 69% of our cases.

Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia

Objective: To demonstrate that manipulation under anesthesia (MUA), a conservative treatment modality, is both safe and efficacious in the treatment of both acute and chronic spinal pain disorders in appropriately selected patients. MUA can be safely used to treat pain arising from the cranial, cervical, thoracic, and lumbar spine, as well as the sacroiliac and pelvic region. Setting: An ambulatory surgical center. Subjects: The treatment group consisted of 177 patients between ages 17 and 65 years. Evaluation followed a treatment algorithm created by the authors as a multidisciplinary approach to patient selection, evaluation, treatment, and timing of specialized referral, in consideration of previously published algorithms. Prior forms of treatment, both conservative and surgical in nature, had failed in these patients. Intervention: Patients underwent three sequential manipulations under intravenous sedation, followed by 4 to 6 weeks of skilled spinal manipulation and therapeutic modalities. Outcome Measures: Data regarding changes in Visual Analog Scale (VAS), range of motion, medication needs, and return to work status were used to document progress. All patients had follow-up for 6 months. Results: On average, VAS ratings improved by 62.2% in those patients with cervical pain problems. On average, VAS ratings improved by 60.1% in those patients with lumbar pain problems. There was a near-complete reversal in patients out of work before MUA (68.6%) and those returning to unrestricted activities at 6 months after MUA (64.1%). There was a 58.4% reduction in the percentage of patients requiring prescription pain medication from the pre-MUA period to 6 months after MUA. Additionally, 24.0% of the treatment group required no medication at 6 months after MUA. Conclusion: A multidisciplinary approach to evaluation and treatment, including MUA, offers patient benefits above and beyond what can be obtained through the individual providers working alone. (J Manipulative Physiol Ther 1999;22:299–308)

Facet blocks and denervations

The lumbar facet (zygapophyseal) joint has been considered to be a significant source of low back pain for almost a century. Ghormley was the first individual to describe “facet syndrome” which he defined as a lumbosacral pain with or without radiculopathy, occurring most often after a sudden twisting or rotary strain of the lumbosacral region [1]. Hirsch et al. [2] injected hypertonic saline in the region of the facet joints and produced low back pain in the sacroiliac and gluteal regions with radiation to the greater trochanter. This was confirmed by Mooney and Robertson [3], who performed intra-articular saline facet injections, producing a similar pain referral pattern, which was relieved by intra articular local anesthetic injection. Also, neck pain and headache were produced by cervical facet injection with hypertonic saline by Pawl [4].

Atrial and Venous Thrombosis Secondary to Septic Arthritis of the Sacroiliac Joint in a Child with Hereditary Protein C Deficiency

Septic arthritis and osteomyelitis in children is seldom accompanied by calf vein thrombosis and rarely by atrial thrombosis. We report the case of an 11-year, 5-month-old boy with septic arthritis and osteomyelitis of the sacroiliac region who developed deep venous thrombosis, in addition to life-threatening right atrial thrombosis. After an intensive hematologic investigation, a hereditary protein C deficiency was revealed. The association of venous thrombosis with septic arthritis or osteomyelitis should raise the possibility of the presence of protein C deficiency.

Primitive Neuroectodermal Tumor of the Meninges: An Histological, Immunohistochemical, Ultrastructural, and Cytogenetic Study.

We report a case of primitive neuroectodermal tumor (PNET) arising from the meninges in a 30-yr-old female patient whose clinical and radiological features were consistent with meningioma. The neoplasm was composed of primitive small, round cells, growing in sheets and nests in continuity with meningeal layers. Ultrastructurally, the neoplastic cells were characterized by large and regular nuclei, primitive cytoplasm with pools of glycogen, and lack of dense core granules. The neuroectodermal nature of the tumor was confirmed by positive immunostaining for vimentin, neurofilaments, neuron specific enolase (NSE), and 013 (an antibody raised against MIC2 antigen). Further support to the diagnosis was obtained by reverse transcriptase-polymerase chain reaction (RT-PCR) detection of Chromogranin A and Secretogranin II genes. t(1 1;22) translocation was also observed by RT-PCR, a finding that was not recorded in previously described intracranial PNET. The tumor followed a malignant course, recurring and spreading to chest wall and sacroiliac region over a 10-yr period. The meningeal location enlarges the topographic spectrum of intracranial PNET, and this tumor has to be considered in the differential diagnosis with meningioma.

Efficacy study of the effect of a myofascial release treatment technique on obtaining pelvic symmetry

Clinicians often identify asymmetries of paired skeletal landmarks as pathomechanic, and use ‘soft tissue’ techniques to restore symmetry, decrease pain and improve function. A common clinical finding is a unilateral anterior rotation of an innominate. This study investigated the efficacy of a myofascial release treatment technique on obtaining pelvic symmetry. Ten symptomatic patients with a unilateral anterior rotation of an innominate ≥10 mm, and perceived low back and/or sacroiliac region pain were studied. Non-parametric data analysis was performed by the Mann-Whitney U-test and the Wilcoxon signed-rank test. A statistical significance was achieved when the amount of change between the control group and treatment group were compared. The results indicate that the treatment has the potential to be effective in facilitating a change in pelvic position toward symmetry. Further research needs to be conducted with a larger sample size to possibly increase the statistical power of the results.

Fluvastatin (Lescol) treatment of hyperlipidaemia in patients with renal transplants.

Hyperlipidaemia of 18 male and 20 female patients following successful renal transplantation was treated with daily 20 mg fluvastatin (Lescol) for 12 weeks. The patients were several months after transplantation, and their total cholesterol levels exceeded 6.5 mmol/l following an 8-week diet. The effect of fluvastatin on the levels of total cholesterol, HDL, LDL, triglyceride, Apo A1 and Apo B, as well as of lipoprotein(a) was examined. Furthermore, changes of the renal function (GFR-urea, creatinine, uric acid) and hepatic function (bilirubin, GOT, GPT, CPK, ALP) were followed up, together with the body weight and blood pressure. The results of the examinations are summarized as follows: Fluvastatin may be administered effectively and without side effects in a daily dose of 20 mg in appropriately selected renal transplant patients. The average total cholesterol values, which were 7.91 mmol/l in men and 7.78 mmol/l in women following the diet, were reduced by 22-25% (p < 0.001) after 6 and 12 weeks, respectively, of fluvastatin treatment. The levels of LDL also decreased significantly (p < 0.001): in response to a 20 mg evening dosage, reduction of more than 25% was observed in 78% of men and 65% of women. Reductions of the Apo B levels were more pronounced in the females (18.3% men vs. 21.2% women). The ratio C/HDL-C decreased both in men (from 5.49 to 4.19) and in women (from 4.83 to 4.02). The ratio Apo B/Apo A1 also decreased (men: from 0.86 to 0.73, women: from 0.73 to 0.66). The concentrations of HDL and Apo A1 did not increase significantly, the reductions in the levels of triglyceride and lipoprotein(a) were not considerable either. An increase in the levels of hepatic enzymes and CPK was not encountered during the administration of fluvastatin. In two patients the levels of serum bilirubin increased by 2-4 micromol/l. Three patients complained about temporary myalgias of the sacroiliac or lumbar region which, however, were not accompanied by elevated CPK levels. The monitored levels of cyclosporine, urea and creatinine did not increase significantly during the 12 weeks of treatment. Two patients had temporary gastric complaints.

Open reduction and internal fixation of the pelvic fractures

For a long time, conservative methods was the mainstay of treatment in pelvic fractures. However, long-term results showed a high complication rate such as pain, shortening, and pelvic deformity especially in disruptions of the sacroiliac region. External fixation proved to be insufficient in the retention of reduction especially in vertical instabilities. In these cases, open reduction and internal fixation will provide anatomic reposition especially in the weight-bearing region and lower the risk of complications. We present the results of 1 Type B case and 8 Type C cases who had open reduction and internal fixation for pelvic fractures. Our results showed that anatomical reduction and integrity of the pelvic ring can be reconstituted with open reduction and internal fixation. We observed that these patients could be mobilized earlier and the hospital stay is significantly shorter than those treated conservatively. Keywords: Fractures of the pelvis, surgical treatment, open reduction and internal fixation

The use of color Doppler imaging for the assessment of sacroiliac joint stiffness: a study on embalmed human pelvises

Purpose: The validity and reproducibility of an instrumented dynamic examination method to measure sacroiliac (SI) joint stiffness was tested in vitro. Methods: Four embalmed human female pelvises were excitated by a pelvic vibrator. A color Doppler imaging (CDI) scanner was used to image the amplitude of vibrations at different sites of the pelvis. Vibrations were applied to the anterior superior iliac spines unilaterally and were received by CDI all over the ipsilateral SI region. Three different stability conditions were created in the SI joints: no intervention, screwed and ligaments cut. Test results were quantified by taking the minimum threshold levels of the bones. The relative difference of vibration intensity between ipsilateral ilium and sacrum at each stability condition is accepted as the stiffness level for the SI joint. Results: Statistics showed high reproducibility and significant differences between the stability conditions. Dynamic testing based on the use of vibrations provides visible and quantifiable intra- and inter-individual differences between SI joint stiffnesses. Conclusions: This new method is objective and reproducible. Future in vivo application is promising since there are no technical and safety restrictions.