Dolor sacroilíaco: revisión actualizada del enfrentamiento diagnóstico / Sacroiliac joint pain: an updated review of the clinical approach for diagnosis

El dolor sacroilíaco es responsable de 15% a 30% de los cuadros de dolor lumbar bajo. El diagnóstico de esta patología es un desafío para el médico, debido a su compleja anatomía, el amplio diagnóstico diferencial, y las diversas etiologías que pueden provocar dolor en la articulación sacroilíaca. Una anamnesis ordenada y dirigida, asociada a un examen físico preciso, ayuda a orientar el diagnóstico. Las pruebas sacroiliacas específicas deben realizarse en aquellos pacientes con sospecha de dolor sacroilíaco, y deben interpretarse en conjunto y no de manera aislada. La resonancia magnética sirve para descartar otras causas de dolor lumbar bajo o diagnosticar casos de sacroileítis inflamatoria. La infiltración de la articulación es el gold standard para el diagnóstico, y debe realizarse en pacientes con alta sospecha de dolor sacroilíaco, por la anamnesis, examen físico, y tres o más pruebas sacroilíacas específicas positivas.

Sacroiliac pain accounts for 15% to 30% of low back pain conditions. Its diagnosis is a challenge for the physician due to its complex anatomy, the wide differential diagnoses list, and its several causes. Diagnosis requires a structured clinical history and an accurate physical examination. Specific sacroiliac physical examination tests should be performed in patients with suspected sacroiliac joint pain and interpreted together, not in isolation. Magnetic resonance imaging can rule out other causes of low back pain or diagnose inflammatory sacroiliitis. Joint infiltration is the gold standard for diagnosis, and it should be performed in patients with a high suspicion of sacroiliac joint pain based on anamnesis, physical examination, and three or more positive specific sacroiliac tests.

Effects of mobilization treatment on sacroiliac joint dysfunction syndrome

SUMMARY OBJECTIVE: This study aims to reveal the short-term effects of exercise therapy and manual therapy plus exercise therapy on pain, quality of life, and physical examination results in the treatment of sacroiliac joint dysfunction syndrome (SIJDS). METHODS: In this study, 64 patients who were participated were divided into two groups. The first group (exercise group) was assigned with the sacroiliac joint (SIJ) home exercise program and the second group (mobilization group) with the combined SIJ manual therapy and home exercise program. Physical examination tests, visual analog scale, and SF-36 evaluation were performed at the beginning of the study, at 24 h, at 1 week, and 1 month after the treatment. RESULTS: Both groups showed that the rate of pain in the posttreatment, after the first week, and the first month; the presence of pain in the sacroiliac region; and VAS values of the patients with SIJDS compared to pretreatment values were clearly decreased (p<0.05). All tests performed in the SIJ physical examination showed significant improvement within both groups (p<0.05). However, there was no statistical difference between the two groups in 1-month period (p>0.05). CONCLUSIONS: We found that the home exercise program and the manual therapy plus exercise program significantly improved pain intensity, quality of life, and the findings of specific tests in patients with SIJDS. In addition, superiority between the two groups in terms of pain intensity, quality of life, and specific tests was not determined.

Estudio de la anatomía sagital de la pelvis de pacientes con dolor sacroilíaco en el ámbito laboral / Study of the sagittal anatomy of the pelvis in workers with sacroiliac pain

Introducción: La articulación sacroilíaca es el origen del dolor en el 10-25% de los pacientes con lumbalgia mecánica. Si no hay traumatismos, tumores, enfermedades metabólicas ni colagenopatías, su papel en la fisiopatología del dolor lumbar aún no está completamente dilucidado. El objetivo fue estudiar la anatomía sagital de la pelvis a través de la medición de la incidencia pélvica en pacientes con dolor sacroilíaco en el ámbito laboral frente a personas asintomáticas. Materiales y métodos: Estudio analítico, observacional, retrospectivo de pacientes con dolor sacroilíaco diagnosticados mediante un bloqueo guiado por tomografía computarizada en un centro de patología laboral, entre enero de 2015 y diciembre de 2018. El grupo de comparación fue una muestra aleatoria de personas sin enfermedad de la pelvis o lumbosacra estudiados con tomografía computarizada de pelvis y columna durante el mismo período. Resultados: La incidencia pélvica media en pacientes con dolor sacroilíaco fue de 52,57 (DE 9) y 46,52 (DE 9) en el grupo de personas sanas. La diferencia fue estadísticamente significativa con valores mayores de incidencia pélvica en pacientes con dolor sacroilíaco (p 0,042). Conclusión: Los pacientes con dolor sacroilíaco presentaron una mayor incidencia pélvica que las personas sanas, con una diferencia estadísticamente significativa en nuestro estudio. Nivel de Evidencia: IV

Introduction: The sacroiliac joint causes pain in 10 to 25% of patients with mechanical low back pain or symptoms radiating to the lower limbs. In the absence of trauma, metabolic disease, and collagen disease, its role in the pathophysiology of low back pain is not yet fully understood. The objective is to study the sagittal pelvic anatomy through the measurement of pelvic incidence (PI) in patients with sacroiliac pain in the workplace compared to asymptomatic patients. Materials and methods: A retrospective observational analytical study of adult patients with sacroiliac pain diagnosed with CT-guided block in an occupational pathology center during January 2015 and December 2018. The comparison group was a random sample of patients without pelvic or lumbosacral pathology studied with CT of the pelvis and spine during the same period. Results: The mean PI in patients with sacroiliac pain was 52.57 (SD 9) and 46.52 (SD 9) in the group of healthy patients. The difference was statistically significant with the higher PI values in patients with sacroiliac pain (p 0.042). Conclusion: Patients with sacroiliac pain had a higher pelvic incidence than healthy patients, with a statistically significant difference in our study. Level of Evidence: IV

Description of the Sacropelvic Parameters Measurement Method for S2-alar iliac Screw Insertion / Descrição do método de aferição dos parâmetros sacropélvicos para a inserção do parafuso S2-asa do ilíaco

Abstract Objective Description of the sacropelvic parameters measurement method for S2-alar iliac (S2AI) screw insertion. Methods Descriptive study of the method for measuring sacropelvic parameters for the insertion of the S2AI screw using computed tomography (CT). The data evaluated in multiplanar reconstructions were the parameters of the screw trajectory, including length, diameter and angles of the trajectory in the axial and sagittal planes. Results From the sagittal reconstruction, the axis of the series of axial slices is angled three-dimensionally so that it is possible to visualize the S2 vertebra, the screw entry point, and the anteroinferior iliac spine (AIIS) in the same plane. The entry point is demarcated at the midpoint between the dorsal foramina of S1 and S2. To measure the length of the screw, lines are drawn tangent to the inner and outer cortices of the iliac. The diameter is determined by the shortest distance between the inner and outer iliac faces minus half of the diameter of the screw chosen medially and laterally. The path angle in the axial plane is formed by the anteroposterior midline of the sacrum and the line of the screw length. The craniocaudal inclination angle in relation to the S1 plateau corresponds to the degree of inclination made in the sagittal plane to find the image in which the entry point and the AIIS are seen in the same plane. Conclusion It was possible to adequately assess, through multiplanar CT reconstructions, the sacropelvic parameters necessary for the safe insertion of the S2AI screw.

Resumo Objetivo Descrever como aferir os parâmetros sacropélvicos para a inserção segura do parafuso S2-asa do ilíaco (S2AI). Métodos Estudo descritivo do método de aferição dos parâmetros sacropélvicos para a inserção do parafuso S2AI por meio de tomografia computadorizada (TC). Os dados avaliados em reconstruções multiplanares foram os parâmetros da trajetória do parafuso, incluindo comprimento, diâmetro e ângulos de trajetória nos planos axial e sagital. Resultados A partir da reconstrução sagital, angula-se tridimensionalmente o eixo da série de cortes axiais de modo que seja possível visualizar a vértebra S2, o ponto de entrada do parafuso e a espinha ilíaca anteroinferior (EIAI) no mesmo plano. O ponto de entrada é demarcado no ponto médio entre os forames dorsais de S1 e S2. Para medir o comprimento do parafuso, traçam-se linhas tangenciando as corticais interna e externa do ilíaco. O diâmetro é determinado pela menor distância entre as tábuas interna e externa do ilíaco subtraindo metade do diâmetro do parafuso escolhido medialmente e lateralmente. O ângulo de trajetória no plano axial é formado pela linha média anteroposterior do sacro e a linha do comprimento do parafuso. O ângulo de inclinação craniocaudal em relação ao platô de S1 corresponde ao grau de inclinação feito no plano sagital para encontrar a imagem em que o ponto de entrada e a EIAI são vistos no mesmo plano. Conclusão Foi possível aferir adequadamente, por meio de reconstruções multiplanares de TC, os parâmetros sacropélvicos necessários para a inserção segura do parafuso S2AI.

Are Anterior Plates More Effective than Iliosacral Screws to Fix the Sacroiliac Joint? Biomechanical Study / Placas anteriores são mais efetivas do que parafusos iliossacrais na fixação da articulação sacroilíaca? Estudo Biomecânico

Abstract Introduction Sacroiliac joint dislocations are caused by high energy trauma and commonly treated with the iliosacral screw fixation or the anterior plating of the sacroiliac joint (SIJ). However, there is a lack of consensus regarding which procedure is the most successful in treating sacroiliac joint dislocations. This aims to compare stiffness and maximum load of pelvises with sacroiliac joint dislocations treated with both procedures in a synthetic bone model. Methods Synthetic pelvises were mounted and divided into 2 treatment groups (n= 5): a model with two orthogonal plates placed anteriorly to the SIJ (PPS group) and another with two iliosacral screws fixating the SIJ (SPS group), both with pubic symphysis fixation. The maximum load supported by each sample was observed and the stiffness was calculated from the curve load vs displacement. The mean values of load to failure and stiffness for each group were compared with the Mann-Whitney U test (p< 0.05 was considered significant for all analysis). Results The mean load to failure supported by the PPS group was 940 ± 75 N and the SPS was 902 ± 56 N, with no statistical difference. The SPS group showed higher values of stiffness (68.6 ± 11.1 N/mm) with statistical significant difference in comparison to the PPS sample (50 ± 4.0 N/mm). The mode of failure was different in each group tested. Conclusion Despite lower stiffness, the anterior plating fixation of the sacroiliac joint can be very useful when the iliosacral screw fixation cannot be performed. Further studies are necessary to observe any differences between these two procedures on the clinical and surgical setting.

Resumo Introdução Usualmente, as luxações sacroilíacas são tratadas com parafusos iliossacrais ou com placas anteriores à articulação sacroilíaca (ASI). Este estudo compara a rigidez e carga máxima suportada pelos dois tipos de fixações acima citados, utilizando pelves sintéticas. Método Dez pelves sintéticas foram divididas em dois grupos (n= 5). No grupo denominado PlaCF, a ASI foi fixada com duas placas anteriores. No grupo ParCF, a ASI foi fixada com dois parafusos iliossacrais no corpo da primeira vertebra sacral (S1). A rigidez e carga máxima suportada por cada montagem realizada, foi mensurada. A análise estatística foi realizada através do teste U de Mann-Whitney (p< 0.05 foi considerado estatisticamente significativo para todas as análises). Resultados A carga máxima suportada até a falha da fixação pelos grupos PlaCF e ParCF foram respectivamente 940 ± 75 N e 902 ± 56 N, não havendo diferença estatística entre eles. A rigidez obtida pelo grupo ParCF foi maior e com diferença estatística em relação ao grupo PlaCF (68.6 ± 11.1 N/mm e 50 ± 4.0 N/mm respectivamente). Conclusão Apesar da menor rigidez obtida no grupo PlaCF, as placas anteriores à ASI podem ser uma ótima opção no tratamento da luxação sacroilíaca quando os parafusos iliossacrais não puderem ser utilizados. Outros estudos são necessários para detectar possíveis diferenças entre os dois procedimentos do ponto vista cirúrgico e clínico.

Accuracy of the Applied Kinesiology Muscle Strength Test for Sacroiliac Dysfunction / Acurácia do teste de força muscular da cinesiologia aplicada para disfunção sacroilíaca

Abstract Objective To investigate the accuracy of the applied kinesiology muscle strength test for sacroiliac dysfunction and compared it with four validated orthopedic tests. Methods This is a cross-sectional accuracy survey developed at a private practice in the city of Manaus, Brazil, during February 2017. The sample consisted of 20 individuals, with a median age of 33.5 years. Four tests were applied: distraction, thigh thrust, compression and sacral thrust, and the diagnosis was confirmed when three of these tests were positive. Soon after, the applied kinesiology test was applied to the piriformis muscle. Results The prevalence of sacroiliac joint dysfunction was of 45%; the thigh thrust test had the highest specificity, and the sacral thrust test had the highest sensitivity. The applied kinesiology test presented good results (sensitivity: 0.89; specificity: 0.82; positive predictive value: 0.80; negative predictive value: 0.82; accuracy: 0.85; and area under the receiver operating characteristic [ROC] curve: 0.85). Conclusion The applied kinesiology muscle strength test, which has great clinical feasibility, showed good accuracy in diagnosing sacroiliac joint dysfunction and greater discriminatory power for the existing dysfunction in comparison to other tests.

Resumo Objetivo Investigar a acurácia do teste de força muscular da cinesiologia aplicada para disfunção sacroilíaca, comparando-o com quatro testes ortopédicos validados. Métodos Trata-se de uma pesquisa transversal de acurácia desenvolvida em uma clínica particular da cidade de Manaus no mês de fevereiro de 2017. A amostra teve 20 indivíduos, com mediana de idade 33,5 anos. Foram aplicados quatro testes: distração, thigh thrust, compressão e thrust sacral, e o diagnóstico foi confirmado quando três destes testes deram positivo. Logo após, foi aplicado o teste da cinesiologia aplicada para o músculo piriforme. Resultados A prevalência de disfunção da articulação sacroilíaca observada foi de 45%, tendo o teste thigh thrust alta especificidade, e o teste thrust sacral, alta sensibilidade. O teste da cinesiologia aplicada obteve bons resultados (sensibilidade: 0,89; especificidade: 0,82; valor preditivo positivo: 0,80; valor preditivo negativo: 0,82; acurácia: 0,85; área abaixo da curva de característica de operação do receptor [COR]: 0,85). Conclusão O teste de força muscular da cinesiologia aplicada, de grande viabilidade clínica, mostrou ter boa acurácia no diagnóstico da disfunção da articulação sacroilíaca, e maior poder discriminatório da disfunção existente, em comparação aos demais testes.

Dolor sacroilíaco: epidemiología, fisiopatología, diagnóstico y tratamiento / Sacroiliac pain: epidemiology, physiopathology, diagnosis and treatment

El dolor sacroilíaco es una causa generalmente subdiagnosticada de dolor lumbar, que afecta del 15% a 30% de los pacientes con dolor lumbar bajo crónico no radicular. La articulación sacroilíaca (ASI) recibe continuo stress durante la bipedestación y marcha, siendo estabilizada por estructuras ligamentarias, capsulares y miofasciales fuertes, que reciben una abundante inervación. Destaca la dificultad en el diagnóstico del dolor sacroilíaco; debido a su naturaleza heterogénea. Éste se debe sospechar en todo paciente con síndrome de dolor lumbar no radicular, unilateral y no central. El examen físico debería descartar patología de cadera y columna lumbar. La realización de maniobras de provocación del dolor sacroilíaco aporta en el diagnóstico, teniendo la combinación de 3 o más maniobras positivas una sensibilidad de 85% y especificidad de 79%. Se ha recurrido a inyecciones diagnósticas con anestésicos locales, tanto intraarticulares como de ligamentos circundantes. El tratamiento del dolor sacroilíaco es multimodal e individualizado para cada paciente. El tratamiento conservador­basado en terapia física y antiinflamatorios no esteroidales­ es la terapia de primera línea. Las infiltraciones esteroidales tanto intra como extraarticulares pueden proveer alivio en un grupo de pacientes con inflamación activa. La denervación de los ramos dorsales laterales con radiofrecuencia ha mostrado ser un tratamiento exitoso en pacientes con dolor sacroilíaco, logrando 6 meses a 1 año de alivio del dolor. En pacientes con dolor refractario, la fusión de la articulación sacroilíaca es una opción, prefiriéndose la técnica mínimamente invasiva de fijación trans-sacroilíaca.

Sacroiliac pain is an frecuent underdiagnosed source of low back pain, affecting 15% to 30% of individuals with chronic, non-radicular pain. The sacroiliac joint (SIJ) is subject to continuous stress during standing position and gait, being stabilized by strong ligament, capsular and myofascial structures with rich innervation. Due to its heterogeneous nature, SIJ pain is difficult to diagnose, and it should be suspected in all patients with non-radicular unilateral and non-central low back pain syndrome. Physical examination should rule out hip and lumbar spine pathology. SIJ provocation maneuvers are used for diagnosis, with the combination of 3 or more positive maneuvers resulting in a sensitivity of 85% and a specificity of 79%. Diagnostic injections of local anesthetics, both intra-articular and in the surrounding ligaments have been used. treatment of SIJ pain is multimodal and individualized for each patient. Conservative treatment, based on physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs) is the first line therapy. Both intra- and extra-articular steroid infiltrations can provide relief in a group of patients with active inflammation. Radiofrequency denervation of lateral dorsal branches has proven to be a successful treatment in SIJ pain patients, achieving 6 to 12 months of pain relief. In patients with refractory pain, SIJ fusion is an option, with minimally invasive trans-sacroiliac fixation being the preferred technique.

Acetabular ventroversion using the sacroiliac wedge, with or without pelvic osteotomies in dogs: an ex vivo study / Ventroversão acetabular associada ou não a osteotomias pélvicas por meio da utilização de cunha sacroilíaca em cães: estudo ex-vivo

Canine hip dysplasia (CHD) is a common condition observed in the surgical clinics for small animals. Among the surgical techniques for management of CHD, triple pelvic osteotomy and sacroiliac wedge promote acetabular lateral axial rotation (ventroversion), increasing acetabular coverage and joint stability. The present study aimed to evaluate radiographically, by measuring the Norberg angle (NA) and the acetabular coverage percentage (ACP), the acetabular ventroversion induced by the sacroiliac wedge technique, with or without pelvic osteotomies; we also checked the feasibility of wedges made of polyamide with an angulation of 20° and 30°. The software used to measure NA and ACP was AutoCAD® 2009. Pelves from 10 canine corpses were evaluated radiographically at four time-points: M0 (Control Group), M1 (wedges of 20° and 30°), M2 and M3 (wedges associated with bilateral pubis and ischium osteotomies, respectively). There was no significant increase in the acetabular ventroversion at M1, M2, and M3. The polyamide sacroiliac wedge technique proved to be feasible, stable, and easy to apply. Further, the software proved to be efficient and easy to use for NA and ACP measurements. In the present study, even in the cases of non-dysplasic adult canine corpses, it was concluded that the sacroiliac wedge technique does not require to be accompanied by pubis and ischial osteotomies because they did not significantly increase the NA and ACP.(AU)

A displasia coxofemoral (DCF) é afecção comum na clínica cirúrgica de pequenos animais. Entre as técnicas cirúrgicas para controle da DCF, a osteotomia pélvica tripla (OPT) e a cunha sacroilíaca (CSI), promovem rotação lateral acetabular no eixo axial (ventroversão), aumentando a cobertura acetabular e a estabilidade da articulação. Desta forma, o presente estudo objetivou avaliar radiograficamente, por meio da aferição do ângulo de Norberg (NA) e da porcentagem de cobertura acetabular (PCA), a ventroversão acetabular induzida pela técnica da cunha sacroilíaca, associada ou não às osteotomias pélvicas, além de verificar a exequibilidade das cunhas confeccionadas de poliamida com angulação de 20ο e 30ο. O software utilizado para aferir o AN e o PCA foi o AutoCAD® 2009. Dez pelves de cadáveres caninos foram avaliadas radiograficamente em quatro momentos: MO (Grupo Controle), M1 (cunhas de 20ο e 30ο), M2 e M3 (cunhas associadas à osteotomia bilateral do púbis e ísquio, respectivamente). Não houve aumento significativo da ventroversão em M1, M2 e M3. A técnica de cunha sacroilíaca de poliamida mostrou-se exequível, estável e de fácil aplicação. Não obstante, o software utilizado mostrou-se eficiente e de fácil utilização nas aferições do AN e PCA. Neste estudo, mesmo tratando-se de cadáveres de cães adultos e de maioria não displásicos, concluiu-se que a utilização da técnica de cunha sacroilíaca não necessita de associação à ostectomia púbica e a osteotomia do ísquio por não promoverem aumento significativo do AN e da PCA.(AU)

Radiologic Comparison of the Sacroiliac Joint Degeneration Following Lumbar or Lumbosacral Fusion / 대한척추외과학회지

STUDY DESIGN: Retrospective study.OBJECTIVES: To compare the degeneration of sacroiliac joint (SIJ) following lumbar or lumbosacral fusion.SUMMARY OF LITERATURE REVIEW: The SIJ is adjacent to lumbosacral junction and its degeneration can be the potential cause of pain. However, the study addressing SIJ degeneration following lumbar or lumbosacral fusion is very limited.MATERIALS AND METHODS: From June 2002 to June 2012, 98 patients who underwent posterior decompression and posterolateral fusion were included in this study. The study group was divided into 2 groups according to the range of fusion. Group A had fusion to L5 and included 34 patients. Group B had fusion to S1 and included 64 patients. We evaluated the five years postoperative radiologic and clinical outcomes retrospectively.RESULTS: There was no statistically significant difference of bilateral preoperative subchondral sclerosis and osteophytes of the SIJ between group A and group B. However, group B revealed statistically significant subchondral sclerosis and osteophyte formation of the SIJ than group A on every radiographs after postoperative 1 year. In group B, the number of fusion segments and age were statistically positively correlated with the degeneration of the SIJ.CONCLUSIONS: Degeneration of the SIJ revealed more rapid and more severe progression in lumbosacral fusion group than in lumbar fusion group. The number of fusion segments and age were positively correlated with the degeneration of the SIJ in lumbosacral fusion group. Therefore, these facts should be taken into account when performing spinal fusion.

Treatment of sacroiliac joint dislocation by Zhuang medicine tendon therapy combined with chiropractic manipulation / 中国骨伤

OBJECTIVE@#To analyze the clinical effect of Zhuang medicine tendon therapy combined with chiropractic manipulation in treating sacroiliac joint dislocation.@*METHODS@#From January 2017 to May 2018, 60 patients with sacroiliac joint dislocation were divided into treatment group and control group according to the order of admission. There were 19 males and 11 females in the treatment group, aged from 23 to 52 (38.97±3.23) years old, with a course of 2 h to 5.1 months, with an average of (2.19±1.12) months. There were 14 males and 16 females in the control group, aged from 26 to 50 (39.07±3.30) years old, with a course of 3 h to 6 months, with an average of(2.41±1.05) months. The treatment group was treated with Zhuang medicine tendon therapy combined with chiropractic manipulation, while the control group was treated with conventional acupuncture and massage. Before treatment, the main clinical symptoms of the patients were lumbosacral pain, posterior superior iliac spine not at the same level and accompanied with dyskinesia. The pelvic separation test and the "4" test were positive. After treatment, the curative effect was evaluated according to the improved Macnab standard and the "score of treatment of lumbar diseases".@*RESULTS@#Sixty patients were followed up for an average of 8 months. At the latest follow-up, the clinical effect of modified Macnab was better in the treatment group than in the control group(<0.01). After treatment, the treatment group was better than the control group on lumbar function score (<0.01).@*CONCLUSIONS@#The treatment of sacroiliac joint dislocation by Zhuang medicine tendon therapy combined with chiropractic manipulation has good clinical effect and is worth further application and development.

Multiple intraosseous cervical pneumatocysts: A case report of a rare incidental finding on cone-beam computed tomography

This report presents a case of cervical pneumatocysts as an incidental finding on cone-beam computed tomography. Pneumatocysts are gas-containing lesions of unknown etiology. They usually present in the ilium or sacrum, adjacent to the sacroiliac joint. In the literature, 21 case reports have described cervical pneumatocysts. Cervical pneumatocysts should be differentiated from other lesions, such as osteomyelitis, osteonecrosis, and neoplasms, as well as post-traumatic and post-surgical cases. Computed tomography, cone-beam computed tomography, and magnetic resonance imaging are appropriate tools to diagnose cervical pneumatocysts.

Enthesitis-related Arthritis

Enthesitis-related arthritis (ERA) is a disease predominantly affecting the joints and entheses of the lower extremities and has the potential to eventually affect the sacroiliac joints and spine evolving to juvenile ankylosing spondylitis. ERA is also characterized by rheumatoid factor seronegativity, paucity of antinuclear antibody, and a strong association with the human leukocyte antigen-B27. ERA accounts for a higher proportion of juvenile idiopathic arthritis (JIA) cases in the Asian population compared to other populations. Advances in the understanding of ERA pathogenesis continue to progress and have led to the development of new treatments targeting pro-inflammatory cytokines. In particular, tumor necrosis factor-α inhibitors have become a mainstay of therapy for patients in whom therapy with anti-inflammatory drugs and/or disease-modifying anti-rheumatic drugs are inadequate or contraindicated. Compared to other JIA subtypes, ERA is associated with a poorer quality of life, worse function, and a higher likelihood of ongoing active disease after the initial treatment. Because the current guidelines for the management of ERA is not considered separately from other categories of JIA, there is a need for treatment guidelines specific to ERA to improve the overall disease outcomes.

Sacral Insufficiency Fractures: How to Classify?

OBJECTIVE: The diagnosis of insufficiency fractures of the sacrum in an elder population increases annually. Fractures show very different morphology. We aimed to classify sacral insufficiency fractures according to the position of cortical break and possible need for intervention.METHODS: Between January 1, 2008 and December 31, 2014, all patients with a proven fracture of the sacrum following a low-energy or an even unnoticed trauma were prospectively registered : 117 females and 13 males. All patients had a computer tomography of the pelvic ring, two patients had a magnetic resonance imaging additionally : localization and involvement of the fracture lines into the sacroiliac joint, neural foramina or the spinal canal were identified.RESULTS: Patients were aged between 46 and 98 years (mean, 79.8 years). Seventy-seven patients had an unilateral fracture of the sacral ala, 41 bilateral ala fractures and 12 patients showed a fracture of the sacral corpus : a total of 171 fractures were analyzed. The first group A included fractures of the sacral ala which were assessed to have no or less mechanical importance (n=53) : fractures with no cortical disruption (“bone bruise”) (A1; n=2), cortical deformation of the anterior cortical bone (A2; n=4), and fracture of the anterolateral rim of ala (A3; n=47). Complete fractures of the sacral ala (B; n=106) : parallel to the sacroiliac joint (B1; n=63), into the sacroiliac joint (B2; n=19), and involvement of the sacral foramina respectively the spinal canal (B3; n=24). Central fractures involving the sacral corpus (C; n=12) : fracture limited to the corpus or finishing into one ala (C1; n=3), unidirectional including the neural foramina or the spinal canal or both (C2; n=2), and horizontal fractures of the corpus with bilateral sagittal completion (C3; n=8). Sixty-eight fractures proceeded into the sacroiliac joint, 34 fractures showed an injury of foramina or canal.CONCLUSION: The new classification allowes the differentiation of fractures of less mechanical importance and a risk assessment for possible polymethyl methacrylate leaks during sacroplasty in the direction of the neurological structures. In addition, identification of instable fractures in need for laminectomy and surgical stabilization is possible.

Freehand S2 Alar-Iliac Screw Placement Using K-Wire and Cannulated Screw: Technical Case Series

OBJECTIVE: Among the various sacropelvic fixation methods, S2 alar-iliac (S2AI) screw fixation has several advantages compared to conventional iliac wing screw. However, the placement of S2AI screw still remains a challenge. The purpose of this study was to describe a novel technique of free hand S2AI screw insertion using a K-wire and cannulated screw, and to evaluate the accuracy of the technique.METHODS: S2AI screw was inserted by free hand technique in sixteen consecutive patients without any fluoroscopic guidance. The gearshift was advanced to make a pilot hole passing through the sacroiliac joint and directing the anterior inferior iliac spine. A K-wire was placed through the pilot hole. After introducing a cannulated tapper along with the K-wire, a cannulated S2AI screw was installed over the K-wire.RESULTS: Thirty-three S2AI screws were placed in sixteen consecutive patients. Thirty-two screws were cannulated screws, and one screw was a conventional non-cannulated screw. Thirty out of 32 (93.8%) cannulated screws were accurately positioned, whereas two cannulated screws and one non-cannulated screw violated lateral cortex of the ilium.CONCLUSION: The technique using K-wire and cannulated screw can provide accurate placement of free hand S2AI screw.

Sacral Insufficiency Fractures: How to Classify?

OBJECTIVE: The diagnosis of insufficiency fractures of the sacrum in an elder population increases annually. Fractures show very different morphology. We aimed to classify sacral insufficiency fractures according to the position of cortical break and possible need for intervention. METHODS: Between January 1, 2008 and December 31, 2014, all patients with a proven fracture of the sacrum following a low-energy or an even unnoticed trauma were prospectively registered : 117 females and 13 males. All patients had a computer tomography of the pelvic ring, two patients had a magnetic resonance imaging additionally : localization and involvement of the fracture lines into the sacroiliac joint, neural foramina or the spinal canal were identified. RESULTS: Patients were aged between 46 and 98 years (mean, 79.8 years). Seventy-seven patients had an unilateral fracture of the sacral ala, 41 bilateral ala fractures and 12 patients showed a fracture of the sacral corpus : a total of 171 fractures were analyzed. The first group A included fractures of the sacral ala which were assessed to have no or less mechanical importance (n=53) : fractures with no cortical disruption (“bone bruise”) (A1; n=2), cortical deformation of the anterior cortical bone (A2; n=4), and fracture of the anterolateral rim of ala (A3; n=47). Complete fractures of the sacral ala (B; n=106) : parallel to the sacroiliac joint (B1; n=63), into the sacroiliac joint (B2; n=19), and involvement of the sacral foramina respectively the spinal canal (B3; n=24). Central fractures involving the sacral corpus (C; n=12) : fracture limited to the corpus or finishing into one ala (C1; n=3), unidirectional including the neural foramina or the spinal canal or both (C2; n=2), and horizontal fractures of the corpus with bilateral sagittal completion (C3; n=8). Sixty-eight fractures proceeded into the sacroiliac joint, 34 fractures showed an injury of foramina or canal. CONCLUSION: The new classification allowes the differentiation of fractures of less mechanical importance and a risk assessment for possible polymethyl methacrylate leaks during sacroplasty in the direction of the neurological structures. In addition, identification of instable fractures in need for laminectomy and surgical stabilization is possible.

Freehand S2 Alar-Iliac Screw Placement Using K-Wire and Cannulated Screw: Technical Case Series

OBJECTIVE: Among the various sacropelvic fixation methods, S2 alar-iliac (S2AI) screw fixation has several advantages compared to conventional iliac wing screw. However, the placement of S2AI screw still remains a challenge. The purpose of this study was to describe a novel technique of free hand S2AI screw insertion using a K-wire and cannulated screw, and to evaluate the accuracy of the technique. METHODS: S2AI screw was inserted by free hand technique in sixteen consecutive patients without any fluoroscopic guidance. The gearshift was advanced to make a pilot hole passing through the sacroiliac joint and directing the anterior inferior iliac spine. A K-wire was placed through the pilot hole. After introducing a cannulated tapper along with the K-wire, a cannulated S2AI screw was installed over the K-wire. RESULTS: Thirty-three S2AI screws were placed in sixteen consecutive patients. Thirty-two screws were cannulated screws, and one screw was a conventional non-cannulated screw. Thirty out of 32 (93.8%) cannulated screws were accurately positioned, whereas two cannulated screws and one non-cannulated screw violated lateral cortex of the ilium. CONCLUSION: The technique using K-wire and cannulated screw can provide accurate placement of free hand S2AI screw.

Ultrasound-Guided Injections in the Lumbar and Sacral Spine / 대한척추외과학회지

STUDY DESIGN: Literature review. OBJECTIVE: Ultrasound-guided injections are a common clinical treatment for lower lumbosacral pain that are usually performed before surgical treatment if conservative treatment fails. The aim of this article was to review ultrasound-guided injections in the lumbar and sacral spine. SUMMARY OF LITERATURE REVIEW: Ultrasound-guided injections, unlike conventional interventions using computed tomography or C-arm fluoroscopy, can be performed under simultaneous observation of muscles, ligaments, vessels, and nerves. Additionally, they have no radiation exposure and do not require a large space for the installation of equipment, so they are increasingly selected as an alternative method. MATERIALS AND METHODS: We searched for and reviewed studies related to the use of ultrasound-guided injections in the lumbar and sacral spine. RESULTS: In order to perform accurate ultrasound-guided injections, it is necessary to understand the patient's posture during the intervention, the relevant anatomy, and normal and abnormal ultrasonographic findings. Facet joint intra-articular injections, medial branch block, epidural block, selective nerve root block, and sacroiliac joint injections can be effectively performed under ultrasound guidance. CONCLUSIONS: Ultrasound-guided injections in the lumbar and sacral spine are an efficient method for treating lumbosacral pain.

Topographic MRI evaluation of the sacroiliac joints in patients with axial spondyloarthritis / Avaliação topográfica das articulações sacroilíacas por ressonância magnética em pacientes com espondiloartrite axial

Abstract Objective: To evaluate the imaging features of spondyloarthritis in magnetic resonance imaging (MRI) of the sacroiliac (SI) joint and topography (in thirds) and affected margin, considering that this issue is rarely addressed in the literature. Methods: A cross-sectional study evaluating MRI (1.5 T) of SI in 16 patients with axial spondyloarthritis, for the presence of acute (subchondral bone edema, enthesitis, synovitis and capsulitis) and chronic (erosions, subchondral bone sclerosis, bony bridges, and fatty infiltration) changes, performed by two blinded radiologists. MRI findings were correlated with clinical data, including age, duration of disease, medications, HLA-B27, BASDAI, ASDAS-ESR and ASDAS-CRP, BASMI, BASFI, and mSASSS. Results: Bone edema pattern and erosions were predominant in the upper third of SI (p = 0.050 and p = 0.0014, respectively). There was a correlation between disease duration and structural changes by affected third (p = 0.028-0.037), as well as between the presence of bone bridges with BASMI (p = 0.028) and mSASSS (p = 0.014). Patients with osteitis in the lower third showed higher values for ASDAS (ESR: p = 0.011 and PCR: p = 0.017). Conclusion: Chronic inflammatory changes and the pattern of bone edema predominated in the upper third of SI, but a simultaneous involvement of middle or lower thirds of the joint was also noted. The location of involvement in the upper third of SI is insufficient to differentiate between degeneration and inflammation.

Resumo Objetivo: Avaliar as características de imagem das espondiloartrites na ressonância magnética (RM) das articulações sacroilíacas (SI) quanto à topografia (em terços) e margem acometida, uma vez que esse aspecto é pouco abordado na literatura. Métodos: Estudo transversal com avaliação por RM (1,5 T) das SI em 16 pacientes com diagnóstico de espondiloartrite axial quanto à presença de alterações agudas (edema ósseo subcondral, entesite, sinovite e capsulite) e crônicas (erosões, esclerose óssea subcondral, ponte óssea e substituição gordurosa), feita por dois radiologistas, cegos para os dados clínicos. Os achados da RM foram correlacionados com dados clínicos, incluindo idade, tempo de doença, medicações, HLA-B27, BASDAI, ASDAS-VHS e ASDAS-PCR, BASMI, BASFI e mSASSS. Resultados: Padrão de edema ósseo e erosões apresentaram predomínio no terço superior das SI (p = 0,050 e p = 0,0014, respectivamente). Houve correlação entre o tempo de doença e alterações estruturais por terço acometido (p = 0,028-0,037), bem como a presença de pontes ósseas com o BASMI (p = 0,028) e o mSASSS (p = 0,014). Pacientes com osteíte no terço inferior apresentaram maiores valores de ASDAS (VHS: p = 0,011 e PCR: p = 0,017). Conclusão: As alterações inflamatórias crônicas e o padrão de edema ósseo predominaram no terço superior das SI, mas também havia acometimento concomitante dos terços médio ou inferior da articulação. A localização do acometimento no terço superior das SI se mostra insuficiente para a diferenciação entre degeneração e inflamação.

Posterior sacroiliac osteotomy: an alternative to the ilioinguinal approach for pelvic reconstruction in misalignment lesions / Osteotomia sacroilíaca posterior: uma opção ao acesso ilioinguinal na reconstrução pélvica em lesões inveteradas

Abstract Pelvic ring fractures occur in association with potentially fatal lesions, whose treatment is a priority in the polytrauma setting. As consequence, the definitive orthopedic approach may be postponed, leading patients to chronic and potentially disabling deformities. The treatment of these deformities is a challenge, requiring highly complex and staged surgical reconstructions. The ilioinguinal approach has been widely used in these surgeries, because it allows the release and mobilization of the hemipelvis and, in some cases, anterior fixation of the sacroiliac joint. However, in most cases, stable pelvic ring reconstruction requires this approach to be complemented by two other surgical approaches (posterior longitudinal and Pfannestiel). This requirement critically increases the surgical time and the risk of complications, such as neurovascular lesions and surgical wound infection. The current study presents a posterior osteotomy technique for posterior and anterior release of the sacroiliac joint, eliminating the need for ilioinguinal approach. The technique is performed by posterior longitudinal access; it allows adequate mobilization of the hemipelvis and reduction of vertical and rotational deformities, before the spinopelvic fixation and reduction of the pubic symphysis.

Resumo As fraturas do anel pélvico ocorrem em associação com lesões potencialmente graves, cujotratamento é prioritário no cenário de atendimento ao politraumatizado. Como consequên-cia, a abordagem ortopédica definitiva pode ser postergada, fazendo com que os pacientes seapresentem com deformidades inveteradas e potencialmente incapacitantes. O tratamentodessas deformidades é um desafio, requer reconstruções cirúrgicas estagiadas e altamentecomplexas. O acesso ilioinguinal tem sido amplamente usado nessas cirurgias, pois permitea liberação e mobilização da hemipelve e, em alguns casos, a fixação anterior da articulaçãosacroilíaca. Entretanto, na maioria das vezes, uma reconstrução estável requer que esseacesso seja usado em associação com outros dois acessos cirúrgicos (longitudinal posteriore Pfannestiel), o que aumenta sobremaneira o tempo cirúrgico e o risco de complicações,como lesões neurovasculares e infecção da ferida operatória. No presente estudo, apresenta-mos uma técnica de osteotomia posterior para liberação posterior e anterior da articulaçãosacroilíaca que elimina a necessidade de uso do acesso ilioinguinal. A técnica é feita peloacesso longitudinal posterior e permite mobilização adequada da hemipelve e redução dedeformidades verticais e rotacionais antes da fixação espinopélvica e redução da sínfisepúbica.