Outcome of distraction interference arthrodesis of the sacroiliac joint for sacroiliac arthritis

Background:

After lumbar or lumbosacral fusion for various spine disorders, adjacent segment disease has been reported. Most of the studies have focused on proximal segment disease. The author has reported sacroiliac joint degeneration in these patients. Based on our own experiences with an increasing number of patients with sacroiliac joint (SIJ) arthralgia after multi-level lumbar or lumbosacral fusion procedures, we evaluated a surgical procedure called distraction arthrodesis of the SIJ for patients with refractory severe pain of the SIJ.

Materials and Methods:

Nineteen (19) consecutive patients were recruited and evaluated prospectively after undergoing distraction arthrodesis of the SIJ. The inclusion criteria for the surgical procedure were degeneration of the SIJ and failed conservative treatment. Magnetic resonance imaging (MRI) scans and CT scans were performed in all cases. The clinical outcome was assessed using the Visual Analog Scale and the Oswestry Disability Index (ODI). CT scans were performed postoperatively and again at the final followup to evaluate assess fusion. The data was analyzed using the SPSS software (version 10.0; SPSS, Chicago, IL) and statistical analysis was performed. The P values were based on the Student t-test.

Results:

The mean followup was 13.2 months. All patients had an instrumented lumbar or lumbosacral fusion. The overall fusion rate of SIJ was 78.9% (15/19 joints). All patients demonstrated significant improvement in VAS and ODI scores compared to preoperative values. The mean VAS score was 8.5 before surgery and was 6 at final followup, demonstrating 30% improvement. The mean ODI scores were 64.1 before surgery and 56.97 at the final followup, demonstrating 12% improvement.

Conclusions:

Refractory sacroiliac pain as a result of multi-level fusion surgery can be successfully treated with minimally invasive arthrodesis. It offers a safe and effective treatment for severe SIJ pain. Careful patient selection is important.     

Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain

Mapping studies of pain elicited by injections into the sacroiliac joints (SIJs) suggest that sacroiliac joint syndrome (SIJS) may manifest as low back pain, sciatica, or trochanteric pain. Neither patient-reported symptoms nor provocative SIJ maneuvers are sensitive or specific for SIJS when SIJ block is used as the diagnostic gold standard. This has led to increasing diagnostic use of SIJ block, a procedure in which an anesthetic is injected into the joint under arthrographic guidance. However, several arguments cast doubt on the validity of SIJ block as a diagnostic gold standard. Thus, the effects of two consecutive blocks are identical in only 60% of cases, and the anesthetic diffuses out of the joint in 61% of cases, often coming into contact with the sheaths of the adjacent nerve trunks or roots, including the lumbosacral trunk (which may contribute to pain in the groin or thigh) and the L5 and S1 nerve roots. These data partly explain the limited specificity of SIJ block for the diagnosis of SIJS and the discordance between the pain elicited by the arthrography injection and the response to the block. The limitations of provocative maneuvers and SIJ blocks may stem in part from a contribution of extraarticular ligaments to the genesis of pain believed to originate within the SIJs. These ligaments include the expansion of the iliolumbar ligaments, the dorsal and ventral sacroiliac ligaments, the sacrospinous ligaments, and the sacrotuberous ligaments (sacroiliac joint lato-sensu). They play a role in locking or in allowing motion of the SIJs. Glucocorticoids may diffuse better than anesthetics within these ligaments. Furthermore, joint fusion may result in ligament unloading.     

Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge

Recently, the sacroiliac joint (SIJ) has gained increased attention as a source of persistent or new pain after lumbar/lumbosacral fusion. The underlying pathophysiology of SIJ pain may be increased mechanical load, iliac crest bone grafting, or a misdiagnosis of SIJ syndrome. Imaging studies show more frequent degeneration of the SIJ in patients with lumbar/lumbosacral fusion than in patients without such fusion. Using injection tests, it has been shown that SIJ pain is the cause of persistent symptoms in a considerable number of patients after fusion surgery. Recent articles reporting on surgical outcomes of SIJ fusion include a high percentage of patients who had lumbar/lumbosacral fusion or surgery before, although well-controlled clinical studies are necessary to assess the efficacy of surgical treatment. Taking these findings into consideration, the possibility that the SIJ is the source of pain should be considered in patients with failed back surgery syndrome after lumbar/lumbosacral fusion.     

Percutaneous sacroiliac joint arthrodesis: a novel technique

STUDY DESIGN: Consecutive case series. OBJECTIVE: To report a new percutaneous sacroiliac joint (SIJ) arthrodesis technique utilizing a Hollow Modular Anchorage screw. SUMMARY OF BACKGROUND DATA: A variety of SIJ arthrodesis techniques have been reported in the established academia to treat intractable SIJ pain. None combines minimal surgical exposure, instrumented fixation, and bone grating. METHODS: We describe a new percutaneous SIJ arthrodesis technique for patients with intractable SIJ pain. Preoperative and postoperative Oswestry Disability Index (ODI), Visual Analog Scale (VAS) for pain, and postoperative subjective patients' satisfaction were assessed for all patients. Minimum 2 years follow-up is documented. RESULTS: Nine patients underwent SIJ arthrodesis with the new technique. The mean ODI value dropped from 59 (range: 34 to 70) preoperatively to 45 (range: 28 to 60) postoperatively (P相似文献   

腰椎融合术后骶髂关节源性下腰痛的诊断和治疗

目的探讨腰椎融合术后骶髂关节病变的特点、治疗方法与疗效。方法回顾性分析34例因腰椎管狭窄、腰椎间盘突出、腰椎滑脱曾行后路减压、后外侧或椎体间植骨融合及椎弓根内固定术,术后随访12～48个月（平均30．6个月）出现新的难治性持续性下腰痛症状的病例。运用骶髂关节内封闭进行诊断性治疗。阳性标准：疼痛缓解75％（采用视觉模拟评分法进行定量分析）。结果阳性率为26．5％,术后腰痛部位不同于术前以及融合范围包含L5、S1是具有统计学意义（P〈0．05）。结论腰椎融合术后下腰痛可能部分是由骶髂关节病变引起的,骶髂关节内封闭是当前诊断和治疗骶髂关节源性下腰痛的最有效的方法。     

CT引导经皮置钉治疗病理性骶髂关节疼痛

目的：探讨在CT引导下经皮微创技术置入空心拉力螺钉治疗病理性骶髂关节疼痛。方法：骶髂关节转移肿瘤患者8例，男4例，女4例；年龄12～83岁，平均53岁。单侧转移5例，双侧3例。肺癌2例，乳腺癌1例，卵巢癌1例，非霍奇金淋巴瘤1例，横纹肌肉瘤1例，骨髓瘤1例，前列腺癌1例。试行在CT引导下经皮微创技术置入空心拉力螺钉稳定病理性骶髂关节不稳。术前和术后通过Ennek—ing疼痛评分进行比较。结果：8例均获随访，随访时间4个月～29个月，平均18．2个月。均1周内疼痛缓解，无并发症发生，3例术后6个月内死亡，余5例疼痛明显减轻。结论：CT引导下经皮置入空心拉力螺钉能有效缓解病理性骶髂关节不稳所致的疼痛。     

Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study

Background The sacroiliac joint (SIJ) can be a source of low back pain. Previous studies indicated that SIJ pain could originate from both the joint capsule and the posterior ligamentous tissues. It has not been clarified as to whether an intraarticular or periarticular injection procedure is more effective for this type of pain. The purpose of this study was to evaluate the effect of two injection procedures prospectively. Methods After a pain provocation test, an intraarticular injection of local anesthetic (2% lidocaine) was performed on the first 25 consecutive patients with SIJ pain and a periarticular injection on another 25. The periarticular injections were given to one or more sections of the posterior periarticular area of the SIJ and to another section in the extracranial portion. The effect of these injections was assessed using the “restriction of activities of daily life” scoring system from the Japanese Orthopaedic Association. Results The periarticular injection was effective in all patients, but the intraarticular one was effective in only 9 of 25 patients. An additional periarticular injection was performed in 16 patients who experienced no effect from the initial intraarticular injection and was considered effective in all of them. The injection into the middle of the periarticular area was more effective for SIJ pain. The improvement rate after the periarticular injection was 96%, which was significantly higher than that after the intraarticular injection, which was 62%. Conclusions For patients with SIJ pain, periarticular injection is more effective and easier to perform than the intraarticular injection and should be tried initially.     

CT-guided sacroiliac joint injections.

Confusion surrounding low back pain syndrome may partially be resolved in a select small group of patients by instituting a provocative intraarticular injection of a combination of a local anesthetic and a steroid. This approach enables one to determine whether the sacroiliac joint (SIJ) is the site of origin of the low back pain syndrome. We carried out a study of 71 computed tomography (CT)-guided injections in 58 patients with noninflammatory etiology. The injection was confirmatory to the SIJ abnormalities in 64 (90.1%) joints. The effect wore off in 2-14 days in 90% of the patients. We conclude that CT guidance is the best method of precise needle placement, and thus CT-guided anesthetic injection is the most specific confirmatory test for diagnosing the SIJ arthritis. In addition, in noninflammatory conditions, the role of intraarticular injection is primarily for diagnostic purposes and it has little or no therapeutic benefit.     

Anterior approach and stabilization of the disrupted sacroiliac joint

Pelvic fractures with disruption of the important weight-bearing sacroiliac area can lead to impaired gait due to malunion or pelvic obliquity, back or buttock pain arising from the sacroiliac joint, and permanent neurologic damage. In eight patients with sacroiliac joint dislocation, an anterior retrofascial approach and stapling of the sacroiliac joint was performed. Six of these patients maintained an anatomic reduction of the sacroiliac joint and their results were rated as excellent. Two of the eight patients had a slight loss of reduction and because of intermittent mild pain were rated as having fair results. In another eight patients, plate fixation of the anterior sacroiliac joint was done. New stabilization methods utilizing dynamic compression plates, reconstruction plates, and a new four-hole plate have been developed to provide more secure fixation of these unstable injuries.     

An alternate method of radiofrequency neurotomy of the sacroiliac joint: a pilot study of the effect on pain, function, and satisfaction

BACKGROUND AND OBJECTIVES: The sacroiliac joint (SIJ) can be a source of chronic refractory mechanical spine pain. Few previous studies have described radiofrequency (RF) sensory denervation of the SIJ; results have been inconsistent and technically demanding. This uncontrolled, prospective, cohort study evaluates the effects of an innovative method of RF ablation of the posterior sensory nerves of the SIJ on pain, analgesic use, disability, and satisfaction of patients suffering with chronic mechanical SIJ pain. METHODS: Nine subjects with SIJ pain, confirmed by a local anesthetic joint block, were studied. Subjects were treated with a series of RF strip lesions performed adjacent to the lateral dorsal foraminal aperture plus conventional monopolar lesioning at the L5 dorsal ramus. Each subject completed a questionnaire twice before and at 1, 3, 6, 9, and 12 months after the procedure. The questionnaire evaluated pain intensity and frequency, analgesic intake, disability, satisfaction (with current pain level and the RF procedure), and procedure complications. Data were analyzed by using linear mixed model analysis. RESULTS: After the procedure, significant reductions of back and leg pain frequency and severity, analgesic intake, and dissatisfaction with their current level of pain occurred. Complications were minimal. Overall, 8 of 9 subjects were satisfied with the procedure. CONCLUSIONS: RF sensory ablation of the SIJ using bipolar strip lesions is a technically uncomplicated and low-risk procedure. The resulting effects on pain, disability, and satisfaction are promising. Further evaluation of this technique, including randomized controlled trials, is recommended.     

Radiofrequency sacroiliac joint denervation for sacroiliac syndrome

BACKGROUND AND OBJECTIVES: Radiofrequency (RF) denervation of the sacroiliac (SI) joint has been advocated for the treatment of sacroiliac syndrome, yet no clinical studies or case series support its use. METHODS: We report the results of a consecutive series of 50 SI joint RF denervations performed in 33 patients with sacroiliac syndrome. All patients underwent diagnostic SI joint injections with local anesthetic before denervation. Changes in visual analog pain scores (VAS), pain diagrams, physical examination (palpation tenderness over the joint, myofascial trigger points overlying the joint, SI joint pain provocation tests, and range of motion of the lumbar spine), and opioid use were assessed pre- and postdenervation. RESULTS: The criteria for successful RF denervation were at least a 50% decrease in VAS for a period of at least 6 months; 36.4% of patients (12 of 33) met these criteria. Failure of denervation correlated with the presence of disability determination and pain on lateral flexion to the affected side. The average duration of pain relief was 12.0 +/- 1.2 months in responders versus 0.9 +/- 0.2 months in nonresponders (P < or = 0.0001). A positive response was associated with an atraumatic inciting event. Successful denervation was associated with a change in the pain diagram and a reduction in the pattern of referred pain, a normalization of SI joint pain provocation tests, and a reduction in the use of opioids. CONCLUSIONS: This study suggests that RF denervation of the SI joint can significantly reduce pain in selected patients with sacroiliac syndrome for a protracted time period. Moreover, certain abnormal physical findings (i.e., SI joint pain provocation tests) revert to normal for the duration of the analgesia.     

Diagram specific to sacroiliac joint pain site indicated by one-finger test

Background  The sacroiliac joint (SIJ) can be a source of low back and lower limb pain. The SIJ pain can originate not only from the joint space but also from the ligaments supporting the joint. Its diagnosis has been difficult because the physical and radiological examinations have proved less than satisfactory. Thus, to know the specific sites of SIJ pain, if these exist, could be very useful for making the diagnosis. The purpose of the present study was to identify the main site of SIJ pain according to the patient’s pointing with one finger and to confirm the site by a pain-provocation test and periarticular lidocaine injection. Methods  Forty-six of 247 consecutive patients with low back pain at our outpatient clinic, who could indicate with one finger the main site of the pain, which presented at only one site and was reproducible, were the subjects of this study. The main site of pain was anatomically confirmed by fluoroscopy. Then, a periarticular SIJ injection was performed. The patients were blindly assessed and a diagram of the main site of the SIJ pain was made. Results  There were 19 males and 27 females and the age averaged 50 years. Eight patients showed a positive placebo response and were excluded from this study. Twenty-five of the remaining 38 patients indicated the main site of pain at the posterior-superior iliac spine (PSIS) or within 2 cm of the PSIS, and 18 of these patients showed a positive effect with periarticular SIJ block. The other 13 patients, including 2 patients with a positive response to the periarticular block, did not show the PSIS as the main site of pain. Conclusions  Our study clearly indicated that when patients point to the PSIS or within 2 cm of it as the main site of low back pain, using one finger, the SIJ should be considered as the origin of their low back pain.     

Value of quantitative radionuclide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain

A prospective study was performed to compare the results of quantitative radionuclide bone scanning with those of sacroiliac joint anesthetic block in patients with unilateral low back pain. Thirty-four subjects, forming the control group, underwent quantitative radionuclide bone scanning of the sacroiliac joints. The normal values in sacroiliac uptake difference were taken to be between –1.7% and +6.2%. Thirty-two patients with chronic unilateral low back pain underwent sacroiliac bone scanning and sacroiliac joint block. Six of the seven patients with increased uptake > 6.2% on the painful side had at least 75% pain reduction in response to the block. The sensitivity, specificity, and positive and negative predictive values of the quantitative bone scanning in the unilateral mechanical sacroiliac joint syndrome were 46.1%, 89.5%, 85.7%, and 72%, respectively. Received: 21 July 1997 Revised: 17 November 1997 Accepted: 22 January 1998     

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.     

Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint.

BACKGROUND CONTEXT: The sacroiliac joint is known to be a possible cause of chronic low back pain, but the diagnosis and treatment of disorders of the sacroiliac joint have been difficult and controversial. PURPOSE: To describe the outcome of sacroiliac joint arthrodesis for sacroiliac joint disorders, with the hypothesis that sacroiliac arthrodesis leads to improved postoperative function. STUDY DESIGN/SETTING: Consecutive case series performed in an academic medical institution. PATIENT SAMPLE: The patient population consisted of 20 patients undergoing sacroiliac joint arthrodesis between December 1994 and December 2001. Patients undergoing concomitant procedures at the time of sacroiliac joint arthrodesis were excluded. The 3 men and 17 women in the study group had an average age of 45.1 years (range 21.8-66.4 years), a mean duration of symptoms of 2.6 years (range 0.5-8.0 years), and a mean follow-up period of 5.8 years (range 2.0-9.0 years). OUTCOME MEASURES: Outcome measures included general health and function, clinical evaluation, and radiographic assessment. METHODS: For all 20 patients, nonoperative treatment had failed, and for all, the diagnosis was confirmed by pain relief with intraarticular sacroiliac joint injections under fluoroscopic guidance. Sacroiliac joint arthrodesis (via a modified Smith-Petersen technique) was recommended only when a positive response to the injection was noted, and patients had recurrence of symptoms after the initial positive response. Preoperative and postoperative general health and function were assessed via the 36-item Short-Form (SF-36) Health Survey and American Academy of Orthopaedic Surgeons (AAOS) Modems Instrument, which were collected prospectively. Medical records and plain radiographs were reviewed retrospectively to determine the clinical and radiographic outcome. RESULTS: Multiple etiologies of sacroiliac symptoms were observed: sacroiliac joint dysfunction (13 patients), osteoarthritis (5 patients), and spondyloarthropathy and sacroiliac joint instability (1 each). Seventeen patients (85%) had solid fusion. Fifteen patients (75%) completed preoperative and postoperative SF-36 forms. Significant (p< or =.05) improvement occurred in the following categories: physical functioning, role physical, bodily pain, vitality, social functioning, role emotional, and neurogenic and pain indices. Improvement (not statistically significant) was also noted in general and mental health. CONCLUSIONS: For carefully selected patients, sacroiliac arthrodesis appears to be a safe, well-tolerated, and successful procedure, leading to significant improvement in functional outcome and a high fusion rate. To the authors' knowledge, the current report is the largest series to document the functional and radiographic outcome of sacroiliac joint arthrodesis.     

骶髂关节脱位及周围骨结构骨折的前后入路手术治疗特点

目的：探讨前后入路手术骶髂关节脱位及周围骨结构骨折的治疗特点。方法：自2006年1月至2012年9月,收治39例骶髂关节脱位及周围骨结构骨折患者,均进行手术治疗。其中男28例,女11例;年龄12-64岁,平均41．3岁。前入路手术处理17例,后入路手术治疗13例,前后联合入路9例。前入路取仰卧位,切开复位,用2块4孔重建钢板,横跨骶髂关节做固定。后入路取俯卧位,选择闭合或切开复位,在C形臂X线机透视下攻入1～2枚直径7．3nlFtl的60～75mm空心松质骨拉力螺丝钉。术后观察两组的并发症情况,参照Matta评分系统评价骨折复位情况,Majeed评分系统评价术后功能情况。结果：所有患者获随访,时间6～36个月。术后2~4周患者可在床上坐起,6周后可扶拐下地活动。术后随访期间未发现内固定松动及螺钉钢板断裂。x线片示除陈旧性骶髂骨骨折1例复位欠佳,其余骶髂关节脱位及周围骨折术后对位良好。根据Matta标准评定：优30例,良8例,可1例;根据Majeed功能评分标准,优14例,良20例,中4例,差1例。结论：经前后入路手术治疗骶髂关节脱位及周围骨结构骨折均有良好的治疗疗效,但需要根据脱位骨折的解剖部位及类型、移位的方向程度以及术前的复位程度,对术中复位的难易程度评估、固定强度等因素综合考虑来确定入路方式。     

Metabolic disturbances identified by SPECT-CT in patients with a clinical diagnosis of sacroiliac joint incompetence

Purpose

To establish the sensitivity and specificity of cross-sectional scintigraphy [single photon emission computed tomography (SPECT)] combined with computed X-ray tomography (CT) in the detection of sacroiliac joint (SIJ) mechanical dysfunction and evaluate reproducibility of reporting.

Methods

Patients with pelvic girdle pain either on the basis of peri-partum SIJ dysfunction or trauma were included. These patients were imaged with bone scintigraphy with hybrid imaging with SPECT/CT.

Results

The study group comprised 100 patients (72 females, 28 males). Trauma accounted for 52 % and the remainder were patients with peri-partum pain. Average age was 43 years and average length of history was >2 years. The major finding was increased uptake in the upper SIJ and posterior soft-tissues/ligaments. Hybrid imaging had a sensitivity of 95 % and specificity of 99 %. Positive predictive value was 99 % and negative predictive value 94 %. Power of the test was 1.0. Reproducibility of the test was good with kappa values of 0.85.

Conclusion

Hybrid imaging with SPECT/CT reproducibly demonstrates metabolic alterations around the SIJ in patients with SIJ dysfunction, which we have termed SIJ incompetence. The condition is more common than previously recognised and frequently occurs after trauma, which has not been reported previously.     

Sacroiliac joint fusion for chronic pain: a simple technique avoiding the use of metalwork

A previously undescribed method for posterior fusion of the sacroiliac joint (SIJ) utilizing the Cloward instrumentation is presented, suitable for cases with chronic pain and intact ligamental structures of the SIJ. The advantages of the method in comparison with other described options include minimal disturbance of the periarticular structures, avoidance of introduction of metalwork and preservation of the iliac crest contour. This technique has been used in five cases with follow-up longer than 2 years (mean 29 months, range 25–41 months). In all cases there was resolution of their painful symtomatology.     

创伤性耻骨联合分离合并骶髂复合体损伤的手术治疗

目的:探讨创伤性耻骨联合分离合并骶髂复合体损伤适应证、手术方法及疗效。方法:2002年3月-2004年6月,对20例创伤性耻骨联合分离合并骶髂复合体损伤患者,采用前路切开复位重建钢板内固定治疗耻骨联合分离和后路在CT引导下经皮空心拉力螺钉固定治疗骶髂复合体损伤。男12例,女8例;年龄18～65岁,平均42.6岁。通过影像学检查明确20例患者有34侧骨盆骶髂复合体损伤。按照AO骨盆环损伤方法分型:B型8例,其中B2型5例,B3型3例;C型12例,其中C1型4例,C2型5例,C3型3例。结果:20例均获随访,随访时间4～21个月,平均14.2个月。平均入院后第8天手术。前路手术时间平均150min,后路手术时间平均60min。前路术中平均失血200ml,后路术中平均失血30ml。20例共置入骶髂螺钉34枚。术后3周患者可扶双拐下地行走,3～4个月可完全负重行走,并逐渐恢复体力劳动。未发生神经损伤及螺钉断裂现象。耻骨联合分离患者术后影像学显示解剖学形态完全恢复,耻骨联合间隙<2cm。结论:前环耻骨联合分离时要考虑可能有后环骶髂复合体损伤存在。耻骨联合分离与骶髂关节损伤应分别根据具体情况采用相应的固定术式。