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.     

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.     

Single photon emission computerized tomography (SPECT) scan–positive facet joints and other spinal structures in a hospital-wide population with spinal pain

Background contextThe current criterion standard for zygapophyseal (facet) joint pain diagnosis is placebo-controlled triple comparative local anesthetic facet joint or medial branch blocks. Single photon emission computerized tomography (SPECT) scanning is a less invasive modality that has been widely used in patients with spinal pain for the diagnosis of facet joint arthritis. Previous studies have shown that SPECT results correlate well with response to facet joints steroid injections.PurposeTo evaluate the prevalence of SPECT scan–positive facet joints and other spinal areas in different age groups in a hospital-wide population with spinal pain.Study designRetrospective study.MethodsThis study included 534 patients who underwent a SPECT scan for spinal pain over 7.5 years in our hospital. All referrals from all doctors for any cervical or lumbar spinal pain were included, and the results were reviewed.ResultsA total of 486 patients (91.1%) had at least one positive abnormality on SPECT scan; 81.3% had increased uptake in different structures and regions of the spine. This included 42.8% increased uptake in the facet joint 29.8% in the vertebral bodies/end plates, and 5.9% in sacroiliac joints. The prevalence of increased uptake in the lumbosacral and cervical spine was 44% and 37%, respectively. When patients were divided into five age groups (below 40, 40–49, 50–59, 60–69, and 70 years and older), there was a significantly higher increased prevalence in advancing age groups.ConclusionsIn a hospital-wide population with spinal pain, there is a 42.88% prevalence of increased uptake in the facet joint on SPECT. The incidence increases significantly with advancing age. SPECT can play a role in investigating patients with spinal pain.     

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。     

Efficacy of Hylan G-F 20 versus 6-methylprednisolone acetate in painful shoulder osteoarthritis: a retrospective controlled trial

Shoulder osteoarthritis affect about 32% of patients over 60 years. Conservative treatment are recommended to restore shoulder function while shoulder arthroplasty remains the standard treatment for severe osteoarthritis. When conservative therapies fail and surgical approach is precluded, viscosupplementation with HA may be the treatment of choice. Currently, there is minimal information available comparing the results of Hylan G-F 20 and corticosteroid injections for the treatment of shoulder osteoarthritis. Therefore, the purpose of this study was to examine the results of these two treatments at specific time points with validated outcome measurements. Retrospective comparative cohort study. The study population included 84 patients, 51 of whom treated with Hylan G-F 20 and 33 with a corticosteroid. Gleno-humeral osteoarthritis was graded according to Samilson-Prieto classification and rotator cuff was assessed with MRI. Both groups received three injections 1 week apart and were evaluated using a Visual Analog Scale (VAS) for pain and satisfaction, the Shoulder Pain and Disability Index (SPADI) and the Constant-Murley scale. Outcomes were registered at 1, 3, and 6 months. The Hylan G-F 20 group showed a significant pain reduction (P < 0.05), improvement in the Constant-Murley, SPADI scores (P < 0.05), and satisfaction (P < 0.01) at all three follow-up times. Pain, clinical scores, and subjective satisfaction in the corticosteroid group improved in the first post treatment month only (P < 0.05) compared with the baseline. Overall, lower clinical advantages were found in patients with greater degree of osteoarthritis and rotator cuff tears. Intra-articular injections with Hylan G-F 20 are effective in reducing pain for up to 6 months in gleno-humeral osteoarthritis whereas corticosteroids injections resulte in improvement at 1 month only. In patients with severe osteoarthritis and/or full-thickness, RC tears results tended to be worse.     

The percutaneous stabilisation of the sacroiliac joint with hollow modular anchorage screws: a prospective outcome study

Purpose

The use of percutaneous iliosacral screw fixation as a treatment of sacroiliac joint pain has been reported to be successful. This study was a prospective single surgeon series to evaluate the short-term outcomes of patients who underwent percutaneous sacroiliac joint stabilisation.

Methods

Between July 2004 and February 2011, 73 patients underwent percutaneous sacroiliac joint fusion in our unit. All patients completed a short form (SF)-36 questionnaire, visual analogue pain score and Majeed scoring questionnaire prior to treatment and at last follow-up.

Results

55 patients (9 male and 46 female) completed follow-up. The average follow-up period was for 36.18 months (range 12–84). The mean preoperative SF-36 scores were 26.59 for physical health and 40.38 for mental health. The mean postoperative SF-36 scores were 42.93 for physical health and 52.77 for mental health. The mean visual analogue pain scores were 8.1 preoperative and 4.5 postoperative. The mean pelvic specific scoring were 36.9 preoperative and 64.78 postoperative. We noted that patients who had previous instrumented spinal surgery did significantly worse than those who had not. We had two nerve root-related complications.

Conclusion

We conclude that in selected patient group who respond positively to CT-guided injection, a percutaneous SI joint stabilisation is beneficial in effecting pain relief and functional improvement.     

Prospective,double-blind,randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us

Background contextThe prospective, double-blind, randomized, placebo-controlled study design is essential in the interventional spine literature to truly evaluate whether or not a procedure is effective.PurposeThis article will critically evaluate the highest quality interventional spine literature with strict interpretation of the results of these trials.Study designReview article.MethodsExtensive Medline/Pubmed searches and searches of the large review articles on the major interventional spine topics were performed to find all prospective, double-blind, randomized placebo-controlled trials in the English language interventional spine literature.ResultsFluoroscopically-guided lumbosacral transforaminal epidural corticosteroid injections are effiective in the treatment of acute/subacute lumbosacral radicular pain, and in preventing future surgeries. Injection of corticosteroid or Sarapin on the cervical or lumbar medical branch nerves is not effective. When done with proper technique, percutaneous radiofrequency lumbar and cervial medial branch neurotomy are both effective. Intraarticular sacrociliac joint corticosteroid injections are effective in patients with spondyloarthropathy. IDET is modestly effective in the treatment of lumbosacral discogenic pain in carefully selected patients. Percutaneous radio frequency neurotomy of the ramus communicans is effective in the treatment of lumbosacral discogenic pain. No firm conclusions can be drawn about cervical epidural corticosteroid injections, lumbosacral epidural corticosteroid injections for the treatment of chronic radicular pain, cervical or lumbosacral intraarticular zygapophysial joint corticosteroid injections for the treatment of degenerative zygapophysial joint pain, or intradiscal corticosteroid injections.ConclusionsThe prospective, double-blind, randomized placebo-controlled trials in the interventional spine literature demonstrate efficacy from several different procedures when properly performed on appropriate patients. Other procedures have been shown to lack efficacy, while inconclusive evidence exists from multiple other interventional spine procedures. Further details are discussed in the text.     

Efficacy and safety of Hylan G-F 20 in shoulder osteoarthritis with an intact rotator cuff. Open-label prospective multicenter study

ObjectiveTo evaluate the feasibility, safety, and symptomatic efficacy of intra-articular Hylan G-F 20 in patients with shoulder osteoarthritis and an intact rotator cuff.MethodsOpen-label, prospective, multicenter study in patients with pain scores on a visual analog scale (VAS) between 40/100 and 90/100. An intra-articular injection of 2 ml of Hylan G-F 20 was given under fluoroscopic guidance. A second injection was given after 1, 2, or 3 months in the event of inadequate pain relief. The primary evaluation criterion was the VAS pain score 3 months after the first injection. Follow-up was 6 months.ResultsOf 39 included patients, 33 received a first injection and, among these, 16 received a second injection; 29 patients completed the study. No serious or severe treatment-related adverse events were recorded. There were 10 mild or moderate adverse events in eight patients. The mean VAS pain score decreased from 61.2 mm at baseline to 37.1 mm after 3 months (P < 0.001), and the decrease was larger in the subgroup that required a single injection.ConclusionThis prospective study shows that treatment with one or two intra-articular injections of Hylan GF 20 in patients who have shoulder osteoarthritis and an intact cuff is feasible, safe, and probably effective. Viscosupplementation using Hylan G-F 20 may constitute a helpful treatment option in patients who have shoulder osteoarthritis with an intact rotator cuff.     

The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right

Background context It is a common practice to the link low back pain with protruding disc even when neurological signs are absent. Because pain caused by sacroiliac joint dysfunction can mimic discogenic or radicular low back pain, we assumed that the diagnosis of sacroiliac joint dysfunction is frequently overlooked. Purpose To assess the incidence of sacroiliac joint dysfunction in patients with low back pain and positive disc findings on CT scan or MRI, but without claudication or objective neurological deficits. Methods Fifty patients with low back pain and disc herniation, without claudication or neurological abnormalities such as decreased motor strength, sensory alterations or sphincter incontinence and with positive pain provocation tests for sacroiliac joint dysfunction were submitted to fluoroscopic diagnostic sacroiliac joint infiltration. Results The mean baseline VAS pain score was 7.8 ± 1.77 (range 5–10). Thirty minutes after infiltration, the mean VAS score was 1.3 ± 1.76 (median 0.000E+00 with an average deviation from median = 1.30) (P = 0.0002). Forty-six patients had a VAS score ranging from 0 to 3, 8 weeks after the fluoroscopic guided infiltration. There were no serious complications after treatment. An unanticipated motor block that required hospitalization was seen in four patients, lasting from 12 to 36 h. Conclusions Sacroiliac joint dysfunction should be considered strongly in the differential diagnosis of low back pain in this group of patients.     

Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome

The purpose of this retrospective study was to evaluate the clinical and radiological outcome of bilateral sacroiliac joint (SIJ) fusion, using a new technique, in patients with a chronic SIJ syndrome. Seventeen patients with chronic low back pain, with a positive response to specific diagnostic tests for the SIJ, were considered candidates for bilateral sacroiliac fusion. The surgical indication was based on the results of local anaesthetic joint infiltration, temporary external fixation or bone scan. Ten patients had had previous surgery on the lumbar spine. Bilateral posterior SIJ fusion was performed with internal fixation and decortication of the sacroiliac joint, using a separate approach to each joint. Local bone grafting was performed. At the time of follow-up (on average 39 months after surgery), 3 patients reported moderate or absent pain, 8 marked pain and 6 severe pain. Seven patients showed a symptomatic non-union; union occurred in only 6 cases. Eighteen percent of the patients were satisfied, but in the other 82% the results were not acceptable. Reoperation was performed in 65% of the patients. Our results with bilateral posterior SIJ fusion were disappointing, which may be related with difficulties in patient selection, as well as with surgical technique. Better diagnostic procedures and possibly other surgical techniques might provide more predictable results, but this remains to be demonstrated.     

Sacroiliac joint pain

The sacroiliac joint is a source of pain in the lower back and buttocks in approximately 15% of the population. Diagnosing sacroiliac joint-mediated pain is difficult because the presenting complaints are similar to those of other causes of back pain. Patients with sacroiliac joint-mediated pain rarely report pain above L5; most localize their pain to the area around the posterior superior iliac spine. Radiographic and laboratory tests primarily help exclude other sources of low back pain. Magnetic resonance imaging, computed tomography, and bone scans of the sacroiliac joint cannot reliably determine whether the joint is the source of the pain. Controlled analgesic injections of the sacroiliac joint are the most important tool in the diagnosis. Treatment modalities include medications, physical therapy, bracing, manual therapy, injections, radiofrequency denervation, and arthrodesis; however, no published prospective data compare the efficacy of these modalities.     

Editorial Commentary: The Pelvis is the Lowest Vertebral Level: Diagnostic Approach to Hip-Spine Syndrome

The human pelvis represents a wonderful example of apparent idealistic simplicity overwhelmed by realistic complexity. Traditionally, the pelvis has been termed a “ring” linking the lower extremity to the spine via the sacroiliac joint. In essence, the pelvis is the lowest vertebral level—“the hip bone’s connected to the spine bone.” Thus, the law of parsimony seemingly applies in the diagnosis and management of both arthritic and nonarthritic hip and spine disorders in isolation or combination. However, an inverse Occam’s razor is much more likely. The layered theory of hip disorders illustrates how a base osteochondral layer (femoroacetabular impingement syndrome, ischiofemoral impingement from either the lesser trochanter or greater trochanter, arthritis), a static inert soft-tissue layer (labrum, capsule, ligament), a dynamic soft-tissue layer (muscle, tendon), and a neurokinetic chain layer all interact and can lead to hundreds, if not thousands, of different combinations of primary and secondary symptom sources. Although correlation does not equal causation, intuitively and overly simplistically, a stiff painful hip can transfer stress across the pelvic ring to the spine, causing back pain. Alternatively, 2 separate symptom sources could be present at the same time. Biomechanical stress transfer can occur from flexion-based (e.g., femoroacetabular impingement syndrome) or extension-based (e.g., ischiofemoral impingement) problems. The diagnosis of hip-spine syndrome in patients becomes really complicated usually really fast, encompassing the hip joint, peritrochanteric space, deep gluteal space, pelvis and pelvic floor, sacroiliac joint, and lumbosacral spine—and don’t forget mental health and the mind controls the musculotendinous system in these challenging, often frustrated, patients. Static imaging findings necessitate dynamic symptom correlation, especially via pertinent values including pelvic incidence; pelvic tilt; sacral slope; lumbar lordosis; femoral and acetabular version; cam, pincer, and dysplastic morphologies; and leg length. Judicious diagnostic injections can greatly assist in clinical symptom interpretation. Successful treatment requires consideration and management of the primary etiology and pertinent secondary downstream effects. When a patient’s hip hurts, one should always look at the patient’s back; when a patient’s back hurts, one should always look at the patient’s hip.     

Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients

Background contextLumbar facet joint synovial cysts are benign degenerative abnormalities of the lumbar spine. Previous reports have supported operative and nonoperative management. Facet joint steroid injection with cyst rupture is occasionally performed, but there has been no systematic evaluation of this treatment option.PurposeTo profile the role of facet joint steroid injections with cyst rupture in the treatment of lumbar facet joint synovial cysts.Study design/settingRetrospective chart review and long-term follow-up of patients treated for lumbar facet joint synovial cysts.Patient sampleOne hundred one patients treated for lumbar facet joint synovial cysts with fluoroscopically guided corticosteroid facet joint injection and attempted cyst rupture.Outcome measuresOswestry Disability Index and numeric rating scale score for back and leg pain.MethodsA retrospective review and a subsequent interview were conducted to collect pretreatment and posttreatment pain and disability scores along with details of subsequent treatment interventions. Group differences in pain and disability scores were assessed using paired t test. Multiple clinical factors were analyzed in terms of risk for surgical intervention using logistic regression modeling and Cox proportional hazards modeling.ResultsSuccessful cyst rupture was confirmed fluoroscopically in 81% of cases. Fifty-five patients (54%) required subsequent surgery over a period averaging 8.4 months because of inadequate symptom relief. All patients reported significant improvement in back pain, leg pain, and disability at 3.2 years postinjection, regardless of their subsequent treatment course (p<.0001 in all groups). There was no significant difference in current pain between patients who received injections only and those who underwent subsequent surgery.ConclusionsThis study presents the largest clinical series of nonsurgical treatment for lumbar facet joint synovial cysts. Lumbar facet joint steroid injection with attempted cyst rupture is correlated with avoiding subsequent surgery in half of treated patients. Successful cyst rupture does not appear to have added benefit, and it was associated with worse disability 3 years postinjection. Long-term outcomes are similar, regardless of subsequent surgery.     

Thoracolumbar syndrome as a cause of low-back pain: a report of two cases

Thoracolumbar syndrome results from irritation of the thoracolumbar facet joints causing pain to be referred to the distribution of the cluneal nerves from T12, L1 and L2. This results in local thoracolumbar backache with referred pain to the iliac crest and buttock. It may present as buttock pain alone resulting in treatment being directed towards the lower lumbar spine and sacroiliac joints rather than the thoracolumbar spine. Two cases of thoracolumbar syndrome treated by posterior joint manipulation are presented.     

Minimally invasive iliac screw fixation in treating painful metastatic lumbosacral deformity: a technique description and clinical results

Introduction

Pelvic fixation via iliac screws is a crucial technique in stabilizing metastatic lumbosacral deformity. MIS iliac screw fixation avoids complications of an open approach and is a viable palliative option in treating patients with painful instability and advanced disease, unsuited for major reconstruction. In this paper we describe the use of MIS iliac screw fixation in treatment of painful metastatic LSJ deformity, highlighting our treatment rationale, selection criteria, technical experience and outcomes.

Methods

Five patients with lumbosacral metastatic deformity who underwent MIS lumbopelvic stabilization using iliac screws were prospectively studied. Patients had severe axial back pain in erect posture with significant resolution when supine. All patients had advanced disease with unfavorable tumor scores for major spinal reconstruction.

Results

Mean cohort age was 62 years. Median pre-op SIN and Tokuhashi scores were 13 and 9, respectively. All patients were instrumented successfully without conversion to open technique. Mean preoperative and postoperative Cobb angle was 11° and 5.4°, respectively. There were no neurological deficits or wound complications postop. Postoperative CT scans showed no iliac screw and sacroiliac joint bony violation. Mean time for commencement of adjuvant therapy was 2.8 weeks. Average follow-up was 13.2 months. No screw breakage, wound complication, symptomatic implant prominence and SI joint pain were noted at last follow-up.

Conclusion

MIS iliac screw fixation is feasible, reproducible and can be employed without complications in metastatic spine. This opens a new avenue of surgical management for metastatic lumbosacral disease patients, who otherwise may be inoperable and provide better soft tissue control and earlier postoperative adjuvant treatment opportunity.

     

Absence de fiabilité des tests cliniques et des blocs pour le diagnostic positif de l’origine sacro-iliaque d’une douleur

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.     

Corticosteroid compared with hyaluronic acid injections for the treatment of osteoarthritis of the knee. A prospective,randomized trial

BACKGROUND: Although both corticosteroid and hyaluronic acid injections are widely used to palliate the symptoms of knee osteoarthritis, little research involving a comparison of the two interventions has been done. We tested the hypothesis that there are no significant differences between Hylan G-F 20 (Synvisc) and the corticosteroid betamethasone sodium phosphate-betamethasone acetate (Celestone Soluspan) in terms of pain relief or improvement in function, as determined by validated scoring instruments. METHODS: One hundred patients with knee osteoarthritis were randomized to receive intra-articular injection of either Hylan G-F 20 or the corticosteroid, and they were followed for six months. The patients treated with Hylan G-F 20 received one course of three weekly injections. The patients treated with the corticosteroid received one injection at the time of enrollment in the study, and they could request one more injection any time during the study. An independent, blinded evaluator assessed the patients with the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), a modification of the Knee Society rating system, and the visual analog pain scale. RESULTS: Both the group treated with the corticosteroid and the group treated with Hylan G-F 20 demonstrated improvements from baseline WOMAC scores (a median decrease from 55 to 40 points and from 54 to 44 points, respectively; p < 0.01 for both). The scores according to the Knee Society system did not significantly improve for the patients who received the corticosteroid (median, 58 to 70 points; p = 0.06) or for those who received Hylan G-F 20 (median, 58 to 68 points; p = 0.15). The scores on the visual analog scale improved for patients receiving Hylan G-F 20 (median, 70 to 52 mm; p < 0.01) but not for the patients who received the corticosteroid (median, 64 to 52 mm; p = 0.28). However, no significant differences between the two treatment groups were found with respect to the WOMAC, Knee Society system, or visual analog scale results. Women demonstrated a significant improvement in only one of the six possible outcome-treatment combinations (the WOMAC scale), whereas men demonstrated significant improvements in five of the six outcomes (all measures except the Knee Society rating system). CONCLUSIONS: No differences were detected between patients treated with intra-articular injections of Hylan G-F 20 and those treated with the corticosteroid with respect to pain relief or function at six months of follow-up. Women demonstrated significantly less response to treatment than men did for both treatments on all three outcome scales. Such significant gender-related differences warrant further investigation.     

Percutaneous fenestration of the anteromedial aspect of the calcaneus for resistant heel pain syndrome

IntroductionThe failure of conservative treatment of chronic heel pain might cause prolonged disability from continued discomfort and pain, which mandates a further treatment modality.Aim of studyThe presentation of the results of percutaneous fenestration of the anteromedial aspect of the calcaneus for symptomatic relief of resistant heel pain syndrome.Material and methodsBetween September 2001 and August 2006, 34 patients (38 feet) with chronic heel pain syndrome reported an unacceptable level of pain despite intensive conservative treatment. There were 23 females and 11 males with an average age of 41 years (25–59 years). The average follow-up was 46 months (range, 14–84 months). Clinical evaluation of the intensity of pain (VAS score system), walking distance, standing duration, fascial tenderness, and ankle and subtalar joint motion were evaluated preoperatively and at regular follow-up.ResultsThe preoperative pain score level was 8.4 (range, 6–10). The mean postoperative VAS for pain at 4 weeks was 5.89 (range, 3–9), at 8 weeks the value was 3.98 (range, 2–7), at 4 months 2.46 (range, 2–5), at 8 months 1.7 (range, 0–3) and at 12 months zero. A clinical improvement was seen in all patients irrespective of the duration of symptoms (p = 0.0041). Three heels (7.9%) had partial relief of pain, but after 43 weeks had complete subsidence of pain. Complications include three transient paraesthesias at the distribution of the medial calcaneal nerve that resolved spontaneously after 8 weeks post-surgery.ConclusionThe results suggest the technique of percutaneous fenestration is a significantly effective treatment modality for patients with recalcitrant heel pain syndrome after failed conservative treatment.The described technique may provide a useful method for treating refractory heel spur syndrome without resorting to invasive surgical techniques and warrants further study.     

Ligaments stabilizing the sacrum and sacroiliac joint: a comprehensive review

The sacroiliac joint is a diarthrodial synovial joint in the pelvis. Anatomically, it is described as a symphysis, its synovial joint characteristics being limited to the distal cartilaginous portion on the iliac side. It is a continuous ligamentous stocking comprising interconnecting ligamentous structures and surrounding fascia. Its ligaments, the primary source of its stability, include the anterior, interosseous and dorsal sacroiliac, the iliolumbar, sacrotuberous, and sacrospinous. Structural reinforcement is also provided by neighboring fascia and muscles. Lower back pain is a common presentation of sacroiliac joint disease, the best-established treatments being corticosteroid injections, bipolar radiofrequency ablation, and sacroiliac joint fusion.

     

Composite sacroiliac joint pain provocation tests: A question of clinical significance

True sacroiliac (SI) joint pain arises for well-established pathological reasons. For example, SI joint infection is characterised by non-specific, diffuse and poorly localised pain that makes an initial clinical diagnosis difficult, even though the condition is a prima facie SI joint lesion. On the other hand, the putative sacroiliac joint pain of the ‘sacroiliac joint syndrome’ that is by definition not associated with morphological and radiological abnormality, is a symptom commonly observed in clinical practice. Such a presentation possesses a typically well-localisable pain in the region overlying the posterior sacroiliac joint. The contention is that composite SI joint pain provocation tests, whilst of arguably statistical ‘significance’, may lack clinical significance particularly in the light of anatomical research that presents an alternative patho-anatomic basis for localisable sacroiliac pain and may offer a rational basis for diagnosis and treatment.