1
|
Völker A, Steinke H, Heyde CE. The Sacroiliac Joint as a Cause of Pain - Review of the Sacroiliac Joint Morphology and Models for Pain Genesis. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2022; 160:507-516. [PMID: 33940639 DOI: 10.1055/a-1398-6055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In recent years, the sacroiliac joint has become increasingly important as a generator of low back pain with and without pseudo-radicular pain in the legs. Up to 27% of reported back pain is generated by disorders in the sacroiliac joint. METHOD This review is based on a selective literature search of the sacroiliac joint (SIJ) as a possible pain generator. It also considers the anatomical structures and innervation of the sacroiliac joint. RESULTS The SIJ is a complex joint in the region of the posterior pelvis and is formed by the sacrum and the ilium bones. The SIJ is very limited in movement in all three planes. Joint stability is ensured by the shape and especially by strong interosseous and extraosseous ligaments. Different anatomical variants of the sacroiliac joint, such as additional extra-articular secondary joints or ossification centres, can be regularly observed in CT scans. There is still controversy in the literature regarding innervation. However, there is agreement on dorsal innervation of the sacroiliac joint from lateral branches of the dorsal rami of the spinal nerves S I-S III with proportions of L III and L IV as well S IV. Nerve fibres and mechanoreceptors can also be detected in the surrounding ligaments. CONCLUSION A closer look at the anatomy and innervation of the SIJ shows that the SIJ is more than a simple joint. The complex interaction of the SIJ with its surrounding structures opens the possibility that pain arises from this area. The SIJ and its surrounding structures should be included in the diagnosis and treatment of back and leg pain. Published literature include a number of plausible models for the sacroiliac joint as pain generator. The knowledge of the special anatomy, the complex innervation as well as the special and sometimes very individual functionality of this joint, enhance our understanding of associated pathologies and complaints.
Collapse
Affiliation(s)
- Anna Völker
- Orthopaedic, Trauma Surgery and Plastic Surgery Clinic, Leipzig University Clinics, Germany
| | | | | |
Collapse
|
2
|
Ashby K, Yilmaz E, Mathkour M, Olewnik Ł, Hage D, Iwanaga J, Loukas M, Tubbs RS. Ligaments stabilizing the sacrum and sacroiliac joint: a comprehensive review. Neurosurg Rev 2021; 45:357-364. [PMID: 34432162 DOI: 10.1007/s10143-021-01625-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/15/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Kara Ashby
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - Emre Yilmaz
- Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, NRW, Germany
| | - Mansour Mathkour
- Tulane University & Ochsner Clinic Neurosurgery Program, Tulane University School of Medicine, New Orleans, LA, USA
| | - Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Lodz, Poland
| | - Dany Hage
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA. .,Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University, New Orleans, LA, USA.
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada.,Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA.,Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University, New Orleans, LA, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA.,Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.,University of Queensland, Brisbane, Australia
| |
Collapse
|
3
|
Anatomical variations of the sacro-iliac joint: a computed tomography study. Surg Radiol Anat 2021; 43:819-825. [PMID: 33630107 DOI: 10.1007/s00276-021-02714-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To identify, describe, and compare the prevalence of sacroiliac joint anatomical variants. METHODS A retrospective study was performed on computed tomography scans. Joint space was measured, and variants were classified as accessory joint, ileosacral complex, bipartite bony plate, semicircular defect, iliac bony plate, and ossification centers. RESULTS 400 scans were analyzed. Mean age was 49 years, 180 men (45%), and 220 women (55%). 209 (52.2%) patients presented an anatomical variant with higher prevalence in women (65.4% vs 36.2%), and those older than 40 years of age (60% vs 40%). Mean joint space was similar bilaterally (right 2.41 ± 0.65 mm vs. left 2.37 ± 0.65 mm). Prevalence was: 19.8% accessory joint, 6.5% ileosacral complex, 12.3% bipartite bony plate, 8% semicircular defect, 5% iliac bony plate, and 0.8% for ossification centers. CONCLUSION Prevalence of anatomical variants of the SIJ is higher in the Hispanic population, women, and those older than 40 years.
Collapse
|
4
|
Subchondral bone strength of the sacroiliac joint-a combined approach using computed tomography osteoabsorptiometry (CT-OAM) imaging and biomechanical validation. J Mech Behav Biomed Mater 2020; 111:103978. [PMID: 32866917 DOI: 10.1016/j.jmbbm.2020.103978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/03/2020] [Accepted: 07/06/2020] [Indexed: 11/23/2022]
Abstract
Bone mineral density distribution patterns at the sacroiliac joint (SIJ) may reflect long-term adaptation patterns to the loading the joint endures. This study aims to display bone mineralisation patterns of the articular SIJ subchondral lamella using computed tomography (CT) osteoabsorptiometry and mechanical indenting, to determine whether a relationship exists between mineralisation and mechanical strength. Twenty hemipelves were CT-scanned before osteoabsorptiometry densitograms were derived. Each articular side of eleven SIJs was mechanically indented following a 10-mm grid scheme. The sacral surface displayed lower Hounsfield unit (HU) values (≤ 700 HU) than the iliac side (> 700 HU). The apex, superior corner and borders yielded the highest HU scores (> 700 HU). Penetration strength was significantly higher on the iliac side (p < 0.04). Mineral density correlated positively with penetration strength of the subchondral bone layer (p < 0.05). No correlations were found between the HU values, nor between penetration strength of corresponding sides of the same SIJ in the majority of cases (p > 0.05). The iliac subchondral lamella is mechanically denser than the sacral aspect. The non-correlation between density and bone strength of articulating sides indicates biomechanical non-conformity. Loading throughout the SIJ may follow a complex distribution pattern involving the surrounding soft tissues, suspending the sacrum between the ilia.
Collapse
|
5
|
Schneider BJ, Rosati R, Zheng P, McCormick ZL. Challenges in Diagnosing Sacroiliac Joint Pain: A Narrative Review. PM R 2019; 11 Suppl 1:S40-S45. [PMID: 31020770 DOI: 10.1002/pmrj.12175] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/19/2019] [Indexed: 11/09/2022]
Abstract
Accurate diagnosis of sacroiliac joint (SIJ) pain is challenging. Diagnosis can be aided by pain referral patterns, historical features, physical examination maneuvers, and imaging. However, all of these diagnostic tools have limitations. The most reliable clinical tools may be a combination of three or more positive physical exam maneuvers, although the evidence is inconsistent even for this strategy. Intra-articular diagnostic SIJ injections are often used as the reference standard for "true" sacroiliac pain. However, such injections do not consider extra-articular sources of pain that may also exist as part of the sacroiliac joint complex. Research has established the posterior sacral ligaments as a possible source of pain, and the innervation of these ligaments has been anatomically defined. It is possible that by expanding our focus from the articular portion of the sacroiliac complex structure to both the joint and extra-capsular ligaments, advancements in clinical diagnosis and treatment will be possible.
Collapse
Affiliation(s)
- Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Renee Rosati
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Patricia Zheng
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, University of California, San Francisco, San Francisco, CA
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT
| |
Collapse
|
6
|
Changes in pelvic anatomy after long corrective fusion using iliac screws for adult spinal deformity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2103-2111. [DOI: 10.1007/s00586-019-06027-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 06/05/2019] [Indexed: 10/26/2022]
|
7
|
Hammer N, Steinke H, Lingslebe U, Bechmann I, Josten C, Slowik V, Böhme J. Ligamentous influence in pelvic load distribution. Spine J 2013; 13:1321-30. [PMID: 23755919 DOI: 10.1016/j.spinee.2013.03.050] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 01/03/2013] [Accepted: 03/20/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The influence of the posterior pelvic ring ligaments on pelvic stability is poorly understood. Low back pain and sacroiliac joint (SIJ) pain are described being related to these ligaments. Computational approaches involving finite element (FE) modeling may aid to determine their influence. Previous FE models lacked in precise ligament geometries and material properties, which might have influence on the results. PURPOSE AND STUDY DESIGN The aim of this study is to investigate ligamentous influence in pelvic stability by means of FE using precise ligament material properties and morphometries. METHODS An FE model of the pelvis bones was created from computer tomography, including the pubic symphysis joint (PSJ) and the SIJ. Ligament data were used from 55 body donors: anterior (ASL), interosseous (ISL), and posterior (PSL) sacroiliac ligaments; iliolumbar (IL), inguinal (IN), pubic (PL), sacrospinous (SS), and sacrotuberous (ST) ligaments; and obturator membrane (OM). Stress-strain data were gained from iliotibial tract specimens. A vertical load of 600 N was applied. Pelvic motion related to altered ligament and cartilage stiffness was determined in a range of 50% to 200%. Ligament strain was investigated in the standing and sitting positions. RESULTS Tensile and compressive stresses were found at the SIJ and the PSJ. The center of sacral motion was at the level of the second sacral vertebra. At the acetabula and the PSJ, higher ligament and cartilage stiffnesses decrease pelvic motion in the following order: SIJ cartilage>ISL>ST+SS>IL+ASL+PSL. Similar effects were found for the sacrum (SIJ cartilage>ISL>IL+ASL+PSL) but increased ST+SS stiffnesses increased sacral motion. The influence of the IN, OM, and PL was less than 0.1%. Compared with standing, total ligament strain was reduced to 90%. Increased strains were found for the IL, ISL, and PSL. CONCLUSIONS Posterior pelvic ring cartilage and ligaments significantly contribute to pelvic stability. Their effects are region- and stiffness dependent. While sitting, load concentrations occur at the IL, ISL, and PSL, which goes in coherence with the clinical findings of these ligaments serving as generators of low back pain.
Collapse
Affiliation(s)
- Niels Hammer
- Faculty of Medicine, Institute of Anatomy, University of Leipzig, Liebigstraße 13, 04103 Leipzig, Germany; Department of Trauma and Reconstructive Surgery, Faculty of Medicine, University of Leipzig, Liebigstraße 13, 04103 Leipzig, Germany.
| | | | | | | | | | | | | |
Collapse
|
8
|
Chang Y, Cantelmi D, Wisco JJ, Fattah A, Hannam AG, Agur AM. Evidence for the functional compartmentalization of the temporalis muscle: a 3-dimensional study of innervation. J Oral Maxillofac Surg 2013; 71:1170-7. [PMID: 23806734 DOI: 10.1016/j.joms.2013.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 04/08/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The temporalis muscle is commonly used for functional transfer. It is architecturally complex, but few studies have examined its intramuscular innervation and none has used 3-dimensional modeling techniques. Understanding neuromuscular compartmentalization may allow the design of local muscle transfers to minimize donor-site morbidity. The purpose of the present study was to document the intramuscular innervation patterns throughout the volume of the temporalis muscle and define functional units within the muscle. MATERIALS AND METHODS In 10 formalin-embalmed cadaveric specimens, the foramen ovale was exposed and the branches of the mandibular nerve were identified. Each branch was digitized in short segments extramuscularly and intramuscularly. Three-dimensional models were reconstructed from the digitized data using Maya software, and the innervation patterns were documented. RESULTS The temporalis muscle was found to have superior and inferior parts that were further grouped by innervation into regions, with each receiving its innervation from 1 primary nerve. The nerves originated directly from the mandibular nerve, except in 3 specimens, where the posterior deep temporal nerve arose from the masseteric nerve. CONCLUSION These results provide a detailed mapping of innervation patterns and suggest there are at least 5 functional compartments. Each of these has the capacity for selective activation, 3 of which have clinical value. These findings may allow for decreased donor-site morbidity and more functionally sophisticated designs in clinical practice.
Collapse
Affiliation(s)
- Youjin Chang
- Division of Anatomy, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|
9
|
Vora AJ, Doerr KD, Wolfer LR. Functional Anatomy and Pathophysiology of Axial Low Back Pain: Disc, Posterior Elements, Sacroiliac Joint, and Associated Pain Generators. Phys Med Rehabil Clin N Am 2010; 21:679-709. [DOI: 10.1016/j.pmr.2010.07.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
10
|
Abstract
STUDY DESIGN The ligaments of the human sacroiliac joint (SIJ) were investigated morphometrically. OBJECTIVE A macroscopical study was performed to measure the anterior sacroiliac ligament (ASL), the interosseous sacroiliac ligament (ISL), and the posterior sacroiliac ligament (PSL), applying different methods of ligament visualization. SUMMARY OF BACKGROUND DATA Little is known about the SIJ ligaments, especially about the ISL. Pelvic computer simulations neglect these ligaments due to the lack of information. Computer simulations of the SIJ ligaments may help to improve the clinical outcome of SIJ operations. METHODS Seven-Tesla MR images, CT images, and corresponding thin slice plastinates of the SIJ of 1 male and 1 female specimen were obtained. Serial sections of the SIJ of 32 frozen specimens (13 males, 19 females) were generated to gather measurements of the SIJ ligaments. RESULTS By means of the MR images and the plastinates, a virtual reconstruction of the SIJ ligaments was accomplished. Parallelepipeds were attributed to the cranial, middle, and caudal parts of all SIJ ligaments. This allowed precise measurements and statistical comparison including positional relationships. The ISL volumes and origin surfaces were the largest. Statistically, the ASL and PSL parameters were larger in males, while the ISL parameters were larger in females. The height of the cranial ASL part showed large negative correlations in spite of positive correlations of the other heights. CONCLUSION The combined use of high-resolution MRI and thin slice plastination allows precise reconstructions of the SIJ ligaments. With these techniques, the ligaments can be visualized in situ and described morphometrically if based on substantive data. The SIJ ligaments are gender-dependent. This has to be taken into account for pelvic computer simulations.
Collapse
|