Estimating the Cost of Spinopelvic Complications After Adult Spinal Deformity Surgery

Objective

Reoperations for spinopelvic failure after adult spinal deformity (ASD) surgery are common. We sought to determine the added costs of ASD surgery attributable to reoperations for spinopelvic construct failures.

Methods

We constructed a Markov process model to calculate the expected discounted 5-year costs of spinopelvic construct failures after ASD surgery. The Nationwide Inpatient Sample (NIS) was queried to estimate the number of ASD surgeries. Model inputs were based on literature review and expert opinion. ASD surgery was defined as thoracolumbar fusion of 4 or more levels with pelvic fixation. The following pelvic fixation failures were included: 1) rod fracture or pseudarthrosis from L4-S1, 2) iliac screw failure or set plug dislodgment, 3) iliac screw prominence, and 4) sacroiliac (SI) joint pain. The number of patients undergoing ASD surgery annually in the US was determined using a commercial claims database.

Results

The net present value 5-year cost per patient for spinopelvic complications was $35,265, equal to 29% of index surgery costs. Given an estimated 27,580 cases annually in the US, the additional cost to address spinopelvic complications reach nearly $1 billion over 5-years. A sensitivity analysis showed that these costs were most sensitive to the rate of rod fracture/pseudarthrosis, iliac screw prominence, and reoperation.

Conclusion

A conservative estimate of the cost of spinopelvic failures after ASD surgery is substantial, nearly $1 billion over 5-years. We propose a method of capturing spinopelvic fixation failures for use in future clinical studies and cost analyses.

Evaluation of a 3-D printed drill guide to facilitate fluoroscopic-assisted Kirschner wire placement for minimally invasive iliosacral screw placement in dog cadavers

OBJECTIVE

To evaluate the ease and accuracy of using a 3-D printed (3-DP) drill guide to insert Kirschner wires through the ilium and into the sacral body in preparation for minimally invasive iliosacral screw placement in dog cadavers.

ANIMALS

10 dog cadavers weighing 20 to 30 kg (mean ± SD, 24.5 ± 5 kg).

METHODS

Kirschner wires were placed using a limited approach to the lateral ilium. Fluoroscopy was used in freehand and 3-DP drill guide application groups to facilitate the placement of a 1.0-mm Kirschner wire that was over-drilled using a 2.5-mm cannulated drill bit. Kirschner wires were placed using a 3-DP drill guide on 1 hemipelvis and freehand wire placement was done on the contralateral hemipelvis. Postprocedural CTs were obtained, and 2-D and 3-D analyses were performed. The Student t-test and Wilcoxon rank sum test were used to compare groups. A Pearson correlation coefficient was performed to evaluate the in-group correlation.

RESULTS

Likert scores that assessed the ease of the procedure were significantly greater (P = .04) and the incision length was significantly shorter (P = .016) in the 3-DP drill guide group compared with the freehand group. The time of the procedure, the number of attempts to obtain accurate Kirschner wire placement, and fluoroscopy images did not differ (P > .05) between application groups. Drill tracks were primarily confined to the sacral body, with minor projected screw thread cortical breeches occurred in 1 cadaver in the freehand group and 2 cadavers in the 3-DP drill guide group.

CLINICAL RELEVANCE

The 3-DP drill guide simplified appropriate iliosacral Kirschner wire placement through a smaller incision compared with freehand drilling and would appear to be an efficient, practical instrument to facilitate accurate fluoroscopic-assisted screw placement when stabilizing sacroiliac luxations in dogs.

Minimally Invasive Postero-Inferior Sacroiliac Joint Fusion: Surgical Technique and Procedural Details

(1) Background: Minimally invasive sacroiliac joint (SIJ) fusion is the preferred surgical intervention to treat chronically severe pain associated with SIJ degeneration and dysfunction. (2) Methods: This paper details the ten-step surgical procedure associated with the postero-inferior approach using the PsiF™ DNA Sacroiliac Joint Fusion System. (3) Results: The posterior surgical approach with an inferior operative trajectory (postero-inferior) utilizes easily identifiable landmarks to provide the safest, most direct access to the articular joint space for transfixing device placement. Implanting the device through the subchondral bone provides maximum fixation and stabilization of the joint by utilizing an optimal amount of cortical bone-implant interface. Approaching the joint from the inferior trajectory also places the implant perpendicular to the S1 endplate at a "pivot point" near the sacral axis of rotation, which addresses the most significant motion of the joint. (4) Conclusions: Further observational data from real-world clinical use are encouraged to further validate this procedure as the surgical preference for minimally invasive SIJ fusion.

18F-FDG and 18F-NaF PET/CT Global Assessment of Large Joint Inflammation and Bone Turnover in Rheumatoid Arthritis

Rheumatoid arthritis (RA) involves chronic inflammation of synovial joints, causing pain, stiffness, and limited mobility. ¹⁸F-sodium fluoride (NaF) is a PET tracer whose uptake reflects bone turnover, while ¹⁸F-fludeoxyglucose (FDG) shows glucose metabolism and can serve as a marker for inflammation. The aim of this study is to determine the feasibility of calculating the FDG and NaF mean standardized uptake value (SUVmean) in the knee joint, hip joint, and sacroiliac (SI) joint of RA patients and to determine their association with patient characteristics. Prospective FDG-PET/CT as well as NaF-PET/CT imaging was performed on 18 RA patients. The global SUVmean was calculated on FDG-PET/CT and NaF-PET/CT images using a semiautomated CT-based method of segmentation. FDG and NaF uptake were found to be significantly correlated in the knee (r = 0.77, p < 0.001), but not in the hip and SI joints. In the knee, both NaF SUVmean and FDG SUVmean were significantly correlated with body weight, BMI, leptin, and sclerostin levels (p < 0.05). NaF SUVmean was significantly positively correlated with BMI and leptin for both the hip and SI joints (p < 0.05). No significant correlation was observed between either PET parameter and age, height, erythrocyte sedimentation rate (ESR), and interleukins 1 and 6 (IL-1 and IL-6); however, FDG was correlated with inflammatory markers such as C-reactive protein (CRP) and patient global visual analogue scale (VAS-PtGlobal) in some joints. In this study, both FDG and NaF uptake were quantified in large joints of patients with RA using CT segmentation. NaF and FDG SUVmean were correlated with clinical variables related to body weight and adiposity, suggesting that degenerative joint disease may play a larger role in influencing the uptake of these tracers in large joints than RA disease activity. FDG and its correlation with markers of inflammation such as CRP and VAS-PtGlobal suggests that this tracer may serve as a more specific marker for RA disease activity than NaF. Larger prospective and longitudinal data are necessary to gain a better understanding of the roles of FDG and NaF in evaluating RA joint activity in these joints.

Robotic-assisted percutaneous pelvis fixation: A case report

Key Clinical Message

It may be possible to extend the use of the robotic arm to pelvic and acetabular surgery leading to safe, repeatable screw placement, and less radiation exposure for patients, surgeons and OR staff.

Abstract

In this case, a novel, robotic-assisted technique was used to place a sacroiliac screw in a patient with unstable injuries of the pelvic ring. Intraoperative and postoperative fluoroscopic, radiographic, and CT imaging demonstrated a safely positioned 6.5 mm cannulated screw without unplanned cortical violation or impingement on neurovascular structures. To our knowledge, this is the first such reported case using a robot widely available in the Americas or Europe.

The effects of supervision on the outcomes of exercise training in patients with ankylosing spondylitis: A single-blind randomized controlled trial

AIM

Exercise training is crucial for managing ankylosing spondylitis. We evaluated the effects of exercise with different levels of supervision on clinical outcomes in patients with ankylosing spondylitis.

METHODS

We performed a single-blind randomized controlled trial in a university outpatient clinic. Overall, 45 (31 men) patients with ankylosing spondylitis were randomly allocated to 3 groups. The mean (SD) for age and disease duration were 39.3 (9.3) and 8.4 (7.8) years. The primary outcome was chest expansion in cm, and the secondary outcomes were the index scores of 5 standard questionnaires. For each participant, adalimumab 40 mg/0.8 mL/2 wk was injected and a 3-session exercise program per week for 1 month was prescribed. Controls received a pamphlet on the exercise program. Another group received the pamphlet and underwent a 2-hour training session. The supervised group received the pamphlet, and the 2-hour training, and completed the program by attending each exercise session in the clinic.

RESULTS

Within-group analysis showed significant improvement in chest expansion (P = 0.016) and all subjective or objective questionnaire scores (all P < 0.001) for the full-supervised group. Between-group analysis implied best outcomes for chest expansion (P = 0.046), Ankylosing Spondylitis Disease Activity Score (P < 0.001), Bath Disease Activity (P = 0.010), and Metrology (P = 0.002) Indices for ankylosing spondylitis. The group with 2-hour training experienced an improvement in some indices, and the control group did not show significant changes in the outcomes.

CONCLUSION

We recommend the prescription of a supervised training program instead of in-home exercises for patients with ankylosing spondylitis.

A Case Report of a Sacral Giant Cell Tumor Treated With Block Resection and Lumbo-Pelvic Fixation

Giant cell tumors (GCT) are benign but locally aggressive neoplasms composed of osteoclast-like giant cells and fusiform to ovoid mononuclear stromal cells. GCT generally comprise 5-10% of all benign bone tumors; they appear most frequently between the second and third decades of life. These tumors are also distributed throughout the vertebral column. Approximately half of all spinal GTCs develop in the sacrum. Many cases remain clinically silent and are discovered incidentally during the study of minor trauma. Symptomatic tumors often mimic other common spinal pathologies. Imaging studies ideal for diagnosis are CT and MRI. The techniques used in the treatment of giant cell tumors are curettage or intralesional surgery, block resection, radiotherapy, and chemotherapy. Herein, we report on a 23-year-old female patient diagnosed with a tumoral mass in the anterior part of the sacrum, suggestive of GCT. The lesion was completely excised in two consecutive surgeries, and lumbopelvic fixation was performed with favorable immediate postoperative results. Careful surgical planning with a multi-disciplinary approach leading to block resection still remains the most viable option for the treatment of vertebral GCT.

Frequency and anatomic distribution of magnetic resonance imaging lesions in the sacroiliac joints of spondyloarthritis and non-spondyloarthritis patients

Background

Lesions detected by magnetic resonance imaging (MRI) of the sacroiliac joints are critical to the diagnosis of non-radiographic axial spondyloarthritis. However, inflammatory and structural lesions may be encountered in other conditions.

Objectives

The objective of this study was to evaluate and compare the frequency and localization of inflammatory and structural lesions on MRIs of the sacroiliac joint of spondyloarthritis (SpA) and non-spondyloarthritis (non-SpA) patients.

Design

This is a retrospective study including 200 patients, each having undergone an MRI of the sacroiliac joints.

Methods

Two experienced readers evaluated the whole set of images to detect erosions, subchondral sclerosis, fatty lesions, bone marrow edema (BME) and ankylosis according to the definitions established by the ASAS MRI working group. We divided sacroiliac joints into five segments: upper, antero-middle, intermediate-middle, postero-middle and lower.

Results

A total of 96 subjects with SpA (mean age 37.4 ± 11.8 years) and 104 without SpA (mean age 39.9 ± 11.6 years) were included. Of the 96 SpA patients, 65% had inflammatory buttock pain compared with 25% in the non-SpA group. BME was seen in 65% of SpA patients, mainly in the intermediate-middle segment, and in 20% of non-SpA patients, predominantly in the antero-middle segment. Subchondral sclerosis occurred in 44% of non-SpA patients, mostly in the antero-middle segment, and in 36% of SpA patients. Fatty lesions were present in 34% of SpA and in 21% of non-SpA patients. Erosions were seen in 25% of non-SpA and in 60% of SpA patients. BME and structural lesions were minimally observed in the postero-middle segment in non-SpA patients.

Conclusion

Inflammatory and structural lesions were observed in all segments of the joint in SpA, mainly in the middle segments, while lesions predominantly affected the antero-middle segment in non-SpA, and were uncommon in the postero-middle segment.

Pelvic tilt from supine to standing in patients with symptomatic acetabular retroversion of the hip

AIMS

Acetabular retroversion is a recognized cause of hip impingement and can be influenced by pelvic tilt (PT), which changes in different functional positions. Positional changes in PT have not previously been studied in patients with acetabular retroversion.

METHODS

Supine and standing anteroposterior (AP) pelvic radiographs were retrospectively analyzed in 69 patients treated for symptomatic acetabular retroversion. Measurements were made for acetabular index (AI), lateral centre-edge angle (LCEA), crossover index, ischial spine sign, and posterior wall sign. The change in the angle of PT was measured both by the sacro-femoral-pubic (SFP) angle and the pubic symphysis to sacroiliac (PS-SI) index.

RESULTS

In the supine position, the mean PT (by SFP) was 1.05° (SD 3.77°), which changed on standing to a PT of 8.64° (SD 5.34°). A significant increase in posterior PT from supine to standing of 7.59° (SD 4.5°; SFP angle) and 5.89° (SD 3.33°; PS-SI index) was calculated (p < 0.001). There was a good correlation in PT change between measurements using SFP angle and PS-SI index (0.901 in the preoperative group and 0.815 in the postoperative group). Signs of retroversion were significantly reduced in standing radiographs compared to supine: crossover index (0.16 (SD 0.16) vs 0.38 (SD 0.15); p < 0.001), crossover sign (19/28 hips vs 28/28 hips; p < 0.001), ischial spine sign (10/28 hips vs 26/28 hips; p < 0.001), and posterior wall sign (12/28 hips vs 24/28 hips; p < 0.001).

CONCLUSION

Posterior PT increased from supine to standing in patients with symptomatic acetabular retroversion. The features of acetabular retroversion were less evident on standing radiographs. The low PT angle in the supine position is a factor in the increased appearance of acetabular retroversion. Patients presenting with symptoms of hip impingement should be assessed by supine and standing pelvic radiographs to highlight signs of acetabular retroversion, and to assist with optimizing acetabular correction at the time of surgery. Cite this article: Bone Joint J 2022;104-B(7):786-791.

Clinical Outcomes Following Minimally Invasive Sacroiliac Joint Fusion With Decortication: The EVoluSIon Clinical Study

BACKGROUND

This report documents 1-year results of 250 patients enrolled in a prospective, multicenter study of a minimally invasive (MI) sacroiliac joint fusion (SIJF) system that uses decortication, graft placement, and joint fixation.

METHODS

The cohort includes all patients enrolled in the EVoluSIon (EVSI) clinical study who had MI SIJF surgery and completed 1-year follow-up. Average age at baseline was 60.5 years, and 70.8% were female. Sacroiliac (SI) joint-related pain duration was ≥2 years in 56% of patients. Visual analog scale (VAS) SI joint pain, Oswestry Disability Index (ODI), quality of life, and opioid use were assessed preoperatively and at 1 year.

RESULTS

At 1 year, the mean VAS pain demonstrated a significant reduction of more than 43 points, from 76.4 at baseline to 33.0 (P < 0.0001), with 72.2% of patients attaining the minimal clinically important difference (MCID, ≥20-point improvement). Mean ODI scores also significantly improved from 54.4 at baseline to 30.5 at 1 year (P < 0.0001), with 62.5% of patients achieving the MCID (≥15-point improvement). Prior to surgery, 62.7% (126/201) of patients were taking opioids or other narcotics, but by 1 year postsurgery, only 26.9% (54/201) of patients reported using these medications, representing a significant 57.1% decrease in narcotic/opioid use (P < 0.0001). Fusion of the SI joint was seen in 68.7% of patients. Few procedural complications were reported. In all, there were 8 (8/250) serious procedure-related events, including 1 device malposition observed on the day of surgery that required replacing the superior screw with a shorter screw.

CONCLUSIONS

Analysis of patients treated with MI SIJF in the EVSI study demonstrated that the procedure can be performed safely and results in significant improvements in pain, quality of life, and opioid use at 1 year as well as causing fusion in the majority of patients.

LEVEL OF EVIDENCE

2.

CLINICAL RELEVANCE

MI SIJF differs from most procedures currently being performed in that it applies true orthopedic principles with decorticating, bone grafting, fusion, and placement of implants perpendicular to the joint for greatest stability. The 12-month data show improvement in functionality, reduction in pain, and, most notably, a reduction in narcotic usage, which is important considering the ongoing opioid epidemic.

Biomechanical Stability of Primary and Revision Sacroiliac Joint Fusion Devices: A Cadaveric Study

STUDY DESIGN

An in vitro biomechanics study.

OBJECTIVE

To evaluate the efficacy of triangular titanium implants in providing mechanical stabilization to a sacroiliac joint with primary and revision sized implants.

METHODS

Ten lumbopelvic cadaveric specimens were tested in 4 stages: intact, pubic symphysis sectioned, primary, and simulated revision. Primary treatment was performed using 3 laterally placed triangular titanium implants. To simulate revision conditions before and after bone ingrowth and ongrowth on the implants, 7.5-mm and 10.75-mm implants were randomly assigned to one side of each specimen during the simulated revision stage. A 6 degrees of freedom spinal loading frame was used to load specimens in 4 directions: flexion extension, lateral bending, axial torsion, and axial compression. Biomechanical evaluation was based on measures of sacroiliac joint rotational and translational motion.

RESULTS

Both primary and revision implants showed the ability to reduce translational motion to a level significantly lower than the intact condition when loaded in axial compression. Simulated revision conditions showed no statistically significant differences compared with the primary implant condition, with the exception of flexion-extension range of motion where motions associated with the revised condition were significantly lower. Comparison of rotational and translation motions associated with the 7.5- and 10.75-mm implants showed no significant differences between the treatment conditions.

CONCLUSIONS

These results indicate that implantation of laterally placed triangular titanium implants significantly reduces the motion of a sacroiliac joint using either the primary and revision sized implants. No statistically significant differences were detected when comparing the efficacy of primary, 7.5-mm revision, or 10.75-mm revision implants.

Self-Treatment of Chronic Low Back Pain Based on a Rapid and Objective Sacroiliac Asymmetry Test: A Pilot Study

Background: Low back pain (LBP) is common, costly, and disabling. This study assesses a novel and simple LBP evaluation method and its merit in guiding the direction of a self-treatment exercise.

Methods: Randomized open-label intention is used to treat the study. Consecutive patients with LBP ≥ three months and pain ≥ 5/10 were evaluated in a Vancouver clinic with the sacroiliac forward flexion test (SIFFT) by comparing the height of posterior superior iliac spines using a level. Those with asymmetry ≥ 5 mm were offered participation. The assistant, who generated and encrypted the randomization, assigned participants: group 1 learned a two-minute, SIFFT-derived, sacroiliac-leveling exercise (SIFFT-E) as needed for LBP relief; group 2 used a pelvic stabilization belt as needed to prevent LBP, and group 3 continued the usual care. After one month, all participants used SIFFT-E and belt as needed for one month. The identifier number of this article in Clinicaltrials.gov is #NCT03888235. The trial is closed.

Our primary outcome measure was the Oswestry disability index (ODI) (decrease) from baseline to one and two months. We also followed SIFFT improvement (decrease).

Findings: Of 72 LBP patients, 62 (86%) had ≥ 5 mm asymmetry. From zero to one month, the 21 (one dropout) SIFFT-E participants outperformed the 20 usual care participants for ODI improvement (12.5 ± 14.8 vs. -3.4 ± 14.9 points; mean difference 15.9 [CI 6.7-25.0]; P = 0.002 with number needed to treat (NNT) of 3.0 for ODI improvement ≥ 11). Belt use results were intermediate. At two months, after all the 62 participants used the exercise and belt as needed, combined ODI improvements were clinically significant (12.0 ± 18.4 points), and SIFFT asymmetry was reduced by 8.6 ± 8.6 mm. Five (8%) exercise and 12 (19%) belt wearers experienced mild side effects.

Interpretation: Sacroiliac asymmetry appears to be frequent. SIFFT may be clinically useful as an evaluation tool for prescribing a simple self-directed corrective exercise as seen by clinically significant improvements in function and asymmetry.

Main Diagnostic Pitfalls in Reading the Sacroiliac Joints on MRI

Magnetic resonance imaging of the sacroiliac joints is now frequently performed to help identify patients with early axial spondyloarthritis. However, differential diagnoses exist and should be recognized. The aim of this article is to review the most frequent differential diagnoses that may mimic inflammatory sacroiliitis in clinical practice.

Change in pelvic incidence between the supine and standing positions in patients with bilateral sacroiliac joint vacuum signs

OBJECTIVE

Pelvic incidence (PI) is a commonly utilized spinopelvic parameter in the evaluation and treatment of patients with spinal deformity and is believed to be a fixed parameter. However, a fixed PI assumes that there is no motion across the sacroiliac (SI) joint, which has been disputed in recent literature. The objective of this study was to determine if patients with SI joint vacuum sign have a change in PI between the supine and standing positions.

METHODS

A retrospective chart review identified patients with a standing radiograph, supine radiograph, and CT scan encompassing the SI joints within a 6-month period. Patients were grouped according to their SI joints having either no vacuum sign, unilateral vacuum sign, or bilateral vacuum sign. PI was measured by two independent reviewers.

RESULTS

Seventy-three patients were identified with an average age of 66 years and a BMI of 30 kg/m2. Patients with bilateral SI joint vacuum sign (n = 27) had an average absolute change in PI of 7.2° (p < 0.0001) between the standing and supine positions compared to patients with unilateral SI joint vacuum sign (n = 20) who had a change of 5.2° (p = 0.0008), and patients without an SI joint vacuum sign (n = 26) who experienced a change of 4.1° (p = 0.74). ANOVA with post hoc Tukey test showed a statistically significant difference in the change in PI between patients with the bilateral SI joint vacuum sign and those without an SI joint vacuum sign (p = 0.023). The intraclass correlation coefficient between the two reviewers was 0.97 for standing PI and 0.96 for supine PI (p < 0.0001).

CONCLUSIONS

Patients with bilateral SI joint vacuum signs had a change in PI between the standing and supine positions, suggesting there may be increasing motion across the SI joint with significant joint degeneration.

[Sacroiliac pain: diagnosis and treatment]

The purpose of this review is to provide an overview of current literature on the diagnosis and treatment of sacroiliac pain. Designation as a source of lower back pain has been controversial; However, as knowledge about the joint increases, its role as a generator of chronic pain has become better elucidated. The literature states that sacroiliac joint is the cause of pain in up to 30% of patients. Clinically, diagnosing sacroiliac pain can be difficult to assess; However, pain semiology, patient posture/movement and manual testing are useful for making the presumptive diagnosis of sacroiliac dysfunction. The most effective diagnostic test is image-guided injection of anesthetic solutions into the joint, which is considered positive if there is at least 75% acute symptom relief. Treatment begins with physiotherapy and/or intra-articular infiltration of steroids. If these fails, a possible option is radiofrequency (rizotomy) denervation of the joint. If this does not provide adequate relief, surgery may be considered, in the form of fusion; various work supports favorable outcomes in selected patients.

The effect of sacroiliac chiropractic adjustments on innominate angles

Aim

The aim of this study was to determine whether or not a measurable change in the angle of the innominate bone could be identified after a chiropractic sacroiliac adjustment using a 'PALM PALpation Meter'. Secondly, if a change in the angle of the innominate bone was identified, what was the degree of change in the angle of the innominate bone, induced by the sacroiliac joint (SIJ) adjustment.

Method

This was a true experimental study that consisted of 100 participants who met the inclusion criteria. The participants were randomly allocated to either the treatment or control group. Each group had 50 participants: 25 females and 25 males. Informed consent was obtained from participants prior to commencement of treatment. The treatment group received a chiropractic adjustment based on their specific SIJ dysfunction. The control group was treated with detuned ultrasound therapy (sham treatment).

Procedure

Treatment consisted of a once-off treatment. The angles of the innominate bones were measured bilaterally pre- and post-treatment in both groups. Objective data were collected using the PALM PALpation Meter. Once the dysfunctional SIJ was identified, participants in group 1 were treated with specific chiropractic adjustment techniques based on the restriction. Group 2 participants were treated with detuned ultrasound only.

Results

The results of this study showed that a specific chiropractic adjustment resulted in a measurable change in the angle of the innominate bone (p ≤ 0.001). The change in angle was evident bilaterally; however, the side that was adjusted shows the greatest degree of change. The mean change in angle for the treatment group was 2.25° on the side of dysfunction.

Conclusion

The results of this study showed that a specific chiropractic adjustment can have a positive effect on the angles of the innominate bone, resulting in the tilt of the pelvis levelling into what is considered to be its correct anatomical alignment.

The Success Rate of Ultrasound-Guided Sacroiliac Joint Steroid Injections in Sacroiliitis: Are We Getting Better?

BACKGROUND

The sacroiliac joint is one of the most common sources of low back pain; however, it is difficult to place the needle accurately inside the joint space without image guidance. Improvement of ultrasound technology may lead to a high success rate for intra-articular drug deposition.

OBJECTIVE

Assessment of the success rate of ultrasound-guided intra-articular sacroiliac joint injection.

DESIGN

Prospective observational study.

METHODOLOGY

Ultrasound-guided injections were performed on 34 patients suffering from sacroiliitis. After injection of the drug solution and withdrawal of the needle, an anteroposterior fluoroscopy image was obtained and recorded for the injected joint to detect whether it was predominantly intra-articular or peri-articular. Clinical outcome using a numeric pain rating scale as well as limitation of physical functioning measured by the Oswestry Disability Index (ODI) were determined.

RESULTS

Thirty-three injections (84.6%) were intra-articular, while 6 injections (15.4%) were peri-articular, as confirmed by fluoroscopy, with no statistical difference regarding clinical outcome between them. The baseline mean pain score decreased from 7.21 to 1.92 1 month after injection, and the mean ODI scores improved from 61.41% to 17.13%. Intervention was well tolerated, and 91.2% of patients were satisfied or mostly satisfied.

CONCLUSION

Ultrasonography provides a high success rate of intra-articular sacroiliac joint injection as confirmed by fluoroscopy. No significant difference in clinical outcome between intra-articular and peri-articular injection was found.

Evaluation and Management of Sacroiliac Dysfunction Utilizing an Evidence-Based Algorithmic Approach: A Case Study

The sacroiliac joint (SIJ) is an important contributor to persistent and functionally limiting lower back pain. Despite extensive debate and research, there is no definitive treatment recommendation or high-level evidence to support a conservative care treatment approach, nor interventional or surgical management procedures for the alleviation of pain originating from the SIJ. Traditional physical therapy and conservative approaches to generalized lower back pain often fail in this patient subset prompting sub-specialty consultation to a pain management center. Diagnosis of the SIJ as the pain generator can be accomplished through physical exam maneuvers and comparative diagnostic blocks; however, upon diagnosis, management remains a challenge. After the diagnosis of SIJ dysfunction is made in our young and active patient population, we have seen significant success in the application of an interdisciplinary and evidence-based treatment algorithm similar to the presented case. To our knowledge, this treatment approach has not been previously described.

Single strip lesions radiofrequency denervation for treatment of sacroiliac joint pain: two years' results

BACKGROUND

Sacroiliac joint pain can be managed by intra-articular injections or radiofrequency of its innervation. Single strip lesions radiofrequency denervation is a new system. The objective of this study was to present one of the first utilizations of this innovative technique.

METHODS

60 patients who met the diagnostic criteria for sacroiliac joint syndrome were enrolled in the study. In total, 102 single strip lesions radiofrequency denervations were performed. Pain intensity was measured with the Oswestry low back pain disability questionnaire and the Oswestry Disability Index whose scores were assessed at 1, 3, 6 and 12 months after the procedure.

RESULTS

91.8 % of the 102 radiofrequency treatments resulted in a reduction of more than 50% pain intensity relief at 1 month, 81.6% at 3 months and 59.16% at 6 months. In 35.7% of cases, the relief was continuative up to 1 year. No relief was observed in 12.24% of cases. The ODI scores improved significantly 1 month after the procedure, compared with the baseline scores. The ODI scores after 6 months improved very clearly compared with the baseline scores and with the 3-month scores.

CONCLUSIONS

Single strip lesions radiofrequency denervation using the Simplicity III probe is a potential modality for intermediate term relief for patients with sacroiliac pain.

Sacroiliac Coalition: First Description and Report of a Successful Resection

Study Design Case report. Objective This report describes the first case of a sacroiliac coalition, its clinical features, the diagnostic difficulties, and the surgical treatment chosen in this case. Methods A 33-year-old man presented to our outpatient clinics complaining of severe left-sided low back pain with an intermitted nondermatomal radiation into the left thigh. The only abnormality on a pelvic radiograph was a coin-size, faint hyperdensity, which was almost overlooked. Subsequent computed tomography (CT) and magnetic resonance imaging (MRI) confirmed two bridging bone spurs on the anterior surface of the left joint with a fibrous interruption at the apex. After the conservative treatment failed, a surgical treatment was offered to the patient. The coalition was resected via an anterior retroperitoneal approach and through the tissue plane between the psoas and the iliacus muscles. A histopathologic examination was performed and confirmed the diagnosis of a coalition. Results The patient's pain resolved immediately after surgery. After 8 months, a follow-up CT scan showed complete removal of the coalition without any signs of recurrence, and at 12 months' follow-up, the patient remained pain-free. Conclusions This is the first published case of a sacroiliac coalition. The only sign of this rare condition on the plain radiographs was very easy to miss. As has been discussed in the literature, CT and MRI are important in the differential diagnostics of such lesions. The histopathologic findings included that of a fibrous bar, confirming the diagnosis, which is further corroborated by the complete resolution of the symptoms.

Spinal and sacroiliac gouty arthritis: report of a case and review of the literature

In this case report, we describe an "uncommon" case of axial gouty arthropathy in a 69-year-old woman with bilateral sciatica that was thoroughly evaluated with conventional radiography, CT scan, magnetic resonance imaging, bone scintigraphy, and PET-CT. Axial gouty arthropathy should be included in the differential diagnosis of chronic low back pain, mainly when several risk factors for gout are present.

Minimally invasive arthrodesis for chronic sacroiliac joint dysfunction using the SImmetry SI Joint Fusion system

Chronic sacroiliac (SI) joint-related low back pain (LBP) is a common, yet under-diagnosed and undertreated condition due to difficulties in accurate diagnosis and highly variable treatment practices. In patients with debilitating SI-related LBP for at least 6 months duration who have failed conservative management, arthrodesis is a viable option. The SImmetry^® SI Joint Fusion System is a novel therapy for SI joint fusion, not just fixation, which utilizes a minimally invasive surgical approach, instrumented fixation for immediate stability, and joint preparation with bone grafting for a secure construct in the long term. The purpose of this report is to describe the minimally invasive SI Joint Fusion System, including patient selection criteria, implant characteristics, surgical technique, postoperative recovery, and biomechanical testing results. Advantages and limitations of this system will be discussed.

Analysis of postmarket complaints database for the iFuse SI Joint Fusion System®: a minimally invasive treatment for degenerative sacroiliitis and sacroiliac joint disruption

BACKGROUND

The sacroiliac joint is a common but under-recognized source of low back and gluteal pain. Patients with degenerative sacroiliitis or sacroiliac joint disruption resistant to nonsurgical treatments may undergo open surgery with sacroiliac joint arthrodesis, although outcomes are mixed and risks are significant. Minimally invasive sacroiliac joint arthrodesis was developed to minimize the risk of iatrogenic injury and to improve patient outcomes compared with open surgery.

METHODS

Between April 2009 and January 2013, 5319 patients were treated with the iFuse SI Joint Fusion System® for conditions including sacroiliac joint disruption and degenerative sacroiliitis. A database was prospectively developed to record all complaints reported to the manufacturer in patients treated with the iFuse device. Complaints were collected through spontaneous reporting mechanisms in support of ongoing mandatory postmarket surveillance efforts.

RESULTS

Complaints were reported in 204 (3.8%) patients treated with the iFuse system. Pain was the most commonly reported clinical complaint (n = 119, 2.2%), with nerve impingement (n = 48, 0.9%) and recurrent sacroiliac joint pain (n = 43, 0.8%) most frequently cited. All other clinical complaints were rare (≤0.2%). Ninety-six revision surgeries were performed in 94 (1.8%) patients at a median follow-up of four (range 0-30) months. Revisions were typically performed in the early postoperative period for treatment of a symptomatic malpositioned implant (n = 46, 0.9%) or to correct an improperly sized implant in an asymptomatic patient (n = 10, 0.2%). Revisions in the late postoperative period were performed to treat symptom recurrence (n = 34, 0.6%) or for continued pain of undetermined etiology (n = 6, 0.1%).

CONCLUSION

Analysis of a postmarket product complaints database demonstrates an overall low risk of complaints with the iFuse SI Joint Fusion System in patients with degenerative sacroiliitis or sacroiliac joint disruption.

Clinical incidence of sacroiliac joint arthritis and pain after sacropelvic fixation for spinal deformity

PURPOSE

Sacroiliac fixation using iliac screws for highly unstable lumbar spine has been reported with an improved fusion rate and clinical results. On the other hand, there is a potential for clinical problems related to iliac fixation, including late sacroiliac joint arthritis and pain.

MATERIALS AND METHODS

Twenty patients were evaluated. Degenerative scoliosis was diagnosed in 7 patients, failed back syndrome in 6 patients, destructive spondyloarthropathy in 4 patients, and Charcot spine in 3 patients. All patients underwent posterolateral fusion surgery incorporating lumbar, S1 and iliac screws. We evaluated the pain scores, bone union, and degeneration of sacroiliac joints by X-ray imaging and computed tomography before and 3 years after surgery. For evaluation of low back and buttock pain from sacroiliac joints 3 years after surgery, lidocaine was administered in order to examine pain relief thereafter.

RESULTS

Pain scores significantly improved after surgery. All patients showed bone union at final follow-up. Degeneration of sacroiliac joints was not seen in the 20 patients 3 years after surgery. Patients showed slight low back and buttock pain 3 years after surgery. However, not all patients showed relief of the low back and buttock pain after injection of lidocaine into the sacroiliac joint, indicating that their pain did not originate from sacroiliac joints.

CONCLUSION

The fusion rate and clinical results were excellent. Also, degeneration and pain from sacroiliac joints were not seen within 3 years after surgery. We recommend sacroiliac fixation using iliac screws for highly unstable lumbar spine.

An annotated bibliography of spinal motion palpation reliability studies

BACKGROUND

Several literature reviews have addressed the reliability of spinal and sacroiliac (SI) motion palpation (MP), finding that, in general, interexaminer reliability is slight and intraexaminer reliability is moderate.

METHODS

We performed a literature search of four biomedical databases to locate articles that dealt with MP of the spine or SI joints. The abstracts of the retrieved citations were independently screened for inclusion by two of the authors. The full-text of potentially includable articles was examined by the same two authors to assess whether they met all of the inclusion criteria. The validity of the included studies was evaluated using a 6-point scale.

RESULTS

The initial searches netted 415 citations; another 30 were harvested from the secondary search. Fifty-nine articles were removed as duplicates and 305 failed to meet the inclusion criteria. Another 33 were excluded because they did not adequately describe the method of analysis, used a combination of tests, were not actually MP studies, or were not reliability studies. ANNOTATED BIBLIOGRAPHY: Summaries of 48 articles that dealt with the reliability of spinal and SI MP are presented. Where appropriate, we have commented on some of the methodological deficiencies that were discovered.

Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature

OBJECTIVE

To determine which physical examination tests have the highest sensitivity, specificity, and predictive values for determining the presence of sacroiliac joint injuries and/or dysfunction when compared with the gold standard of a sacroiliac joint block.

DATA SOURCES

A systematic search of the literature was conducted for articles that evaluated clinical sacroiliac joint tests for sensitivity, specificity, and predictive value when compared to sacroiliac joint block. The search was conducted using several online databases: Medline, Embase, Cinahl, AMED, and the Index to Chiropractic Literature. Reference and journal searching and contact with several experts in the area was also employed.

DATA EXTRACTION

Studies selected for inclusion were evaluated with a data extraction sheet and assessed for methodological quality using an assessment tool based on accepted principles of evaluation.

DATA SYNTHESIS

Article results were compared, no attempt to formally combine the results into a meta-analysis was made.

RESULTS

Seven papers were identified for inclusion in the review, two of which dealt with the same study, thus six studies were to be assessed although one paper could not be obtained. The most recently published article had the highest methodological quality. Study designs rarely incorporated randomized, placebo controlled, double blinded study designs or confirmatory sacroiliac joint blocks. There was considerable inconsistency between studies in design and outcome measurement, making comparison difficult. Five tests were found to have sensitivity and specificity over 60% each in at least one study with at least moderately high methodological quality. Using several tests and requiring a minimum number to be positive yielded adequate sensitivity and specificity for identifying sacroiliac joint injury when compared with sacroiliac joint block.

CONCLUSION

Practitioners may consider using the distraction test, compression test, thigh thrust/posterior shear, sacral thrust, and resisted hip abduction as these were the only tests to have specificity and sensitivity greater than 60% in at least one study. Further research using improved methodology is required to determine the optimal tests and combinations of tests to identify sacroiliac joint injuries.