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The effect of thread length and location on extraction strengths of iliosacral lag screws.

Although iliosacral lag screws are an established technique for fixation of sacroiliac joint dislocation and sacral fractures, there is a paucity of data on the relative strength of fixation of screws in the sacral ala and body. The purpose of this study was to quantify and compare the extraction strength of cancellous screws in the sacral ala and body. Twelve fresh frozen cadaveric human pelves (mean age 76) were used to test the extraction strength of three groups of 7.0 mm cannulated cancellous screws: long-threaded in the sacral body, short-threaded in the body and short-threaded in the ala. The mean extraction strengths were 925, 374 and 71 newtons (or 92, 37, and 7 kg) respectively. The differences between the three groups were highly significant (all P < 0.0025). These data strongly recommend that the goal in iliosacral lag screw fixation should be to insert a long-threaded screw into the sacral body, if safely feasible. Fixation in the ala is inferior and should be avoided in the elderly.

Aged↗

Failed back surgery: etiology and diagnostic evaluation.

BACKGROUND CONTEXT: This is a synopsis of a symposium presented to the North American Spine Society Annual Meeting in Montreal, Canada, 2002. PURPOSE: To provide the reader with a distillation of the material presented regarding the diagnosis of failed back surgery syndrome (FBSS). METHODS: Panel presentation. RESULTS: The proper treatment of patients with FBSS depends on a precise and accurate diagnosis. With a careful history, examination, imaging studies, psychological evaluation and diagnostic injections, a diagnosis can be reached in over 90% of patients. The most common diagnoses are foraminal stenosis (25% to 29%), painful disc (20% to 22%), pseudarthrosis (14%), neuropathic pain (10%), recurrent disc herniation (7% to 12%), facet joint pain (3%) and sacroiliac joint (SIJ) pain (2%). Psychological factors are always present and may help or hinder. Common psychological diagnoses include depression, anxiety disorder and substance abuse disorder. Diagnostic injections are very useful for facet joint pain, SIJ pain and discogenic pain; they may also be used to confirm a putative neural compression as a cause of pain. CONCLUSIONS: Spine surgeons must be aware of the common causes of FBSS in order to be able to thoroughly evaluate their patients and to minimize the occurrence of this problem.

Back Pain↗

Sacroiliac lesions as a cause of chronic poor performance in competitive horses.

The histories and clinical signs in 11 horses with longstanding poor performance attributed to chronic sacroiliac damage are described. The main clinical feature was a lack of impulsion from one or both hindlimbs causing a restriction in the hind gait or lowgrade lameness. A temporary improvement was often achieved using anti-inflammatory medication, but eventually all the horses were killed because of unsatisfactory progress at exercise. Post mortem examination revealed that changes were confined to the sacroiliac joints. The macroscopic and histological findings varied considerably and in only two cases could the changes be classified histologically as arthrosis. In the other nine horses there was increased joint surface area or irregular outline associated with extensions of the joint on the caudomedial aspect. These changes were interpreted as indicating a chronic instability of the joint leading to restriction of hindlimb impulsion. The underlying cause of the problem was not ascertained but the significance and possible pathogenesis of the lesions are discussed.

Animals↗

[A case of pityriasis rubra pilaris associated with rapidly progressive finger joint destruction].

A 40-year-old female noticed edema of the lower limbs in March 1995. Nephrotic syndrome due to membranous nephropathy was diagnosed and administration of high-dose corticosteroids resulted in incomplete remission. Progressively enlarging, red scaling skin lesions developed concomitantly from the scalp to the extremities. Pityriasis rubra pilaris (PRP) was diagnosed in 1996 in the Department of Dermatology at Sapporo Medical University hospital. Various treatments proved ineffective. Arthritis of the finger joints developed in July 1999, and proteinuria recurred in April 2000. She was admitted to our department in August 2000. Physical examination on admission revealed marked swelling of both distal interphalangeal (DIP) joints and the right fourth proximal interphalangeal (PIP) joint. Results of testing for antinuclear antibody, rheumatoid factor, and HLA-B27 were all negative. Radiography of the hands revealed destruction of the DIP and PIP joints where MRI indicated the presence of synovitis. Bone scintigraphy demonstrated accumulation in bilateral metatarso-phalangeal joints and the left sacroiliac joint. Arthritis associated with PRP was diagnosed, as both PRP and psoriasis represent keratinizing disorders of the skin and clinical features in the present case resembled those of psoriatic arthritis. Despite administration of high-dose corticosteroids, destruction of finger joints progressed rapidly. Administration of cyclosporine in April 2002 improved arthritic symptoms. Cases of PRP accompanied by arthritis need to be accumulated to allow analysis of the pathogenesis and clinical picture of this association.

Adult↗

[Physical medicine in the diagnosis and treatment of functional disorders of the spinal column].

INTRODUCTION: Manual (Physical) Medicine is concerned with physiology, pathophysiology, diagnosis and therapy of the musculoskeletal system functional disorders. Functional disorders are caused by direct or indirect injury (muscular spasm), inflammation, sudden movements etc. Functional disorders in regard to decreased joint volume are also called segmental or peripheral joint dysfunction, somatic dysfunction and function blocking. Blocking means: reversible disorder with decreased functional joint movement; muscular spasms caused by neurophysiological changes including decreased movement; pain and functional disorder of internal organs and tissues being part of the joint. Intervertebral joints, intervertebral discs, muscles and their nerve control belong to such control circles which are integrated within an organism. The basic principles of Manual (Physical) Medicine are good knowledge of functional anatomy and three-dimensional imaging of biochemical functions of the spine. The most important functions of the spinal column are as follows: it is an organ of axis with a protective and supportive function and it enables normal walk and balance. The basic functional unit in the architecture of the vertebral column is the dynamic spinal segment. Its basic function is movement, posture maintenance and protection of spinal nerve roots. The functional disorder of one part of the dynamic segment cannot be isolated from other parts. Thus functional blocks within the fascial joints, abnormalities within intervertebral discs, changes within the ligament apparatus, and muscular disorders may be both causes and consequences at the same time. The dynamic segment is thus included into a mechanical functional circle. Its mechanical function is tightly connected with the statics of the whole body. Different leg length, severe abnormalities of great leg joints may cause blocks within the fascial joints. The vertebral dynamic segment is also a part of the nervous, functional reflex circle. Clinical symptoms associated with functional disorders within intervertebral joints are as follows: restricted joint mobility and nervous reflex disorders (local segmental and peripheral segmental injuries). MANUAL (PHYSICAL) DIAGNOSIS: In order to make physical diagnosis it is necessary to have good knowledge of anatomy, functional anatomy, kinesiology and neurology. History taking is of great importance for the physician who establishes physical therapy. It is also necessary to note various abnormalities, muscle atrophy and to analyze patient's walk. Palpation at rest reveals changes, skin disorders, subcutaneous and fatty tissues and muscles and it assesses the status of soft tissues. By physical examination of the spine it is possible to diagnose intervertebral joint blocks. Thus examination of joint mobility is performed. It is important to differ physiological, anatomic and pathologic ranges of mobility and to determine the greatest mobility and joint play. Joint play represents the property of the joint to achieve some additional mobility. This examination requires knowledge of a special technique. Palpation of local segmental irritation is performed on all spinal segments after a special technique examining bone-transversal joints as well as sacroiliac joints. Local irritation points, muscle spasms and tendomyosis are being detected. The diagnosis of blocks is also the therapeutic diagnosis at the same time. Physicians using physical medicine must apply x-ray of the spinal column, whereas the aim of physical therapy is to eliminate functional blocks, which occur in the form of reduced reversible mobility in one or more directions. Only physical examination can establish this, while apparatuses cannot objectivize it. Manipulative techniques on the spine should be performed only by specialists. MANUAL (PHYSICAL) THERAPY: Manual (Physical) therapy comprises numerous techniques and is used in various indications. (ABSTRACT TRUNCATED)

Contraindications↗

Nuclear medicine techniques in arthritis.

An historical review of radionuclide applications to the assessment of synovitis is presented. Contemporary radiopharmaceuticals are grouped into vascular, bone, and inflammatory markers, and their clinical utility and efficacy in disclosing peripheral synovitis and osteoarthritis are surveyed. There is focus on the debate over the usefulness of quantitative sacroiliac joint measurements for screening sacroiliitis, the significance of the negative peripheral joint scan in patients presenting with polyarthralgia, and the suitability of the joint scan to monitor the response to medical treatment objectively.

Arthritis↗

[Sacroiliac infection: clinical characteristics in 11 cases].

We report clinical and laboratory findings in 11 patients with septic sacro-iliitis. Fever, pain and immobility were prominent symptoms. Acute tenderness of the sacroiliac joint and elevation of the ESR were present in all. Joint puncture allowed identification of the infectious agent in 10 patients: S aureus 4, S typhi 3, E coli 2 and P mirabilis 1. Good clinical results were obtained after appropriate antibiotic therapy.

Adolescent↗

[Psoriatic arthritis: case report of acute HLA-B27 positive polyarthritis preceding the onset of typical skin changes].

Psoriasis usually occurs many years before development of arthritis. This is a case report of a patient with acute polyarthritis affecting both peripheral joints and the left sacroiliac joint, preceding the appearance of typical skin manifestations for almost two months. A 44-year-old male mechanic was admitted to our institution for acute additive polyarthritis. Inflammatory synovitis primarily affected large peripheral joints (knees, ankles) in an asymmetrical pattern, with a concomitant development of unilateral sacroiliitis and later with asymmetrical involvement of several proximal and distal interphalangeal joints of the hands and feet. There were also signs of enthesopathy of the right heel. Arthritis was not proceeded by infection of the lower genital or gastrointestinal tract or serological and bacteriological evidences of streptococcal or HIV infection. Laboratory findings showed an erythrocyte sedimentation rate (92 in the first hour), positive histocompatibility antigen HLA-B27 and an increased level of acute phase reactants. Almost two months after affecting the locomotor system a typical psoriatic rash developed, first affecting the scalp and then spreading over the trunk and extremities. It was accompanied by severe onychodystrophy. The patient underwent intensive treatment with methylprednisolone (1.5 mg/kg) and cyclosporine A with significant results.

Adult↗

Reactive oligoarthritis in a patient with Clostridium difficile pseudomembranous colitis. Review of the literature.

A 57-year-old man developed oligoarthritis of the right sacroiliac joint, knee and elbow in the wake of Clostridium difficile pseudomembranous colitis. He was HLA B27-positive and had a history of Reiter's syndrome. His joint manifestations resolved after a course of nonsteroidal antiinflammatory drug therapy and injection of the right knee with triamcinolone acetonide. Clostridium difficile should be recognized as a rare cause of reactive arthritis.

Anti-Inflammatory Agents, Non-Steroidal↗

Sacroiliac arthrodesis using a posterior midline fascial splitting approach and pedicle screw instrumentation: a new technique.

Many techniques for sacroiliac arthrodesis have been described. No single technique is universally accepted as the standard. The current report describes a new technique using a midline fascial-splitting approach and pedicle screw instrumentation. Four consecutive patients with nontraumatic disorders of the sacroiliac joint who have undergone successful arthrodesis by the described technique are presented. One patient had a spontaneous sacroiliac disruption secondary to rheumatoid arthritis, and was returned to her previous ambulatory status after fusion of the disrupted joint. Her fusion remained stable for 9 years postoperatively. The others had degeneration of the sacroiliac joint that was symptomatically improved by arthrodesis. The described method of sacroiliac arthrodesis may be an attractive option for surgeons who are familiar with pedicle screw instrumentation techniques.

Adult↗

HLA-DR4 in ankylosing spondylitis with different patterns of joint involvement.

Fifty patients with ankylosing spondylitis (AS) confined to the spine and sacroiliac joints were compared with 50 cases of AS complicated by various patterns of non-axial joint involvement. Radiological and clinical features were evaluated and HLA-DR4 typing was carried out. This antigen was found in 16% of 200 normal individuals in 18% of patients suffering from exclusively axial AS, and in 54% of patients with additional purely peripheral joint involvement (wrist, finger, ankle, toe). The possibility that HLA-DR4 represents a non-specific marker for peripheral arthritis in patients with ankylosing spondylitis is discussed.

Adult↗

Studying patients with inflammatory back pain and arthritis of the lower limbs clinically and by magnetic resonance imaging: many, but not all patients with sacroiliitis have spondyloarthropathy.

OBJECTIVE: Clinical and magnetic resonance imaging (MRI) data of 170 consecutive patients with inflammatory back pain (IBP) and/or oligoarthritis of the lower limbs were evaluated in a retrospective study. The aim was to determine the frequency of sacroiliitis and spondyloarthropathy (SpA) in this population, and to assess the significance of HLA B27 measurements for diagnosis in early disease. METHODS: Pelvic X-rays were performed in all IBP patients and dynamic MRI of the sacroiliac joints in patients with IBP who had indefinite results on sacroiliac X-rays (n = 32). RESULTS: European Spondyloarthropathy Study Group criteria for SpA were fulfilled by 106/170 patients (62.4%); eight additional patients had symptoms suggestive of SpA (4.7%). The most frequent SpA subset was undifferentiated SpA (uSpA), diagnosed in 46/106 patients (43.4%). Sacroiliitis was detected by MRI in 21/32 patients with IBP and unclear X-rays (65.6%). Of those, 14 were diagnosed as SpA and seven females with moderate unilateral sacroiliitis, but no features of SpA, also not on follow-up (at least 1 yr), were classified as undifferentiated sacroiliitis (US). Ten of the 14 SpA (71.4%) and none of the seven US patients were HLA B27 positive. CONCLUSION: HLA B27 positivity in IBP patients with MRI-proven sacroiliitis positively predicts SpA. uSpA is a frequent SpA subset. There are HLA B27-negative non-SpA patients with moderate unilateral sacroiliitis whom we propose to be classified as US.

Adult↗

Computed tomography-guided fixation of unstable posterior pelvic ring disruptions.

Open reduction and internal fixation (ORIF), the current treatment of choice of posterior pelvic ring disruptions with instability, has significant disadvantages. These include relatively "blind" placement of the fixation screws, infection, exsanguinating hemorrhage, and high wound complication rates. We feel fluoroscopy does not offer significant clarity in defining the posterior structure. Advantages of computed tomography (CT)-guided sacral fixation are direct visualization of the course of the screws and absence of significant wound complications. This technique provides superior visualization of the nerve roots and sacral canal compared to fluoroscopic methods. Thirteen patients (10 unilateral and 3 bilateral) with unstable but reducible sacral fractures or sacroiliac joint (SIJ) disruptions underwent CT-guided posterior pelvic ring fixation using a cannulated screw system. Skeletal traction was required intraoperatively in one case by a traction-counteraction pulley system in the CT scanner. All other reductions were performed by preoperative skeletal traction or manually by the surgeons after anesthesia in the scanner or after push-pull films demonstrated instability. The guide pin, using depth and angulation measurements derived from the scout CT scans, was positioned across the fracture or SIJ. Following CT confirmation of the position of the pin, the screw tract was drilled and the cannulated screw was placed into position. Radiographic and clinical follow-up observation (7-24 months) showed healing with no significant complications in all 13 patients. Computed tomography-guided sacral fixation is a safe alternative to ORIF in selected patients with reducible unstable pelvic fractures.

Adolescent↗

[Osteoarticular lesions in Whipple's disease. Apropos of a destructive form and review of the literature].

A patient with Whipple's disease was considered as cured after treatment for two years, but relapse occurred as the neurological form. Radiographic imaging showed destructive osteoarticular lesions, with few or no symptoms, affecting the peripheral skeleton but also the sacroiliac joints. The published literature is reviewed and the different osteoarticular radiologic forms of the affection described.

Bone Diseases↗

[Surgical management of injuries to the dorsal pelvic ring by elastic stabilization].

A new method of operative stabilization of injuries of the dorsal ring of the pelvis is demonstrated. The necessity of conservation of the elasticity of the pelvic ring is discussed. Only an elastic stabilization can preserve the mobility of the sacroiliac joint. This method is simple and involves little risk. Special instruments and implants are not necessary.

Bone Screws↗

Pyogenic sacroiliitis: another imitator of the acute abdomen.

Acute suppurative infection of the sacroiliac joint can mimic the acute abdomen. Experience with a patient who had exploratory laparotomy for acute appendicitis prompted a review of the literature, which indicated that 12.6% of patients with pyogenic sacroiliitis have acute abdominal pain. A high index of suspicion is necessary to establish this diagnosis.

Abdomen, Acute↗