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PubMed1995

Intraoperative somatosensory evoked potential monitoring during acute pelvic fracture surgery.

Independent clinical neurological evaluation and intraoperative somatosensory evoked potential (SSEP) monitoring was performed on 30 vertically unstable hemipelvis fractures in 28 patients undergoing acute open reduction and internal fixation. Preoperative ipsilateral neurologic injury of the sciatic/lumbosacral plexus was noted in 15 of 30 fractures (50%). Significant unilateral SSEP changes occurred during manipulative reduction of two displaced sacroiliac joints and one sacral fracture. Because of the expeditious response of the surgical team, with release of traction/retraction, SSEP returned to baseline and no patient sustained an iatrogenic nerve injury or worsening of their preoperatie neurologic status. The incidence of postinjury lumbosacral plexopathy in unstable pelvic fractures is high (50%) when careful preoperative evaluation including SSEP is performed. The use of intraoperative SSEP monitoring is feasible in acute posterior pelvic fracture surgery and can help identify potential intraoperative iatrogenic lumbosacral neurological compromise.

Adolescent↗
PubMed1996

Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study.

Malpositioning of iliosacral screws happens more often when common variations in the morphology of the upper sacral segments are unrecognized. Radiological-anatomic correlations of sacral anatomy were studied in 10 fresh-frozen cadaveric pelvises without evidence of skeletal disease, obtained from six male and four female donors. Eighty consecutive patients with complicated pelvic fractures treated operatively by the same surgeon using percutaneously placed iliosacral screws were evaluated. Variations in the sacral alar anatomy and slope found in upper sacral segmentation anomalies are common. Surgically important and predictable abnormal morphological patterns can be easily identified using pelvic outlet and lateral sacral plain radiographs along with computed tomographic scans. On the true lateral projections, the iliac cortical density adjacent to the sacroiliac joint parallels the sacral alar slope and is almost always caudal and posterior to it; it delineates the anterior extent of the "safe zone" for iliosacral screw insertion. Thus, the lateral sacral image provides the surgeon with a better understanding of the sacral alar slope and can help prevent iliosacral screw placement errors. The lateral sacral image should always be used intraoperatively with the inlet and outlet images to guide iliosacral screw placement.

Adolescent↗
PubMed1997

Associated lumbosacral junction injuries (LSJIs) in pelvic fractures.

OBJECTIVE: To study lumbosacral junction injuries (LSJIs) associated with displaced sacral fractures. DESIGN: Prospective. SETTING: University hospital. PATIENTS: Eighty-nine patients with pelvic fractures. INTERVENTIONS: All patients underwent standard x-ray examination consisting of anteroposterior and inlet and outlet views of the injury. In 50 percent of the cases, oblique views were also obtained. Computed tomography (CT) scans were obtained for all vertically unstable lesions and for fifteen of the lateral compression lesions. MAIN OUTCOME MEASURES: Pelvic fractures were classified according to Tile's classification. LSJIs associated with pelvic ring fractures were classified according to Isler. RESULTS: Lumbosacral junction injuries, including one bilateral lesion, were found in thirteen patients. One lesion was associated with a compression fracture, and the other twelve were associated with vertically unstable fractures. In one patient, a facet fracture was associated with a contralateral sacroiliac joint dislocation. A new type of LSJI was identified in three patients: it was characterized by disruption of the annulus fibrosus associated with rising of the hemipelvis and inclination of the L5 body. CONCLUSION: Lumbosacral junction injuries should be suspected in cases of transforaminal sacral fracture, especially when these fractures are displaced. In such cases, we recommend that the lumbosacral junction be evaluated with appropriate CT scans.

Adolescent↗
PubMed2002

Pelvic fractures in a pediatric level I trauma center.

OBJECTIVES: Assess the characteristics associated with the risk of complications and mortality in children sustaining pelvic fractures. SETTING: Urban university pediatric Level I trauma center in a large metropolitan community. PATIENTS/PARTICIPANTS: Retrospective analysis of 57 consecutive children with 66 pelvic fractures seen between 1993 and 1999. INTERVENTION: Fifty-two patients were treated nonoperatively, and five patients required operative stabilization (four acetabular fractures and one partial sacroiliac joint disruption). MAIN OUTCOME MEASURE: Type and cause of pelvic fracture, type of management used, incidence of associated injuries, hemorrhage requiring transfusion, and mortality. RESULTS: Hemorrhage directly related to the pelvic fracture occurred in only one patient (2%), whereas 11 other patients required transfusions associated with other body-area injuries. Three patients with pelvic fractures died (5%), but deaths were due to other body-area injuries. CONCLUSIONS: Children with pediatric pelvic fractures require careful evaluation for other body-area injuries, as these are most likely to be related to hemorrhage or mortality.

Acetabulum↗
PubMed2003

The significance of anode location for stimulus-evoked electromyography during iliosacral screw placement.

OBJECTIVES: To determine the effect of anode location on the current threshold required to provoke an electromyograph response during stimulus-evoked electromyography for iliosacral screw placement. DESIGN: Prospective cohort. SETTING: Level I trauma center. PATIENTS: Nineteen consecutive patients with 23 unstable posterior pelvic ring injuries treated with iliosacral screws. INTERVENTION: Iliosacral screws were inserted percutaneously over guidewires. Twenty-seven screws were inserted, all into the first sacral vertebrae. The guidewire was used as the cathode for constant-current, stimulus-evoked electromyography for all data collection. Stimulus-evoked electromyographs were obtained with the guidewire at four different stations: at the sacroiliac joint (station I), at the first sacral neuroforamen (station II), in the body of the sacrum (station III), and when the iliosacral screw was in final position over the guidewire (station IV). MAIN OUTCOME MEASURE: Stimulus-evoked electromyographs were obtained with the anode at four different locations for each of the implant stations. Location A had the anode adjacent to the percutaneous insertion site of the guidewire, location B at the ipsilateral anterior superior iliac spine, location C at the midline, and location D at the contralateral anterior superior iliac spine. RESULTS: Moving the anode from midline (location C) toward the entry point of the guidewire increased the current threshold required to provoke an EMG response as much as 67.1% (p < 0.05). Moving the anode from midline to the contralateral anterior superior iliac spine decreased thresholds as much as 3.4% (p > 0.05). In one case, anode placement close to the guidewire insertion site (locations A and B) failed to identify a potentially dangerous implant because current thresholds were >8 mA. With the anode at the midline, current thresholds were <8 mA, indicating unsafe guidewire position leading to redirection of the guidewire. CONCLUSION: The physical location of the anode during stimulus-evoked electromyography monitoring for iliosacral screw placement significantly changes the current thresholds required to provoke an electromyograph response. Current thresholds required to stimulate nerves increase as the anode is moved toward the stimulating electrode. Anode placement ipsilateral to the stimulating electrode may provide a false indication of safe guidewire placement. We recommend anode location at or beyond the midline for stimulus-evoked electromyography monitoring during iliosacral screw placement.

Adolescent↗
PubMed2003

Clinical effectiveness of the physical examination in diagnosis of posterior pelvic ring injuries.

OBJECTIVE: To determine if physical examination (PE) of the posterior pelvis in awake and alert trauma patients with known pelvic ring injuries can accurately predict a potentially unstable posterior ring injury and guide the use of computed tomography (CT) more effectively. DESIGN: Patients with pelvic fracture noted on anteroposterior (AP) pelvic radiographs were prospectively evaluated over a 21-month period. AP, inlet, and outlet radiographs as well as CT scans were obtained on all patients. SETTING: Level I trauma center. PATIENTS: Patients were excluded who had a Glasgow Coma Scale score less than or equal to 12, were unable to cooperate with a PE, were 12 years old or younger, or had concomitant acetabular fracture. INTERVENTION: A focused PE protocol with emphasis on the posterior pelvis, including posterior palpation of the sacrum and sacroiliac joint, AP and lateral iliac wing compression, active hip range of motion, and a digital rectal examination. If an individual PE parameter resulted in tenderness, it was considered positive. MAIN OUTCOME MEASUREMENTS: The 4 PE modalities were compared with CT scan results using sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratio, and McNemar's test for discordant pairs. RESULTS: The study group included 66 patients. Of patients, 49 (74%) had posterior pelvic injury diagnosed by CT scan. Of the patients with positive posterior CT scan findings, 48 (98%) had pain with posterior palpation. Sensitivity and specificity were 0.98 and 0.94, and the likelihood ratio was 16.3. CONCLUSIONS: PE, specifically palpation of the posterior pelvis, in patients with pelvic fractures can accurately detect injuries of the posterior ring.

Adolescent↗
PubMedDate not supplied

Spontaneous atlantoaxial subluxation as a presenting manifestation of juvenile ankylosing spondylitis. A case report.

Juvenile-onset ankylosing spondylitis is an unusual disorder which can present with either peripheral arthritis or with more classic hip girdle and back symptoms. Atlantoaxial instability has been recognized as a late complication in only one patient and has not been reported as an early manifestation. This paper presents a case in which atlantoaxial instability and neck pain without neurologic involvement was a presenting manifestation. The laboratory and clinical features of juvenile ankylosing spondylitis are discussed, along with the importance of qualitative sacroiliac joint scintigraphy in the diagnosis of early or confusing cases.

Axis, Cervical Vertebra↗
PubMed1989

Harvesting autogenous iliac bone grafts. A review of complications and techniques.

Autogenous bone grafts from the ilium are frequently harvested for purposes of bone union and/or stability. Although some donor site complications may be unavoidable, awareness of the anatomy and complications may aid in planning the approach and minimizing the risks. Documented donor site complications include pain, nerve and arterial injury, peritoneal perforation, sacroiliac joint instability, and herniation of abdominal contents through defects in the ilium. Strict observation of relevant anatomic considerations will help in avoiding these complications.

Abdomen↗
PubMed1993

Sacral insufficiency fractures presenting as acute low-back pain. Biomechanical aspects.

Sacral insufficiency fractures are an often unsuspected cause of low-back pain in elderly women with osteopenia who have sustained unknown or only minimal trauma. The authors describe 10 cases of spontaneous sacral insufficiency fractures, confirmed by computed tomography, characterized by the onset of acute low-back pain. Differential clinical and radiographic diagnosis of these fractures is often difficult. Recognition of the characteristic scintigraphic patterns in sacral fractures, which are frequent in osteopenic patients, could avoid mistaken diagnoses and unnecessary tests or treatment. One of the striking feature of these sacral fractures is their invariable location. The fractures extend vertically in the sacral alae, parallel to the sacroiliac joints. They are located just lateral to the margins of the lumbar spine. This distribution suggests that such fractures could be partially caused by weight-bearing transmitted through the spine.

Aged↗
PubMed1996

Radiologic evaluation of iliosacral screw placement.

STUDY DESIGN: This study analyzed anteroposterior, lateral, inlet, and outlet radiographic representations of different iliosacral screw orientations and evaluated anatomic features of the superior aspects of the sacral alae. OBJECTIVES: The purpose of this anatomical and radiologic study was to assess the value of anteroposterior, inlet, outlet, and lateral views with regard to the planning of iliosacral screw placement, to determine if screws penetrating the sacral surfaces and foramina can be detected during or after operation, and to evaluate the anatomy of the superior aspects of the sacral ala quantitatively. SUMMARY OF BACKGROUND DATA: Direct iliosacral screw fixation has recently become popular because it provides stable fixation using reasonably small implants and is biomechanically equal or superior to other techniques of internal fixation. However, misinterpretation of the relationship of pelvic radiographs and the position of a screw may result in incorrect screw placement during surgery or misdiagnosis of postoperative neurologic complications. The morphology of the sacrum is complex. No previous data relative to the superior aspect of the sacral alae are available. METHODS: Four bony pelves were used to model the different iliosacral screw orientations possible during iliosacral reconstruction. A drill bit was inserted laterally from the posterior ilium through the sacroiliac joint and into the S1 vertebra. Radiographs were taken from anteroposterior, lateral, inlet, and outlet views for evaluation of placement. Twenty-two dry sacra were obtained for anatomic evaluation of the superior aspects of the sacral alae. All symmetrical structures were measured bilaterally. Measurements included three angular and two linear parameters. RESULTS: The results showed that a misdirected drill bit penetrating the anterior aspect of the ala is best appreciated by the inlet view. A misdirected drill bit penetrating the superior aspect of the ala or the S1 foramen is best represented in the outlet view. The average angle between the coronal plane of the S1 vertebra and the anterior aspect of the ala was 27.1 degrees; between the superior aspect of the S1 vertebral body and superior edge of the ala, 36.9 degrees; and between the superior aspect of the S1 vertebral body and posterosuperior edge of the ala, 24.5 degrees. CONCLUSIONS: The inlet view shows the orientation of screws relative to the coronal plane and extraosseus screws extending anterior to the ala, whereas the outlet view elucidates the placement of screws relative to the transverse plane and extraosseus screw tips extending into the sacral foramina or superior to the ala. Evaluation of preoperative pelvic computed tomography scans may be helpful in understanding the unique morphology of each individual patient and enhancing the safety of iliosacral screw placement.

Bone Screws↗
PubMed1997

Pain pattern in pregnancy and "catching" of the leg in pregnant women with posterior pelvic pain.

STUDY DESIGN: A cross-sectional study of symptoms and signs in pregnant women. OBJECTIVES: To describe the clinical appearance of back pain in pregnancy and the relation between pain distribution and symptoms in women with posterior pelvic pain, in order to shed light on etiologic factors. SUMMARY OF BACKGROUND DATA: Back pain is common in the general population. During pregnancy, it is even more common, and back pain is experienced by about 50% of pregnant women. In the pregnant woman, differentiation between common low back pain and posterior pelvic pain is believed to be essential because these symptoms should be treated in different ways. METHODS: The women were interviewed with a questionnaire. Those with back symptoms completed a pain drawing and were examined by an orthopedic surgeon. Based on the symptoms and findings, the women were divided into three groups: thoracic pain, lumbar pain, and posterior pelvic pain. RESULTS: Of 335 pregnant women, 51% had back pain at the time of examination. The pain was more widespread compared with common low back pain. Seventy-one percent of the 171 patients examined by the orthopedic surgeon had a positive posterior pelvic pain test. These women more often had pain in the gluteal and posterior thigh regions. A "catching" feeling of the leg was described when walking by 44 of 122 these women, whereas only 1 of 49 women without a posterior pelvic pain test had such symptoms. CONCLUSIONS: The higher prevalence of back pain in pregnancy may be due to several factors. In women with posterior pelvic pain, there is a specific symptom-a catching of the leg when walking. The most probable explanation for the catching is that local nociception disturbs muscular function in women with posterior pelvic pain because changes in the sacroiliac joint range of motion, which is very small, cannot cause this symptom.

Adult↗
PubMed1997

Injuries presenting to an Australian sports medicine centre: a 12-month study.

OBJECTIVE: To document the conditions seen by medical practitioners at a multidisciplinary sports medicine clinic during a 12-month period on the basis of site of injury, pathology, and sport played. DESIGN: A coding system for anatomical region, pathology, and sport played was designed. PATIENTS: The total number of patient diagnoses coded and entered for analysis was 2,429. RESULTS: The most common sports involved were Australian football 322 (13.3%), distance running 299 (12.3%), netball/basketball 210 (8.6%), racquet sports 140 (5.8%), and track running 135 (5.6%). The most commonly injured region was the knee with 668 presentations (27.5%), followed by the upper limb (8.8%). The most frequently diagnosed pathology was overuse/inflammation with 1,115 (45.9%). Other pathologies diagnosed were partial ligament sprains 316 (13.0%), muscle strain 99 (4.1%), compartment syndrome 85 (3.5%), and third-degree ligament tear (3.5%). The most common diagnoses seen were patellofemoral syndrome, lumbar spine disorders, rotator cuff tendinitis, lateral ligament ankle sprain, medial meniscus tear, medial collateral ligament knee sprain, lateral meniscus tear, achilles tendinosis, anterior cruciate ligament tear and sacroiliac joint inflammation. CONCLUSION: A study of this nature provides valuable information both to the epidemiologist and clinician.

Athletic Injuries↗
PubMed2005

Symphyseal separation.

BACKGROUND: Separation of the pubic symphysis up to 1 cm during pregnancy and delivery occurs frequently. This report presents a woman who experienced a large symphyseal separation. CASE: Following delivery, a 35-year-old primipara complained of hip and groin pain associated with leg movement. An anterior-posterior pelvic X-ray showed a pubic separation of 9.5 cm and a 3-5 mm widening of the sacroiliac joints. She was treated with a pelvic binder, walker, and physical therapy. The diastasis has since undergone progressive reduction. CONCLUSION: Separation of the pubic symphysis during pregnancy and delivery is normal. However, a large separation is a potential complication requiring treatment and follow-up. Conservative management including analgesia, rest, and a pelvic binder is a reasonable method of management.

Adult↗
PubMed2005

Pathogenesis of ankylosing spondylitis and reactive arthritis.

PURPOSE OF REVIEW: The hallmark of ankylosing spondylitis is acute and chronic spinal inflammation initiating in the sacroiliac joints, often coupled with enthesitis, presenting as chronic inflammation at the sites of ligamentous and tendinous insertions into bone. Peripheral joint synovitis can be a prominent feature as well. Reactive arthritis is a sterile synovitis arising after an extra-articular infection of enteric or urogenital tracts. HLA-B27 has been known for about the past 30 years to be associated with ankylosing spondylitis and reactive arthritis, but the pathogenesis of ankylosing spondylitis and reactive arthritis is still not well defined. Although the clinical manifestations of ankylosing spondylitis and reactive arthritis may differ, this update discusses the two diseases together and focuses on recent evidence in both. RECENT FINDINGS: With respect to HLA-B27 several recent studies address arthritogenic peptides, molecular mimicry, and aberrant forms of B27. Several candidate genes in addition to B27 have been implicated in recent genetic studies. With respect to bacterial infection, recent findings in bacterial antigenicity, host response through interactions of antigen-presenting cells, T cells, and cytokines are providing new understanding of host-pathogen interactions and the pathogenesis of arthritis. Endogenous host factors such as proteoglycans may play a role as autoantigens and contribute to chronic inflammation on that basis. SUMMARY: Recent advances provide additional new insights into distinct pathogenetic mechanisms in AS and ReA that arise from a complex interplay between genetic factors including HLA-B27 and environmental factors.

Arthritis, Reactive↗
PubMed2006

An MRI investigation into the function of the transversus abdominis muscle during "drawing-in" of the abdominal wall.

STUDY DESIGN: An operator blinded dual modality trial of measurement of the abdominal muscles during "drawing-in" of the abdominal wall. OBJECTIVES: 1) To investigate, using magnetic resonance imaging (MRI), the function of the transversus abdominis muscle bilaterally during a drawing-in of the abdominal wall. 2) To validate the use of real-time ultrasound imaging as a measure of the deep abdominal muscle during a drawing-in of the abdominal wall. SUMMARY OF BACKGROUND DATA: Previous research has implicated the deep abdominal muscle, transversus abdominis, in the support and protection of the spine and provided evidence that training this muscle is important in the rehabilitation of low back pain. One of the most important actions of the transversus abdominis is to "draw-in" the abdominal wall, and this action has been shown to stiffen the sacroiliac joints. It is hypothesized that in response to a draw in, the transversus abdominis muscle forms a deep musculofascial "corset" and that MRI could be used to view this corset and verify its mechanism of action on the lumbopelvic region. METHODS: Thirteen healthy asymptomatic male elite cricket players aged 21.3 +/- 2.1 years were imaged using MRI and ultrasound imaging as they drew in their abdominal walls. Measurements of the thickness of the transversus abdominis and internal oblique muscles and the slide of the anterior abdominal fascia were measured using both MRI and ultrasound. Measurement of the whole abdominal cross-sectional area (CSA) was conducted using MRI. RESULTS: Results of the MRI demonstrated that, as a result of draw-in, there was a significant increase in thickness of the transversus abdominis (P < 0.001) and the internal oblique muscles (P < 0.001). There was a significant decrease in the CSA of the trunk (P < 0.001). The mean slide (+/-SD) of the anterior abdominal fascia was 1.54 +/- 0.38 cm for the left side and 1.48 +/- 0.35 cm for the right side. Ultrasound measurements of muscle thickness of both transversus abdominis and the internal oblique, as well as fascial slide, correlated with measures obtained using MRI (interclass correlations from 0.78 to 0.95). CONCLUSIONS: The MRI results demonstrated that during a drawing-in action, the transversus abdominis contracts bilaterally to form a musculofascial band that appears to tighten (like a corset) and most likely improves the stabilization of the lumbopelvic region. Real-time ultrasound imaging can also be used to measure changes in the transversus abdominis during the draw-in maneuver.

Abdominal Muscles↗
PubMed2006

Radiographic measurement techniques for sacral fractures consensus statement of the Spine Trauma Study Group.

STUDY DESIGN: Literature review. OBJECTIVES: Members of the Spine Trauma Study Group evaluated various imaging methods and compiled standardized approaches to making radiographic measurements for the assessment of sacral fractures. SUMMARY OF BACKGROUND DATA: The diagnosis of sacral fractures is frequently missed or delayed, and the treatment is controversial, with significant variations in recommendations regarding nonoperative treatment, neural decompression, and internal fixation. A paucity of specific radiographic measurements and criteria exist to aid the clinician in making sound treatment decisions. This may obligate surgeons to base clinical decisions on nonstandardized, nonvalidated recommendations and measures and, in some cases, anecdotal evidence. We think that a critical first step toward valid and optimal clinical decision-making requires an accurate and clear definition of imaging measurement parameters used to evaluate sacral injuries and gather data for future studies. METHODS: A review of the English-speaking literature was performed to assess cited radiographic measurement techniques of sacral fractures currently in use. This allowed the formulation of detailed radiographic assessments designed to more reliably describe sacral fracture morphometry. RESULTS: These measurements include: anterior-posterior sacral fracture displacement (axial computed tomography [CT] of the pelvis), vertical sacral fracture displacement (coronal CT reconstruction), anterior-posterior translation and kyphotic angulation (sagittal CT reconstructions), and degree of central canal involvement and foraminal encroachment (axial CT with fine cuts and coronal and sagittal reconstructions). Other radiographic factors that should be considered that may impact treatment outcomes include the level and type of sacral fracture, lumbosacral junction and sacroiliac joint involvement, and associated pelvic ring injury. CONCLUSIONS: With adoption of these radiographic guidelines, future studies will have a uniform method in which to describe sacral injuries and therefore allow study of the efficacy of various recommended treatment protocols.

Consensus↗
PubMed2006

Osteochondroma of the sacrum: a case report and review of the literature.

STUDY DESIGN: A case report and review of the literature. OBJECTIVES: To describe the en bloc excision and postoperative outcome of an osteochondroma of the sacrum compressing the neural elements, as well as review the literature on solitary osteochondroma involving the sacrum. SUMMARY OF BACKGROUND DATA: Osteochondroma is the most common primary benign bone tumor. However, this tumor rarely involves the spine and even more rarely involves the sacrum. To the best of our knowledge, en bloc excision of a solitary osteochondroma of the sacrum has not been previously reported. METHODS: An 11-year-old male presented with disabling radicular pain in the right lower extremity. Radiologic studies showed a lesion occurring from the sacral lamina that was compressing the S2 nerve root. The tumor was excised en bloc through a posterior approach. The cavitary defect within the sacrum was reconstructed with crushed cancellous allograft and demineralized bone matrix putty. A literature review of solitary sacral osteochondroma was conducted of the English-based medical literature. RESULTS: Histologic studies showed the tumor to be an osteochondroma. After surgery, pain was completely relieved, and neurologic function was normal. At the last follow-up, the sacroiliac joint remained intact, and there was no evidence of local recurrence. A literature review revealed 4 previous cases addressing osteochondroma of the sacrum. CONCLUSIONS: Osteochondroma is a rare primary benign bone tumor that can occur in the sacrum. Local contamination and, therefore, the likelihood of local recurrence, are decreased when an en bloc, as opposed to an intralesional, excision is performed.

Child↗
PubMedDate not supplied

Chronic recurrent multifocal osteomyelitis: a follow-up study.

Thirteen children/adolescents and two young adults with unifocal or multifocal nonpyogenic inflammatory bony lesions with a prolonged, fluctuating course are reported. The lesions were most often located at the metaphyseal region of tubular bones and the clavicle, but also at the spine, ischiopubic bone, and the sacroiliac joint. Progressive sclerosis and hyperostosis occurred mostly in the clavicle and occasionally in the tibia, femur, metatarsal, and ischiopubic bone, linking the changes to those described under the name Garré osteomyelitis. Seven patients had pustulosis palmoplantaris, and the skeletal disorder may be regarded a form of pustulotic arthroosteitis.

Adolescent↗