[Clinical & radiological manifestations of sacroiliac diseases].
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Disease↗
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Intervertebral disc space infection: another low back syndrome of the young.
Pyogenic disc space infection is a rare and unappreciated cause of low back pain. Reported herein is a young man with chronic low back pain and the HLA-B27 antigen which initially led to the diagnosis of ankylosing spondylitis. However, serial lumbar radiographs and bone scan established an inflammatory lesion involving the L2-L3 intervertebral disc space, and persistently normal sacroiliac joints. A needle biopsy and culture of the disc space yielded Staphylococuss aureus. Treatment with antibiotics, bed rest and back bracing resulted in a complete resolution of symptoms and healing of the vertebral lesion. It is the purpose of this report to review the clinical, laboratory and radiographic features of intervertebral disc space infection as well as pitfalls in its diagnosis.
Adolescent↗
Skin temperature assessment for neuromusculoskeletal abnormalities of the spinal column.
OBJECTIVE: A qualitative review of the scientific literature on thermographic instrumentation for detecting neuromusculoskeletal abnormalities of the spinal column was made. Electronic infrared instrumentation (telethermography), liquid crystal thermography and various hand-held devices were scrutinized in terms of reliability and comparison with other diagnostic tests (e.g., computed tomography, myelography, electromyography, magnetic resonance imaging). DATA SOURCES: A Medline literature search was performed from 1966 through 1990. English language material was retrieved using the following key words: thermography and spine, spinal injuries, cervical vertebrae, thoracic vertebrae, lumbar vertebrae, sacroiliac joint, lumbosacral region, back or neck. The Index to Chiropractic Literature was also reviewed. The categories of skin temperature and thermography were scrutinized. Chapters of texts and nonpublished works were not incorporated. STUDY SELECTION: Studies involving the comparison of thermographic findings with those of other tests were the primary focus of the review. Case reports, as well as the use of thermography as an outcome measure, were also studied. Interexaminer reliability studies are reported. DATA EXTRACTION: The study populations are characterized as well as binding procedures, if any. The authors' statistical work, if applicable, is presented and criticized. DATA SYNTHESIS: Relatively few reliability studies exist for thermography. Emphasis has been on validity studies that compare the results of the thermogram with other reference tests. There has been a general lack of high-quality research design (e.g., blinding) throughout the thermographic literature base. The sensitivity of the various thermographic instrumentation has shown encouraging results, although this must be tempered with the generally poor design of many studies. Specificity, in contrast, has shown mixed results. The review indicated telethermography to be a sensitive diagnostic procedure for detecting abnormalities, such as disc protrusion, of the lumbar and cervical spine. Liquid crystal thermography effectiveness is difficult to determine due to the paucity of blinded investigations, although normative data for the cervical spine and upper extremities is present. Literature on the various hand-held instruments has revealed moderate levels of examiner reliability for infrared devices, with less information available for thermocouple instruments. Normative data for hand-held instruments is absent. CONCLUSION: Continued investigation is needed in the area of thermographic research in light of the paucity of blinded and/or controlled investigations. More sensitive neurophysiological and anatomical measures must be used when comparing the results from thermography. The lack of an available gold standard for comparing thermographic findings has been problematic. Future research should focus on thermography as a noninvasive outcome measure and interpreter reliability.
Chiropractic↗
[Reiter syndrome after intravesical Bacillus Calmette-Guerin (BCG) immunotherapy: a case report].
A 56-year-old man who had previously undergone transurethral resection and intra-arterial chemotherapy for bladder cancer developed irritable bladder, bilateral conjunctivitis and arthritis including the knees, ankles and sacroiliac joints after starting intravesical Calmette-Guerin bacillus (BCG) immunotherapy. These symptoms were in agreement with the features of Reiter syndrome. One month after cessation of the intravesical BCG immunotherapy and initiation of the treatment with a non-steroidal anti-inflammatory drug (NSAID), he was not complaining of symptoms. Reiter syndrome is an uncommon complication after intravesical BCG immunotherapy. Nevertheless, since the prolonged arthritis has a possibility to cause joint deformity, we must pay serious attention to this side effect.
Administration, Intravesical↗
[Malgaigne pelvic ring injury in childhood].
Pelvic girdle injuries leading to anterior and posterior disruption are rarely seen in children. External fixation is useful to reduce and stabilize the pelvis in order to control massive blood loss due to severe venous bleeding. The anterior tension band element of the external fixator can successfully maintain reduction of the pelvic girdle. Dislocation or fracture dislocation of the sacroiliacal joint cannot be reduced with simple traction techniques. Leg length discrepancy is to be expected when the hemipelvis is displaced. Seven cases of this rare injury in children are presented together with the late outcome. Treatment modalities are discussed.
Adolescent↗
Accessory sacro-iliac articulations.
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Humans↗
Reliability of real-time ultrasound for the assessment of transversus abdominis function.
UNLABELLED: Transversus abdominis (TrA) has now been established as a key muscle for the stabilization of the lumbar spine and sacroiliac joints. Significantly, dysfunction of this muscle has also been implicated in low back pain. Real-time ultrasound (US) is a non-invasive procedure that has the potential to evaluate objectively the function of TrA. OBJECTIVE: To investigate M-mode US as a reliable method of assessing TrA function. METHOD: M-mode US was used to measure the width of TrA as subjects drew in their lower abdominal wall at a controlled speed to a target depth. Eleven subjects were imaged. RESULTS: the measures of TrA width were reliable and ranged between 3.14mm relaxed and 6.35mm contracted. The standard error of measurement ranged between 0.18mm and 0.57mm. CONCLUSION: M-mode US provides a reliable non-invasive measure of a controlled contraction of TrA.
Evaluation Study↗
Conventional radiography and CT examination of pelvic ring fractures. A comparative study of 90 patients.
In a retrospective study, we compared the interpretation of conventional X-ray films of the pelvis and the CT images for 90 patients who were treated in our department for a pelvic ring fracture and who had a CT examination between January 1987 and December 1990. The conventional X-ray films and CT scans were interpreted independently by a team of two surgeons and one radiologist. Following Dunn, Berry and Connally, we classified the CT images as very helpful, quite helpful or no help at all. Only 52 of 105 (49.5%) existing bony or ligament lesions of the pelvic ring were recognized in routine X-ray films; 11 of them resulted in a false diagnosis. In 14 cases important additional information about the associated-soft tissue lesions was acquired. In the same CT session, 30 additional CT examinations were performed. Using the Dunn, Berry and Connally classification, only 18 (or 20%) of all CT images were classified as "not helpful". Fifty-nine examinations (or 65.5%) were "quite helpful" and 13 (or 14.5%) were "extremely helpful." In our retrospective study we demonstrated that a complete evaluation of the pelvic ring is not possible with a series of pelvic overviews alone. Fractures of the sacral body and lateral part of the sacrum are overlooked especially often, but second-degree lesions of sacroiliac joint are also often not seen.
Diagnosis, Differential↗
[Ureteral injury in gynecologic laparoscopies].
OBJECTIVE: To investigate the ureteral injury in gynecological laparoscopies and discuss its diagnosis, treatment and prevention. METHODS: Ureteral injury in gynecological laparoscopies during the past 13 years was reviewed retrospectively. The clinical features of initial operations including the types of disease, uterine size, pelvic adhesion, operative procedures and the methods of diagnosis, treatment and prognosis of ureteral injury were studied. RESULTS: There were 8 ureteral injuries (0.14%) in 5 541 gynecological laparoscopies with seven in laparoscopically assisted vaginal hysterectomy (LAVH)/total laparoscopic hysterectomy (TLH) (0.45%) and one in non-LAVH (0.03%). The main gynecological disorders included adenomyosis, endometriosis and leiomyoma. All patients had pelvic adhesions and 4 had previous pelvic operations. Uterine enlargement was found in 7. Patients presented increased vaginal drainage, flank pain, increased volumes of vaginal discharge, nausea and vomiting, fever, edema, or peritonitis from 0 to 13 days postoperatively. Ureteral injuries were mainly diagnosed via excretory urogram (IVP). The sites of injury were near the inferior margin of the sacroiliac joint in two women and at the inferior part of ureter (near the uterine vessel, uterosacral ligament and ureterovesical junction) in 6. Two patients whose injuries were found soon after operation received ureteral repair by laparotomy successfully. Two of the six patients whose injuries were found several days later were treated with internal ureteral stenting successfully, the other four failed with ureteral stenting and received ureteral repair by laparotomy. Outcomes were good in all cases. CONCLUSIONS: Ureteral injury is an uncommon and severe complication in gynecological laparoscopies. Symptoms like abnormally increased drainage, fever, flank pain, abnormal vaginal discharge and peritonitis after operation should be paid attention to and ureteral injury be considered. Surgical repair is the primary treatment.
Adult↗
The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea.
OBJECTIVE: The primary objectives of this study were to compare the effect of spinal manipulation vs. sham manipulation on a) circulating plasma levels of the prostaglandin F2a metabolite, 15-keto-13,14-dihydroprostaglandin (KDPGF2a), b) perceived abdominal and back pain and c) perceived menstrual distress in women with primary dysmenorrhea. DESIGN: This randomized clinical pilot study investigated the outcome measures before and after either a spinal manipulation treatment (SMT) or a sham manipulation. SETTING: All subjects were treated at the National College Chiropractic clinic, a private chiropractic clinic in the suburban Chicago area. PARTICIPANTS: Forty-five women with a history of primary dysmenorrhea were recruited from the local community. The volunteers ranged in age from 20-49 (mean age = 30.3 yr), and were entered into the study between April 1990 and January 1991. Twenty-four were randomly assigned to the spinal manipulation group and 21 were assigned to the sham group. INTERVENTIONS: Subjects treated with spinal manipulation were placed in a side-lying position with the bottom leg straight and the top leg flexed at the knee and hip. They received a high-velocity, short lever, low-amplitude thrust to all clinically relevant vertebral levels within T10 and L5-S1 and the sacroiliac joints. In the sham manipulation, subjects were placed in a side-lying position with both hips and knees flexed. Their manipulation consisted of a similar thrust administered to the midline base of the sacrum. OUTCOME MEASURES: Perceived abdominal and back pain were measured with a visual analog scale, and menstrual distress was measured with the Menstrual Distress Questionnaire. Both were administered 15 min before and 60 min after treatment. Blood samples were collected by venipuncture for the determination of plasma levels of KDPGF2a at the same times. The plasma was then assayed for KDPGF2a by radioimmunoassay. RESULTS: Analysis of covariance and paired Student's t tests were used for the statistical evaluation. Immediately after treatment, the perception of pain and the level of menstrual distress were significantly reduced by SMT. This reduction was associated with a significant reduction in plasma levels of KDGPF2a in the SMT group. A significant and similar reduction in plasma KDPGF2a also occurred in the sham group, indicating that a placebo effect was associated with a single sham intervention. CONCLUSIONS: This randomized pilot study suggests that SMT may be an effective and safe nonpharmacological alternative for relieving the pain and distress of primary dysmenorrhea. However, the large change in KDPGF2a observed in both treatment groups clearly indicates that further studies with more subjects, studied over a longer time frame, are needed to resolve the question of a placebo effect.
Abdominal Pain↗
[Extraskeletal manifestations of seronegative spondyloarthropathies].
Spondyloarthropathies constitute a cluster of interrelated and overlapping chronic inflammatory rheumatic diseases of unknown etiology that include ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis and undifferentiated spondyloarthritis. These diseases are not associated with rheumatoid factor, they occur in genetically predisposed individuals and show a strong association with HLA-B27. The primary pathologic sites include the entheses, the sacroiliac joints and the axial skeleton with or without some nonarticular structures, such as the skin, eye, aortic valve, heart and kidney.
Arthritis, Psoriatic↗
[Two cases of postpartum pubis diastasis mistaken for neurological complications of epidural analgesia].
Two healthy 31- and 34-year-old parturients received uncomplicated epidural analgesia for labor and delivery using standard techniques. Twenty-four and 12 hours postpartum, respectively, they developed severe lower back pain and difficulty moving their lower extremities. At first the symptoms were attributed to neurological complications of epidural analgesia and for this reason the anesthetist was called. Although both women appeared healthy and the neurological examinations were normal, emergency computed tomography scans were performed to rule out spinal compression because of the severity of pain and difficulty of movement. The diagnosis was only established after suspecting pubis diastasis, confirmed by palpation of symphysis gaps of 3 and 2 cm, respectively. Pelvic dysfunction associated with pregnancy and labour is a complication whose incidence varies from 1 in 300 to 1 in 30,000. It presents with severe pain located in the areas supplied by pudendal and genitofemoral nerves. The pain may radiate to the sacroiliac joints and shoot down the buttocks and legs. In the most severe cases it may be accompanied by urinary dysfunction and inability to walk. If the clinical features are not recognized, it can be difficult to differentiate pubis diastasis from severe neurological complications in women who have received a central nervous system block. We report two cases of peripartum pubis symphysis diastasis that were both initially mistaken for neurological complications of epidural analgesia for labor.
Adult↗
Bullet fragment within the appendix: a case report.
A 9-year-old Caucasian male presented initially to his pediatrician with abdominal pain. The child underwent a UGI, which showed mild gastric erosions, however the scout film revealed a metal fragment lodged near the right sacroiliac joint on the AP view. The child was referred to a general surgeon who conducted a series of other diagnostic tests, which ultimately revealed and verified that the metal fragment was lodged in the distal appendix. Careful family history obtained showed that the family eats a great deal of wild game, including deer meat. It was felt that this metal fragment was a portion of a consumed bullet, which was retained in the appendix. The child's blood lead (Pb) level was elevated at 16ug/dl. An elective prophylactic appendectomy was performed due to the potential for developing appendicitis and possible lead toxicity.
Abdominal Pain↗
Enthesial fibrocartilage - bone interaction: a radiographic study of selected sites of nonsynovial peripheral enthesopathy.
OBJECTIVES: To assess radiological imaging and prevalence of pelvic (excluding sacroiliac joints), calcaneal, patellar and humeral enthesopathy (EN) in a cohort study. MATERIALS-METHODS: Outpatients attending a state hospital rheumatology clinic for a continuous 4-year period, were consecutively screened for radiographic evidence of peripheral nonsynovial EN in pelvis, ankle, knee and shoulder regions and in particular sites within these regions regardless of symptoms. Imaging and prevalence were assessed in patients suffering from a variety of myoskeletal disorders by applying either of the following two plain X-ray criteria: a) tendon and/or ligament and/or fascia ossification, b) reactive bone proliferation resulting in excrescences and/or sclerosis and/or erosions. RESULTS: A total of 3,670 patients were screened and a cohort of 585 patients (16%) with extraspinal peripheral EN was selected. Plain radiography provided good imaging of pelvic EN at iliac crests, greater trochanters, pubic symphysis and pubic rami, as well as of calcaneal, patellar and humeral head enthesopathic changes. Cohort recruitment by applying the two aforementioned criteria resulted in the formation of 2 groups: Group A, consisting of 169 patients (mean age in years 34 -/+ 8 SD) suffering from inflammatory myoskeletal disease represented by Seronegative Spondyloarthropathies (SSp); and Group B, including 416 patients (mean age 63 -/+ 7) suffering from degenerative/metabolic disorders classified as degenerative disease of the spine, hip or knee (70%), Diffuse Idiopathic Skeletal Hyperostosis (DISH) (11%) and rotator cuff (Rot/Cuff) syndromes (19%). Females were the predominant gender in the cohort and in Group B patients (both p<0.001 vs. males), while the opposite was true for the group of inflammatory diseases. Patients in Group A were younger and had shorter disease duration than those of group B (p<0.001 for both). Pelvic EN was the most frequent localization of EN within the cohort (46%, p<0.001) followed by both multiple site and patellar EN (24% and 22% respectively). Patients in Group A, had a significantly higher prevalence of pelvic EN compared to those in Group B (60% vs. 39%, p<0.001) and the former group was significantly associated with pelvic EN. On the contrary, although pelvis was also the predominant EN site in Group B, patellar and humeral head EN were significantly associated with noninflammatory diseases. In patients with SSps, pelvic EN predominance (60%) was followed by calcaneal involvement (p<0.01 vs. patellar and humeral head). These two were the skeletal sites that were significantly associated with individual diseases within Group A (pelvis with AS and Ps-Sp and calcaneus with RR). Within Group B, patients with knee OA, hip OA and Rot/Cuff showed EN site localization in absolute proximity with disease process, while in those with Deg/Sp or DISH pelvis was the predominant site involved. CONCLUSIONS: Plain radiography provides good imaging of peripheral nonsynovial EN at well defined skeletal sites. Within a general rheumatic population, pelvic EN is the most prevalent localization followed by multiple site and patellar reactive bone lesions. Apart from seronegative spondyloarthopathies, degenerative and metabolic myoskeletal disorders contribute substantially to local induction of abnormal fibrous tissue/fibrocartilage-bone interactions resulting in radiographically detectable EN.
Journal Article↗
Low frequency of axial involvement in Caucasian pediatric patients with seronegative enthesopathy and arthropathy syndrome after 5 years of disease.
In order to establish how many children with seronegative spondyloarthropathy (SpA) starting with peripheral arthritis and/or enthesitis will develop ankylosing spondylitis (AS), 13 consecutive Caucasian pediatric patients, (11 with the seronegative enthesopathy and arthropathy (SEA) syndrome and 2 with isolated B27 associated peripheral arthritis or enthesitis at entry), were followed prospectively with no loss for more than 5 years. Sacroiliac joint plain films obtained at the last visit were mixed with those of 14 control subjects and read blindly. The course of SpA was self-limiting in 6 patients and recurrent in the other 7. Six patients had episodes of inflammatory cervical and/or lumbar pain during followup. However, none showed any limitation of spinal movement in the asymptomatic periods. Only one patient (9.1%) of 11 with the SEA syndrome showed bilateral sacroiliitis and met New York criteria for AS after 5 years of disease. Our results suggest that the proportion of Caucasian children with the SEA syndrome developing AS is much lower than the 75% found in a similar study on Mexican children. Lack of evaluation of all patients after 5 years, the reading of pelvic plain films without reducing observer error, and the male predominance in the Mexican study, probably in addition to ethnic or environmental factors, may account for differences.
Adolescent↗
Supra-acetabular placement of external fixator pins: a safe and expedient method of providing the injured pelvis with stability.
Applying a stable anterior pelvic external fixator frame is a skill that should be mastered by all orthopedic surgeons who treat acutely injured patients. Splinting of an unstable pelvis during resuscitation can help to reduce the volume of the true pelvis, pending definitive surgical stabilization of the pelvic ring. Supra-acetabular pin placement, less familiar to most surgeons than iliac wing pin placement is, can provide a more reliable pin-bone interface and thus allow improved reduction ability with fewer soft-tissue complications. Because of their location, supra-acetabular pins also seem to be better tolerated than iliac crest pins when used for definitive management of the pelvic ring disruption. A young man who sustained a type II anteroposterior compression injury in a motor vehicle accident presented with symphyseal disruption (7 cm wide) and left anterior sacroiliac joint disruption. During resuscitation, the pelvis was anatomically reduced and stabilized with a supra-acetabular pin-based external fixator. Pin locations, chosen using palpable and cutaneous landmarks, were inserted without additional imaging guidance. The fracture was reduced anatomically, and the frame was used for definitive management of the pelvic ring injury.
Accidents, Traffic↗
[The clinical feature, diagnosis and treatment of uveitis associated with juvenile chronic arthritis].
OBJECTIVE: To investigate the clinical features, diagnosis and treatment of uveitis associated with juvenile chronic arthritis (JCA). METHODS: A retrospective study was performed on the clinical data of 26 patients with uveitis associated with JCA, referred to Zhongshan Ophthalmic Center from 1996 to 2002. Taking of history, examination with slit-lamp microscope and ophthalmoscope were carefully performed in all of these patients. Laboratory tests including antinuclear antibodies, erythrocyte sedimentation rate, rheumatoid factor, C reactive protein and antistreptolysin O were used to disclose possible causes. Human leukocyte antigen B 27 and X-ray examination of sacroiliac joints and spine were carried out if necessary. Data about the treatment, visual outcome and complications were analyzed. RESULTS: Twenty-six patients, 11 males and 15 females, were included in the present studies. Age of onset of JCA and uveitis averaged 8 years and 9 years, respectively. Twenty-one patients had chronic anterior uveitis. Acute anterior uveitis and chronic panuveitis were noted in 3 and 2 patients, respectively. Twenty-two patients had bilateral uveitis, the other 4 had unilateral involvement. The ophthalmologic examination revealed that 33 of the 48 affected eyes showed mild aqueous humor flare, 24 had few cells in the anterior chamber. Complicated cataract, band keratopathy and secondary glaucoma were noted in 30, 20 and 12 eyes, respectively. The laboratory examination revealed positive antinuclear antibodies in 18 cases and rheumatoid factor positive in one case. In acute episode, patients were treated with extensive topical cycloplegic agents and corticosteroids eyedrops. In the 6 cases with severe uveitis, 3 patients were treated with cyclosporine A (5 mg.kg(-1).d(-1)) and the other 3 were treated with chlorambucil (0.1 mg.kg(-1).d(-1)). The intraocular inflammation in all of these patients was satisfactorily controlled with these treatments. Visual acuity improvement was noted in 32 affected eyes but not in the other 16 eyes which had already serious complications before the treatment. CONCLUSIONS: Uveitis associated with JCA is characterized by a chronic and recurred iridocyclitis, which usually developed within 5 year after JCA onset. Although the intraocular inflammation associated with JCA is usually white uveitis, complications such as cataract, secondary glaucoma and keratopathy occur frequently in these patients. The diagnosis is mainly based on typical clinical manifestations, the history of arthritis and positive antinuclear antibodies. Adequate application of cycloplegic agents, corticosteroids eyedrops, immunosupressives and the regular follow-up should be kept in mind in the treatment of these patients.
Adolescent↗
Finite element method based stress analysis of zone I and zone II sacral fractures.
BACKGROUND: Sacral bone fractures after direct traumas such as gunshot wounds and blunt sacral traumas are rarely, whereas those occurring after indirect traumas with vertical shear mechanisms ( car accidents or falls) are more frequently seen. METHODS: A cadaver sacrum was modelled 3-dimensionally using finite element software. Left sacroiliac joint was modeled to simulate a 75- kg man falling on one leg from a height of 5 meters. An impact load of 10 kN was transferred to the sacrum via intervertebral disc surface and two facets. Von Mises equivalent stress distribution was estimated. RESULTS: Von Mises stress distribution was calculated for sacral ala (430 MPa), S1 pedicle (225 MPa), and S1 lamina (35 MPa). Stress values were 200 Mpa, 130 Mpa, 105 Mpa, and 55 MPa on ventrolateral, dorsomedial, ventromedial and dorsolateral sides of S1 foramen respectively. Vertical shear injury caused stress distribution to concentrate at sacral ala and S1 pedicle (zone I). Local stress distribution around S1 foramen is concentrated ventrolaterally CONCLUSION: High incidence of zone I sacral fractures and low incidence of neurological deficits could be explained by concentration of stress at sacral ala. Zone II fractures might be due to by transfer of triggered stresses from sacral ala and S1 pedicle to ventrolateral side of S1 foramen.
Accidental Falls↗