PROFFESOR THAMER AHMED HAMDAN M.B.CH.B, F.R.C.S(ED), F.R.C.P(ED), F.A.C.S,F.I.C.S CHANCELLOR OF BASRA UNIVERSITY SICOT VICE PRESEDENT

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1 PROFFESOR THAMER AHMED HAMDAN M.B.CH.B, F.R.C.S(ED), F.R.C.P(ED), F.A.C.S,F.I.C.S CHANCELLOR OF BASRA UNIVERSITY SICOT VICE PRESEDENT DR.RAFID A. ALADAB M.B.CH.B,F.I.C.M.S(ORTHO),SICOT DIPLOMA ORTHOPEDIC SURGEON

2 The sacroiliac joint SI is an enigma. It is obviously an important set of joints that anchor the pelvis to the sacrum,which in turn acts as supporting ''DOOR FRAME'' for the mobile lumbar spine and even more mobile legs.

In the early 1900s symptoms which seemed to arise from the back were frequently attributed to the sacroiliac (SI) joint, and open surgical procedures were used to treat the joint.

3 In the early 1900s symptoms which seemed to arise from the back were frequently attributed to the sacroiliac (SI) joint, and open surgical procedures were used to treat the joint. In 1934, a paper was published on the spinal disc as a source of pain in the back. As a result, disc treatment became the most common operation for orthopedic surgeons, and the sacroiliac (SI) joint was all but forgotten. Now, 80 years later, orthopedic and spine surgeons have recognized that the disc is not the only source of low back pain (LBP). According to scientific data, it's common for pain from the SI joint to mimic disc or low back pain. To avoid unnecessary lumbar spine surgery, SI joint disorders should be strongly considered in low back pain diagnosis. Mixter, WJ, and JS Barr. Rupture of the Intervertebral Disc with Involvement of the Spinal Canal. New England Journal of Medicine 211, no. 5 (1934): Weksler, Velan, et al. The role of Sacroiliac (SI) Joint dysfunction in the genesis of low back pain: the obvious is not always right. Archives of ortho and trauma surgery Dec; 10(127)

4 Anatomy The SI joint is a combination of a synarthrdial and diarthrodial joint-a unique joint in the body. The major portion of the joint is a syndesmosis ''synarthrodial'' joint and is characterized by a very irregular topography. Strong fibrous connections within the joint and strong extra-articular supporting ligaments. The message from study of joint morphology is that this joint moves very little. the inferior portion of the joint is synovial, but it offers up no increase mobility.

Strongest Most ligamentous Least flexible ligamentous portion (superior 2/3 to 1/2 of joint): formed by interosseous sacroiliac ligament synovial component (inferior 1/3

5 Strongest Most ligamentous Least flexible ligamentous portion (superior 2/3 to 1/2 of joint): formed by interosseous sacroiliac ligament synovial component (inferior 1/3 to 1/2 of joint): the sacral surface is lined by 3 5 mm-thick hyaline cartilage; the iliac surface of joint is lined by 1 mm-thick fibrocartilage 2 5 mm normal joint width

6 anatomical variants of sacroiliac joint accessory joints in 102 patients (19.1%), "iliosacral complex" in 31 (5.8%), bipartite iliac bony plate in 22 (4.1%), crescent-like iliac bony plate in 20 (3.7%), semicircular defects at the sacral or iliac side in 16 (3%), ossification centers in 3 patients (0.6%). Prassopoulos PK, Faflia CP, Voloudaki AE, Gourtsoyiannis NC, Sacroiliac joints: anatomical variants on CT. J Comput Assist Tomogr Mar-Apr;23(2):323-7.

7 Accessory joints were more common in obese than in normal-weight individuals (p < 0.05) and in older than younger (<60 years) patients (p < 0.001) and presented degenerative alterations especially in patients with episodes of low back pain. Three of these variants (iliosacral complex, bipartite iliac bony plate, and crescent-like iliac bony plate) had higher incidence in women than in men (p < 0.05) and were not associated with degenerative changes. Knowledge of the normal variations in the SJ appearance broadens the understanding of SJ anatomy, facilitating image interpretation. Prassopoulos PK, Faflia CP, Voloudaki AE, Gourtsoyiannis NC, Sacroiliac joints: anatomical variants on CT. J Comput Assist Tomogr Mar-Apr;23(2):323-7.

8 The joint is said to move 2 to 3 in any one direction, a phenomenon that decreases with aging changes that stabilize the joint. These aging changes start by age 30 and obviously decrease movement in the joint, just as patients enter the decades of backache (30 to 60 years of age).

9 prevalence % of adults presenting with low back pain, whereas 26% to 33.5 % of a sample with school aged children have low back pain and some form of sacroiliac joint dysfunction,respectvely. The older age group of students (12-17 years) had a 41.5% prevalence of Sacroiliac joint dysfunction,which is lower than the reported for the adults but represents a very high incidence for a young age group population.

10 Embriology The joint has a very special character because the sacral portion developed from somatic mesoderm while the innominate portion developed from lateral plate mesoderm

11 Sacroiliac joint syndrome (SIJS) Sacroiliac joint syndrome (SIJS) is an extraspinal cause of low-back and lower-extremity pain that can present in a myriad of ways. Archives of Physical Medicine and Rehabilitation / Volume 81, Issue 3, Pages , March 2000

12 Classical symptoms of sijs Aching pain over the back of the sacroiliac joint Variable discomfort usually radiating into the buttock, as well as diffusely into the posterior proximal thigh,rarely extending below the knee. Additional Variable discomfort into the groin, anterior pelvis, or anterior proximal thigh. Absence of paresthesia. Transient sharp pains on certain movements.

13 Clinical signs of the classic sijs Local tenderness over the posterior aspect of the sacroiliac joint. Pain on mechanically stressing the joint. Hamstring tightness. Absence of neurological defecit. Absence of root tension sign. Abberent sacroiliac movement pattern. Hyperasthesia over the ipselateral buttock extending into posterolateral thigh

The painful si joint of pregnancy latter months of pregnancy. Ligaments laxity = strain as a result of trivial trauma. pain localized to the involved si joint.

14 The painful si joint of pregnancy latter months of pregnancy. Ligaments laxity = strain as a result of trivial trauma. pain localized to the involved si joint. pain radiate around the greater trochanter and down the anterolateral aspect of the thigh. Treatment Bed rest, Analgesic, Anti-inflammatory medications. The use of trochanteric belt can give relief while walking and can obviate the antalgic gait. In a few patients whose symptoms persist, administration of intra-articular

15 Osteitis condensans ilii: mild to moderate si joint pain postpartum women 30 to 40 years of age. The major problem with this diseasde is its confusing with ankylosing spondylitis. The cause is unknown, but its very high prevalence in women suggest some relationship to the laxity of the si joint late in pregnancy and delivery being the cause.

iliac side of the si joint, with no evidence

benignity of the problem heat or ice mild

16 radiographic presentation is classic. the triangular seclerosis is confined to the iliac side of the si joint, with no evidence of the destruction of the si joint that occur in ankylosing spondylitis. treatment explanation to the patient of the benignity of the problem heat or ice mild analgesic/anti-inlammatory medicine. With time,the symptoms almost always disappear

17 Sacroiliac joint abnormality in sickle cell disease

19 Sickle cell disease

inflammatory lesion of the si joint There

pathogenesis ankylosing Reiter's ankylosing

21 inflammatory lesion of the si joint There are so called seronegative spondyloarthropathies that They are overlapping entities, likely of a common pathogenesis ankylosing Reiter's ankylosing spondylitis spondylitis psoriatic syndrome enteropathic arthritis arthropathy

Ankylosing spondylitis AS affects both synovial and fibrous joints; the pathological changes take the form of chronic synovitis followed by cartilage

22 Ankylosing spondylitis AS affects both synovial and fibrous joints; the pathological changes take the form of chronic synovitis followed by cartilage desrucution, erosion, sclerosis of underlying bone, and finally, fibrosis and ankylosis of the affected joints. The si joint are involoved 100% of the time Basdia.com

23 clinical criteria suggesting AS Insidious onset of discomfort Age less than 40 years Persistence for more than 3 months Association with morning stiffness Improvement with exercise

Both of these changes may occur through out the si joint but are seen earlier in the lower two thirds (the

24 Stages of radiographic changes in the si joint Early stages *blurring of the joint margins *erosions and seclerosis of bone Late stages *calcification and interosseous bridging of the si joint. Both of these changes may occur through out the si joint but are seen earlier in the lower two thirds (the synovial portion) of the si joint. The erosions eventually leave the appearance of widening (pseudowidening) of the si joint.

25 Infections of SI joints In the past, tuberculosis recently, pyogenic, especially in children. The clinical picture is vague. There is pain and tenderness over the SI joint and the ESR is raised. With pyogenic infections, the patient may be febrile, but there is very little else to define the nature of the underlying lesion.

26 The damage to the SI joint may be not apparent for several weeks, therefore, be delayed for a long period of time. A bone scan ;(hot spot) tomography; bony changes. It must be remembered that this area of skeleton always takes up more technetium on a routine scan than other portion of the pelvis.

27 On occasion, a fluctuant abscess will form, so needle biopsy is indecated. If aspiration proves impossible, with the presumptive diagnosis provided by the overall clinical picture, the bone scan, and the CT scan, open biopsy is mandatory in order that appropriate antibiotic therapy can be instituted. Ewing's sarcoma may mimic the radiological appearance of destructive pyogenic arthritis. the differentiation by open biopsy. Because of the rarity of septic arthritis of the SI joint as a cause of backache and because of the nonspecific nature of the clinical picture, the diagnosis may be missed easily.

28 Clinical tests for sacroiliac joint dysfunctions

29 Provocative tests FABER - (Flexion, ABduction, External Rotation)

30 Compression test

31 Posterior shear (thigh thrust) test

32 Sacral thrust test

33 Distraction Gapping (Sacroiliac Stretch) test

34 Gaenslen,s test

35 Hibb's test

36 Stork / Gillet / Fowler tests

37 Adam's and supported Adam's test

38 Yeoman s test

39 Straight-leg Raising And Double Leg Raising Test

40 Goldthwaite s test

41 Pointing test

42 Fluoroscopic guided intr-articular injection The gold standard for diagnosis False positive in 8%-20% Laslett et al 2005

43 RECOMMONDATION Think of it.. Think of it.. Think of it.. As a cause of lower back pain

44 Thanks for listening

Imaging and intervention of sacroiliac joint. Dr Ryan Lee Ka Lok Associate Consultant Prince of Wales Hospital

Imaging and intervention of sacroiliac joint Dr Ryan Lee Ka Lok Associate Consultant Prince of Wales Hospital Introduction 15%-25% of low back pain is related to sacroiliac joint (SIJ) pain SIJ pain is