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

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

2 Introduction 15%-25% of low back pain is related to sacroiliac joint (SIJ) pain SIJ pain is usually under-diagnosed clinically

3 Anterior : Synovial joint Sacroiliac joint Posterior : ligamentous connection Sup Ant Post Inf

4 Sacroiliac joint

5 Iliac side Ant Post

6 Sacral side Ant Post

7 Imaging modalities XR USG CT NM Bone scan MRI

8 MRI Oblique axial Oblique coronal

9 Sagittal planning

10 Oblique axial True axial Oblique coronal True coronal

11 SIJ pathology 1. Inflammatory sacroiliitis 2. Infective sacroiliitis 3. Osteoarthrosis Rheumatic 4. Stress reaction/insufficiency fracture 5. Osteitis condensan ilii 6. Others : tumour Non-Rheumatic

12 1. Inflammatory sacroiliitis Sacroiliitis on imaging Plus >1 SpA feature or HLA-B27 plus >2 other SpA features Sacroiliitis on imaging: Active(acute) inflammation on MRI highly suggestive of sacroiliitis associated with SpA or Definite radiographic sacroiliitis according to modified New York criteria Assessment in SpondyloArthritis international society (ASAS) classification criteria for axial spondyloarthritis (SpA) 2009

13 A. Active (acute) sacroiliitis Bone marrow edema (BME)/osteitis Capsulitis Enthesitis Synovitis

14 Bone marrow edema / osteitis

15 Bone marrow edema / Osteitis T2W STIR Contrast T1W FS T2W STIR Contrast T1W FS

16 ? Bone marrow edema / osteitis T2W STIR Contrast T1W FS

17 Bone marrow edema/osteitis At least one signal on consecutive slice

18 Bone marrow edema/osteitis Or more than one signal on single slice

19 Capsulitis Anterior capsulitis Posterior capsulitis

20 Enthesitis T2W STIR Contrast T1W FS

21 Enthesitis

22 Synovitis

23 B. Definite radiographic sacroiliitis According to modified New York Criteria Subchondral sclerosis Subchondral periarticular erosion Periarticular fat deposition Bony bridges / ankylosis

24 Grade Radiographic findings 0 Abnormalities are present 1 Suspicious areas are noted 2 Minor erosions 3 Unequivocal abnormalities in the joint 4 Severe change in the joint Modified New York criteria for the classification of ankylosing spondylitis Radiographic sacroiliitis + one clinical symptoms = AS Low back pain for at least 3 months improved by exercise and not relieved by rest Limitation of lumbar spine in sagittal and frontal planes Reduced chest expansion relative to normal values for age and sex Bilateral sacroiliitis grades 2-4 Unilateral sacroiliitis grades 3-4

25 Subchondral sclerosis T1W

26 Subchondral periarticular erosion Erosion Pseudo-widening

27 Peri-articular fatty infiltration T1W T1W T2W STIR

28 Bony bridges / Ankylosis

29 Radiograph Subchondral sclerosis and erosion Ankylosis

30 Radiographic involvement of sacroiliac joints in different conditions Bilateral, symmetric Ankylosing spondylitis Juvenile spondyloarthropathy (SpA) Osteitis condensus ilii Bilateral, asymmetric Psoriatic arthropathy IBD-associated SpA Reactive arthropathy Undifferentiated SpA Unilateral Infection (including TB) Malignancy

31 Joint fluid 2. Infective sacroiliitis Iliacus muscle involvement Gluteal muscle involvement

32 Infective sacroiliitis Iliacus and gluteal muscle involvement

33 Infective sacroiliitis Abscess T2W STIR Contrast T1W FS

34 TB sacroiliitis

35 Infective or inflammatory sacroiliitis?

36 3. Osteoarthritis

37 Osteoarthritis

38 4a. Stress reaction

39 4b. Stress fracture Honda sign

40 4c. Insufficiency fracture

41 4d. Stress related

42 5. Osteitis condensans ilii

43 Osteitis condensans ilii

44 Image guided intervention CT guided biopsy/aspiration CT guided injection USG guided injection Floroscopic guided injection

45 Joint fluid CT guided aspiration

46 Bone CT guided biopsy

47 CT guided pig tail insertion Needle Guidewire Dilator Pigtail

48 CT guided injection

49 CT guided injection

50 Ultrasound guided injection 2 nd sacral foramen

51 Floroscopic guided

52 Take Home Message MRI is imaging of choice to diagnosis different SIJ pathology CT is useful for SIJ related diagnostic and therapeutic intervention

53 End Thank You

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