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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