THE SACROILIAC (SI) JOINT & - PDF Document

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  1. THE SACROILIAC (SI) JOINT & SACRAL INSUFFICIENCY FRACTURES Allan L. Brook, M.D., FSIR Director, Interventional Neuroradiology Montefiore Medical Center Professor of Clinical Radiology & Neurosurgery Albert Einstein College of Medicine Past President ASSR

  2. Evaluating the SI Joint • Patient history • Perform physical examination • Palpation • Provocative tests (minimum 3 out of 5 tests should be positive) • Review or order imaging studies – for abnormalities / asymmetry • Administer diagnostic injections

  3. Faber • Flexion • ABduction • External Rotation Spine Health web site

  4. Lateral Compression

  5. Thigh Thrust

  6. Distraction

  7. Gaenslen

  8. Ex. Ankylosing spondylitis case spondyloarthritis on active inflammatory lesions MRI before and after treatment with etanercept Song et al., Ann Rheum Dis 2011;70:590–596.

  9. During physical exam, patients with sacroiliac (SI) joint pain may exhibit any/all of the following symptoms: • Low back pain • Palpable tenderness of the posterior pelvic sacroiliac (SI) region • Pain from provocative maneuvers to the hip (i.e. Faber test) and the absence of neurologic deficit • Joint asymmetry as seen on CT and MRI

  10. Sacral Insufficiency Fractures & Augmentation • History • Anatomy • Function • Pathology • Imaging • Techniques of augmentation • Sacral insufficiency fractures were originally described by Lourie in 1982 • 2000- Dehdashti et al., first reported sacral cementoplasty Lourie H ., JAMA 1982;248:715–7 Dehdashti et al., Cardiovasc Intervent Radiol 2000;23:235–7

  11. Sacrum - Anatomy • A shield-shaped bone • A kyphotic structure with a sagittal angulation ranging from 0° to 90° Lyders et al., AJNR Feb 2010

  12. Sacrum • History and importance • Anatomy • Function • Pathology • Imaging • Techniques of augmentation • Serving as the base for the spinal column as well as the keystone for the pelvic ring Vaccaro et al. JBJS Am 86 (1): 166. (2004) Anatomical and Biomechanical Analyses • Linstrom et al

  13. Leads to Classification Re-analysis • Classic Trauma Denis scheme less applicable as the quality of bone and its ability to heal is not the same • Based on neural involvement and stability Denis et al., Clin Orthop. 1988;227:67-81

  14. • Goes along with biomechanical modeling • Sacral insufficiency fractures occur at consistent locations Linstrom et al., Spine • Volume 34 • Number 4 • 2009

  15. Insufficiency Fractures • Sub-type of stress fracture • Results from normal stress applied to weak abnormal bone • Unilateral or bilateral • High incidence of concomitant pelvic fractures

  16. Sacral Insufficiency Fractures Risk Factors • Osteoporosis- most common • Radiation • Steroid induced osteopenia • Rheumatoid arthritis • Any lytic neoplasm / mets, MM • Paget disease • Renal osteodystrophy • Hyperparathyroidism Ortiz and Brook Tech Vasc Interventional Rad 12:51-63 ; 2009

  17. Epidemiology of SIF • Almost 2% of women who present to ER with LBP • Antecedent trauma- rarely identified and is usually minor • Low back pain presentation • Pain typically radiates to buttocks, hips or groin • Can be point tender to palpation • 45% have malignancy in their history Lyders et al., AJNR 2010

  18. injection is the diagnostic "litmus test. • Administer diagnostic injections (75% pain relief from one injection, or 50% pain relief from two injections to confirm SI joint diagnosis) • Steroids • Fusion- minimally invasive and surgical methods

  19. Sacral Imaging • History and importance • Anatomy • Pathology • Function • Imaging • Techniques of augmentation

  20. Plain Films • Acute fractures • Subacute fractures • Chronic fractures • Lucent lines or cortical disruption • Sclerotic bands usually parallel to SI joints

  21. Plain Films = NOT THE STANDARD OF CARE • < 20-38% of pelvic ring fractures identified • Osteoporosis and bowel gas are not helpful! Gotis-Graham et al., J Bone Joint surg 1994 Peh et al., Clin Imaging 1995

  22. Nuclear Medicine • Tc99m-labeled MDP - very sensitive~96% • Positive predictive value 92% • Posterior planar images put sacrum closest to detector • “Honda or H pattern” 20- 40% Fujii et al., Clin Nuc Med 2005

  23. Nuclear Imaging • Bone Scintigraphy is nonspecific– infection, tumor, fracture… • Lytic lesions may take weeks to become “hot”-uptake tracer • SPECT helpful- differentiates djd… AJSM 2013 E.N. Thomas et al. / Annals of Physical and Rehabilitation Medicine 52 (2009) 427–435

  24. CT • Similar to plain film patterns just better! • Coronal > sagittal • Sclerosis • Fracture lines with or without callous>75% • Sensitivity 60-75% • Great detail if fractures extend into neural foramina • Can help differentiate tumor

  25. CT- Imaging • Can be complimentary to MRI and Nukes • Linear vertical or oblique medullary sclerosis on CT when delay in diagnosis, representing some healing • Ct + Nukes ~=MR

  26. MRI • Sensitivity near 100% with T2 STIR & T1W sequences & multiple planes • Bone marrow edema & fracture lines Lyders et al., AJNR 2010

  27. Imaging- MR “The Gold Standard” ” • Can delineate edema & fracture lines • T1w- low signal marrow • T2w- high signal edema • Fat suppression Neccessary

  28. Lymphoma DWI Byun et al., Spine 2007

  29. Management of Sacral Insufficiency Fractures • The standard of care for the treatment of SIFs has been conservative management, with variable courses of bed rest, rehabilitation, and analgesics • Case series and prospective studies suggest that sacroplasty is a safe and effective procedure, providing early symptomatic relief in patients with SIFs. Gotis-Graham I, McGuigan L, Diamond T, et al. Sacral insufficiency fractures in the elderly. J Bone Joint Surg BR 1994;76:882–86 Peh WC, Khong PL, Ho WY, et al. Sacral insufficiency fractures: spectrum of radiological features. Clin Imaging 1995;19:92–101

  30. CT Guided

  31. Post CT

  32. Methods & Issues Flouroscopic CT • See neural boundaries and lesions more precisely • Real time injection Radiation dose and speed vary by operator Similar for both

  33. J.M. Mathis and S. Golovac

  34. 65 y.o.f. bed ridden due to pain Fell while walking dog Brook AL, Mirsky DM, Bello JA:. Sacroplasty Spine (Phila Pa 1976); 2005 Aug 1;30(15):E450-4

  35. Place Needles Within Fracture Lines

  36. Cement tends to follow least resistant path along lines of fxs. Brook AL, Mirsky DM, Bello JA:. Sacroplasty Spine (Phila Pa 1976); 2005 Aug 1;30(15):E450-4

  37. Coccyx Augmentation Young pt fell on ICE Pain 9/10 VAS Wanted to return to work…

  38. Anterior sacral lytic met-lung cancer • VAS 10+++ • No posterior approach

  39. Trans-iliac sacral cementation Avoids Neural Elements - can add tumor ablation

  40. “ “Metastatic Lesions” ” A.R. Dehdashti et al.: PMMA Cementoplasty in Symptomatic Metastases of S1

  41. First Reported Sacral Augmentation • Dehdashti et al., Cardiovasc Intervent Radiol (2000) 23:235-241 • 3 pts with metastatic disease to S1

  42. Largest Series to Date J Neurointerv Surg. 2012

  43. Largest Series to Date • 243 patients • 204 with painful sacral insufficiency fractures • 39 with symptomatic sacral neoplastic lesions • The average pre-treatment VAS score of 9.2±1.1 was significantly improved after sacroplasty to 1.9±1.7 in patients with sacral insufficiency fractures (p<0.001) • The average pre-treatment VAS score of 9.0±0.9 in patients with sacral lesions was significantly improved after sacroplasty with neoplasm to 2.6±2.4 (p<0.001) • There were no major complications or procedure-related deaths

  44. Outcomes- other centers Decrease Narcotics and Increase Mobility Kamel et al., Eur Radiol (2009) 19: 3002–3007

  45. Lessons • Patient Selection is key to good outcomes • Informed Consent: risks, benefits, and alternatives • Conservative management involves various combinations of bed rest, rehabilitation, analgesics & narcotics Lyders et al. 31 (2): 201. (2010) THE JOURNAL OF BONE & JOINT SURGERY VOLUME 86-A · NUMBER 1 · JANUARY 2004

  46. SIF’s Summary • Commonly are missed or delayed diagnosis • The incidence of sacral insufficiency fracture is increasing within growing population of osteoporosis & oncologic cases with increased survival • The overall 1-year mortality rate associated with pelvic insufficiency fractures is ~14% Taillandier J, Langue F, Alemanni M, Taillandier-Heriche E (2003) Mortality and functional outcomes of pelvic insufficiency fractures in older patients. Joint Bone Spine 70:287–289

  47. Conclusion • Sacral augmentation in well selected patients can decrease pain • Sacral augmentation can improve mobility and quality of life! Kortman K, Ortiz O, Miller T, et al. J NeuroIntervent Surg (2012).