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Facet & SacroIliac Joints Arthropathy

Dr. Hitesh S. PatelM.D.,FIPM

18 Oct. 2016

Abnormalities affects bones & joints

1. Congenital Arthropathy

2. Degenerative Arthropathy

3. Traumatic, & Occupational

4. Dietetic: Vitamin deficiency

5. Endocrine: Acromegaly, myxedema, and hyperparathyroidism

6. Hematological: factor VII or IX deficiency, Leukemia

7. Infective: gonococcus, Brucella, Rubella, virus-induced

8. Post infective Arthropathy

9. Metabolic: Amyloidosis Calcium,

10. Vascular: Avascular necrosis

11. Neoplastic:

12. Therapeutic: alcohol, anticoagulants, corticosteroids

13. Idiopathic

British Medical Journal, 2, 210-213

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Facet Joints Disease

4LUMBAR VERTEBRAL BODY

•Facet joints are lined with smooth cartilage, and are lubricated with synovial fluid. .

•Healthy joints are able to glide effortlessly as the spine performs movements, such as bending, twisting, and turning

5Innervation

6InnervationMedial branch

Facet ArthropathyThe primary cause of facet arthropathy or spinal osteoarthritis is spinal degeneration which typically occurs in later life (disease of aging).Lumber segments tends to experience degenerative changes more frequently than other areas of the spine. Over time, however, the cartilage can dehydrate and the synovial fluid can dry up. Years of normal wear and tear on the facet joints lead to cartilaginous errosion, which can expose raw bone.

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Diagnosis

Diagnosis depend on:

History and Clinical features Medical imaging: X-rays, CAT scans, and Magnetic

Resonance Imaging (MRI) may be used to exclude other abnormalities may help in diagnose of facet arthropathy.

Diagnostic injection. LA and dye are injected. If the facet joint is injected and pain relief is the result, that serves to confirm the diagnosis of facet arthropathy.

History and Clinical Features:

Low back pain is the most frequent (Pain is generally a deep, dull ache)

The pain is typically worse following sleep or rest morning stiffness .

In advance stage Bone spurs may develop and become in contact with the spinal cord (spinal stenosis ) or a nerve root (radiculopathy) leading to radiating pain to hip, buttocks, legs and even feet.

Pain radiation in different types of spinal nerve injuries

Remember that Facet joints are not in lumber only

12Aggravated by:

Extension (Arching backwards) Standing Repeated movements or activities. Prolonged sitting

Relieved by: Flexion Standing Walking Sitting

Differential Diagnoses

Sacroiliac joint syndrome Internal disk disruption syndrome Spondyloarthropathy (ankylosing spondylitis, reactive

arthritis, psoriatic arthritis . . .). Lumbar nerve root compression. Hip pain. Endometriosis. Myofascial pain. Piriformis syndrome

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Management

1.Nonpharmacological 2.Pharmacological 3.Interventional

Managements

Nonpharmacological

(physiotherapy)

Pharmacological

•Rest •Sleep positions recommended.•traction•strengthening and aerobic exercise•water therapy•spinal manipulation

•Paracetamol•(NSAIDs), •Narcotic•Co-analgesic•Muscle relaxants•Corticosteroids

Interventional Intra-articular injections of local

anesthetic or steroid.Medial branch of dorsal ramus

block or ablationInjections are indicated after a minimum of 4 weeks of appropriate, directed conservative care has failed to bring relief

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Medial Branch of Dorsal Ramus Block

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Facet Injection

C-arm rotation 45° L4-5,L5-S130° upper lumbar facet

19RadioFrequency Ablation

Surgery

rarely required but options do exist Facet rhizotomy of the nerves going to

facet joint Fusion of two or more vertebrae to

eliminate movement in facet joints (sometimes facet joints are removed during spinal fusion)

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Sacroiliac Joints

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Sacroiliac Joint :Large synovial joint about 1-2 mm wide

Auricular (C)-shaped on sides of fused sacral vertebrae Covered with hyaline cartilageThicker than iliac cartilage

Covered with fibrocartilageType II collagen, typical of hyaline cartilage, has been identified

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1. Joint between articular surfaces on sacrum and iliac bones. (a diarthrodial synovial joint)

Only the anterior part is a true synovial joint. The posterior part is a fibrous tissue, strong ligaments

2. It is stable, rigid, very strong, reinforced by strong ligaments and muscles surround it

3. relatively immobile (Does not have much motion2mm)

4. Transmits all the forces of the upper body to the pelvis (hips) and legs (effective load transfer)

5. Acts as a shock-absorbing structure

Sacroiliac Joints

24 Connects spine to pelvis

Absorbs vertical forces from spine and transmitting them to pelvis and lower extremities

25Primary Ligaments: Secondary Ligaments:

a. Anterior sacroiliac a. Sacrotuberous

b. Posterior sacroiliac b. Sacrospinous

c. Interosseous

mainly by the Sacral Rami Dorsales

26Innervation

Anterior aspect of SI Joint by: • lumbosacral plexus

Posterior aspect of SI Joint by : • medial branches L4, L5, • lateral branches S1, S2, S3 and S4

Causes SI Joint Syndrome

the prevalence of SI pain among patients with axial low back pain varies between 16% and 30%.Degenerative arthritis of the SI joints due to

Trauma (direct fall on the buttocks, a motor vehicle accident, or even a blow to the side of your pelvis).

The excess motion can lead to wear and tear of the joint and pain from degenerative arthritis.

Pain can also be caused by an abnormality of the sacrum bone. During pregnancy, the SI joints can cause discomfort both from the effects of the hormones that loosen them and from the stress of the growing baby.

28Risk Factor include

leg length discrepancy, abnormal gait pattern, trauma, heavy physical exertion, pregnancy. scoliosis, lumbar and sacrum fusion surgery

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Diagnosis

30IASP criteria for diagnosing SI

joint pain Pain present in the region of the

SIJ +ve Clinical SI joint stress tests

(painful). +ve diagnostic interventional

procedure (completely relieves the pain)

IASP International Association for the Study of Pain

Pain radiationPain from the SI joint is generally localized in the gluteal region (94%).

Referred pain may also be perceived in the lower lumbar region (72%), groin (14%), upper lumbar region (6%), or abdomen (2%). the lower limb in (28%). The Foot in (12%)

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History Signs and symptoms Physical examination

inspectionPalpation Special tests

Medical imagining X-RaysCT scanMRI

Accurate diagnosis

Symptoms of SI Joint Syndrome

It is often hard to distinguish from other types of LBP; because the pattern of back and pelvic pain that mimic each other.

In SI joint syndrome we find: Low back pain bilateral or unilateral in the posterior aspect of SI

joint Unilateral Buttock, hip or Thigh pain Difficulty sitting in one place for too long due to pain LBP with radiculopathy

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Physical Examination and provocative maneuvers (clinical tests)Solitary provocative maneuvers have little diagnostic value.

The 7 most important clinical tests which are positive when patient has typical SI joint pain:

1. Compression test (approximation test):

2. Distraction test (gapping test):

3. Patrick’s sign (Flexion Abduction External Rotation test):

4. Gaenslen test (pelvic torsion test):

5. Thigh thrust test (posterior shear test):

6. Fortin’s finger test:

7. Gillet test:

35Compression test

(approximation test):

The patient lies on his or her side with the affected side up; the Patient’s hips are flexed 45°, and the knees are flexed 90°.The examiner stands behind the patient and places both hands on the front side of the iliac crest and then exerts downward, medial pressure.2.

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Distraction test (ant & post gapping test)

The examiner stands on the affected side of the supine patient and places his/her hands on the ipsilateral spinae iliacae anteriores superiores. The examiner then applies pressure in the dorso-lateral direction.3.

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Faber’s test or Patrick’s sign (flexion abduction external rotation test):

The patient is positioned supine with the examiner standing next to the affected side. The tested leg flexed, abducted, and externally rotated. with the foot positioned above the opposite knee. Downward pressure is then applied to the knee of the affected side

If pain is elicited on the ipsilateral side anteriorly, it is suggestive of a hip joint disorder on the same side. If pain is elicited on the contralateral side posteriorly around the sacroiliac joint, it is suggestive of pain mediated by dysfunction in that joint.

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Gaenslen test (pelvic torsion test):

The patient lies in a supine position with the affected side on the edge of the examination table. The unaffected leg is flexed at both the hip and knee, and maximally flexed until the knee is pushed against the abdomen. The contralateral leg (affected side) is brought into hyperextension, and light pressure is applied to that knee.

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Thigh thrust test (posterior shear test):

The patient lies in the supine position with the unaffected leg extended. The examiner stands next to the affected side and flexes the extremity at the hip to an angle of approximately 90° with slight adduction while applying light pressure to the bent knee.

Fortin’s finger test:

The patient can consistently indicate the location of the pain with 1 finger infero-medially to the posterior superior iliac spine .

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41Gillet test:

Gillett test to estimate rotation of the sacroiliac joints. The knee on the right-hand side is raised as high as possible. The ilium on that side rotates posteriorly, which can be established by palpation of the posterior superior iliac spine.

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Investigations:Medical imaging is indicated only to rule out so-called “red flags.”

Medical imaging includes: radiography, computed tomography (CT), single photon emission CT, bone scans, and nuclear imaging techniques Magnetic resonance imaging (MRI) does not allow evaluation

of normal anatomy. However, in the presence of spondylarthropathy, MRI can detect inflammation and destruction of cartilage despite normal clinical presentation

43Diagnostic injection

The IASP criteria mandate that pain should disappear after intra-articular SI joint infiltration with local anesthetic in order to confirm the diagnosis.

Potential causes of inaccurate blocks include dispersal of the local anesthetic to adjacent pain-generating

structures (muscles, ligaments, nerve roots), the overzealous use of superficial anesthesia or sedation, failure to achieve infiltration throughout the entire SI joint

complex.

44Differential Diagnosis

Spondyloarthropathy (ankylosing spondylitis, reactive arthritis, psoriatic arthritis . . .).

Lumbar nerve root compression. Facetogenic pain. Hip pain. Endometriosis. Myofascial pain. Piriformis syndrome

Ankylosing spondylitis may affect SI joint as well

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Treatment

46Treatment Options

Pharmacological Physiotherapy, and Rehabilitation

Electrical therapy: TENS (Transcutaneous Electrical Nerve Stimulation),

Ultrasound therapy, laser therapy. Strengthening/stretching exercises Hydrotherapy

Interventional procedures.

47Interventional

Patients with SI joint pain resistant to conservative treatment are eligible for

intra-articular injectionsperi-articular infiltrationsradiofrequency (RF) ablation.

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Intra-articular injections

intra-articular injections with local anesthetic and corticosteroids may provide good pain relief for periods of up to 1year.It produces better results than peri-articular infiltrations.

49RF ablation of SI Joint

Single needle technique

Bipolar Technique

can increase the ablative area by minimizing the effect of tissue charring to limit lesion expansion

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Complications Of Interventional

infection, hematoma formation, neural damage, sciatic nerve damage, gas and vascular particulate embolism, weakness secondary to extra-articular extravasation, complications related To drug administration,

For intra-articular injections, Maugars et al. reported only transient perineal anesthesia lasting a few hours and mild sciatalgia (sciatica) lasting 3weeks

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Thank you