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Vertebral Column > Sacroiliac Joint > Flashcards

Sacroiliac Joint Flashcards

1
Q

What is the orientation of the SIJ in the transverse plane?

A

Anterolaterally

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2
Q

What are the functions of the SIJ?

A 
Transmit forces from lumbar spine to:
- Femur (when standing)
- Ischial tuberosities (when sitting)
Relieves stress:
- Point of max. torsional strain in pelvis
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3
Q

Why could the SIJ be classed as a diarthrodial joint?

A

2 articular surfaces
Separated by synovial fluid-filled cavity
Surrounded by joint capsule

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4
Q

Why is the SIJ an atypical diarthrodial joint?

A

Also has fibrocartilage
Posterior capsule absent
Articular surfaces not smooth

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5
Q

How could the joint be described in regards to the type?

A

Synovial in anterior 1/3

Fibrous in posterior 2/3

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6
Q

Describe the inner layer of the SIJ capsule?

A 
Synovial membrane (intima)
2-3 cellular layers
Contains synovial villi which extend into joint
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7
Q

What does the connective tissue of the outer fibrous layer of the SIJ capsule contain?

A

Fibroblasts
Blood vessels
Collagen fibres

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8
Q

How does the joint capsule change with age?

A

Becomes more fibrous

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9
Q

One part of the SIJ capsule is rudimentary/absent and the other is thin. Which is which?

A 
Rudimentary/absent = Posterior capsule
Thin = Anterior capsule
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10
Q

What does the study by Sakomoto et al., (2013) say about the SIJ capsule?

A

90% of mechanosensitive units are found in the joint capsule
Nerve fibres in joint capsule:
- Joint disturbance = Pain

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11
Q

What are useful references for overview of the SIJ and the joint capsule?

A

Bogduk, 2005
Cohen, 2005
Forst et al., 2017

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12
Q

What is the general shape of the articular surfaces of the SIJ?

A

L or C shaped

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13
Q

Describe the ‘undulating’ surfaces of the SIJ? What is its purpose?

A

Complementary depressions and elevations

  • Increases stability by interlocking
  • Protects from vertical shear force
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14
Q

Describe the cranial limb of the articular surfaces of the SIJ?

A

Shorter

More horizontal

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15
Q

Describe the caudal limb of the articular surfaces of the SIJ?

A

Longer

More vertical

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16
Q

How do the articular surfaces vary between the sexes?

A

Sacral surface is smaller in females:

- Only covers S1-S2 (vs S1-S3 in males)

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17
Q

What does the high coefficient of friction of the SIJ infer?

A

High stability

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18
Q

Describe the articular cartilage of the sacral surface of the SIJ?

A

Typical hyaline cartilage
White, glossy and smooth
1-3mm thick (2-3x thicker than iliac)
Doesn’t change much throughout life

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19
Q

How does Paquin, (1983) describe the iliac articular cartilage of the SIJ?

A

Special hyaline

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20
Q

How does Kampen and Tillmann, (1998) describe the iliac articular cartilage of the SIJ?

A

Fibrocartilage in childhood

Hyaline as it matures

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21
Q

How does Tuite, (2008) describe the iliac articular cartilage of the SIJ?

A

Both surfaces are hyaline inferiorly

Cartilage thinner on iliac surface (<1mm):

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22
Q

What reasons does Tuite, (2008) suggest may be why the iliac articular cartilage is thinner than the sacral cartilage of the SIJ?

A

It only absorbs forces (vs the sacral surfaces transmitting them)
Only stressed by vertical shear

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23
Q

How does the sacral articular surface appear histologically?

A

Thick

Similar to hyaline cartilage in limb joints

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24
Q

How does the iliac articular surface appear histologically?

A

Thin

Rich in perpendicular and oblique collagen fibre bundles

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25
Q

Where is an accessory SIJ found?

A

Posterior to true SIJ between:

  • Medial aspect of PSIS and
  • Transverse tuberosity lateral to 2nd sacral foramen
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26
Q

What is the incidence of accessory SIJ in CT scans and cadavers? (Reference?)

A

13/100 CT scans
9/56 cadavers
(Ehara et al., 1998)

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27
Q

In what populations are accessory SIJs more common? (Reference?)

A

Elderly
Obese patients
(Prassopoulos et al., 1999)

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28
Q

What variations of the SIJ are more common in women?

A

Iliosacral complex
Bipartite iliac bony plate
Crescent-like iliac bony plate

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29
Q

What are the two less common SIJ variations?

A

Semicircular defects on both surfaces of SIJ

Ossification centres

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30
Q

What are the prevalence rates of the 6 variations of the SIJ according to Prassopoulos et al., (1999)?

A 
Accessory SIJ = 19.1%
Iliosacral complex = 5.8%
Bipartite iliac bony plate = 4.1%
Crescent-like iliac bony plate = 3.7%
Semicircular defects on both surfaces of SIJ = 3%
Ossification centres = 0.6%
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31
Q

What is the course of the anterior sacroiliac ligament?

A

From ala and pelvic surface of sacrum

To adjoining margin of anterior surface of ilium

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32
Q

What is the anterior sacroiliac ligament an extension of?

A

Anterior joint capsule

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33
Q

What does the anterior sacroiliac ligament prevent?

A

Anterior diastasis of SIJ

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34
Q

What causes the greatest stress to the anterior sacroiliac ligament?

A

Axial loading

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35
Q

Where does the short posterior sacroiliac ligament lie?

A

Superiorly

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36
Q

Where does the long posterior sacroiliac ligament lie?

A

Inferiorly

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37
Q

What is the posterior sacroiliac ligament a continuation of?

A

Fibrous tissue (capsule)

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38
Q

How do the fibres of the posterior sacroiliac ligament compress the sacrum between the ilia?

A

FIbres run anterolaterally:

  • Axial weight pulls ilia medially
  • Compresses sacrum
  • Locks congruent articular surfaces of SIJ
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39
Q

What is the course of the long posterior sacroiliac ligament?

A

Fibres run vertically:

  • From PSIS
  • To 3rd/4th transverse tubercles of sacrum
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40
Q

What is the function of the long posterior sacroiliac ligament?

A

Prevents excessive counternutation:

  • Sacral promontory moving posterosuperiorly
  • Ilia moving anteriorly on sacrum
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41
Q

What does the long posterior sacroiliac ligament work with to prevent SIJ separation?

A

Interosseous SIJ ligament

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42
Q

What is the course of the short posterior sacroiliac ligament?

A

Runs from 1st/2nd transverse tubercles

TO iliac tuberosity

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43
Q

What is the function of the short posterior sacroiliac ligament?

A

Limits nutation:
- Forward movement of sacral promontory
Resists anterior displacement of SIJ

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44
Q

Where does the interosseous sacroiliac ligament lie?

A

In recess between sacrum and ilium dorsal to joint cavity

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45
Q

What is the function of the interosseous sacroiliac ligament?

A

Infers multi-directional stability
Very important in limiting movement:
- Severing it in cadavers increased joint movement

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46
Q

What is the deepest ligament of the SIJ?

A

Interosseous sacroiliac ligament

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47
Q

What is the course of the sacrotuberous ligament?

A 
From:
- Posterior ilium
- Lateral sacrum
- Lateral coccyx
To ischial tuberosity
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48
Q

What is the function of the sacrotuberous ligament?

A

Anchors inferior sacrum to ischium:

- Counterbalances rotation at superior sacrum

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49
Q

What is the course of the sacrospinous ligament?

A

From:
- Lateral sacrum
- Lateral coccyx
To ischial spine

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50
Q

What is the function of the sacrospinous ligament?

A

Perhaps acts as a fibrous part of coccygeus

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51
Q

Why are the sacrotuberous and sacrospinous ligaments important in high impact activities?

A

Superior sacrum receives great force via lumbar vertebrae
Weight transferred anterior to SIJ which would pull sacrum anteroinferiorly:
- Prevented by STL and SSL

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52
Q

What muscle, acting via the sacrotuberous ligament, stabilises the SIJ?

A

Long head of biceps femoris

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53
Q

What is the course of the iliolumbar ligament?

A

From tips of L4/L5 transverse processes

To posterior iliac crest

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54
Q

What are the functions of the iliolumbar ligament?

A

Strengthens relationship between ilium and vertebral column
Prevents L5 from anterior displacement on S1
Opposes gliding movements between vertebrae

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55
Q

What is the reference for the iliolumbar ligament?

A

Palanstanga, 2013

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56
Q

When does the SIJ develop?

A

Initially thought to develop in week 10

Recently suggested it develops in week 8

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57
Q

From what layers does the SIJ develop?

A

Three layers in pelvic mesenchyme:

  1. Sacral cartilage
  2. Iliac cartilage
  3. Interposed zone of mesenchyme
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58
Q

In what zone of mesenchyme does the early articular cavity form?

A

Interposed zone of pelvic mesenchyme

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59
Q

When does the synovial membrane form and from what?

A

Shortly before birth

Formed from mesenchyme surrounding edge of primordial central cavity

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60
Q

At what stage do bony ridges and bony grooves form on the bony surfaces of the SIJ?

A

Puberty

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61
Q

What is the arterial supply to the SIJ?

A

Anteriorly = Branches of iliolumbar artery
Posteriorly = Superior gluteal artery
Anteriorly and posteriorly = Lateral sacral arteries

62
Q

Where do the venous draining the SIJ drain to?

A

Internal iliac vein

63
Q

Where does lymph drain from the SIJ?

A

Internal iliac nodes

64
Q

What is the anterior nervous supply to the SIJ?

A

L4-S2 ventral rami

65
Q

What do earlier studies suggest give nervous supply to the anterior SIJ?

A

Obturator nerve
Superior gluteal nerve
Lumbosacral trunk

66
Q

What is the posterior nervous supply to the SIJ?

A

Medial branches of L4-S3 dorsal rami

Some studies also suggest contributions from L3 and S4

67
Q

What do some studies also suggest about the nervous supply to the SIJ?

A

Anterior SIJ is devoid of nervous tissue

68
Q

What 4 movements are possible at the SIJ?

A

Rotation
Translation
Nutation
Counternutation

69
Q

What movements of the SIJ are possible in the x (transverse) axis?

A

Sacral rotation in sagittal plane:

  • Nutation
  • Counternutation
70
Q

What movements of the SIJ are possible in the y (longitudinal) axis?

A

Sacral rotation in the horizontal plane

71
Q

What movements of the SIJ are possible in the z (sagittal) axis?

A

Sacral rotation in the coronal plane

72
Q

How much does SIJ movement decrease with age?

A

~40-50% in males

~50% in females

73
Q

How is the amount of movement of the SIJ measured?

A

Roentgen stereophotogrammetric motion analysis (RSA)

74
Q

How much rotation is possible at the SIJ?

A

Maximum is 4 degrees (mean is 2.5)

75
Q

How much translation is possible at the SIJ?

A

Maximum is 1.6mm (mean is 0.7mm)

76
Q

What IV joints do nutation and counternutation affect?

A

Mainly L5-S1 (but also those superior to it)

77
Q

What ligaments resist nutation?

A

Sacrotuberous ligament

Sacrospinous ligament

78
Q

What ligament resist counternutation?

A

Long posterior sacroiliac ligament

79
Q

How can pain at the SIJ arise with age?

A

Increased joint laxity with age

Therefore increased counternutation = Pain

80
Q

What is the combined range of counternutation in individuals older than 72?

A

4 degrees (normal is <2 degrees)

81
Q

What is force closure?

A

Anticipation for SIJ loading

Ligaments of SIJ tighten = Nutation

82
Q

What induces force closure?

A

Sacral connections of erector spinae induce nutation by pulling ilia together

83
Q

What is the course of the first pelvic trabecular system?

A

Arises from inferior auricular surface

Runs in an arc shape toward superior surface of acetabulum

84
Q

What does the first pelvic trabecular system align with?

A

Vertical trabeculae bundle:

- Supports head and neck of femur

85
Q

What is the course of the second pelvic trabecular system?

A

Begins at superior auricular surface
Runs to:
- Posterior border of greater sciatic notch
- Inferior border of acetabulum

86
Q

What does the second pelvic trabecular system align with?

A

Arcuate bundle in femur

87
Q

In what motion are the first and second pelvic trabecular systems important?

A

Bidepal motion

88
Q

Why are there different pelvic trabecular system patterns in apes?

A

Different weight distribution

89
Q

What is the alternate name for the third pelvic trabecular system?

A

Sacroischial trabeculae

90
Q

What is the course of the third pelvic trabecular system?

A

Begins at auricular surface

Extends to ischium

91
Q

When is the third pelvic trabecular system important?

A

When sitting:

- ischium supporting weight of body

92
Q

At birth, the structure of the SIJ in humans is similar to that of quadrupeds. Why does it change with age?

A

Locomotion

93
Q

How do the bony surfaces of the SIJ change after puberty?

A

Become rough

Fibrous plaques form in some areas

94
Q

What age related changes of the SIJ are seen in a person’s 20s?

A

Fusion of sacral vertebrae

95
Q

What age related changes of the SIJ are seen in a person’s 30s and 40s?

A

More grooves

Bony ridges on articular surface of ilium to increase stability

96
Q

What age related changes of the SIJ are seen in a person’s 50s?

A

Degeneration begins:

  • Synovial articular surfaces erode
  • Synovial cleft narrows to 1-2mm
97
Q

What age related changes of the SIJ are seen in a person’s 60s?

A

Capsule becomes more collaginous

98
Q

What age related changes of the SIJ are seen in a person’s 70s?

A

Synovial cleft only 0-1mm

Ankylosis often present

99
Q

What age related changes of the SIJ are seen in a person’s 80s?

A

Erosions and plaques:

  • Inevitable
  • Pervasive
100
Q

When does SIJ pain arise in pregnancy?

A

Week 18 of gestation

101
Q

What causes SIJ pain in pregnancy?

A

Increased oestrogen and relaxin:

  • Relaxation of ligaments
  • Less SIJ interlocking
  • Increased pelvic rotation
  • Increased lordosis
102
Q

What does SIJ ligament relaxation allow?

A

Increased SIJ diameter by 10-15% for passage of baby

103
Q

In what women are SIJ changes during pregnancy more prominent?

A

Multiparous women

104
Q

How does a sacroiliac belt reduce pain? (Reference?)

A

Reduces SIJ mobility

Mens et al., 2006

105
Q

What can cause a lateral compression injury to the SIJ?

A

RTAs
Fall from height (>15 feet)
Sports injuries
Crush injuries

106
Q

What is the most common mechanism of injury to the SIJ?

A

Lateral compression

107
Q

What does the mortality of a SIJ fracture depend on?

A

Severity of bleeding

Presence of thoracic/abdominal injures

108
Q

In what individuals are low energy stress fractures more common in?

A

Females

109
Q

In what individuals are high energy fractures (lateral compression, AP compression or vertical shear) more common in?

A

Males

110
Q

What conditions are SIJ fractures related to?

A

Osteoarthritis

Ankylosing spondylitis

111
Q

What are the three types of lateral compression and anterior pelvic rami fracture?

A

Type I = Ipsilateral sacral fracture
Type II = Ipsilateral crescent fracture
Type III = Ipsilateral Type I/II and contralateral open-book fracture

112
Q

What are the three types of AP compression and symphysis diastasis injuries?

A

Type I = Minor opening of symphysis and anterior SIJ
Type II = Anterior SIJ opening but intact posterior ligs.
Type III = Complete SIJ disruption

113
Q

What pelvic injury can a vertical shear force result in?

A

Displacement of hemipelvis

114
Q

What is the classification system of pelvic fractures called?

A

Young-Burgess Classification

115
Q

What is a crescent fracture?

A

Combination of:

  • Vertical iliac fracture
  • SIJ dislocation
116
Q

What is a crescent fracture characterised by?

A

SIJ disruption:

- Extended proximally as a fracture of posterior iliac wing

117
Q

What are the three types of crescent fractures?

A

Type I = Less than or equal to 1/3 of SIJ dislocated
Type II = 1/3-2/3 of SIJ dislocated
Type III = More than or equal to 1/3 of SIJ dislocated

118
Q

How long would a pelvic injury take to recover?

A

8-12 weeks

119
Q

What are the benefits of ORIF for a pelvic fracture?

A

High success rate

120
Q

How can the pelvis be stabilised prior to ORIF?

A

External fixation via pins in ilia

121
Q

When might external fixation be enough in pelvic fractures?

A

If minimal displacement

122
Q

What are the downsides of ORIF?

A 
Long recovery
Risk of re-displacement
Surgical risks:
- Haemorrhage
- Infection
- Nerve damage
123
Q

How is ORIF carried out in SIJ disruptions?

A

Plates

124
Q

How is ORIF carried out in crescent fractures?

A

Screws

125
Q

How is ORIF carried out in sacral fractures?

A

Screws

126
Q

What can improve outcomes in pelvic injuries?

A

Early stabilisation of pelvic ring

127
Q

What injury has a worse prognosis; SIJ injuries of iliac wing fractures?

A

SIJ injuries

128
Q

What can pelvic injuries predispose the patient to?

A

SIJ dysfunction syndrome

129
Q

What did Borg, (2011) find regarding the prognosis of pelvic injuries?

A

30% satisfied with QoL post-surgery:
- 20% less than those who did not require surgery
10% unsatisifed

130
Q

In pelvic fractures, what injuries can the strong ligaments cause?

A

Avulsion fractures

131
Q

What SIJ ligaments are most likely to be ruptured with pelvic fractures? What ligaments require a severe fracture to be disrupted

A

Anterior sacroiliac ligaments

Posterior sacroiliac ligaments

132
Q

Why are NSAIDs prescribed in pelvic fractures?

A

Ligament damage results in inflammation
Inflammation results in pain
NSAIDs reduce inflammation

133
Q

What percentage of lower back pain cases are due to SIJ dysfunction?

A

15-25%

134
Q

What injury mechanism tends to result in SIJ dysfunction?

A

Combination of:

  • Axial loading and
  • Abrupt rotation
135
Q

What are some intra-articular causes of SIJ dysfunction?

A

Arthritis

Inflammatory conditions

136
Q

What are some extra-articular causes of SIJ dysfunction?

A

Enthesopathy
Fracture
Ligamentous damage

137
Q

What factors can predispose to SIJ dysfunction?

A 
Leg length discrepancy
Gait abnormalities
Prolonged vigorous exercise
Scoliosis
Spinal fusion to sacrum
Lumbar spine surgery
Pregnancy
138
Q

What are the SIJ pain criteria?

A
  1. Pain in region of SIJ
  2. Stressing SIJs in clinical tests reproduces pain
  3. Selectively infiltrating SIJ relieves pain
139
Q

Where does SIJ pain radiate?

A 
Buttocks (94%)
Thigh
Leg
Ankle/Foot
Groin
Abdomen
140
Q

Why is SIJ dysfunction difficult to diagnose?

A

Cannot be diagnosed by:

  • Examination
  • Osteopathic or chiropractic techniques
  • Imaging
141
Q

What physical exam tests can be used to attempt to diagnose SIJ dysfunction?

A

Compression test

Bilateral internal hip rotation test

142
Q

How sensitive and specific is radionucleotide bone scanning for SIJ dysfunction?

A

13% sensitive

100% specific

143
Q

Why can CT be useful in SIJ dysfunction?

A

Can find other potential pathologies

144
Q

What does Bogduk, (2005) suggest is the only reliable way to diagnose SIJ dysfunction?

A

Analgesic response to small-volume local anaesthetic block

145
Q

What is the basis of management of SIJ pain?

A

Target underlying pathology and alleviate symptoms

146
Q

What conservative therapies can be used for SIJ dysfunction?

A 
Shoe insoles if:
- Leg length discrepancies
- Gait abnormalities
Physiotherapy/Chiropractic techniques
Mobilisation-stabilisation
Pelvic belt
147
Q

When is radiofrequency ablation used to treat SIJ pain?

A

If positive response to diagnostiv block

148
Q

When might radiofrequency ablation not be successful in relieving pain?

A

If pain is from ventral SIJ

149
Q

How else can SIJ pain be relieved?

A

Intra-articular hyaluronic acid injections

Surgical arthrodesis

150
Q

Why is the SIJ the 1st joint affected in ankylosing spondylitis?

A

Clefts in iliac cartilage allow osteophyte invasion

151
Q

What is the most common SIJ disorder (especially if 40 years old +)? Is it usually unilateral or bilateral?

A

Osteoarthritis

Unilateral

Vertebral Column (14 decks)

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