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Summary Most sacral cysts are accidentally found on lumbar myelograms and are usually asymptomatic. We operated on two patients with giant sacral cysts from S3 nerve roots who complained of neurogenic bladder and perianal sensory disturbance as well as buttock pain. Morphology of these cysts and intraoperative electrophysiological findings of nerve conduction block showed two kinds of pathogenesis causing these neurological symptoms. One was attributed to conduction block of more caudal sacral nerves squeezed between these giant sacral cysts and the other was due to degeneration of nerve root fibers involved in the sacral cyst walls. Postoperatively, buttock pain and perianal hypesthesia were resolved, but the neurogenic bladder showed only partial recovery.

We report a series of 18 patients with non tuberculous pyogenic sacroiliitis. All patients presented with unilateral buttock pain associated with fever. Pelvic radiographs, CT and bone scan were diagnostic of sacroiliac joint disorder. We emphasize the usefulness of the sacroiliac joint needle biopsy which permitted the bacteriological diagnosis in 13 out of 18 patients.

osteomyelitis, whereas only eight of those patients had abnormal radiographic evidence. The bone scan cannot distinguish between infectious and neoplastic processes. However, in an otherwise healthy child with an acute onset of symptoms and signs such as those reported, the positive scan suggests an infective focus, which may be confirmed by lateappearing classical radiologic changes of osteomyetitis. Hence, sacroiliac osteomyelitis should be suspected and included in the differential diagnosis of hip or buttock pain or an unexplained painful limp. In the absence of radiologic changes in the bone or pus on aspiration of the sacroiliac joint, the positive bone scan becomes a valuable, nonsurgical diagnostic procedure in early detection of pelvic osteomyelitis in the pediatric patient.

A follow-up study of post-operative instability after decompression for lumbar spinal canal stenosis is reported. We operated on 39 patients in our hospital from 1979 to 1985, including degenerative spondylosis; 15 patients, degenerative spondlylolisthesis; 9 patients, and combined; 1 patient. We examined 25 patients personally, 4 patients by questionnaire, and 10 patients were missed. Vertebral slip (3mm or more) occurred postoperatively in 6 out of 25 patients. Abnormal tilting (by Knutsson) in 3 out of 25 patients. The most frequent residual complaint was low back pain and buttock pain. However vertebral slip and abnormal tilting did riot influence the clinical results of the operation.

Entrapment of the superior gluteal nerve can occur as a result of compression by anterior-superior tendinous fibers of the piriformis muscle and cause aching claudication-type buttock pain, weakness of abduction of the affected hip with a waddling gait, and tenderness to palpation in the area of the buttock superolateral to the greater sciatic notch. Instilling anesthetic into the point of entrapment may relieve the pain completely, but superior gluteal neurolysis may be required to effect a permanent cure.

Sacroiliac joint (SIJ) involvement has been reported in up to 9.7 percent of patients with skeletal tuberculosis. Lack of awareness of this now uncommon form of infection often leads to diagnostic delay and increased morbidity. Eleven consecutive cases of SIJ tuberculosis are reported; clinical and radiologic features, diagnosis, treatment, and outcome are discussed. Buttock pain was the presenting complaint in all patients. However, radicular pain in the lower back (seven patients) or lower limb (10 patients) was common and in one patient precipitated an unnecessary surgical intervention. SIJ tuberculosis is frequently an isolated phenomenon. Therefore, direct sampling of the SIJ is necessary to establish the diagnosis. The recently described technique of closed needle biopsy of the SIJ was employed in all 11 patients and established the diagnosis in nine of the 11.

Objetivo: analisar as variáveis demográficas e clínicas associadas à diminuição da qualidade de vida em uma grande coorte brasileira de pacientes com espondiloartrite (EpA). Métodos: Foi aplicado um protocolo de pesquisa único a 1.465 pacientes brasileiros classificados como tendo EpA de acordo com os critérios do European Spondyloarthropaties Study Group (ESSG), atendidos em 29 centros de referência em reumatologia do Brasil. Foram registradas as variáveis clínicas e demográficas. A qualidade de vida foi analisada por meio do questionário Ankylosing Spondylitis Quality of Life (ASQoL). Resultados: A pontuação média do ASQoL foi de 7,74 (+ 5,39). Ao analisar doenças específicas no grupo de EpA, as pontuações do ASQoL não apresentaram diferença estatisticamente significativa. Os dados demográficos mostraram piores escores de ASQoL associados ao gênero feminino (p = 0,014) e etnia negra (p < 0,001). Quanto aos sintomas clínicos, a dor na região glútea (p = 0,032), a dor cervical (p < 0,001) e a dor no quadril (p = 0,001), estiveram estatisticamente associadas a piores escores no ASQoL. O uso contínuo de fármacos anti-inflamatórios não esteroides (p < 0,001) e agentes biológicos (p = 0,044) esteve associado a escores mais elevados de ASQoL, enquanto outros medicamentos não interferiram nos escores do ASQoL. Conclusão: Nesta grande série de pacientes com EpA, o sexo feminino e a etnia negra, bem como sintomas predominantemente axiais, estiveram associados a uma qualidade de vida reduzida. Objective: to analyze quality of life and demographic and clinical variables associated to its impairment in a large Brazilian cohort of patients with spondyloarthritis (SpA). Methods: A common protocol of investigation was applied to 1465 Brazilian patients classified as SpA according to the European Spondyloarthropaties Study Group (ESSG) criteria, attended at 29 reference centers for Rheumatology in Brazil. Clinical and demographic variables were recorded. Quality of life was analyzed through the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. Results: The mean ASQoL score was 7.74 (± 5.39). When analyzing the specific diseases in the SpA group, the ASQoL scores did not present statistical significance. Demographic data showed worse scores of ASQoL associated with female gender (p = 0.014) and African-Brazilian ethnicity (p < 0.001). Regarding clinical symptoms, buttock pain (p = 0.032), cervical pain (p < 0.001) and hip pain (p = 0.001), were statistically associated with worse scores of ASQoL. Continuous use of nonsteroidal anti-inflammatory drugs (p < 0.001) and biologic agents (p = 0.044) were associated with higher scores of ASQoL, while the other medications did not interfere with the ASQoL scores. Conclusion: In this large series of patients with SpA, female gender and African-Brazilian ethnicity, as well as predominant axial symptoms, were associated with impaired quality of life.

Objective: Evaluate the initial results and the possible complications of the combination of pelvic fixation using iliac screws in long instrumentations of the lumbar spine in elderly patients. Methods: An analysis of 38 patients who underwent lumbar spine arthrodesis instrumentation with more than 3 levels, in which we included level L5-S1 and extended the fixation to the iliac crest. Radiological assessment of instrumentation through X-ray of the lumbar spine and pelvis, and computed tomography, to investigate the presence of radiological fusion. Clinical evaluation through a questionnaire of buttock pain including the visual analogue pain score (VAS). Complications related to pelvic instrumentation were investigated. Results: All patients had radiological fusion in the lumbosacral transition. A halo was found around the iliac screw on imaging studies in 31% of patients, but without related symptoms. The questionnaire of buttock pain found that 15% of patients had some low intensity buttock pain (VAS 1-2) and no need to or interest in removing the screws. There was infection at the surgical site in 2% of cases, hematoma in the buttocks in 5%, and vertebral body fracture in the cranial level instrumented in 7% of cases. Conclusions: Pelvic fixation through the iliac screws proved to be effective in protecting the S1 screws in long instrumentations including the L5-S1 level in elderly patients, allowing the radiological bone fusion. The overall results for pain were satisfactory, based on a questionnaire of buttock pain. There are no signs of overload or degeneration of the sacroiliac joints in the early years after surgery. Level of Evidence IV; Case series - therapeutic study. RESUMO Objetivo: Avaliar os resultados iniciais e as possíveis complicações da combinação da fixação pélvica através dos parafusos nos ilíacos nas instrumentações longas da coluna lombar em pacientes idosos. Métodos: Análise de 38 pacientes, submetidos a artrodese da coluna lombar com instrumentação maior que três níveis, incluímos o nível L5-S1 e estendemos a fixação ao ilíaco. Avaliação radiológica da instrumentação, através de radiografia da coluna lombar e da bacia, e tomografia computadorizada, pesquisando-se presença de fusão radiológica. Avaliação clínica através de questionário sobre dor glútea, incluindo o escore visual analógico de dor (VAS). Foram pesquisadas complicações relacionadas a instrumentação pélvica. Resultados: Todos os pacientes possuíam fusão radiológica na transição lombossacra. Foi encontrado halo ao redor do parafuso ilíaco nos exames de imagem de 31% dos pacientes, porém sem sintomas relacionados. O questionário sobre dor glútea identificou que 15% dos pacientes possuíam alguma dor glútea de baixa intensidade (VAS 1 a 2) e sem necessidade ou interesse de retirar os parafusos. Houve infecção em sitio cirúrgico em 2% dos casos, hematoma em região glútea em 5% e fratura do corpo vertebral no nível mais cranialmente instrumentado em 7% dos casos. Conclusão: A fixação pélvica, através de parafusos ilíacos, mostrou-se eficaz na proteção dos parafusos de S1 em instrumentações longas, que incluam o nível L5-S1 em pacientes idosos, permitindo a fusão óssea radiológica. Os resultados gerais de dor foram satisfatórios com base em um questionário sobre dor glútea. Não há sinais de sobrecarga ou degeneração das articulações sacro-ilíacas nos primeiros anos após a cirurgia. Nível de Evidência IV; Estudo terapêutico - série de casos. RESUMEN Objetivo: Evaluar los resultados iniciales y las posibles complicaciones de la combinación de la fijación pélvica con tornillos en los ilíacos en las instrumentaciones largas de la columna lumbar en pacientes ancianos. Métodos: Análisis de 38 pacientes sometidos a la artrodesis de la columna lumbar con instrumentación de más que tres niveles cuando se incluyó L5-S1 y se extendió la fijación al ilíaco. Evaluación radiológica de la instrumentación de la columna lumbar y cadera y tomografía computarizada para investigar la presencia de fusión radiológica. Evaluación clínica con cuestionario sobre dolor glúteo, incluyendo la Escala Visual Analógica (EVA). Se han investigado las complicaciones relacionados con la instrumentación pélvica. Resultados: Todos los pacientes tenían fusión radiológica en la transición lumbosacra. Se encontró halo radiológico alrededor del tornillo ilíaco en los estudios de imagen del 31% de los pacientes, pero sin síntomas relacionados. El cuestionario sobre el dolor glúteo identificó que el 15% de los pacientes tenían algún dolor de baja intensidad (EVA 1-2) y no había necesidad o interés en retirar los tornillos. Se produjo una infección en el sitio quirúrgico en 2% de los casos, hematoma en la región glútea en un 5% y fractura del cuerpo vertebral en el nivel más craneal de instrumentación en el 7% de los casos. Conclusiones: La fijación de la pelvis a través de tornillos en ilíacos se mostró eficaz en la protección de los tornillos de S1 en instrumentaciones largas que incluyan el nivel L5-S1 en pacientes ancianos, permitiendo la fusión ósea radiológica. Los resultados generales del dolor fueron satisfactorios sobre la base de un cuestionario sobre el dolor glúteo. No hay signos de sobrecarga o degeneración de las articulaciones sacroilíacas en los primeros años después de la cirugía. Nivel de Evidencia IV; Estudio terapéutico – Serie de casos.

Of five patients in who sciatic paresis developed as the result of hemorrhage and hematoma following hip surgery, four were receiving prophylactic or therapeutic anticoagulants. The patient who was managed expectantly still had disabling motor and sensory deficity at follow-up. Three patients who had early operative decompression showed more complete return of nerve function. The fifth patient died three weeks after onset with the neuropathy still present. Severe low-back and buttock pain, ecchymosis over these regions, marked swelling in the thigh, sciatic-nerve tenderness, and a distal sciatic neural deficit in the ipsilateral lower limb of a patient who has had hip surgery are evidence of hemorrhage in the vicinity of the sciatic nerve. Early recognition and prompt surgical decompression can prevent irreversible nerve damage.

Epidermoid cysts are found in practically no bones other than the skull and distal phalanges. A search of literature failed to find any other report of an epidermoid cyst of the sacrum. We experienced such a rare case.A 45-year-old female with a 13-year history of urinary hesitancy had low-back and buttock pain 5 years before admission to our department. At an outside hospital physical examination revealed a large sacral mass. Roentgenogram showed rarefied defect of the sacrum. A sensory examination showed hypesthesia of the second to fifth sacral dermatome. We suspected chordoma. At surgery in October 1985, removal of the tumor with en block excision was impossible because of adhesion of external iliac vein. Accordingly the tumor was treated by curetting and filling with bone cement in June 1986.Histologically the cyst wall was composed of a squamous epithelium, establishing a diagnosis of epidermoid cyst. Six months after the last operation she was ambulating with two crushes.

All 132 participants in a 500 mile, 8 day bicycle tour were surveyed by questionnaire to characterize the demographics and bicycling experience of the riders, and to determine the frequency and severity of non traumatic injuries they experienced. Riders who devel oped significant symptoms were interviewed and/or examined. Eighty-six percent of ride participants re sponded to the survey.The average age of the riders was 41.4 years (±11.7 years). They rode an average of 95.8 miles per week on a routine basis, but the majority were new to long distance touring. Most were healthy, but 5% had seri ous cardiovascular disease and bicycled as part of a rehabilitation program.The most common nontraumatic injury was buttocks pain (experienced by 32.8% of riders); four had skin ulceration of the buttocks. Knee problems occurred in 20.7% of riders; patellar pain syndromes and lateral knee complaints were the most common knee prob lems. One cyclist withdrew from the tour because of knee pain.Neck-shoulder pain occurred in 20.4% of the riders. Groin numbness and palmar pain or paresthesias each occurred in approximately 10%. Other less common problems were foot and ankle symptoms and sunburn.

Twenty-six patients with a pauciarticular arthritis have been studied clinically, radiologically and with histocompatibility typing. An increased frequency of HLA B27 was found (p = 1.87 x 10(-12)). Low back and buttock pain, Achilles tendinitis and dactylitis of the toes were more frequent in HLA-B27 positive patients. It is suggested that histocompatibility testing may be of some value in diagnosis and in the investigation of the possible 'reactive' nature of this type of arthritis.

Pelvic fractures with disruption of the important weight-bearing sacroiliac area can lead to impaired gait due to malunion or pelvic obliquity, back or buttock pain arising from the sacroiliac joint, and permanent neurologic damage. In eight patients with sacroiliac joint dislocation, an anterior retrofascial approach and stapling of the sacroiliac joint was performed. Six of these patients maintained an anatomic reduction of the sacroiliac joint and their results were rated as excellent. Two of the eight patients had a slight loss of reduction and because of intermittent mild pain were rated as having fair results. In another eight patients, plate fixation of the anterior sacroiliac joint was done. New stabilization methods utilizing dynamic compression plates, reconstruction plates, and a new four-hole plate have been developed to provide more secure fixation of these unstable injuries.

THE FACT that the abdominal aorta distal to the renal arteries can be totally occluded by disease and the legs still be viable has been recognized for many years. Reports by Ortner and Griswold,1Goodwin and Petrie,2and deWolfe and his associates3have described cases of this type. Leriche4has given his name to the resulting symptom-complex of severe low back and buttock pain on walking, characteristic of high-level intermittant claudication associated with leg ischemia and impotence in the male. This segmental lower aortic and/or common iliac segmental occlusion is commoner than previously realized, and the increasing awareness of its existence has resulted in the discovery of many previously unrecognized cases. In the past year I have seen 10 such cases and their description and management form the basis of this report. Segmental occlusion of the distal aorta is frequently associated with varying degrees of involvement

Dear Editor: With great interest, I read the recent publication of Dietz et al. [1] in your journal. The authors describe that buttock pain occurred post-operatively in ~18% of patients undergoing sacrospinous hysteropexy for pelvic organ prolapse. The authors state in their discussion that the pain can be explained by injury to nerves of the sacral plexus, such as the branches of the pudendal nerve. In this letter, I would like to propose that this pain can be explained by injury of the ‘levator ani nerve’, the nerve that lies on the superior surface of the sacrospinous ligament and in the area of the operative field. This explanation has been neglected in clinical studies so far. Recent research by our group [2, 3] and others [4–8] has emphasized that the levator ani muscle is innervated not only by the pudendal nerve from its inferior surface but also by the levator ani nerve from its superior surface. The levator ani nerve originates directly from the sacral plexus and courses on the superior surface of the coccygeus muscle/sacrospinous ligament complex towards the superior surface of the levator ani muscle (Fig. 1). On its trajectory, it crosses the sacrospinous ligament 0–4 cm medial to the ischial spine [2, 6–8]. As sutures are placed through the sacrospinous ligament approximately 2 cm medial to the ischial spine during sacrospinous hysteropexy or sacrospinous ligament fixation in general, the procedure can injure the levator ani nerve [2, 5–8] and thereby entail the sensation of buttock pain. Additional injury to the pudendal nerve may also occur because the pudendal nerve, which lies inferior to the sacrospinous ligament, is only 4–11 mm apart from levator ani nerve [2]. Int Urogynecol J (2008) 19:1729–1730 DOI 10.1007/s00192-008-0646-3

Three patients developed lumbar radicular pain after Harrington instrumentation and posterior spinal fusion for idiopathic scoliosis. They required a second surgical procedure for nerve root decompression. The presenting complaint after the initial procedure was persistent radicular and buttock pain. Subsequent evaluation revealed direct compression by the inferior hook. At surgery the inferior hook was noted to be encased in bone and had imploded into the canal after a stress fracture of the lamina. Removal of the entire Harrington instrumentation resulted in effective relief of nerve root compression and resolution of radicular pain. To avoid this occurrence the addition of a leg extension to a postoperative brace has been instituted for procedures involving instrumentation to L5 and occasionally to L4.

In 3 cases of pyogenic infection of the sacro-iliac joint, the diagnosis was difficult. Limp, buttock pain and upper sciatica were the most common presenting symptoms. Differential limitation of hip motion, positive straight leg raising, a positive Gaenslen test and pain on pelvic compression were frequent fingings. Increased E.S.R., W.B.C. count and fever were seen in 2/3 cases. Plain and tomographic X-rays are often helpful but bone scan has been helpful in localizing early lesions. Treatment after early diagnosis may consist of antibiotics and immobilization alone while in the more chronic cases surgical drainage and debridement may be necessary.

Twenty-four patients with lumbar pseudarthroses following attempted fusion were investigated by preoperative discography. The pseudarthroses were confirmed at surgical exploration. In 19 patients, discography at the level of a pseudarthrosis reproduced typical back pain, and in two patients the level above the fusion reproduced typical pain. Discography is not indicated when the major symptoms are leg or buttock pain. Technical errors included injection into the annulus fibrosis and impingement of the needle into the vertebral endplate. The latter may produce a false-positive result. Previous posterior fusions and very narrow disc spaces prevented insertion of the needle in some patients. Not all lumbar pseudarthroses were symptomatic, and two frequently occurred in the same patient. Discography is a useful adjunct to the traditional investigation of lumbar pseudarthroses.

We greatly appreciate the comment by Dr. Wallner [1] on the new insight into the positioning of the pudendal and levator ani nerves in relation to the complaint of buttock pain after sacrospinous hysteropexy [2].