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Isotretinoin, a medication for acne, has been reported to cause a variety of side effects on the musculoskeletal system. We present a case of sacroiliitis (a relatively uncommon feature) and sensorimotor demyelinating polyneuropathy, which has been reported previously in only a few cases during isotretinoin therapy. Clinical symptoms were improved after the withdrawal of isotretinoin and the follow-up electrophysiological study performed 2 years after the initial diagnosis of polyneuropathy showed mild improvement. Dermatologists are advised to be alert to symptoms of polyneuropathy and sacroiliitis during treatment with isotretinoin.

Introduction: Image-guided sacroiliac joint injections are frequently employed for both diagnostic and therapeutic relief of low back pain., Case Report: An 83-year-old male with chronic lumbrosacral pain previously responsive to right sacroliac joint injections presented for repeat injection. His medical history included Parkinsonism and stool incontinence. Forty-two hours after the injection, he developed fever, dyspnea, and crepitus on the right buttock and thigh. Surgical debridement was recommended, but the family wished for comfort care only. The patient died hours later. The autopsy revealed Gram positive bacilli consistent with Clostridial myonecrosis., Discussion: Pyogenic sacroiliitis is rare and usually occurs in the setting of trauma, drug abuse, or extraspinal infections. Joint infections with Clostridium have been reported after traumatic events including puncture, surgery, and abrasions. Clostridium spores are resistant to chemical preparations used for skin sterilization and require high heat for destruction. Possible practice guidelines with patients that are stool incontinent include mechanical wash prior to sterile preparation and placement of an occlusive sterile dressing after injection to prevent stool contamination of the needle puncture site. As with all rare complications, large scale studies are needed to better identify risk factors to formulate practice management strategies.

The concurrence of ankylosing spondylitis (AS) in a patient with mixed connective tissue disease (MCTD) is rarely described in the literature. Significant and sustained efficacy with tumor necrosis factor (TNF)-alpha blockers has been demonstrated in AS patients. However, evidence to date has revealed associated side effects, including antinuclear antibody induction and development of a lupus-like syndrome. Several authors have reported lupus-like manifestations in MCTD patients treated with TNF-alpha blockers used to control peripheral polyarthritis. In our case report, we demonstrate a good response to etanercept therapy for refractory sacroiliitis in a patient with coexisting AS and MCTD, without development of a lupus-like syndrome. This demonstrates that etanercept therapy may be an appropriate therapeutic agent for sacroiliitis in MCTD patients, as it is in AS alone.

Efficacy of a second magnetic resonance (MR) imaging guided corticosteroid injection of inflamed sacroiliac joints (SIJ) in patients with spondylarthropathy. Thirty-one patients received 50 injections in an outpatient basis. Fifteen of 31 patients who relapsed or were non-responders received a second injection. All had MR guided injection of 40 mg triamcinolone acetonide into SIJ using an open 0.2 Tesla unit. Twenty of 31 patients after the first injection, and 9 of 15 patients after the second injection reported subjective improvement, which lasted for a mean of 8.7+/-10.9 and 16.1+/-15.8 months for each group. Subchondral bone marrow edema resolved in 15 of 20 patients who reported subjective improvement, after the first injection. No complications occurred. MR guided steroid injection of SIJ is effective and safe. Since there is no exposure to radiation it could be performed many times. Repeated injections seem to be beneficial for primary non-responders and patients who relapsed.

Objective: To compare the diagnostic accuracy of a multitest regimen of 5 sacroiliac joint (SIJ) pain provocation tests with fluoroscopically controlled double SIJ blocks using a short- and long-acting local anesthetic in order to reduce the exposure of patients to unnecessary invasive SIJ procedures., Design: Prospective, observational study., Setting: Hospital setting., Participants: Sixty patients with chronic low back pain., Interventions: Not applicable., Main Outcome Measures: Visual analog scale score and receiver operating characteristic (ROC) curve., Results: Twenty-seven patients responded positively to the blocks, of whom 23 were found positive after the multitest regimen and 4 were negative. For the nonresponders (n=33), these figures were 7 positive and 26 negative. The calculated sensitivity and specificity were .85 (95% confidence interval [CI], .72-.99) and .79 (95% CI, .65-.93), respectively. Positive and negative predictive values were .77 (95% CI, .62-.92) and .87 (95% CI, .74-.99), respectively. The positive likelihood ratio was 4.02 (95% CI, 2.04-7.89); the negative likelihood ratio was .19 (95% CI, .07-.47). The area under the ROC curve was .799., Conclusions: The test regimen with 3 or more positive tests is indicative of SIJ pain. It can be used in early clinical decision making to reduce the number of unnecessary minimally invasive diagnostic SIJ procedures.

Purpose: To evaluate the efficacy and specific properties of MR imaging-guided corticosteroid infiltration of the sacroiliac (SI) joints in the treatment of therapy-refractory sacroiliitis in patients with ankylosing spondylitis., Materials and Methods: In this study, 26 patients were prospectively included. Inclusion criteria were AS with therapy refractory acute sacroiliitis and inflammatory back pain > or = 6 months. The intervention was performed using an open low-field MR-scanner. Inflammatory back pain was assessed on a visual analog scale (VAS). Success of the therapy was defined as an absolute reduction of the VAS score or = 35 % and persisting improvement > or = 2 months. The grade of sacroiliitis was documented using high-field MR imaging. Variables were compared using McNemar test and Wilcoxon test. The mean remission time was calculated using a Kaplan-Meier analysis. A p-value < 0.05 was considered statistically significant., Results: The intervention was technically successfully performed in all patients. Following MR imaging-guided corticosteroid infiltration of the SI joints, the VAS score improved from 8 (5 - 10) points to 4.5 (0 - 8) points (- 44 %) in all patients (n = 26), which was statistically significant (p < 0.001). Of 26 patients, 22 (85 %) fulfilled the predefined criteria for successful therapy. This group had a statistically significant (p < 0.01) improvement of the VAS score from 8 (6 - 10) to 3 (0 - 5) (- 63 %). Improvement was seen after 7 (1 - 30) days. There was a marked reduction of the subchondral bone marrow edema (- 38 %). The mean remission time was 12 (4 - 18) months., Conclusion: MR imaging-guided corticosteroid infiltration of the SI joints proved to be an effective therapy of inflammatory back pain in patients with therapy refractory AS. With the ability of multiplanar imaging, precise localization of the bone marrow edema and the lack of ionizing radiation, interventional MR imaging currently represents the superior method for the treatment of the predominantly young patient group presenting with ankylosing spondylitis. Owing to short intervention times, open MR-scanners are ideally suited for MR imaging-guided infiltration of the SI joints.

Objective: To determine the inciting events leading to the development of sacroiliac joint syndrome (SIJS)., Methods: This was a retrospective descriptive cohort series from an academic interdisciplinary spine center. Consecutive patients presenting with low back or buttock pain with or without leg symptoms who met specific inclusion and exclusion criteria for the diagnosis of SIJS were included in the study. Inciting events leading to the development of SIJS in these patients were categorized into traumatic, cumulative, and idiopathic events., Results: Of 194 patients who were included in the study, 54 patients had symptom resolution with one or more therapeutic intraarticular sacroiliac joint injections, following a positive diagnostic injection. Those patients were given the diagnosis of SIJS. Of these, 24 (44%) had had a traumatic event (13 motor vehicle accidents, six falls onto the buttock, three immediately postpartum, one severe football tackle, and one pelvis fracture). Eleven (21%) patients were considered to have a cumulative injury (four lifting, two running, three altered gait due to lower extremity disorder, one crew training injury, and one forceful hip extension injury). Nineteen (35%) patients had spontaneous or idiopathic onset of sacroiliac joint pain., Conclusion: SIJS can occur following a traumatic event or cumulative shear events, or can occur spontaneously., (Copyright American Academy of Pain Medicine)

Purpose: The prospective investigation of the therapeutic effect of CT-guided intra-articular corticosteroid injection into inflammatory sacroiliac (SI) joints compared to conventional treatment with nonsteroidal anti-inflammatory drugs (NSAIDS) in children with juvenile spondyloarthropathy (jSpA) and the determination of the role of dynamic magnetic resonance imaging (MRI) in establishing the indication and monitoring the therapy., Materials and Methods: The study comprises 89 children with known jSpA who were diagnosed by MRI to have a unilateral or bilateral sacroiliitis. Therapy with NSAIDS was initiated or continued in all 89 patients. Four weeks after the diagnostic MRI, two groups were distinguished according to the clinical response to NSAIDS, with group 1 consisting of 33 responders and group 2 of 56 non-responders. The patients of group 2 were treated with CT-guided intra-articular corticosteroid injection (low-dose injection) while the therapy with NSAIDS was continued. A total of 83 SI joints were punctured without complications, 27 bilaterally and 29 unilaterally. The indication for the intervention was based on inflammatory activity as determined by MRI. The therapy was monitored by clinical follow-up every 8 to 12 weeks over a period of 20 months. Follow-up by dynamic MRI was performed in all 56 children of group 2 and in 15 of the 33 children of group 1 within 8 +/- 4 months of the initial examination., Results: A total of 87.5% of the children in group 2 showed a statistically significant decrease in their subjective complaints from 6.9 +/- 3.4 to 1.8 +/- 1.7 (p < 0.05) as measured on a visual analog scale (VAS from 0 to 10). Improvement was seen as early as 1.5 +/- 1.0 weeks after the intervention and lasted for a mean of 12 +/- 6 months. The children in group 1 already showed similar improvement of the VAS from 6.8 +/- 3.2 to 1.5 +/- 1.4 (p < 0.05) during the initial four weeks of NSAIDS therapy, with the improvement lasting for the 20-month observation period. The follow-up dynamic MRI (0.1 mmol/kg body weight) during therapy showed a statistically significant lower contrast-enhancement in both groups (group 1: 117 +/- 43 % versus 38 +/- 24 %, p < 0.05; group 2: 127 +/- 59 % versus 38 +/- 22 %, p < 0.05). One third of the patients of group 2 showed progression of joint destruction despite absence of subjective complaints., Conclusion: CT-guided intra-articular corticosteroid injection has proven an effective, symptomatic, and uncomplicated therapy of acute sacroiliitis in patients with jSpA. Dynamic MRI has a role in establishing the indication for intervention but its role for any follow-up is restricted to cases with inconclusive clinical response.

The sacroiliac joint (SIJ) can cause pain after lumbosacral fusion. Diagnosis requires >75% relief after local anesthetic SIJ injection. This study is a retrospective review of patients with low back pain after lumbosacral fusion who had SIJ injections. Percentage and duration of pain relief were noted. Results are as follows: there were 34 patients; 8 fused at L5-S1, 14 fused at L4-S1, and 12 had multilevel fusions. Twenty had >75% relief within 45 minutes, and 11 had prolonged relief. Six had relief >20% but <75%, and one had prolonged relief. Eight never improved. Eight had posterior iliac crest bone harvested, and there was no correlation between donor side and pain side. In 34 patients with low back pain after lumbosacral fusion, SIJ was the cause of pain in 32% and possibly the cause in 29%. This is the first detailed description of this problem.

Pyogenic sacroiliitis is an extremely rare disease in the field of obstetrics and gynecology, and especially for the cases discovered and treated during pregnancy, only five cases can be found in literature. We experienced one case of the disease in which the patient needed urgent hospitalization due to dysbasia caused by fever and pain at the left hip at the 27th week of her pregnancy. The patient was a 31-year-old primipara presenting typical clinical symptoms of pyogenic sacroiliitis along with evidence of severe infection as represented by fever of 39.7 degrees C and CRP of 12.6 mg/dl. She showed a good response to meropenem (MEPM) at 1 g twice a day for 8 days and then at 0.5 g twice a day for 2 days, followed by faropenem (FRPM) at 200 mg three times a day for 12 days, which successfully improved her subjective and objective findings as well as her laboratory test values, resulting in a complete cure. The definitive diagnosis of the disease in the patient was made on the basis of MRI findings, but no pathogen was identified. The patient was found to have marginal placenta previa as a complication, but she had an uneventful trans-vaginal delivery at the 37th week of her pregnancy and left hospital after both she and her baby showed favorable post-delivery progress. The case reported here is the first case of pyogenic sacroiliitis that has ever been discovered and treated during pregnancy in Japan.

Objective: To evaluate changes in articular symptoms, spinal mobility, and global function over 6 months after intraarticular injections of long acting corticosteroid into the sacroiliac (SI) joints of patients with inflammatory low back pain (ILBP)., Methods: Nineteen patients with symptoms of ILBP were studied. Thirteen (68%) had radiographic evidence of sacroiliitis. The remaining 6 patients (32%) had normal imaging studies and thus were considered to have mechanical low back pain. All patients received bilateral SI joint injections of triamcinolone hexacetonide (40 mg/joint) under computer tomographic guidance. Outcome variables included the duration of low back morning stiffness, back pain (by visual analog scale, McGill Pain Questionnaire), spinal mobility (chest expansion, Schober test, 10 cm segments test, finger-fibula distance), and self-report health status (SF-36)., Results: Both groups of patients showed a transient improvement in stiffness and pain, spinal mobility, and general health status that was most pronounced at 1-3 months after intraarticular therapy. This did not reach statistical significance (p > 0.05) and by 6 months, followup all outcome variables had reverted to pretherapy levels in both groups., Conclusion: These preliminary observations suggest that SI corticosteroid injections are ineffective in the management of patients with inflammatory spondyloarthropathy.

Objective: To evaluate magnetic resonance imaging (MRI) guided corticosteroid injections of inflamed sacroiliac (SI) joints in patients with spondyloarthropathy with therapy resistant sacroiliitis., Methods: We performed 16 injections in 9 patients on an outpatient basis (6 men, 3 women, mean age at onset 24.7 +/- 7.5 yrs). All patients had MRI guided injection of 40 mg triamcinolone acetonide into SI joints using an open 0.2 Tesla unit. Before and 3 months after corticosteroid injection they underwent an MRI examination with a closed 1.5 Tesla unit., Results: Seven of 9 patients reported subjective improvement that lasted at least a mean of 10.8 +/- 5.6 months. Subchondral bone marrow edema on fat suppressed images resolved in 8 patients after corticosteroid injection., Conclusion: MRI guided corticosteroid injection of SI joints appears to be an effective and safe procedure without exposure to radiation. It is a useful therapeutic modality, especially in young patients with severe isolated sacroiliitis.

The authors performed fluoroscopy-guided sacroiliac (SI) joint injections. With the patient prone and the x-ray tube perpendicular to the fluoroscopic table, the skin was marked over the distal 1 cm of the SI joint. With the tube angled 20 degrees - 25 degrees cephalad, a 22-gauge needle was inserted at the skin mark and advanced perpendicular to the fluoroscopic table toward the posterior joint. Nonionic contrast material was injected to confirm the intraarticular position of the needle. Of 31 SI joint injections, 30 (97%) were intraarticular. Mean procedure time was 108 seconds. This technique is safe, rapid, and reproducible.

Objective: To evaluate the efficacy of periarticular corticosteroid injection of the sacroiliac joint (SIJ) in patients with seronegative spondylarthropathy in a double blind, controlled study., Methods: 20 patients with seronegative spondylarthropathy and clinical sacroiliitis entered the study. In 10 patients one affected SIJ was treated with periarticular injection of 1.5 ml (40 mg/ml) methylprednisoloneacetate and 1.5 ml (20 mg/ml) lignocaine (MP group), whereas 10 patients received 1.5 ml isotonic sodium chloride and 1.5 ml (20 mg/ml) lignocaine (non-MP group). Clinical assessment at the onset of the study and after two months follow-up included the patients' estimation of pain in the SIJ by the visual analogue scale (VAS) and by a pain index which was calculated from tenderness and stressing tests on the SIJ., Results: At the two months follow-up examination the VAS (p = 0.02) and the pain index (p = 0.01) had improved significantly in the MP group compared with the non-MP group., Conclusion: The results of our study indicate that the periarticular injection of methylprednisolone may be effective in the treatment of clinical sacroiliitis in patients with seronegative spondylarthropathy.

A 57-year-old man developed oligoarthritis of the right sacroiliac joint, knee and elbow in the wake of Clostridium difficile pseudomembranous colitis. He was HLA B27-positive and had a history of Reiter's syndrome. His joint manifestations resolved after a course of nonsteroidal antiinflammatory drug therapy and injection of the right knee with triamcinolone acetonide. Clostridium difficile should be recognized as a rare cause of reactive arthritis.

Buttock pain was a predominant symptom in a series of patients seen with recalcitrant "backache" in the author's pain clinic which has a musculoskeletal emphasis. Assessment suggested the sacroiliac joint as the culprit pain generator and patients underwent confirmatory testing which included fluoroscopy-guided intra-articular injections of lignocaine and steroid along with combined therapeutic modalities of oral analgesics, physical therapy, manual medicine techniques and ergonomic assessments. Two case reports illustrate this condition which is probably under-recognised and inadequately addressed locally.

A 26-year-old male patient being treated with alpha-interferon for chronic hepatitis C developed psoriasis, seronegative oligoarthritis and sacroiliitis after four months. The close temporal relationship between the alpha-interferon therapy and the onset of skin and articular lesions strongly suggests that the drug played a role in the induction of the disease despite the absence of HLA antigens related to psoriatic arthritis. We cannot exclude the possibility that immunological alterations associated with HCV infection could have constituted a predisposing factor in the onset of the disease.

Study Design: This prospective study consisted of the evaluation of a double sacroiliac block in patients with low back pain., Objectives: To determine the prevalence of sacroiliac pain in a selected population of patients suffering from low back pain, and to assess certain pain provocation tests., Summary of Background Data: Previous studies have implicated the sacroliac joint as a potential etiology of back and leg pain, but none has tested double anesthetic blocks in a prospective fashion., Methods: Fifty-four patients with unilateral low back pain, pain mapping compatible with a sacroiliac origin, tenderness over the sacroiliac joint, and no obvious source of pain in the lumbar spine were selected for a double anesthetic block. The procedure consisted of a through clinical examination with a visual analog scale, testing of sacroiliac pain provocation tests followed by a first screening block with a short-acting anesthetic. A second examination consisting of the same tests assessed the efficacy of the first block. If results were positive, a confirmatory block was performed. All blocks were performed under fluoroscopic guidance., Results: Nineteen patients had a positive response to the first block. Among them, 10 (18.5%) were temporarily relieved by the confirmatory block. No pain provocation test reached statistical significance., Conclusion: The present study suggests the sacroiliac joint is an uncommon but real source of low back pain. The accuracy of some of the presumed "sacroiliac pain provocations tests" is questioned.

Objective: To evaluate computed tomography (CT) guided corticosteroid injections of inflamed sacroiliac (SI) joints in patients with spondyloarthropathies (SpA), and to evaluate dynamic magnetic resonance imaging (DMRI) of the SI joints in serial examinations of these patients, who had different degrees of inflammatory back pain., Methods: We examined and treated 30 patients with ankylosing spondylitis (n = 9) or undifferentiated SpA (n = 11) (14 women and 16 men, mean age 36.5 +/- 13.4 years, mean disease duration 5.4 +/- 4.0 years) who had severe inflammatory back pain for more than 3 months. All patients had DMRI of the SI joints before and 4-6 months after a CT guided injection of 40 mg triamcinolone acetonide into SI joints (n = 54; 24 patients received injections in both joints). Enhancement of the contrast agent gadolinium-DTPA was quantified by calculating the enhancement of the contrast agent gadolinium-DTPA was quantified by calculating the enhancement gradient Fenh. A subjective index with a visual analog scale (0 = no pain, 10 = very severe pain) was used for assessment of back pain. Followup visits were done every 3 months for a maximum of 18 months., Results: There was significant improvement of inflammatory back pain and sacroiliitis at 5.2 +/- 1.3 months after therapy in 25/30 patients (83.3%). The differences between the Fenh values before (98.2 +/ 56.1) and after (44.3 +/- 31.2) therapy and of the subjective pain index (8.5 +/- 1.5 and 3.0 +/- 2.3, respectively) were statistically significant. Subjective improvement lasted a mean of 8.9 +/- 5.3 months., Conclusion: CT guided corticosteroid injection of inflamed SI joints is a useful option in therapy for sacroiliitis in patients with SpA. Different degrees of inflammation in the SI joints can be quantitatively assessed by DMRI.

On the basis of biochemical indices the anthors assessed the efficacy of a 6-month treatment with D-penicillin in 49 patients with ankylosing arthritis of the spine who did not respond to nonsteroid antiinflammatory drugs. Improvement in the movements of the spine was observed in patients with less marked roentgenological changes.