Characteristics of the spinopelvic parameters of patients with sacroiliac joint pain.

To evaluate the characteristics of the spinopelvic parameters on radiography in patients with sacroiliac joint pain (SIJP). Two hundred fifty patients were included and divided into the SIJP group (those diagnosed with SIJP based on physical findings and response to analgesic periarticular injections; n = 53) and the non-SIJP group (those with low back pain [LBP] because of other reasons; n = 197). We compared their demographic characteristics and spinopelvic parameters using radiography. All differences found in the patients' demographic characteristics and spinopelvic parameters were analyzed. More female participants experienced SIJP than male participants (P = 0.0179). Univariate analyses revealed significant differences in pelvic incidence (PI) (P = 0.0122), sacral slope (SS) (P = 0.0034), and lumbar lordosis (LL) (P = 0.0078) between the groups. The detection powers for PI, SS, and LL were 0.71, 0.84, and 0.66, respectively. Logistic regression analyses, after adjustment for age and sex, revealed significant differences in PI (P = 0.0308) and SS (P = 0.0153) between the groups, with odds ratios of 1.03 and 1.05, respectively. More female participants experienced SIJP than male participants. Higher PI and SS values were related to SIJP among LBP patients.

Sacroiliac joint injections with the guidance of three-dimensional cone beam computed tomography (3D-CBCT) and fluoroscopy fusion.

BACKGROUND: We describe our diagnostic sacroiliac joint (SIJ) injection technique under the guidance of three-dimensional cone beam computed tomography (3D-CBCT) fused with real-time fluoroscopy. METHODS: A retrospective review of 17 patients (mean age 55.4 (range 40-74) years) who received a total of 23 diagnostic SIJ injections between March 2016 and November 2017 were performed. Pre- and post-procedure pain scores were reviewed from the medical records and then these findings were correlated with which patients were and were not diagnosed with SIJ pain by clinical management. The final diagnosis of SIJ-related pain was made in cases with at least 50% symptomatic improvement following SIJ-specific pain treatments. RESULTS: Some 87% (n=20/23) of injections achieved more than 50% pain relief after the diagnostic SIJ injection. The final diagnosis of the target SIJ-related pain after follow-up and management was found in 90% (n=18/20) of cases. There were two cases with positive tests diagnosed as non-SIJ pain including one with the diagnosis of femuroacetabular impingement and one with pain related to loosening of knee hardware. The sensitivity, specificity, positive predictive value, and negative predicative value of diagnostic SIJ injections were 100%, 60%, 89%, and 100%, respectively, with a 40% false-positive rate. There were no procedure-related complications. CONCLUSION: 3D-CBCT fused with real-time fluoroscopy for SIJ injection is accurate and safe.

Image guided sacroiliac joint corticosteroid injections in children: an 18-year single-center retrospective study.

BACKGROUND: Sacroiliitis is commonly seen in enthesitis-related arthritis (ERA), a subtype of juvenile idiopathic arthritis (JIA). Sacroiliitis is characterized by the inflammation of the sacroiliac (SI) joints (+/- adjacent tissues). The treatment options include systemic therapy with or without corticosteroid SI joint injections. Image guided SI joint injections are frequently requested in pediatric patients with sacroiliitis. The purpose of this study was to evaluate the feasibility and efficacy of SI joint injections in children with sacroiliitis. METHODS: A retrospective study of patients referred to Interventional Radiology (IR) for SI joint corticosteroid injections (2000-2018). Clinical information was collected from Electronic Patient Charts and procedural details from PACS. Efficacy was determined clinically, by MRI, or both when available. RESULTS: 50 patients (13.8 years; M:F = 35:15) underwent image-guided SI joint corticosteroid injections. Most common indications were JIA (84%) and inflammatory bowel disease (14%). 80% had bilateral injections. 80% were performed under general anesthesia and 20% under sedation. The corticosteroid of choice was triamcinolone hexacetonide in 98% of patients. Needle guidance and confirmation was performed using CT and fluoroscopy (54%), Cone Beam CT (CBCT, 46%), with initial ultrasound assistance in 34%. All procedures were technically successful without any complications. 32/50 patients had long-term follow-up (2 years); 21/32 (66%) had clinical improvement within 3-months. Of 15 patients who had both pre- and post-procedure MRIs, 93% showed short-term improvement. At 2 years, 6% of patients were in remission, 44% continued the same treatment and 47% escalated treatment. CONCLUSION: Image-guided SI joint injections are safe and technically feasible in children. Imaging modalities for guidance have evolved, with CBCT being the current first choice. Most patients showed short-term clinical and imaging improvement, requiring long-term maintenance or escalation of medical treatment.

Clinical application of diffusion-weighted imaging and dynamic contrast-enhanced MRI in assessing the clinical curative effect of early ankylosing spondylitis.

The study aimed to demonstrate the clinical application value of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in assessing a clinical curative effect of early ankylosing spondylitis (AS).Forty-eight patients with early AS who were already treated combinations by traditional Chinese and Western medicine were involved in this study. All subjects underwent the conventional MRI, DWI, and DCE-MRI scanning of bilateral sacroiliac joints before and after treatment. The relevant data, such as the mean apparent diffusion coefficient (ADC) value, time-intensity curve of subarticular surface bone marrow, and the relationship between ADC value and enhancement factor (Fenh), enhancement slope (Senh), and time to peak (TTP), were obtained.1. The mean ADC value of the subarticular surface bone marrow of patients and after clinical treatment was (5.05 ±â€Š1.10) × 10 and (4.34 ±â€Š0.55) × 10 mm/s in ilium and (4.63 ±â€Š0.79) × 10 and (3.96 ±â€Š0.23) × 10 mm/s in sacrum, respectively. 2. In the DCE-MRI follow-up treatment imaging of 48 patients with AS (192 parts), the TIC curve type recorded was as follows: 43.75% (84/192) of type II, 56.25% (108/192) of type III, and type I curve was not seen. The number of type II curve was significantly reduced for pre treatment group (84 cases) compared with that post treatment group (124 cases). The Fenh, Senh, and TTP values were respective (113.38 ±â€Š44.71)%, (60.94 ±â€Š38.56)% min, (129.52 ±â€Š42.66) s in ilium and (83.03 ±â€Š20.39)%, (44.91 ±â€Š15.19)% min, (123.44 ±â€Š28.50) s in sacrum before clinical treatment. After the treatment, the Fenh, Senh, and TTP values were respective (75.90 ±â€Š17.97)%, (33.96 ±â€Š11.36)% min, (138.67 ±â€Š26.60) s in ilium and (73.28 ±â€Š15.67)%, (31.92 ±â€Š8.15)% min, (140.19 ±â€Š19.88) s in sacrum. The Fenh, Senh, and TTP values of semiquantitative indexes before and after clinical treatment were significantly different.DWI and DCE-MRI sequences can help evaluate the degree of active changes in AS inflammation and treatment effect in patients with early AS, and provide reliable imaging evidence.

Fluoroscopically Guided vs Landmark-Guided Sacroiliac Joint Injections: A Randomized Controlled Study.

OBJECTIVES: To determine the prevalence of intra- and extra-articular sacroiliac joint (SIJ) pain, which injection is more beneficial, and whether fluoroscopy improves outcomes. PATIENTS AND METHODS: This patient- and evaluator-blinded comparative effectiveness study randomized 125 participants with SIJ pain from April 30, 2014, through December 12, 2017, to receive fluoroscopically guided injections into the joint capsule (group 1) or "blind" injections to the point of maximum tenderness using sham radiographs (group 2). The primary outcome was average pain on a 0 to 10 scale 1 month after injection. A positive outcome was defined as at least a 2-point decrease in average pain score coupled with positive (>3) satisfaction on a Likert scale from 1 to 5. RESULTS: For the primary outcome, no significant differences were observed between groups (mean ± SD change from baseline, -2.3±2.4 points in group 1 vs -1.7±2.3 points in group 2; 95% CI, -0.33 to 1.36 points for adjusted difference; P=.23), nor was there a difference in the proportions of positive blocks (61% vs 62%) or 1-month categorical outcome (48% vs 40% in groups 1 and 2, respectively; P=.33). At 3 months, the mean ± SD reductions in average pain (-1.8±2.1 vs -0.9 ± 2.0 points; 95% CI, 0.11 to 1.58 points for adjusted difference; P=.02) and worst pain (-2.2±2.5 vs -1.4±2.0 points; 95% CI, 0.01 to 1.66 points for adjusted difference; P=.049) were greater in group 1 than 2, with other outcome differences falling shy of statistical significance. CONCLUSION: Although fluoroscopically guided injections provide greater intermediate-term benefit in some patients, these differences are modest and accompanied by large cost differences. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02096653.

Evaluation of disease chronicity by bone marrow fat fraction using sacroiliac joint magnetic resonance imaging in patients with spondyloarthritis: A retrospective study.

AIM: This study investigated the use of fat fraction (FF) measurements in the sacroiliac (SI) joint to determine radiologic progression in patients with spondyloarthritis (SpA). METHOD: A total of 138 patients who underwent pelvic magnetic resonance imaging (MRI) between September 2014 and March 2015 were retrospectively evaluated. The FF based upon fat deposition (%) using fat signaling on T1 and T2 weighted images in the sacroiliac joint was quantified using a 6-echo variant of the modified Dixon technique. We defined the normal bone marrow as normal FF, bone marrow edema as active inflammatory FF, and fat metaplasia as post-inflammatory FF. RESULTS: The mean FF of normal marrow was 52.0% ± 10.4% and 50.5% ± 10.1% in the left and right SI joints, respectively. The mean FF of post-inflammatory fat deposition was 81.9% ± 9.7% and 82.3% ± 9.6% in the left and right SI joints, respectively. The mean FF of active inflammatory fat deposition was 15.8% ± 5.9% and 13.5% ± 6.7% in the left and right SI joints, respectively. In multiple linear regression, post-inflammatory FF was found to be significantly associated with radiologic progression, such as symptom duration, SI joint grade, and modified Stoke Ankylosing Spondylitis Spine Score. CONCLUSION: Post-inflammatory FF indicates the chronicity of SpA. Evaluating FF using MRI in the SI joint will help to determine radiologic progression.

Secukinumab: A Review in Ankylosing Spondylitis.

Secukinumab (Cosentyx®), a first-in-class fully human monoclonal antibody against interleukin-17A, is approved in several countries, including the USA and those of the EU, for the treatment of ankylosing spondylitis (AS). Subcutaneous secukinumab significantly improved the clinical signs and symptoms of AS versus placebo in three of four phase III trials. The benefits of secukinumab were generally seen regardless of whether patients had or had not received previous tumour necrosis factor (TNF) inhibitor therapy, and were sustained during longer-term (up to 5 years) treatment. Secukinumab was also associated with improvements in spinal mobility, physical function, health-related quality of life and work productivity in some of the trials. In MEASURE 1, secukinumab reduced inflammation in the sacroiliac joint, and slowed radiographic progression. Secukinumab was generally well tolerated during up to 5 years' treatment; the most commonly reported adverse event was nasopharyngitis. In the minority of patients who developed anti-drug antibodies (ADAs), ADAs did not decrease efficacy or increase adverse events. In conclusion, secukinumab is an effective therapy for TNF inhibitor-naive patients with active AS, and provides a useful treatment option for patients who have an inadequate response to or are intolerant of TNF inhibitors.

Comparison of Efficacy of Lateral Branch Pulsed Radiofrequency Denervation and Intraarticular Depot Methylprednisolone Injection for Sacroiliac Joint Pain.

BACKGROUND: Sacroiliac joint dysfunctional pain has always been an enigma to the pain physician, whether it be the diagnosis or the treatment. Diagnostic blocks are the gold standard way to diagnose this condition. Radiofrequency neurotomy of the nerves supplying the sacroiliac joint has shown equivocal results due to anatomical variation. Intraarticular depo-steroid injection is a traditional approach to treating sacroiliac joint pain. For long-term pain relief, however, lesioning the sacral lateral branches may be a better approach. OBJECTIVE: This study compared the efficacy of intraarticular depo-methylprednisolone injection to that of pulsed radiofrequency ablation for sacroiliac joint pain. STUDY DESIGN: This study used a randomized, prospective design. SETTING: Thirty patients with diagnostic block-confirmed sacroiliac joint dysfunctional pain were randomly assigned to 2 groups. One group received intraarticular methylprednisolone and another group underwent pulsed radiofrequency of the L4 medial branch, the L5 dorsal rami, and the lateral sacral branches. RESULTS: Reduction in Numeric Rating Scale (NRS) for pain at 1 month post-procedure remained similar in Group A, while in Group B few patients reported a further decrease in the NRS score (3.333 ± 0.4880 and 2.933 ± 0.5936, respectively). At 3 months post-procedure, the NRS score began to rise in most patients in group A, while in Group B, the NRS score remained the same since the last visit (4.400 ± 0.9856 and 3.067 ± 0.8837, respectively). At 6 months post-procedure, the NRS score began to rise further in most patients in group A. In Group B, the NRS score remained the same in most of the patients since the last visit (5.400 ± 1.549 and 3.200 ± 1.207). There was a marked difference between the 2 groups in Oswestry Disability Index (ODI) scores at 3 months post-procedure (Group A, 12.133 ± 4.486 vs Group B, 9.133 ± 3.523) and at 6 months post-procedure there was a significant (P = 0.0017) difference in ODI scores between Group A and Group B (13.067 ± 4.284 and 8.000 ± 3.703, respectively). Global Perceived Effect (GPE) was assessed in both groups at 3 months post-procedure Only 33.3% (Confidence Interval (CI) of 11.8- 61.6 ) of patients in Group A had positive GPE responses whereas in Group B, 86.67% (CI of 59.5- 98.3 ) of patients had positive GPE responses. At 6 months post-procedure, the proportion of patients with positive GPE declined further in Group A, while in Group B, positive GPE responses remained the same (20% with a CI of 4.30- 48.10 and 86.67% with a CI of 59.5- 98.3, respectively ). LIMITATIONS: Small sample size. CONCLUSION: This comparative study shows that pulsed radiofrequency denervation of the L4 and L5 primary dorsal rami and S1-3 lateral branches provide significant pain relief and functional improvement in patients with sacroiliac joint pain. KEY WORDS: Low back pain, sacroiliac joint dysfunctional pain, radiofrequency, intraarticular injection.

Severe systemic inflammatory response syndrome immediately after spinal surgery in a patient with axial gout.

We report a 55-year-old man with gouty arthritis who developed a 3-month history of low back pain, gradual lower extremities weakness and urinary incontinence. Lumbar MRI showed an exophytic lesion at L3-L4. Immediately after spinal decompression surgery, he developed fever, disorientation, polyarthritis, acute kidney injury and leucocytosis. He was treated with multiple antimicrobial agents for presumed spinal abscess but did not improve. Multiple body site cultures were negative. Aspiration of the sacroiliac joint revealed the presence of monosodium uric acid crystals. A diagnosis of acute gout was done, and he was treated with high-dose intravenous methylprednisolone and colchicine. Within 48 hours, he had a remarkable clinical improvement. At discharge, neurological and laboratory abnormalities had resolved. Awareness of risk factors for axial gout and a high degree of suspicion are important to establish a prompt diagnosis and treatment to prevent severe complications as seen in this case.

Association Between Inflammatory Back Pain Characteristics and Magnetic Resonance Imaging Findings in the Spine and Sacroiliac Joints.

OBJECTIVE: To investigate the association between magnetic resonance imaging (MRI) findings at the sacroiliac (SI) joints and vertebral endplates and pain characteristics assumed to be indicative of axial inflammation. METHODS: Patients ages 18-40 years with persistent low back pain referred to an outpatient spine clinic participated, including an unknown proportion of axial spondyloarthritis patients. Data included MRI of the spine and SI joints and self-reported responses to questions covering the Calin, Berlin, Assessment of Spondyloarthritis International Society, and Bailly inflammatory back pain (IBP) definitions. RESULTS: In the 1,020 included patients, 53% were women, and the median age was 33 years. Positive associations were found between the SI joint MRI findings and pain characteristics, odds ratios ranging from 1.4 to 2.7. SI joint bone marrow edema (BME) was associated with morning stiffness >60 minutes, and SI joint erosions with the Calin, Berlin, and Bailly IBP definitions, alternating buttock pain, and good response to nonsteroidal antiinflammatory drugs. SI joint fatty marrow deposition (FMD) was associated with insidious onset, and SI joint sclerosis with pain at night. In addition, the spinal MRI changes were associated with IBP, odds ratios ranging from 1.4 to 2.0; vertebral endplate BME was associated with morning stiffness, and vertebral endplate FMD with the Calin and Bailly IBP definitions, improvement with exercise, morning stiffness >30 minutes, and pain worst in the morning. CONCLUSION: The identified associations between inflammatory MRI findings and pain characteristics indicate that axial inflammation to some degree induces a specific pain pattern. Thus, the results add to knowledge of axial inflammatory processes. However, all identified associations were weak, which compromises the use of IBP as a marker of axial inflammation.

Fluoroscopic-guided sacroiliac, joint injections for treatment of chronic axial low back pain in a tertiary Hospital in Nigeria: a preliminary study.

BACKGROUND: The injection of mixture of plain bupivacaine and triamcinolone acetonide into the sacroiliac joint (SIJ) to relieve chronic low back pain is uncommon in the West African sub-region. The objective of this study was to demonstrate the efficacy or otherwise of fluoroscopic-guided SI joint injection in the management of chronic axial low back pain in Nigeria. DESIGN: This was a prospective observational interventional study. SETTING: The study was carried out at a tertiary hospital in Nigeria. PARTICIPANTS: Twenty-six patients with SI joint pain, based on IASP diagnostic criteria, who presented to our unit over 36 months from March 2012 to March 2015 and. INTERVENTIONS: Fluoroscopic-guided injections of 5mls mixture of bupivacaine and triamcinolone acetonide into the sacro-iliac (SI) joints of 26 patients with SI joint pain out of 116 patients who were offered different interventions for chronic low back pain. The patients were followed up for year and pain intensity and functional status were assessed at 3-, 6- and 12 months post-intervention. MAIN OUTCOME MEASURES: Pain relief and functional improvement were the main outcome measures. RESULTS: The mean numeric rating score (NRS) and Oswestry Disability index (ODI) score in 14 (53.9%) patients at 12 months post-interventions were significantly lower compared with baseline values; 3.19 ± 1.10 vs 8.54 ±1.14 p=0.000 and 25.35 ± 5.40 vs 37.54 ±8.41, p=0.000 respectively. CONCLUSION: Fluoroscopic-guided steroid injection into the SI joint resulted into reduction in pain intensity and improved physical function in the majority of patients with SI joint pain. FUNDING: Not declared.

MRI evidence of structural changes in the sacroiliac joints of patients with non-radiographic axial spondyloarthritis even in the absence of MRI inflammation.

BACKGROUND: Studies have shown that structural lesions may be present in patients with non-radiographic axial spondyloarthritis (nr-axSpA). However, the relevance of structural lesions in these patients is unclear, particularly without signs of inflammation on magnetic resonance imaging (MRI). We assessed the presence of structural lesions at baseline on MRI in the sacroiliac joints (SIJ) of patients with nr-axSpA with and without SIJ inflammation on MRI. METHODS: Bone marrow edema (BME) was assessed on short tau inversion recovery (STIR) scans from 185 patients with nr-axSpA, by two independent readers at baseline using the Spondyloarthritis Research Consortium of Canada (SPARCC) score. Structural lesions were evaluated on T1 weighted spin echo scans, with readers blinded to STIR scans, using the SPARCC MRI SIJ structural score. Disease characteristics and structural lesions were compared in patients with SIJ BME (score ≥2) and without SIJ BME (score <2). RESULTS: Both SIJ BME and structural lesions scores were available for 183 patients; 128/183 (69.9%) patients had SIJ BME scores ≥2 and 55/183 (30.1%) had scores <2. Frequencies of MRI structural lesions in patients with vs without SIJ BME were: erosions (45.3% vs 10.9%, P < 0.001), backfill (20.3% vs 0%, P < 0.001), fat metaplasia (10.9% vs 1.8%, P = 0.04), and ankylosis (2.3% vs 1.8%, P = ns). Significantly more patients with both SIJ BME and structural lesions were male and/or HLA-B27 positive than patients with only SIJ BME. Mean (SD) spinal scores (23 discovertebral units) were significantly higher in patients with SIJ structural lesions than without: 6.5 (11.5) vs 3.3 (5.1), respectively, P = 0.01. CONCLUSIONS: In patients with nr-axSpA, SIJ structural lesions, particularly erosions, may be present on MRI when radiographs are normal or inconclusive, even in patients negative for MRI SIJ inflammation. They may reflect more severe disease with greater spinal inflammation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01258738 . Registered on 9 December 2010.

The effect of intra-articular stimulation by pulsed radiofrequency on chronic sacroiliac joint pain refractory to intra-articular corticosteroid injection: A retrospective study.

We investigated the degree of pain reduction following intra-articular (IA) pulsed radiofrequency (PRF) stimulation of the sacroiliac joint (SIJ) in patients with chronic SIJ pain that had not responded to IA corticosteroid injection. Twenty patients were recruited. Clinical outcomes after applying PRF stimulation of the SIJ were evaluated by a numeric rating scale (NRS) and a 7-point Likert scale. The NRS scores significantly changed over time. The NRS scores at 1, 2, and 3 months after PRF were significantly lower than those before PRF. However, 4 of the 20 patients (20%) reported successful pain relief (pain relief of ≥ 50%) and were satisfied with the PRF stimulation at 3 months after treatment. IA PRF stimulation of the SIJ was not successful in most patients (80% of all patients). Based on our results, we cannot recommend this procedure to patients with chronic SIJ pain that was unresponsive to IA SIJ corticosteroid injection. Further studies on the effective mode of PRF stimulation and appropriate patient group, and studies on pain conditions that are most responsive to PRF are needed in the future.

Leg symptoms associated with sacroiliac joint disorder and related pain.

OBJECTIVE: The symptoms of sacroiliac joint (SIJ) disorders are usually detected in the buttock and groin, and occasionally referred to the thigh and leg. However, lumbar disorders also cause symptoms in these same body regions. The presence of a characteristic, symptomatic pattern in the legs would be useful for diagnosing SIJ disorders. This study aimed to identify specific leg symptoms in patients with SIJ pain originating from the posterior sacroiliac ligament and determine the rate of occurrence of these symptoms. PATIENTS AND METHODS: The source population consisted of 365 consecutive patients from February 2005 to December 2007. One hundred patients were diagnosed with SIJ pain by a periarticular SIJ injection (42 males and 58 females, average age 46 years, age range, 18-75 years). A leg symptom map was made by subtracting the symptoms after a periarticular SIJ injection from the initial symptoms, and evaluating the rate of each individual symptom by area. RESULTS: Ninety-four patients reported pain at or around the posterior-superior iliac spine (PSIS). Leg symptoms comprised pain and a numbness/tingling sensation; ≥60% of the patients had these symptoms. Pain was mainly detected in the back, buttock, groin, and thigh areas, while numbness/tingling was mainly detected in the lateral to posterior thigh and back of the calf. CONCLUSIONS: Leg symptoms associated with SIJ pain originating from the posterior sacroiliac ligament include both pain and numbness, which do not usually correspond to the dermatome. These leg symptoms in addition to pain around the PSIS may indicate SIJ disorders.

A Randomized Comparison Between Ultrasound- and Fluoroscopy-Guided Sacral Lateral Branch Blocks.

BACKGROUND AND OBJECTIVES: This randomized trial compared ultrasound (US)- and fluoroscopy-guided sacral lateral branch (SLB) blocks. We hypothesized that US would require a shorter performance time. METHODS: Forty patients who required unilateral sacral lateral branch blocks for chronic low back pain were randomized to US or fluoroscopy guidance. Before the performance of the assigned block, an investigator who was not involved in patient care carried out baseline analgesic testing. With US, the dorsal sacroiliac ligament, the sacroiliac joint, and the interosseous ligament were probed with a 22-gauge block needle. The patient was asked to rate the level of discomfort using an 11-point numerical rating scale.After the analgesic test, attending anesthesiologists or supervised trainees carried out the SLB blocks. The local anesthetic agent (lidocaine 2%) was identical in all subjects. In the US group, local anesthetic (1.5 mL) was first injected on the lateral crest at the mid-point between S2 and S3. Subsequently, 2 more injections of 0.5 mL were carried out on the lateral crest, immediately cephalad to S2 and at the S1 level. In the fluoroscopy group, SLB blocks were performed according to a previously described 17-injection technique, which involves 9 skin entry sites and the targeting of the L5 posterior root and S1-S3 sacral lateral branches. A 0.4-mL volume of local anesthetic was deposited at each target point. The performance time, number of needle passes, and the incidence of vascular breach were recorded during the performance of the block.Twenty minutes after the end of local anesthetic injection, the same investigator who performed preblock analgesic testing carried out postblock testing in an identical manner. RESULTS: Compared with fluoroscopy, the US technique was associated with a shorter performance time (267.5 ± 99.3 vs 628.7 ± 120.3 seconds; P < 0.001), fewer needle passes and a lower incidence of vascular breach (0 vs 10 occurrences; P = 0.001). However, the block effect (ie, the proportional decrease in numerical rating scale between preblock and postblock analgesic testing) was similar in both groups. Furthermore, no statistical differences were found in the proportions of patients achieving complete analgesia at each test site. The level of experience (ie, expert vs novice operator) significantly affected performance time with US but not with fluoroscopy. No procedural complications were recorded with either imaging modality during the 30-day follow-up period. CONCLUSIONS: Compared with their fluoroscopic counterparts, US-guided SLB blocks require a shorter performance time as well as fewer needle passes and carry a lower risk of vascular breach.

A New Sacroiliac Joint Injection Technique and Its Short-Term Effect on Chronic Sacroiliac Region Pain.

OBJECTIVES: Sacroiliac joint (SIJ) injections have been used to provide short-term relief of SIJ pain. In this study, the authors investigated a new technique using a superior approach. METHODS: Twenty four patients with chronic SI joint paint were recruited. Each patient was treated with a single SIJ intra-articular injection plus a periarticular injection of local anesthetic and corticosteroid in one procedure. Technical accuracy of the intra-articular procedure was determined by having 2 independent observers review and rate the quality of arthrograms obtained. Treatment effects were evaluated using a numerical rating scale, the Oswestry disability index (ODI) and global perceived effect (GPE). RESULTS: Both independent observers agreed that satisfactory arthrograms were obtained in all patients. Pain scores and disability were significantly reduced at 2 weeks and 4 weeks after treatment. Nineteen patients (79%) reported satisfaction with treatment. No serious adverse effects were encountered. CONCLUSIONS: The superior approach consistently achieves good access to the SI joint, and achieves outcomes that are compatible with those of other techniques. The superior approach constitutes an alternative to other techniques for injections into the SI joint.

Efficacy, safety and cost per responder of biologics in the treatment of non-radiographic axial spondyloarthritis.

Anti-tumour necrosis factor (TNF) agents are recommended as second-line therapy for patients with axial spondyloarthropathies. This analysis reviewed data on studies investigating the efficacy and tolerability of anti-TNF agents in patients with non-radiographic axial spondyloarthritis (nr-axSpA) who had failed first-line non-steroidal anti-inflammatory (NSAID) treatment. Efficacy data from RCTs were used to calculate the number needed to treat (NNT) for individual anti-TNFs and then the cost per responder was determined to provide an indication of the value of each therapy. A systematic literature review and analysis of search results over the period January 2008 to September 2014 identified four randomised placebo-controlled trials that were included in the analysis. Adalimumab, etanercept and certolizumab pegol were all effective and well tolerated in patients with nr-axSpA. A patient was more likely to reach ASAS20 or ASAS40 when treated with etanercept or adalimumab, the NNT was lowest for adalimumab, and the risk of adverse events was higher with certolizumab pegol 200 mg every 2 weeks. The cost per responder (NNT) was lowest for adalimumab, followed closely by certolizumab 400 mg every 4 weeks, intermediate for certolizumab 200 mg every 2 weeks and highest for etanercept. Although all anti-TNF agents were associated with clinical improvement in patients with nr-axSpA, adalimumab presented a better cost per responder than etanercept and certolizumab pegol.

Secukinumab: A Review in Ankylosing Spondylitis.

Secukinumab (Cosentyx(®)) is a fully human monoclonal antibody against the proinflammatory cytokine interleukin-17A. It is the first drug in its class to be approved for use in patients with active ankylosing spondylitis (AS). This article reviews the efficacy and tolerability of secukinumab in this indication and briefly summarizes its pharmacology. In ongoing phase III trials, 16 weeks' treatment with subcutaneous secukinumab 150 mg was effective in terms of improving the clinical signs and symptoms of disease and health-related quality of life in patients with AS, with these improvements maintained during longer-term (up to 2 years) treatment. In subgroup analyses, secukinumab was effective both in tumour necrosis factor (TNF) inhibitor-naïve patients and in patients intolerant of or refractory to TNF inhibitors. Secukinumab was generally well tolerated, with a tolerability profile consistent with that seen previously in patients with plaque psoriasis. In the absence of head-to-head trials, the position of secukinumab with respect to TNF inhibitors remains to be fully determined. Nevertheless, secukinumab is an effective and generally well tolerated treatment option for patients with AS.

The Best-Laid Plans of "Back Mice" and Men: A Case Report and Literature Review of Episacroiliac Lipoma.

BACKGROUND: Back mice, or episacroiliac lipoma, represent a potentially treatable cause of low back pain that may be under-recognized in clinical practice. Despite being well characterized based on clinical history and physical examination findings, implementation of appropriate treatment may be delayed or missed based on a lack of familiarity with the diagnosis. OBJECTIVES: In this case report and literature review, we describe a 47-year-old woman with history of persistent low back pain who presented with a pain exacerbation consistent with a back mouse. The history, epidemiology, clinical characteristics, differential diagnosis, potential mechanisms for pain, and treatment options for back mice were then reviewed. STUDY DESIGN: Case report and literature review. SETTING: Academic university-based pain management center. RESULTS: Studies included one randomized clinical trial, 4 cross-sectional studies, 8 case reports or series, and 16 other publications prior to 1967. LIMITATIONS: A single case report. CONCLUSIONS: Firm, rubbery, mobile nodules that are located in characteristic regions of the sacroiliac, posterior superior iliac, and the lumbar paraspinal regions may represent fatty tissue that has herniated through fascial layers. When painful, these back mice may be confused with other causes of low back pain. In particular, the presence of point tenderness may mimic myofascial pain, and reports of radicular pain may imitate herniated nucleus pulposus. However, back mice may be distinguished from other entities based on findings from the history and physical examination such as absence of neurological deficit. Treatment consisting of injection of local anesthetic into the nodule with or without corticosteroid followed by repeated, direct needling has been reported to relieve pain in many case reports. The one clinical trial comparing injection of local anesthetic to normal saline, which did not include repeated needling, found only mild and transient benefit in the treatment group.