INFORMATION REGARDING FACET JOINT ARTHROPATHY AND SI JOINT ARTHROPATHY

1. Facet & SacroIliac
Joints Arthropathy
1
Dr. Hitesh S. Patel
M.D.,FIPM
18 Oct. 2016

2. Abnormalities affects bones & joints
1. Congenital Arthropathy
2. Degenerative Arthropathy
3. Traumatic, & Occupational
4. Dietetic: Vitamin deficiency
5. Endocrine: Acromegaly,
myxedema, and
hyperparathyroidism
6. Hematological: factor VII or IX
deficiency, Leukemia
7. Infective: gonococcus, Brucella,
Rubella, virus-induced
8. Post infective Arthropathy
9. Metabolic: Amyloidosis Calcium,
10. Vascular: Avascular necrosis
11. Neoplastic:
12. Therapeutic: alcohol,
anticoagulants, corticosteroids
13. Idiopathic
British Medical Journal, 2, 210-213

3. Facet Joints Disease
3

4. LUMBAR VERTEBRAL
BODY
4
•Facet joints are lined with
smooth cartilage, and are
lubricated with synovial fluid.
.
•Healthy joints are able to glide effortlessly as the spine
performs movements, such as bending, twisting, and
turning

5. Innervation 5

6. Innervation 6
Medial branch

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

8. Diagnosis
8

9. Diagnosis depend on:
 History and Clinical features
 Medical imaging: X-rays, CAT scans, and Magnetic
Resonance Imaging (MRI) may be used to exclude
other abnormalities may help in diagnose of facet
arthropathy.
 Diagnostic injection. LA and dye are injected. If the
facet joint is injected and pain relief is the result, that
serves to confirm the diagnosis of facet arthropathy.

10. History and Clinical Features:
Low back pain is the most frequent
(Pain is generally a deep, dull ache)
The pain is typically worse following
sleep or rest morning stiffness .
In advance stage Bone spurs may develop and become in contact
with the spinal cord (spinal stenosis ) or a nerve root
(radiculopathy) leading to radiating pain to hip, buttocks, legs and
even feet.

11. Pain radiation in different types
of spinal nerve injuries
Remember that Facet joints are not in lumber only

12. Aggravated by:
 Extension (Arching backwards)
 Standing
 Repeated movements or activities.
 Prolonged sitting
Relieved by:
 Flexion
 Standing
 Walking
 Sitting
12

13. Differential Diagnoses
Sacroiliac joint syndrome
Internal disk disruption syndrome
 Spondyloarthropathy (ankylosing spondylitis, reactive
arthritis, psoriatic arthritis . . .).
 Lumbar nerve root compression.
 Hip pain.
 Endometriosis.
 Myofascial pain.
 Piriformis syndrome

14. Management
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1.Nonpharmacological
2.Pharmacological
3.Interventional

15. Managements
Nonpharmacological
(physiotherapy)
Pharmacological
•Rest
•Sleep positions recommended.
•traction
•strengthening and aerobic exercise
•water therapy
•spinal manipulation
•Paracetamol
•(NSAIDs),
•Narcotic
•Co-analgesic
•Muscle relaxants
•Corticosteroids

16. Interventional
Intra-articular injections of local
anesthetic or steroid.
Medial branch of dorsal ramus
block or ablation
Injections are indicated after a minimum of 4 weeks
of appropriate, directed conservative care has failed
to bring relief

17. 17Medial Branch of Dorsal Ramus Block

18. Facet Injection
C-arm rotation
45° L4-5,L5-S1
30° upper lumbar facet
18

19. RadioFrequency Ablation 19

20. Surgery
rarely required but options do exist
 Facet rhizotomy of the nerves going to
facet joint
 Fusion of two or more vertebrae to
eliminate movement in facet joints
(sometimes facet joints are removed during
spinal fusion)
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21. Sacroiliac Joints
21

22. 22
Sacroiliac Joint :
Large synovial joint about 1-2 mm wide
Auricular (C)-shaped on
sides of fused sacral
vertebrae
Covered with hyaline
cartilage
Thicker than iliac
cartilage
Covered with
fibrocartilage
Type II collagen,
typical of hyaline
cartilage, has
been identified

23. 1. Joint between articular surfaces on sacrum and iliac bones. (a
diarthrodial synovial joint)
 Only the anterior part is a true synovial joint.
 The posterior part is a fibrous tissue, strong ligaments
2. It is stable, rigid, very strong, reinforced by strong ligaments
and muscles surround it
3. relatively immobile (Does not have much motion2mm)
4. Transmits all the forces of the upper body to the pelvis (hips)
and legs (effective load transfer)
5. Acts as a shock-absorbing structure
Sacroiliac Joints 23

24.  Connects spine to pelvis
 Absorbs vertical forces from spine and transmitting
them to pelvis and lower extremities
24

25. Primary Ligaments: Secondary Ligaments:
a. Anterior sacroiliac a. Sacrotuberous
b. Posterior sacroiliac b. Sacrospinous
c. Interosseous
25

26. mainly by the Sacral Rami Dorsales
26Innervation
Anterior aspect of SI Joint by:
• lumbosacral plexus
Posterior aspect of SI Joint by :
• medial branches L4, L5,
• lateral branches S1, S2, S3 and S4

27. Causes SI Joint Syndrome
the prevalence of SI pain among patients with axial low back pain
varies between 16% and 30%.
Degenerative arthritis of the SI joints due to
 Trauma (direct fall on the buttocks, a motor vehicle accident,
or even a blow to the side of your pelvis).
 The excess motion can lead to wear and tear of the joint and
pain from degenerative arthritis.
Pain can also be caused by an abnormality of the sacrum bone.
During pregnancy, the SI joints can cause discomfort both from the
effects of the hormones that loosen them and from the stress of the
growing baby.

28. Risk Factor include
 leg length discrepancy,
 abnormal gait pattern,
 trauma,
 heavy physical exertion,
 pregnancy.
 scoliosis,
 lumbar and sacrum fusion surgery
28

29. Diagnosis
29

30. IASP criteria for diagnosing SI
joint pain
 Pain present in the region of the
SIJ
 +ve Clinical SI joint stress tests
(painful).
 +ve diagnostic interventional
procedure (completely relieves
the pain)
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IASP International Association for the Study of Pain

31. Pain radiation
Pain from the SI joint is generally
localized in the gluteal region (94%).
Referred pain may also be perceived in
 the lower lumbar region (72%),
 groin (14%),
 upper lumbar region (6%),
 or abdomen (2%).
 the lower limb in (28%).
 The Foot in (12%)
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32.  History
 Signs and symptoms
 Physical examination
inspection
Palpation
Special tests
 Medical imagining
X-Rays
CT scan
MRI
Accurate diagnosis 32

33. Symptoms of SI Joint Syndrome
 It is often hard to distinguish from other types of LBP; because the
pattern of back and pelvic pain that mimic each other.
In SI joint syndrome we find:
 Low back pain bilateral or unilateral in the posterior aspect of SI
joint
 Unilateral Buttock, hip or Thigh pain
 Difficulty sitting in one place for too long due to pain
 LBP with radiculopathy

34. Physical Examination and provocative
maneuvers
(clinical tests)
Solitary provocative maneuvers have little diagnostic value.
The 7 most important clinical tests which are positive when patient has typical
SI joint pain:
1. Compression test (approximation test):
2. Distraction test (gapping test):
3. Patrick’s sign (Flexion Abduction External Rotation test):
4. Gaenslen test (pelvic torsion test):
5. Thigh thrust test (posterior shear test):
6. Fortin’s finger test:
7. Gillet test:
34

35. Compression test
(approximation test):
The patient lies on his or her side with
the affected side up;
the Patient’s hips are flexed 45°, and
the knees are flexed 90°.
The examiner stands behind the
patient and places both hands on the
front side of the iliac crest and then
exerts downward, medial pressure.2.
35

36. Distraction test (ant & post gapping test)
The examiner stands on the affected side of the supine patient and
places his/her hands on the ipsilateral spinae iliacae anteriores
superiores. The examiner then applies pressure in the dorso-lateral
direction.3.
36

37. Faber’s test or Patrick’s sign
(flexion abduction external rotation test):
The patient is positioned supine with the examiner standing next to the
affected side. The tested leg flexed, abducted, and externally rotated. with
the foot positioned above the opposite knee. Downward pressure is then
applied to the knee of the affected side
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If pain is elicited on the
ipsilateral side anteriorly, it
is suggestive of a hip joint
disorder on the same side.
If pain is elicited on the
contralateral side
posteriorly around the
sacroiliac joint, it is
suggestive of pain
mediated by dysfunction in
that joint.

38. Gaenslen test
(pelvic torsion test):
The patient lies in a supine
position with the affected side on
the edge of the examination table.
The unaffected leg is flexed at
both the hip and knee, and
maximally flexed until the knee is
pushed against the abdomen. The
contralateral leg (affected side) is
brought into hyperextension, and
light pressure is applied to that
knee.
38

39. Thigh thrust test
(posterior shear test):
The patient lies in the supine
position with the unaffected leg
extended. The examiner stands
next to the affected side and
flexes the extremity at the hip to
an angle of approximately 90°
with slight adduction while
applying light pressure to the
bent knee.
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40. Fortin’s finger test:
The patient can
consistently indicate the
location of the pain with 1
finger infero-medially to the
posterior superior iliac spine
.
40

41. Gillet test:
Gillett test to estimate rotation of
the sacroiliac joints. The knee on the
right-hand side is raised as high as
possible. The ilium on that side
rotates posteriorly, which can be
established by palpation of the
posterior superior iliac spine.
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42. Investigations:
Medical imaging is indicated only to rule out so-called “red flags.”
Medical imaging includes:
 radiography,
 computed tomography (CT),
 single photon emission CT,
 bone scans, and
 nuclear imaging techniques
 Magnetic resonance imaging (MRI) does not allow evaluation
of normal anatomy. However, in the presence of
spondylarthropathy, MRI can detect inflammation and
destruction of cartilage despite normal clinical presentation
42

43. Diagnostic injection
The IASP criteria mandate that pain should disappear after intra-
articular SI joint infiltration with local anesthetic in order to
confirm the diagnosis.
Potential causes of inaccurate blocks include
 dispersal of the local anesthetic to adjacent pain-generating
structures (muscles, ligaments, nerve roots),
 the overzealous use of superficial anesthesia or sedation,
 failure to achieve infiltration throughout the entire SI joint
complex.
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44. Differential Diagnosis
 Spondyloarthropathy (ankylosing spondylitis, reactive
arthritis, psoriatic arthritis . . .).
 Lumbar nerve root compression.
 Facetogenic pain.
 Hip pain.
 Endometriosis.
 Myofascial pain.
 Piriformis syndrome
44
Ankylosing spondylitis may affect SI joint
as well

45. Treatment
45

46. Treatment Options
 Pharmacological
 Physiotherapy, and Rehabilitation
 Electrical therapy: TENS (Transcutaneous Electrical
Nerve Stimulation),
 Ultrasound therapy,
 laser therapy.
 Strengthening/stretching exercises
 Hydrotherapy
 Interventional procedures.
46

47. Interventional
Patients with SI joint pain resistant to conservative treatment are eligible
for
intra-articular injections
peri-articular infiltrations
radiofrequency (RF) ablation.
47

48. Intra-articular injections
intra-articular injections with
local anesthetic and
corticosteroids may provide
good pain relief for periods of
up to 1year.
It produces better results
than peri-articular
infiltrations.
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49. RF ablation of SI Joint 49
Single needle technique
Bipolar Technique
can increase the ablative area by minimizing the
effect of tissue charring to limit lesion expansion

50. Complications Of Interventional
 infection,
 hematoma formation,
 neural damage,
 sciatic nerve damage,
 gas and vascular particulate embolism,
 weakness secondary to extra-articular extravasation,
 complications related To drug administration,
For intra-articular injections, Maugars et al. reported only transient
perineal anesthesia lasting a few hours and mild sciatalgia (sciatica)
lasting 3weeks
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51. Thank you
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