Skeletal Radiol DOI 10.1007/s00256-014-1999-y

SCIENTIFIC ARTICLE

Pyogenic sacroiliitis: diagnosis, management and clinical outcome Tomas Kucera & Jindra Brtkova & Pavel Sponer & Lenka Ryskova & Eduard Popper & Martin Frank & Marie Kucerova

Received: 5 April 2014 / Revised: 18 August 2014 / Accepted: 28 August 2014 # ISS 2014

Abstract Objective The purpose of the present study was to evaluate the role of diagnostic tools and management options for patients with pyogenic sacroiliitis, including potential complications. Materials and methods This retrospective study included 16 patients with pyogenic sacroiliitis who were admitted to a single orthopaedic centre between 2007 and 2012. The following data were collected: demographics, history, radiography, magnetic T. Kucera (*) : P. Sponer Department of Orthopaedic Surgery, Charles University in Prague, Faculty of Medicine and University Hospital in Hradec Králové, Sokolska 581, 500 05 Hradec Kralove, Czech Republic e-mail: [email protected] T. Kucera e-mail: [email protected] J. Brtkova Department of Diagnostic Radiology, Charles University in Prague, Faculty of Medicine and University Hospital in Hradec Králové, Hradec Kralove, Czech Republic L. Ryskova Department of Clinical Microbiology, Charles University in Prague, Faculty of Medicine and University Hospital in Hradec Králové, Hradec Kralove, Czech Republic E. Popper Department of Rehabilitation, Charles University in Prague, Faculty of Medicine and University Hospital in Hradec Králové, Hradec Kralove, Czech Republic M. Frank Department of Surgery, Charles University in Prague, Faculty of Medicine and University Hospital in Hradec Králové, Hradec Kralove, Czech Republic M. Kucerova Department of Neurosurgery, Regional Hospital in Pardubice, Hradec Kralove, Czech Republic

resonance images (MRI), biological data, type of pathogenic agent, abscess formation, type of management, and clinical outcome. Results Our study demonstrated that only one-fifth of the patients with lumbogluteal or hip pain had established diagnoses of suspected pyogenic sacroiliitis upon admission. MRIs confirmed this diagnosis in all cases. MRI examinations revealed joint fluid in the sacroiliac joint and significant oedema of the adjacent bone and soft tissues. In 12 of the 16 cases, erosions of the subchondral bone were encountered. Contrast-enhanced MRI revealed that 9 patients had abscesses. All patients received antibiotic therapy. Antibiotic treatment was only successful in 9 cases. The other 7 patients underwent computed tomography (CT)-guided abscess drainage. Drainage was sufficient for 4 patients, but 3 patients required open surgery. One patient required sacroiliac arthrodesis. The clinical outcomes included minimal disability (n=10), moderate disability (n=5), and full disability (n=1) of the spine. Conclusions Contrast-enhanced MRI is mandatory for a reliable diagnosis. Abscess formation was observed in approximately half of the MRI-diagnosed sacroiliitis cases and required minimally invasive drainage under CT guidance or frequently open surgery. Keywords Pyogenic sacroiliitis . Drainage of abscesses . Arthrodesis . Contrast-enhanced MRI

Introduction Pyogenic sacroiliitis is considered to be a relatively rare condition that can affect paediatric and adult patients. According to the current literature, pyogenic sacroiliitis occurs in only 1 to 2 % of all septic arthritis cases [1]. However, the incidence of pyogenic sacroiliitis may be higher than reported owing to undiagnosed cases. This condition is typically characterised

Skeletal Radiol

by non-specific initial symptoms and non-specific physical examination findings; thus, it is difficult to differentiate pyogenic sacroiliitis from other causes of sepsis syndrome. Low awareness of the clinical presentation, lack of knowledge regarding appropriate diagnostic procedures, and a lack of appropriate management have effects on both the functional prognosis of the joint involved and the overall prognosis of the patient [2]. To avoid potentially severe complications, it is important to consider the diagnoses, management and clinical outcomes of patients with pyogenic sacroiliitis. The purpose of the present study was to evaluate the role of diagnostic tools and management options for patients with pyogenic sacroiliitis and potential complications.

Materials and methods This retrospective study included all patients with pyogenic sacroiliitis who were hospitalised between 2007 and 2012 in the orthopaedic department of our university hospital. The crucial inclusion criterion for our study was magnetic resonance imaging (MRI) findings that were compatible with the diagnosis of pyogenic sacroiliitis. To visualise the features of pyogenic sacroiliitis, MRI examinations were performed on one of two machines: a 1.5 T Avanto, or a 1.5 T Symphony (both from Siemens, Erlangen, Germany). The following MRI protocol was applied: a routine transverse T1-weighted sequence (TR 350, TE 12, SL 2.1 and FOV 400 for the Avanto, and TR 480, TE 12, SL 4 and FOV 380 for the Symphony), and a routine transverse T2-weighted sequence with fat saturation (TR 3560, TE 100, SL 3.5 and FOV 310 for the Avanto and TR 3770, TE 108, SL 4 and FOV 380 for the Symphony). For cases in which greater than minimal soft tissue involvement was observed (10 patients), a contrast-enhanced transverse T1-weighted sequence with fat saturation (TR 674, TE 12, SL 2.5 and FOV 380 for the Avanto, and TR 520, TE 20, SL 4 and FOV 380 for the Symphony with 7.5 ml or 10 ml of Gadovist (Bayer Pharma AG, Berlin, Germany) according to the weight of the patient) was added, and, when required, plain coronal images were also acquired (6 patients). A nonenhanced T1 fat-saturated sequence was not included in our diagnostic protocol. Gradient echo sequences or protondensity-weighted sequences were non-systematically used in a total of 3 patients. The patients were considered to suffer from infectious sacroiliitis when the following findings were encountered: oedema in the bone marrow and erosion of the cortical bone in the T1-weighted sequence; and joint fluid, oedema/osteitis in the bone, oedema/phlegmon in the soft tissues, and fluid collections that were regarded as potential abscesses in the T2weighted sequence with fat saturation. The T1-weighted sequence with fat saturation and contrast medium administration improved the visualisation of hyperaemia and confirmed fluid

collection by enhancing the capsule, while the fluid centres remained non-enhanced. Diagnostic computed tomography (CT) of the sacroiliac joints (2-mm slices with bone and soft tissue kernels; Somatom Emotion 6 [Siemens, Erlangen, Germany]) was performed in 3 patients. These cross-section methods of imaging were preceded by AP radiographs in all patients. Overall, 16 patients were diagnosed with pyogenic sacroiliitis based on clinical, laboratory and MRI findings; these patients included 7 men and 9 women (male:female ratio, 1:1.3) with a mean age of 43.2 years (range 13–75 years). Three patients were children aged ≤18 years. In all cases, the involvement of the sacroiliac joint was unilateral, and 63 % of patients (n=10) exhibited left side involvement. The clinical records of all 16 patients were reviewed to collect the following data for each patient: demographics (age at diagnosis and gender); time between the first clinical signs and the confirmed diagnosis of pyogenic sacroiliitis; clinical findings; intensity of pain upon admission as graded from 0 to 10 on a visual analogue scale (VAS); the presence of fever (body temperature above 38 °C); and laboratory assessments of erythrocyte sedimentation rate (ESR; N

Pyogenic sacroiliitis: diagnosis, management and clinical outcome.

The purpose of the present study was to evaluate the role of diagnostic tools and management options for patients with pyogenic sacroiliitis, includin...
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