ArticlePDF Available

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

Authors:

Abstract and Figures

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.
This content is subject to copyright. Terms and conditions apply.
R E S E A R C H A R T I C L E Open Access
Image guided sacroiliac joint corticosteroid
injections in children: an 18-year single-
center retrospective study
Racha Chamlati
1
, Bairbre Connolly
1
, Ronald Laxer
2
, Jennifer Stimec
3
, Jyoti Panwar
3
, Shirley Tse
2
,
Prakash Muthusami
1
, Joao Amaral
1
, Michael Temple
1
and Dimitri A. Parra
1*
Abstract
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 (20002018). 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.
Keywords: Sacroiliac joints, Corticosteroid injections, Juvenile idiopathic arthritis, Children
Background
Juvenile idiopathic arthritis (JIA) is the most common
pediatric rheumatic disease and cause of arthritis in chil-
dren, with an incidence of 1 to 22 in 100,000 and a
prevalence of 7 to 150 in 100,000 [1]. JIA is defined as
persistent arthritis for at least 6 weeks, presenting before
16 years of age, of unknown etiology after excluding
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: dimitri.parra@sickkids.ca
1
Division of Image Guided Therapy, Department of Diagnostic Imaging, The
Hospital for Sick Children, University of Toronto, 555 University Avenue,
Toronto, ON M5G 1X8, Canada
Full list of author information is available at the end of the article
Chamlati et al. Pediatric Rheumatology (2020) 18:52
https://doi.org/10.1186/s12969-020-00435-8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
other causes [2]. The International League of Associ-
ation for Rheumatology (ILAR) classifies JIA into seven
subtypes: systemic arthritis, oligoarthritis (persistent and
extended), polyarthritis rheumatoid factor negative, poly-
arthritis rheumatoid factor positive, enthesitis-related
arthritis (ERA), psoriatic arthritis, and undifferentiated
arthritis [3,4]. An important goal in JIA is early recogni-
tion and management to achieve inactive disease, main-
tain remission, and prevent irreversible joint damage
and deformities [2].
Sacroiliitis can be seen in JIA, especially ERA, and is
characterized by the inflammation of the sacroiliac joint
and adjacent tissues. Sacroiliitis is a common feature of
spondyloarthritis (SpA) with incidences that range from
20% in SpA related to inflammatory bowel disease, to
100% in ankylosing spondylitis [5]. Although frequently
asymptomatic, sacroiliitis can present as lower back or
buttock pain aggravated with movements, such as rising
to stand, walking, running, and climbing. If untreated, it
may lead to fusion of the SI joints. Sacroiliitis should be
suspected if there is a history of inflammatory back pain
or demonstration of positive SI provocation tests [6]. MRI
is considered the gold standard for imaging of SI joints
with a high sensitivity and specificity compared to plain
radiography and bone scanning respectively [7,8]. It dem-
onstrates early features of inflammation and effusion, as
well as chronic changes such as sclerosis, erosions, anky-
losis and bone marrow changes. Although plain radiog-
raphy can still be accepted if patients fulfill the New York
criteria for sacroiliitis [7,8], it can lead to a delay in diag-
nosis as x-rays are often normal at disease onset [9].
Multiple medications are used to treat patients with JIA,
specifically those with ERA, including nonsteroidal Anti-
Inflammatory Drugs (NSAIDs), Disease-Modifying Anti-
rheumatic Drugs (DMARDs), corticosteroids and biologic
agents including anti-tumor necrosis factor-alpha (anti-
TNFα) inhibitors [10]. There are insufficient comparison
studies on the efficacy of different treatment plans for the
management of sacroiliitis in the pediatric population.
NSAIDs are found to be effective in the short term, for
direct symptomatic relief and are particularly effective for
enthesitis in children [11]. Continuous use of NSAIDs in
adults has been shown to achieve improvement radio-
logically, and to slow disease progression, however, their
efficacy has not been determined in children [11]. An
emerging trend is the use of anti-TNFαinhibitors, specif-
ically etanercept, adalimumab and infliximab. They have
shown exceptional clinical results and can be used as first
line treatment for JIA patients with axial involvement [11].
Precautions with anti-TNFαinhibitors are required given
the associated risk of infections, hypersensitivity reactions,
psoriasis, demyelination and malignancy [11].
Another therapeutic option for arthritis in children is
intra-articular (IA) corticosteroid injections, providing
rapid improvement and with minimal systemic risks in
comparison with systemic corticosteroids [12]. Potential
risks of IA injections include infection, bleeding, skin at-
rophy, hypopigmentation, chemical irritation and cal-
cium deposits and focal demineralization [12]. IA
injections are often used in conjunction with systemic
therapy at presentation or during the course of treat-
ment. Corticosteroid injections (IA and tendon sheath)
are performed by many paediatric interventional radi-
ology (IR) practices using image guidance [2]. Image
guided SI joint injections have been performed in our
center for more than 15 years. In the context of new sys-
temic therapies, the current role of IA injections in the
treatment of pediatric patients with sacroiliitis is still to
be determined. The aim of this retrospective study was
to review the feasibility and efficacy of image guided cor-
ticosteroid SI joint injections in children.
Methods
Research Ethics Board approval was obtained. This
retrospective study was conducted at a pediatric tertiary
care hospital. The study population included patients re-
ferred to IR for SI corticosteroid joint injections (Jan
2000 Jan 2018). Patient demographics and clinical his-
tories were collected from the Electronic Patient Charts
(EPC). Procedural details and imaging were collected
from Picture Archiving and Communication System
(PACS, GE Milwaukee, USA).
Technique
Referral for SI joint injections were done by the rheuma-
tology team. Sacroiliitis was diagnosis based on clinical
symptoms, associated with consistent findings in MRI.
Sedation or anesthetics were given based on patient
preferences and cooperation, which was assessed by the
nurse or anesthesiologist, as well as procedure details
(e.g. number of concomitant joint injections). A staff
pediatric interventionalist performed the procedures
under image guidance. The interventional radiologist
performing the injection obtained informed consent.
Procedures were performed with the patient in the
prone position and using a sterile technique. Needle
guidance and positioning within the joint was performed
and confirmed with CT fluoroscopy, or Cone Beam CT
(available since 2010), depending on availability and/or
radiologist preference (Fig. 1). Cone beam CT is a mo-
dality in which cross sectional images are generated
from a flat panel C arm in the interventional radiology
room. The images generated have a similar quality to
conventional CT and allow procedure guidance with less
radiation exposure. Ultrasound (US) was occasionally
used, according to radiologist preference as well. The
needle was placed in the lower third of the SI joint. The
corticosteroid was prescribed by the rheumatology team
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 2 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
based on the patients body weight. Triamcinolone hexa-
cetonide was used in most cases and the doses are as fol-
low: 10 to 20 Kg: 20 mg; more than 20 to 40 Kg: 30 mg;
more than 40 Kg: 40 mg. In the case of triamcinolone
acetonide the doses are 40, 60 and 80 mg respectively.
The corticosteroid injection was followed by a similar
volume of lidocaine 1%. Most of the time, no contrast
was used due to the small joint space. A sterile dressing
was applied to the skin. The referring rheumatologist
was informed of the outcome of the procedure. Post-
procedure, the patients were transferred to the post
anesthesia care unit (PACU) and discharged home 2
hours later.
The efficacy of the SI corticosteroid injection was
assessed both clinically and by MR imaging. Patients
with incomplete data and those with IBD were excluded
for this assessment. Medical records were reviewed for
peri- and post-procedural complications. Clinical out-
comes were based on the information available in clin-
ical notes and assessed at two time periods, within 3
months (short term) and 2 years post injection (long
term). Short term response was classified as Good or
Poor; patients rendered asymptomatic or experiencing a
decrease in severity of symptoms such as pain at the
injected joints within a 3 month period as per docu-
mented in the chart were classified as having a good re-
sponse to treatment; patients experiencing the same or
an increase in severity of symptoms within a 3 month
period were classified as having a poor response to treat-
ment. Two radiologists (JS, JP) assessed imaging re-
sponse in patients with both pre- and post-injection
MRI by using the Spondyloarthritis Research Consor-
tium of Canada (SPARCC) scoring system. Both ob-
servers were blinded to clinical information and timing
of the studies and they worked independently. All
examinations were performed on a 1.5-T MRI system
(Magnetom Avanto, Siemens, Erlangen, Germany), using
a dedicated surface coil system and included oblique
coronal short tau inversion recovery (STIR) imaging
(repetition time msecTR/TE/TIecho time msec of 2250/
69/x msec, with a field of view of 25 cm, slice thickness
of 4 mm with a slice gap of 4.5 mm) of the SI joints.
Scoring was performed on six consecutive oblique cor-
onal slices, covering most of the cartilaginous and syn-
ovial portion of the joint, by utilizing three MR indices:
1) presence of bone marrow edema, 2) extent or depth
of edema and 3) intensity of edema [13,14]. Patients ex-
periencing a decrease in SPARCC score post-injection
were classified as having a good response to treatment,
whereas those with an increase in score were classified
as having a poor response to treatment.
Clinical status 2 years post-injection, long term re-
sponse was categorized as inactive disease (remission
and off medications) and ongoing disease activity that
was then divided into 3 subcategories: decreased (de-
crease dose/frequency or removal of drug), maintained
(unchanged dose/frequency of drug) or escalated (in-
crease dose/frequency or addition of drug).
Results
Patient population
Fifty patients with sacroiliitis underwent SI joint injec-
tions during the study period and all injection were tech-
nically successful. Thirty-five (70%) were male and 15
were female (30%), ranging from 8 to 18 years old with a
median age of 14 years, IQR of 4. 32/50 (64%) had a two
year follow up and were included in the clinical response
assessment; 15/50 (30%) had both pre- and post-
injection MRI imaging and were included in the imaging
assessment; 15/50 (30%) had both clinical and imaging
assessment performed (Fig. 2).
The most common etiology was JIA (84%) followed by
inflammatory bowel disease (14%). 26 patients (52%)
were HLA B27 positive, 17 patients (34%) were HLA
B27 negative and 7 patients (14%) were not tested.
Twenty-two out of the 26 HLA B27+ patients (85%)
were diagnosed with ERA, 1 (4%) had psoriatic arthritis
and 3 (11%) had IBD (Table 1). 3/50 (6%) required two
SI joint injections during the study period. Injections
were performed bilaterally in 80% and unilaterally in
20% (40% left and 60% right). General anesthesia was
used in 80% and sedation in 20% (14% nurse sedation,
6% anesthesiologist). Triamcinolone hexacetonide was
used in 49 patients (98%) as this is our preferred intra-
articular corticosteroid. Triamcinolone acetonide was
employed in 1 patient (2%) due to shortage of triamcino-
lone hexacetonide in the country. A 22 G Chiba needle
was most commonly used (17 patients, 40%).The other
Fig. 1 Cone beam CT guided SI joint injection w/o contract
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 3 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
needles used were: 22 Spinal (16.6%), 25 Spinal (38.1%),
20 Chiba (2.4%) and 18 Trocar (2.4%). The greater part
of the patients (18 patients, 36%) received a dose of 20
mg (1 ml). CT fluoroscopy (20002016) was used for
image guidance and confirmation in 27 patients (54%),
with adjunctive US in 12/27; Cone Beam CT (2010
2018) was employed in 23 patients (46%), with adjunct-
ive US in 5/23. All procedures were technically success-
ful without any complications.
Of the 32 patients with a short (3-month) and long-
term (2 year) follow-up, 18 patients (56%) had only SI
joint involvement, while the remaining 14 patients (44%)
had multiple joints involved. In the 3-month follow up
period, 21 (66%) patients improved clinically and had no
residual SI joint tenderness, whereas 11/32 (34%)
remained symptomatic with active sacroiliitis (Fig. 3).
Within two years post injection, remission was achieved
in 2/32 patients (6%); treatment was reduced in 1/32 pa-
tient (3%), maintained in 14 patients (44%) and escalated
in 15 patients (47%), with 13/15 starting on biologics.
Among the 13 patients who were escalated to biologics,
7 (54%) had isolated sacroiliitis and 6 (46%) had multiple
joint involvement.
Fifteen out of the 32 patients had a pre- and post-
procedure MRI with a mean of 9.4 months (range 0.25
to 33 months) post injection. 11/15 (73%) had isolated
sacroiliitis and 4/15 (27%) had multiple joint involve-
ment. On post-procedure MRI, 14/15 (93%) showed a
decrease in their SPARCC score, 2 of whom (14%) were
on biologics prior to the injection, 10/14 (66.7%) im-
proved clinically and the remaining 4 patients (26.7%)
reported worsening of symptoms (Fig. 4); 1/15 (6.6%)
had a higher SPARCC score. The median change in
SPARCC score was found to be 14.5 with an inter-
quartile range of 12.5. Out of the 14 patients with a de-
crease in SPARCC score, 12 (86%) met the minimal
clinically important difference of 2.5.
As mentioned before, In the 2-year follow up period,
13 patients had an escalation of treatment starting bio-
logic agents, with a mean initiation time of 6.11 months
(range 0.5 to 18 months) post-injection. When taking
into account joint involvement, in the 11 patients with
isolated sacroiliitis, 1 (9%) achieved remission, 1 (9%) re-
duced treatment, 4 (36%) remained on the same treat-
ment plan and 5 (46%) escalated. Among the 4 patients
with multiple joint involvement, 3 (75%) remained on
the same treatment plan and 1 (25%) escalated to
Fig. 2 Patient flow chart
Table 1 Patient demographics
Mean Age (years) 13.8 (818)
Gender F: 15 (30%); M: 35 (70%)
HLA B 27 Status Number of Patients (%)
Positive 26 (52)
Negative 17 (34)
Not Done 7 (14)
Patient Diagnosis Number of Patients (%)
Juvenile Idiopathic Arthritis 42 (84)
Inflammatory Bowel Disease 7 (14)
Isolated Sacroiliitis 1 (2)
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 4 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
biologics. Table 2ilustrates the long term follow up in
the group of patients in whom a change of SPARCC
score was assessed.
Discussion
Sacroiliitis is a prominent clinical manifestation of the
ERA sub-type of JIA and is frequently associated with
HLA B27 positivity. It can be treated medically or by SI
corticosteroid joint injections. The management of pa-
tients with JIA requires a multidisciplinary approach as
shown in this study in which rheumatology, diagnostic
imaging and interventional radiology worked together to
provide diagnosis, treatment and follow up. Prior to
image guided techniques, corticosteroid injections were
performed by palpation of anatomical landmarks. How-
ever, this technique lacked specificity or efficiency due
to the complexity of the sacroiliac joint anatomy [15].
With evolving imaging technology, image guided tech-
niques have become increasingly available. Historically,
fluoroscopy was employed. With the advent of cross sec-
tional imaging, conventional CT or cone beam CT has
been used to guide needle placement and ensure suc-
cessful intra-articular injections [15]. US has also been
utilized for needle guidance, on its own or combined
with cross sectional imaging [16]. More recently there
are reports of MRI guided injections [17]. The use of
three needles has been reported in the literature, in the
inferior, middle and superior aspects of the joint [17],
however currently only one needle in the inferior or
middle synovial portion of the joint is preferred [18]. Al-
though two different cross sectional imaging modalities
were used in this study, all cases were successfully com-
pleted without any peri- or post-procedure complication.
US assisted in approximately one third of the SI joint in-
jections. From 2000 to 2009, CT fluoroscopy were the
only cross sectional imaging option available in this IR
practice. In 2010, Cone Beam CT became available and
provided satisfactory image guidance for the procedure.
It eventually replaced CT fluoroscopy in 2016 due to its
adequate performance, ease of use and recognized radi-
ation dose reduction, as has been demonstrated in the
literature [19,20]. The corticosteroid currently used is
triamcinolone hexacetonide as studies have shown that
it is more effective than hydrocortisone succinate and
triamcinolone acetonide in reducing pain and joint in-
flammation [21,22].
Similar to the benefits of injections in other joints, cor-
ticosteroids relieved the symptoms (especially pain) with
SI joint inflammation in the majority of the patients.
This was assessed in two ways: clinically by patient his-
tory/physical exam, and on imaging by assessing and
scoring MRIs before and after the procedure. Most of
the patients with a decrease of inflammation on post in-
jection MRI also reported symptomatic improvement
and met the MCID in the SPARCC SIS of 2.5 [23]. An
interesting finding is that a group of patients despite the
imaging improvement had worsening of symptoms. The
Fig. 3 Post injection short term assessment
Table 2 Long term management Vs. MRI findings
Decrease SPARCC Increase SPARCC
Decrease Treatment 1 (6.7%) 0
Same Treatment 6 (40%) 1 (6.7%)
Escalated Treatment 6 (40%); 5 (33%) started biologics 0
Remission 1 (6.7%) 0
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 5 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
reason why this happens is currently unclear to us
and warrants further studies.
Clinical improvements were not sustained in the
majority of patients who received joint injections.
Within 2 years, only two patients achieved remission
and one patient a reduction in treatment. The re-
mainder stayed on the same management plan or es-
calated to a higher level of medical therapy (eg.
biologic agents) within a year. More than half of the
patients who transitioned to biological agents had ex-
clusively SI joint involvement.
There are several limitations with this retrospective
study. Disease severity may have been underestimated as
patient history and complaints were limited to those re-
corded in the rheumatology clinic notes. Radiological re-
ports may not have captured all procedural details or
difficulties encounter during SI joint injections, resulting
in an underestimate. Some patients were transferred to
adult facilities once they came of age or were simply lost
to follow-up. Follow-up MRIs were not consistently per-
formed on a protocol basis, but variably depending on
clinical indication. Due to the complexity of the manage-
ment of sacroiliitis in JIA patients, a comparison of
monotherapy with corticosteroid injections to medical
management alone was not possible.
Conclusion
Image guided SI joints injections are safe and feasible in
pediatric patients. With the evolution of fluoroscopic
systems, CBCT has replaced conventional CT as the im-
aging modality of choice. In our cohort of patients,
intra-articular injections provided short-term symptom
relief, but in the longer term, most of the patients were
maintained or escalated to systemic medical therapy
within months to a year. The lack of standardized man-
agement and follow up protocols makes it difficult to
analyze the clinical evolution of these patients. Collabor-
ation between rheumatology, diagnostic and
interventional radiology is beneficial in their manage-
ment. The role of corticosteroid SI joint injections in the
context of new systemic therapies requires further
investigation.
Abbreviations
ERA: enthesitis-related arthritis; JIA: juvenile idiopathic arthritis;; SI: sacroiliac;
IR: interventional radiology; CBCT: cone beam CT; ILAR: International League
of Association for Rheumatology; SpA: spondyloarthritis; NSAIDs: nonsteroidal
Anti-Inflammatory Drugs; DMARDs: Disease-Modifying Antirheumatic Drugs;
anti-TNFα: anti-tumor necrosis factor-alpha; IA: intra-articular; EPC: Electronic
Patient Charts PACS: Picture Archiving and Communication System; US:
Ultrasound; PACU: post anesthesia care unit; IBD: inflammatory bowel
disease; SPARCC: Spondyloarthritis Research Consortium of Canada; STIR:
short tau inversion recovery; MCID: minimal clinically important differences;
SPARCC SIS: Spondyloarthritis Research Consortium of Canada sacroiliac joint
inflammation score.
Acknowledgements
Not applicable
Authorscontributions
DP was the primary investigator of the paper, supervising, analyzing and
interpreting patient data. RC gathered, analyzed and interpreted the patient data
from charts, as well as wrote the manuscript. JP and JS assessed imaging
response in patients with both pre- and post-injection MRI. All authors read,
edited and approved the final manuscript.
Ethics approval and consent to participate
Research Ethics Board approval was obtained.
Consent for publication
Not Applicable
Competing interests
The authors declare that they have no competing interests.
Author details
1
Division of Image Guided Therapy, Department of Diagnostic Imaging, The
Hospital for Sick Children, University of Toronto, 555 University Avenue,
Toronto, ON M5G 1X8, Canada.
2
Division of Rheumatology, Department of
Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto,
Canada.
3
Department of Diagnostic Imaging, The Hospital for Sick Children,
University of Toronto, Toronto, Canada.
Fig. 4 Post injection SPARCC score assessment
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 6 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Received: 2 November 2019 Accepted: 6 May 2020
References
1. Weiss JE, Ilowite NT. Juvenile idiopathic arthritis. Pediatr Clin N Am. 2005;52:
41342.
2. Hashkes PJ, Laxer RM. Medical treatment of juvenile idiopathic arthritis.
JAMA. 2005;294:167184.
3. Barut K, Adrovic A, Sahin S, Kasapcopur O. Juvenile idiopathic arthritis.
Balkan Med J. 2017;34:90101.
4. Classification of Juvenile Arthritis. Uptodate. https://www.uptodate.com/
contents/classification-of-juvenile-arthritis. Accessed 7 Aug 2017.
5. Spondyloarthropathies. American Family Physician. https://www.aafp.org/
afp/2004/0615/p2853.html. Accessed 7 Aug 2017.
6. Comprehensive Diagnostic Approach for the Sacroiliac (SI) Joint. Spine-
Health. https://www.spine-health.com/education-centers/sacroiliac-joint-
disorders/physicians/comprehensive-diagnostic-approach-sacroiliac.
Accessed 7 Aug 2017.
7. Kennedy DJ, Engel A, Kreiner SD, Nampiaparampil D, Duszynski B, Macvicar
J. Fluoroscopically guided diagnostic and therapeutic intra-articular
sacroiliac joint injections: a systematic review. Pain Med. 2015;16:150018.
8. Tins BJ, Butler R. Imaging in rheumatology: reconciling radiology and
rheumatology. Insights Imaging. 2013;4:799810.
9. Feldtkeller E, Khan MA, Van Der Heijde D, Van Der Linden S, Braun J. Age at
disease onset and diagnosis delay in HLA-B27 negative vs positive patients
with ankylosing spondylitis. Rheumatol Int. 2003;23:616.
10. Celluci T, Guzman J, Petty RE, Batthish M, Benseler SM, Ellsworth JE, et al.
Management of Juvenile Idiopathic Arthritis 2015: a position statement
from the pediatric Committee of the Canadian Rheumatology Association. J
Rheumatol. 2016;43:17736.
11. Gmuca S, Weiss PF. Evaluation and treatment of childhood Enthesitis-
related arthritis. Curr Treatm Opt Rheumatol. 2015;1:35064.
12. Kumar N, Tan BWL. Sacroiliac joint injections. Tech Orthop. 2013;28:504.
13. Review of Paediatric SPARCC SIJ Scoring Methodology with Examples.
Paediatric SPARCC SIJ Module. https://www.carearthritis.com/mriportal/
pedisij/index/. Accessed 23 Aug 2017.
14. Panwar J, Tse SML, Lim L, Tolend MA, Radhakrishnan S, Salman M, et al.
Spondyloarthritis research consortium of Canada scoring system for
Sacroiliitis in juvenile Spondyloarthritis/Enthesitis-related arthritis: a reliability,
validity, and responsiveness study. J Rheumatol. 2019.
15. News & Articles: The Evolution Of Image Guidance & Injection Therapy.
Virginia Spine Institute. https://www.spinemd.com/news-philanthropy/the-
latest-diagnostic-tools-to-locate-pain-generators. Accessed 23 Aug 2017.
16. Chang W, Lew HL, Chen CPC. Ultrasound-guided sacroiliac joint injection
technique. Am J Phys Med Rehabil. 2013;92:2789.
17. Sacroiliac Joint Injection: Background, Indications, Contraindications.
Medscape. https//www/emedicine.medscape.com/article/103399-overview.
Accessed 7 Aug 2017.
18. Silbergleit R, Bharat MA, Sanders WP, Sanjay TJ. Imaging-guided injection
techniques with fluoroscopy and CT for spinal pain management.
RadioGraphics. 2001;21:92739.
19. Zhu X, Felice M, Johnson L, Sarmiento M, Cahill AM. Developing low-dose
C-arm CT imaging for temporomandibular joint (TMJ) disorder in
interventional radiology. Pediatr Radiol. 2010;41:47682.
20. Shkumat N, Shroff MM, Muthusami P. Radiation dosimetry of 3D rotational
Neuroangiography and 2D-DSA in children. AJNR Am J Neuroradiol. 2018;
39:72733.
21. Zulian F, Martini G, Gobber D, Agosto C, Gigante C, Zacchello F. Comparison
of intra-articular triamcinolone Hexacetonide and triamcinolone Acetonide
in Oligoarticular juvenile idiopathic arthritis. Rheumatology. 2003;42:12549.
22. Zulian F, Martini G, Gobber D, Plebani M, Zacchello F, Manners P.
Triamcinolone Acetonide and Hexacetonide intra-articular treatment of
symmetrical joints in juvenile idiopathic arthritis: a double-blind trial.
Rheumatology. 2004;43:128891.
23. Weiss P, Maksymowych W, Lambert R, Jaremko J, Biko D, et al. Feasibility
and reliability of the Spondyloarthritis research consortium of Canada
sacroiliac joint inflammation score for children with Spondyloarthritis.
Arthritis Res Therapy. 2018;20:56.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 7 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
... Intraarticular injection of corticosteroids into the SI joints is conditionally recommended as an adjunct therapy. Chamlati et al assessed the feasibility and efficacy of image guided intraarticular corticosteroid injections of the sacroiliac joints in 50 children, predominantly JIA, with sacroiliitis based on clinical symptoms and MRI findings [68]. Majority of patients (66%) had clinical improvement 3 months after injection; however, within 2 years 47% required escalation in therapy, most commonly (13/15) to biologic therapy. ...
Article
Full-text available
Purpose To provide an overview of recent studies on pathogenesis, diagnosis, and management of juvenile spondyloarthritis (JSpA). Recent Findings Recent studies show differences in gut microbiome in patients with JSpA in comparison to healthy controls. There is increased recognition of the impact of the innate immune system on disease pathology. Normative reference on MRI of sacroiliac (SI) joints in children is now available. However, there is significant variability in interpretation of MRI of SI joints in children and a need for standardization. NSAIDs, physical therapy, and Tumor Necrosis Factor Inhibitors (TNFi) remain the mainstay of management for patients with JIA who have polyarthritis, sacroiliitis, and/or enthesitis as per recent ACR guidelines. Newer therapeutic options beyond TNFi are needed to manage patients who fail TNFi. Summary This review highlights some of the recent advances in our knowledge of JSpA pathophysiology, diagnosis, and treatment. It also identifies areas in need of further research and standardization to improve our understanding and outcomes in JSpA.
Article
Axial spondylarthritis in adulthood (SpAA) is frequently initially manifested as a sacroiliitis, whereas this not true for enthesitis-related arthritis (EAA), which begins in childhood and adolescence. Classically, EAA begins with peripheral arthritis and only a part transitions into a juvenile SpA (jSpA) or SpAA. The criteria used for classification of SpAA and EAA are currently being validated and revised. For the first time imaging is included for EAA. For both diseases nonsteroidal anti-inflammatory drugs (NSAID) are initially used therapeutically, followed by biologicals or synthetic targeted disease-modifying drugs in refractory courses. Steroids should be avoided in long-term treatment. For optimal transition and further care in adulthood, a close cooperation between internistic and pediatric rheumatologists is necessary.
Article
Axial spondylarthritis in adulthood (SpAA) is frequently initially manifested as a sacroiliitis, whereas this not true for enthesitis-related arthritis (EAA), which begins in childhood and adolescence. Classically, EAA begins with peripheral arthritis and only a part transitions into a juvenile SpA (jSpA) or SpAA. The criteria used for classification of SpAA and EAA are currently being validated and revised. For the first time imaging is included for EAA. For both diseases nonsteroidal anti-inflammatory drugs (NSAID) are initially used therapeutically, followed by biologicals or synthetic targeted disease-modifying drugs in refractory courses. Steroids should be avoided in long-term treatment. For optimal transition and further care in adulthood, a close cooperation between internistic and pediatric rheumatologists is necessary.
Article
Full-text available
Background: Published methods for quantification of magnetic resonance imaging (MRI) evidence of inflammation in the sacroiliac joint lack validation in pediatric populations. We evaluated the reliability and construct validity of the Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joint inflammation score (SIS) in children with suspected or confirmed juvenile spondyloarthritis (JSpA). Methods: The SPARCC SIS measures the presence, depth, and intensity of bone marrow inflammation on MRI through the cartilaginous part of the joint. Six readers blinded to clinical details except age, participated in two reading exercises, each preceded by a calibration exercise. Inter-observer reliability was assessed using intraclass correlation coefficients (ICCs) and for pre-specified acceptable reliability the inraclass correlation coefficient (ICC) was > 0.8. Results: The SPARCC SIS had face validity and was feasible to score in pediatric cases in both reading exercises. Cases were mostly male (64%) and the median age at the time of imaging was 14.9 years. After calibration, the median ICC across all readers for the SIS total score was 0.81 (IQR 0.71-0.89). SPARCC SIS had weak correlation with disease activity (DA) as measured by the JSpADA (r = - 0.12) but discriminated significantly between those with and without elevated C-reactive protein (p = 0.03). Conclusion: The SPARCC SIS was feasible to score and had acceptable reliability in children. The ICC improved with additional calibration and reading exercises, for both experienced and inexperienced readers.
Article
Full-text available
Juvenile idiopathic arthritis is the most common chronic rheumatic disease of unknown aetiology in childhood and predominantly presents with peripheral arthritis. The disease is divided into several subgroups, according to demographic characteristics, clinical features, treatment modalities and disease prognosis. Systemic juvenile idiopathic arthritis, which is one of the most frequent disease subtypes, is characterized by recurrent fever and rash. Oligoarticular juvenile idiopathic arthritis, common among young female patients, is usually accompanied by anti-nuclear antibodie positivity and anterior uveitis. Seropositive polyarticular juvenile idiopathic arthritis, an analogue of adult rheumatoid arthritis, is seen in less than 10% of paediatric patients. Seronegative polyarticular juvenile idiopathic arthritis, an entity more specific for childhood, appears with widespread large- and small-joint involvement. Enthesitis-related arthritis is a separate disease subtype, characterized by enthesitis and asymmetric lower-extremity arthritis. This disease subtype represents the childhood form of adult spondyloarthropathies, with human leukocyte antigen-B27 positivity and uveitis but commonly without axial skeleton involvement. Juvenile psoriatic arthritis is characterized by a psoriatic rash, accompanied by arthritis, nail pitting and dactylitis. Disease complications can vary from growth retardation and osteoporosis secondary to treatment and disease activity, to life-threatening macrophage activation syndrome with multi-organ insufficiency. With the advent of new therapeutics over the past 15 years, there has been a marked improvement in juvenile idiopathic arthritis treatment and long-term outcome, without any sequelae. The treatment of juvenile idiopathic arthritis patients involves teamwork, including an experienced paediatric rheumatologist, an ophthalmologist, an orthopaedist, a paediatric psychiatrist and a physiotherapist. The primary goals of treatment are to eliminate active disease, to normalize joint function, to preserve normal growth and to prevent long-term joint damage. Timely and aggressive treatment is important to provide early disease control. The first-line treatment includes disease-modifying anti-rheumatic drugs (methotrexate, sulphasalazine, leflunomide) in combination with corticosteroids, used in different dosages and routes (oral, intravenous, intra-articular). Intra-articular application of steroids seems to be an effective treatment modality, especially in monoarthritis. Biological agents should be added in the treatment of unresponsive patients. Anti-tumour necrosis factor agents (etanercept, infliximab, adalimumab), anti-interleukin-1 agents (anakinra, canakinumab), anti- interleukin-6 agents (tocilizumab) and T-cell regulatory agents (abatacept) have been shown to be safe and effective in childhood patients. Recent studies reported sustained reduction in joint damage with even complete clinical improvement in paediatric patients, compared to previous data.
Article
Full-text available
Enthesitis-related arthritis (ERA) is phenotypically distinct from the other categories of juvenile idiopathic arthritis (JIA). Therefore, patients with ERA warrant distinct pharmacological treatments tailored to their disease process. The advent of biologic disease-modifying agents (biologics) has revolutionized the treatment of ERA. Biologics are drugs that are genetically engineered from a living organism (such as a virus, gene, or protein) to modify signaling along the inflammatory pathway and thereby modulate the immune system. There has been movement over the last decade to categorize and treat patients with spondyloarthritis on the basis of axial disease since axial involvement warrants treatment with a biologic, in particular, a tumor necrosis factor alpha (TNF-α) blocker. To help identify ERA patients correctly for research purposes, the use of ultrasound with Doppler (USD) and/or whole-body magnetic resonance imaging (MRI) is being increasingly used; their role in clinical practice, however, is still undetermined. We strongly recommend that MRI of the pelvis be performed for any ERA patient in whom axial disease is suspected as its presence may influence the medication regimen, specifically initiation of a biologic. The recent development of a spondyloarthritis (including ERA)-specific disease activity tool called the Juvenile Spondyloarthritis Disease Activity Score (JSpADA) will hopefully allow pediatric rheumatologists to better monitor disease activity over time. Over the last decade, there has been a plethora of research to help advance our understanding of the etiopathogenesis of spondyloarthritis. Future promising treatments for ERA are evidenced by research implicating the role of the IL-12/23 and IL-17 axis in spondyloarthritis. Investigations examining the microbiome will further elucidate the interactions between genetics and the environment that lead to the development of ERA. With more randomized therapeutic trials and more microbiome and genetics-related research, we will likely see the development of targeted therapies for the treatment of ERA in the near future.
Article
Full-text available
The medical management of juvenile idiopathic arthritis (JIA) and its complications has undergone significant changes in the last decade, a result largely of the introduction of biologics and increased availability of expertise in the diagnosis and management of rheumatic diseases in children and adolescents. The result is that clinical outcome has improved and complete disease control can often be achieved1. In 2010, the British Society for Paediatric and Adolescent Rheumatology (BSPAR) proposed guidelines for the optimal management of children and adolescents with JIA2. This advocacy statement emphasizes the importance of empowering children and their caregivers, facilitating early detection of JIA, prompt referral to a team of health professionals who are expert in the diagnosis and management of childhood rheumatic diseases, prompt access to all appropriate pharmacologic and biologic therapies, and regular followup and monitoring. The Canadian Wait Time Alliance sets acceptable wait times as 4 weeks in children with JIA, other than systemic onset JIA, and within 7 days of disease onset for children with systemic onset JIA. Screening for asymptomatic uveitis should take place within 4 weeks of the diagnosis of JIA3. Ideally, children and adolescents with JIA should be managed by a team of health professionals with training and experience in pediatric rheumatology given … Address correspondence to Dr. R.E. Petty, Division of Rheumatology, Department of Pediatrics, University of British Columbia, British Columbia’s Children’s Hospital, 4480 Oak St., Room K4-114, Vancouver, British Columbia V6H 3V4, Canada; E-mail: rpetty{at}cw.bc.ca
Article
Full-text available
Imaging in rheumatology was in the past largely confined to radiographs of the hands and sacroiliac joints (SIJs) helping to establish the diagnosis and then monitoring disease progression. Radiographs are not very sensitive for early inflammation in inflammatory rheumatic disorders and the demand on imaging services was therefore limited. However, over the last 10–15 years new drugs and new technologies have brought new challenges and opportunities to rheumatology and radiology as specialties. New drug treatments allow more effective treatment, preventing many complications. Early diagnosis and disease monitoring has become the challenge for the rheumatologist and radiologist alike. The best possible patient outcome is only achieved if the two specialties understand each other’s viewpoint. This article reviews the role of imaging—in particular radiography, magnet resonance imaging, computer tomography, ultrasound and nuclear medicine—for the diagnosis and monitoring of rheumatological disorders, concentrating on rheumatoid arthritis, inflammatory spondylarthropathies and gout. Teaching Points • New drugs for the treatment of inflammatory disorders has led to greatly improved outcomes. • Imaging often allows for earlier diagnosis of inflammatory disorders. • Early diagnosis and treatment can often prevent the development of crippling disease manifestations. • Tailored imaging examinations are best achieved by consultation of rheumatologist and radiologist.
Article
Background Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease characterized by onset before the age of 16. This term encompasses several disease categories, each of which has distinct methods of presentation, clinical signs, and prognosis. The study aimed to determine JIA complications in 51 patients. Methods A cross-sectional study including patients diagnosed with JIA according to ILAR criteria was conducted for 26 years [1995– 2021]. Epidemiological, clinical, therapeutic, and evolutive aspects were noted. Results Twenty-nine males and 22 females were included. The mean age of the disease onset was 7.6 years [1,5–16]. The mean age of patients at the time of the study was 23.29 years [9–45]. Polyarticular and seronegative form was the most frequent (34.5%). Other subtypes diagnosed were systemic (25%), enthesitis-related arthritis (21.2%), oligoarticular (12.5%), and seropositive polyarticular (5.8%). Standard X-Ray imaging showed articular damage in 50% of the cases. Hip arthritis was observed in 32% and surgery was needed in 16.9%. One patient presented with atlantoaxial subluxation. Growth retardation was noted in 28.6%. Cardiac manifestations were seen in 3 patients (pericarditis = 2, myocarditis = 1), uveitis in 3 cases, renal manifestation (extra membranous glomerulonephritis) in one patient with polyarticular form. One patient was diagnosed with multiple sclerosis. Small doses of corticosteroids were prescribed in 71.7%. Methotrexate was prescribed in 70.5% (interrupted for adverse effects in 3 patients), sulfasalazine in 30.6%, hydroxychloroquine in 5.7%, leflunomide in 15.4%. bDMARDs were needed in 16 patients: 14 patients received TNF alpha inhibitors, rituximab was prescribed for one patient with a polyarticular form, and tocilizumab in a patient with a systemic form. A switch of bDMARDs was conducted in 10 patients: for inefficiency in 4 cases and adverse effects in other 4 cases. Three patients developed uveitis under Etanercept, septicemia under Adalimumab, an allergic reaction, and depression under Infliximab. One patient died from a convulsive seizure at the age of 9. Conclusion The presence of complications is an additional burden to JIA patients. A multidisciplinary approach is required for the management of these complications.
Article
Objective Intra- and interreader reliability, construct validity, and responsiveness of the Spondyloarthritis Research Consortium of Canada (SPARCC) magnetic resonance imaging (MRI) scoring system were investigated for scoring sacroiliitis in patients with juvenile spondyloarthritis (JSpA)/enthesitis-related arthritis (ERA) who have received biologic and/or nonbiologic treatment. Methods Ninety whole-body MRI examinations with dedicated oblique coronal planes of the sacroiliac joints in 46 patients were independently reviewed and scored by 2 pediatric musculoskeletal radiologists, blinded to clinical details, using the SPARCC system. Intra- and interreader reliability was assessed by intraclass correlation coefficients (ICC). Construct validity testing was done by (1) correlating the SPARCC MRI scores of sacroiliitis with clinical disease activity indicators (crosssectional validity), and (2) correlating the change in the MRI score with the change in clinical indicators before and after treatment (longitudinal validity). Responsiveness of the MRI and clinical indicators was also evaluated, grouped by biologic and nonbiologic treatment. Results When applied in children with JSpA/ERA, the SPARCC showed almost perfect intra- and interreader reliability (ICC 0.79–1.00). There was poor cross-sectional and longitudinal correlation between clinical assessment indicators and MRI scoring. SPARCC scores showed higher responsiveness to treatment-related change than most clinical outcome measures. Three clinical outcome measures correlated longitudinally with SPARCC score in nonbiologic treatment: active joint count (r = 0.72, p < 0.001), FABER (Flexion, Abduction, External Rotation) test (r = 0.58, p = 0.012), and physician’s global assessment (r = 0.61, p = 0.034). Conclusion The SPARCC MRI scoring system is a reliable tool with relatively higher responsiveness than clinical indicators and is suitable for objective quantification of sacroiliitis when applied to pediatric patients with JSpA/ERA.
Article
Background and purpose: The benefit-risk assessment concerning radiation use in pediatric neuroangiography requires an extensive understanding of the doses delivered. This work evaluated the effective dose of 3D rotational angiography in a cohort of pediatric patients with complex neurovascular lesions and directly compared it with conventional 2D-biplane DSA. Materials and methods: Thirty-three 3D rotational angiography acquisitions were acquired in 24 pediatric patients (mean age, 10.4 years). When clinically indicated, following 2D-biplane DSA, 3D rotational angiography was performed with 1 of 3 technical protocols (2 subtracted, 1 unsubtracted). The protocols consisted of 1 factory and 2 customized techniques, with images subsequently reconstructed into CT volumes for clinical management. Raw projections and quantitative dose metrics were evaluated, and the effective dose was calculated. Results: All 3D rotational angiography acquisitions were of diagnostic quality and assisted in patient management. The mean effective doses were 0.5, 0.12, and 0.06 mSv for the factory-subtracted, customized-subtracted, and customized-unsubtracted protocols, respectively. The mean effective dose for 2D-biplane DSA was 0.9 mSv. A direct intraprocedural comparison between 3D and 2D acquisitions indicated that customized 3D rotational angiography protocols delivered mean relative doses of 9% and 15% in unsubtracted and subtracted acquisitions, respectively, compared with biplane DSA, whereas the factory subtracted protocol delivered 68%. Conclusions: In pediatric neuroangiography, the effective dose for 3D rotational angiography can be significantly lower than for 2D-biplane DSA and can be an essential adjunct in the evaluation of neurovascular lesions. Additionally, available 3D rotational angiography protocols have significant room to be tailored for effectiveness and dose optimization, depending on the clinical question.
Article
Chronic low back pain secondary to sacroiliac joint pathology is a clinical entity that is increasingly recognized and has controversial treatment options. Sacroiliac joint injection is a common diagnostic and therapeutic modality utilized in sacroiliac joint pathologies. It is regarded as a gold-standard diagnostic modality and offers a plausible alternative to surgical treatment with increasing evidence of its efficacy. Sacroiliac joint injections are typically performed under fluoroscopic guidance and the injections usually comprise a combination of local anesthetic and steroid. Despite its popularity and reported efficacy, the current available literature is unable to fully conclude the effectiveness of the modality and provide adequate comparison against surgical treatment. The underlying mechanism of action is also yet to be well elucidated. We hereby describe the technique of fluoroscopy-guided sacroiliac joint injections for both diagnostic and therapeutic purposes. The article gives an overview of essential requirements for the procedure, concepts, technical tips, and potential complications.
Article
To assess the validity of fluoroscopically guided diagnostic intra-articular injections of local anesthetic and effectiveness of intra-articular steroid injections in treating sacroiliac joint (SIJ) pain. Systematic review INTERVENTIONS: Ten reviewers independently assessed 45 publications on diagnostic validity or effectiveness of fluoroscopically guided intra-articular SIJ injections. For diagnostic injections, the primary outcome was validity; for therapeutic injections, analgesia. Secondary outcomes were also described. Of 45 articles reviewed, 39 yielded diagnostic data on physical exam findings, provocation tests, and SIJ injections for diagnosing SIJ pain, and 15 addressed therapeutic effectiveness. When confirmed by comparative local anesthetic blocks with a high degree of pain relief, no single physical exam maneuver predicts response to diagnostic injections. When at least three physical exam findings are present, sensitivity, and specificity increases significantly. The prevalence of SIJ pain is likely 20-30% among patients that have suspected SIJ pain based on history and physical examination. This estimate may be higher in certain subgroups such as the elderly and fusion patients. Two randomized controlled trials and multiple observational studies supported the effectiveness of therapeutic sacroiliac joint injections. Based on this literature, it is unclear whether image-guided intra-articular diagnostic injections of local anesthetic predict positive responses to therapeutic agents. The overall quality of evidence is moderate for the effectiveness of therapeutic SIJ injections. Wiley Periodicals, Inc.