Study of Sacroiliac fixation in patients with sacroiliitis associated with L5 Lythesis

INTRODUCTION

Growing evidence points to the sacroiliac joint (SIJ) as a frequent source of persistent low back discomfort. The SIJ may be involved in 15–30% of patients who attend for examination of low back pain. ¹

Exercise, SIJ steroid injections, RF ablation of the sacral nerve roots' lateral branches, and open or minimally invasive SIJ procedures surgery are currently available treatments for SIJ dysfunction. ²

*Nonsurgical treatments are used to address the majority of cases of discomfort caused by the sacroiliac joint. Surgery is a possibility for patients with significant, strict pain linked to Lumber vertebrae lythesis that interferes with their daily lives and is refractory to nonsurgical treatments. Sacroiliac joint fixation is the procedure. ³

The sacrum, which supports the spine, distributes pressure from the spine to the pelvis through the sacroiliac joints. Reconstructing the spine-pelvic connection as a result of surgical fixation enables early weight-bearing. ⁴

This work aimed to evaluate sacroiliac fixation in patients with sacroiliitis associated with L5 lythesis

PATIENTS AND METHODS

This is prospective and retrospective study that was conducted on 10 patients with spinal pathologies. The following methods were applied for the studied cases:

Preoperative evaluation:

Clinical, radiographic, and other preoperative laboratory evaluations are performed on each patient to determine whether they are fit for general anesthesia. all patients were neurologically free. Parenteral analgesics are used for severe pain and oral analgesics for mild pain. The physician went over the surgical process and subsequent care with the patient and his relative, and he answered any questions the patient had regarding the procedure.

Clinical evaluation:

Personal history including: Name, Age, Sex, Occupation, Address and Special habits. History of back pain. Neurological disorders including: Sensory, Motor and sphincteric disorders. History of chest, cardiac or general health problems that may hinder anesthesia.

Examination: General examination including: Evaluation of hemodynamic state of the patient (Pulse, blood pressure, temperature and respiratory rate). Head, chest and abdomen for life threatening injuries. Examination of extremities for associated injuries.

Spine examination: Inspection of the back and other related regions. Palpation of the spine. Evaluation of deformity especially in old cases. Neurological evaluation: A-Sensory examination: Superficial sensation including: Pain, Touch, Temperature, Perianal sensation. Deep sensation: Joint sensation: Sense of joint motion, sense of position and deep pressure sense.

B-Motor examination for Muscle power. Reflexes: Superficial: Abdominal reflexes Planter reflex Deep: Knee reflex. Ankle reflex.

Radiological evaluation: plain X- ray, CT and MRI. After hospital admission to the following were done.

Preoperative preparation and positioning:

 All of the patients were given prophylactic antibiotic (3rd generation Cephalosporin) 1gm before induction of anesthesia. The patients were positioned prone, under general anesthesia on a radiolucent table with a small towel under chest of the patient with hyper extension of the leg.

Operative techniques:

General anesthesia

The patient is kept in the prone position (back in semiflexion) on a typical spine table that is well-padded at pressure points. Along with the C-arm image intensifier, all the equipment is maintained available.

Midline lumber incision of the skin and subcutaneous tissue

Subperiosteal separation of paravertebral muscles

Identification the lamina laterally up to the facet joint and transverse processes

Good leveling using C-arm

S2-alar-iliac screw technique

During the SAI fixation procedure, S2 alar iliac screws (S2AI fixation) are inserted from the S2 region of the sacrum, over the sacroiliac joint, and into the ilium. The S2 alar iliac (S2AI) screw must be placed distal to the S1 superior endplate, 5 mm inferior-lateral to the S1 foramen, and 25 mm inferior-lateral to the midline. Since the S2AI screws are typically aligned with the S1 pedicle screws at the more medial entrance joint site, it is simple to attach the lumbosacral rod to the distal anchor without the use of medial to lateral connectors or several separate fascial incisions.

Aiming directly above the anterior inferior iliac spine, the screw should ideally be inclined 40 degrees laterally in the transverse plane and 40 degrees caudally in the sagittal plane (AIIS). The S2AI screw's pullout strength has increased since it traverses three distinct cortical bone structures in the sacroiliac joint. An S2AI screw typically measures 80 to 100 mm in length. The S2AI screw's pullout strength is increased if it is positioned just above the bigger sciatic notch, close to the thick cortical bone. Due to improved visualisation of the screw crossing the SI joint, the AP view is commonly employed for S2AI screw placement. One issue with S2AI screws is that they sometimes need to be driven through the hard bone cortices of the SI joint with a power drill.

Post-operative care:

Before leaving the operating room following recovery, each patient underwent a neurological examination. They were also all given 3rd generation Cephalosporin (Cefotaxime 1 gm every 12 hours) for one week, and non-steroidal anti-inflammatory drugs were administered in accordance with each patient's tolerance. All patients used lumbar braces for two to three weeks before discarding them and being instructed to walk immediately post-op. However, for three months, patients are often not allowed to bend or twist at the waist or lift more than five pounds. Limitations include prohibiting excessive exertion from stair climbing, pushing or pulling motions, lengthy sitting, and extended standing, all of which are typically only allowed for a period of 3-6 months.

Evaluation two weeks after surgery: The patients were examined for the removal of stitches and a clinical and neurological assessment. Follow-up: Follow-up was conducted after six weeks and three months. At each visit, the following things were assessed: Neurological testing was part of the clinical evaluation. Back pain, spinal movement, resumed employment, satisfaction, and problems. radiological evaluation, which may have included plain x-rays and a CT scan.

RESULTS

The Social Sciences Statistical Package, version 20.0, was used to analyze the data collected (SPSS Inc., Chicago, Illinois, USA). The mean and standard deviation of the quantitative values were displayed (SD). Frequency and percentages of data were used to express qualitative data.

The subsequent tests were conducted: The proportions between qualitative measures were compared using the Chi-square (x2) test of significance. When comparing two related samples, the paired sample t-test of significance was employed. The allowable margin of error was set at 5%, while the confidence interval was set at 95%. In light of the above, the p-value was deemed significant: likelihood (P-value) P-values under 0.05 were regarded as significant.

Table (1): description of sex and age in all studied patients

The sex and age breakdown for each patient under study is shown in this table. The patients under study were split equally between 5 males and 5 girls in terms of sex. The average age of all the patients in the study was 45.8 7.2 years, with a minimum age of 33 and a maximum age of 55.

Table (2): description of hospital stay in all studied patients

This table details each patient's hospital stay during the course of the study. The average hospital stay for all patients in the study was 4.8 +/- 1.5 days, with a minimum and maximum stay of 3 and 8 days, respectively.

Table (3): description of Screw position in all studied patients

This table shows the description of Screw position in all studied patients. It was good position in 7 patients (70%), accepted position in 2 patients (20%) and bad position in 1 patient (10%).

Table (4): description of fusion level in all studied patients

This table shows the description of fusion level in all studied patients. It was at L2-S2 in2 patients (20%), L3-S2 in 3 patients (30%) and L4-S2 in 5 patients (50%).

Table (5): description of post-operative VAS and ODI in all studied patients

This table shows the description of post-operative VAS and ODI in all studied patients. As regard post-operative VAS, the mean post -operative VAS of all studied patients was 3.9 ± 1.9 with minimum post-operative VAS of 2 and maximum post-operative VAS of 7. As regard post-operative ODI, the mean post-operative ODI of all studied patients was 31.7 ± 19.2 with minimum post-operative ODI of 10 and maximum post-operative ODI of 70.

T: independent sample T test.                  HS: p-value < 0.001 is considered highly significant.

Table (6): comparison between pre-operative and post-operative (VAS & ODI) in studied patient

This table shows: Highly statistically significant (p-value < 0.001) decreased post-operative VAS (3.9 ± 1.9) when compared with pre-operative VAS (8.1 ± 0.7). Highly statistically significant (p-value < 0.001) decreased post-operative ODI (31.7 ± 19.2) when compared with pre-operative ODI (66.2 ± 11.1).

Table (7): description of VAS difference in all studied patients

This table shows the description of VAS difference in all studied patients. The mean VAS difference of all studied patients was 4.2 ± 2.09 with minimum VAS difference of 1 and maximum VAS difference of 7.

Table (8): description of follow up day in all studied patients

This table shows the description of follow up days in all studied patients. The mean follow up days of all studied patients was 8.2 ± 3.2 days with minimum follow up days of 6 days and maximum follow up days of 14 days.