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The Sacroiliac Problem: Review of Anatomy, Mechanics, and Diagnosis

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The Sacroiliac Problem: Review of Anatomy, Mechanics, and Diagnosis The sacroiliac problem: Review of anatomy, mechanics, and diagnosis MYRON C. BEAL, DD., FAAO East Lansing, Michigan methods have evolved along with modifications in Studies of the anatomy of the the hypotheses. Unfortunately, definitive analysis sacroiliac joint are reviewed, of the sacroiliac joint problem has yet to be including joint changes associated achieved. with aging and sex. Both descriptive Two excellent reviews of the medical literature and analytical investigations of joint on the sacroiliac joint are by Solonen i and a three- movement are presented, as well as part series by Weisl. clinical hypotheses of sacroiliac joint The present treatise will review the anatomy of motion. The diagnosis of sacroiliac the sacroiliac joint, studies of sacroiliac move- joint dysfunction is described in ment, hypotheses of sacroiliac mechanics, and the detail. diagnosis of sacroiliac dysfunction. Anatomy The formation of the sacroiliac joint begins during the tenth week of intrauterine life, and the joint is fully developed by the seventh month. The joint In recent years it has been generally recognized surfaces remain flat until sometime after puberty; that the sacroiliac joints are capable of movement. smooth surfaces in the adult are the exception. The clinical significance of sacroiliac motion, or The contour of the joint surface continues to lack of motion, is still subject to debate. The role of change with age. 2m In the third and fourth decades the sacroiliac joints in body mechanics can be illus- there is an increase in the number and size of the trated by a mechanical analogy. A 1 to 2 mm. mal- elevations and depressions, which interlock and alignment of a bearing in a machine can cause ab- limit mobility. Schunke 5 reported that a variety of normal wear or a breakdown in function, not only grooves, ridges, eminences, and depressions can of the bearing and adjacent parts, but also of parts occur. After the third decade the opposing carti- remotely related to it through the creation of ab- lages are roughened, furred, and frayed, resem- normal forces. Joints in the body are subject to bling worn, degenerate areas. In the elderly, the similar types of dysfunction, which also may have joint cavity is partly obliterated by fibrous or fibro- local and remote effects. cartilaginous adhesions. 6 Ankylosis is first ob- Low-back pain is often accompanied by marked served in the ventral margins of the cranial part of changes in the soft tissues and in the gross motion the joint. It may be unilateral, occurring predomi- of the lumbar spine. There has been a tendency to nantly on the right. In some males, ankylosis ap- let these changes overshadow those observed at pears as early as the third decade. Holladay re- the sacroiliac joints. The interest of clinical inves- ported a case of unilateral ankylosis at age 25. He tigators has been stimulated by the potential of also observed that ankylosis was usually not de- the sacroiliac joints to cause dysfunction resulting veloped to the same degree on both sides. Brookes in both local and remote effects. Many clinicians reported that 75 percent of 54 sacra in men above believe that slight changes in mobility at the sa- the age of 50 were ankylosed. croiliac joints are responsible for a variety of clini- Wide variations in the structure of the sacroiliac cal conditions. These range from simple strains to joints have been noted. 1'5'8-18 The joint surfaces complex problems involving the spine, pelvis, and show divergence in size, shape, contour, facing, lower extremities. and location. They vary from individual to individ- Hypotheses on the nature of sacroiliac function ual, as well as from side to side in the same person. have been advanced to explain clinical problems of The joint is usually described as "L-shaped," the low back and pelvis. These concepts have been with the long arm directed caudally and the short the basis for the development of diagnostic tests arm cranially. Sometimes the arms appear to be and treatment procedures. Refinements in testing nearly equal in length. The joint may also be "V- The sacroiliac problem: Review of anatomy, mechanics, and diagnosis 667/73 shaped," with varying angles between the arms. aspect of the auricular surface is hollowed out pos- The short arm may be absent, and the surface re- terior to the elevations, forming a groove for the semble a rectangle, a triangle, or an intermediate longitudinal ridge, which characterizes the iliac form. The shape of the ventral border is related to surface. the curvature of the sacrum and the shape of the The sacral surface of the joint consists of three a 1 a . parts. Part 1, the cranial segment, is the largest The sacral surface of the joint is longer and nar- and is located on the body of the first sacral verte- rower than that of the ilia. The iliac surfaces of the bra. Part 2 is the narrowest portion and forms an joint are reciprocally shaped but not exactly con- isthmus joining the two facet segments. Part 3, the gruent with the sacral surface. caudad segment, is narrower and shorter than Weisl2 described the sacral joint surfaces in the Part 1 (Fig. 2). Part 3 may end at the junction of young adult as two elevations separated by a sad- the second and third sacral vertebrae, or it can ex- dle-shaped depression (Fig. 1). One elevation is tend to the mid-portion of the third sacral body". found on the cranial part of the lateral aspect of The latter is the most frequent occurrence. Other the first sacral vertebra. The second elevation is on variations have been reported by Peterson and the ventral aspect of the caudad part. The dorsal Solonen l (Table 1). The dimensions on the sacral articular surface have been reported by several investigators. De- scriptions of the method of measurement were giv- en in only two cases (Table 2). The articular surface may be located more for- ward or backward on the sacrum. Usually the shift is caudal rather than cephalic. The sacral surface is usually covered with hya- line cartilage, and the iliac surface is covered with fibrocartilage. 5 The cartilage layer fills out and partly obliterates the small depressions and ridges of both the sacral and iliac surfaces. The thickness of the cartilage has been estimated at 1-3 mm. on the sacral surface and about 1 mm. on the iliac sur- face. The thickness of the sacral cartilage surface is such that it resembles an articular disk and, Fig. 1. Auricular surface of sacrum. Adapted from Weisl (+ = thus, can facilitate joint movement." elevations). The planes of the articular surface of the sacroil- iac joint vary considerably from outflaring to in- flaring. In addition, the three parts of the sacroili- ac joint usually differ in the facing of the facet plane. The right and left sides are commonly dis- similar. Three types of sacral vertebrae have been described on the basis of measurements of the transverse distance of the dorsal and ventral sur- faces of the first three sacral segments9 (Fig. 3). Another study demonstrated four different types of sacral wedging based upon measurements of the transverse width of the sacrum. Variations in sacroiliac movement have been re- lated to age and sex. 2 The dimensions and relative proportions of the sacroiliac articular surfaces do not vary significantly for males and females. How- ever, one observer9 reported that the auricular sur- faces in females are smaller and smoother than in males. Irregularities in the facet surface that are associated with the aging process are observed ear- lier and are more pronounced in males. The loss of Fig. 2. Lateral view of sacral vertebra. Sacral segments are num- sacroiliac joint mobility occurs earlier in males, at bered I , 2, 3, 4, and 5. ages 40 to 50 and older; similar changes are not 118174 June 1082"Jouroal d A0Ahol. 81/no. 10 noted in the female until the end of the fifth de- TABLE 1. VARIATIONS OF THE AURICULAR JOINT SURFACE ON THE cade.22 SACRUM. Accessory auricular facets have been observed Vertebral dorsal to the auricular surface between a rudimen- segments No. of cases tary transverse process of the second sacral verte- Peterson Solonen SI, S2 21 3 bra and the ilium. 5 They range in size from 2 mm. Sl, S2, S3 242 23 to over 1 cm. in diameter and have a fibrocartilag- SI, S2, S3, S4 3 2 inous surface. S2, S3 3 The sacroiliac ligaments have been classified as S2, S3, S4 3 L5, Sl, S2 1 capsular and accessory ligaments (Fig. 4). The L5, Sl, S2, S3 4 ventral, interosseous, and dorsal sacroiliac liga- L6, Sl, S2 2 ments are capsular ligaments, and they play an L6, Sl, S2, S3 1 important part in maintaining the integrity of the Solonen observed two cases with Sl, S2, and S3 on one side, and Sl, sacroiliac joint. The interosseous ligament forms S2, S3, and S4 on the other side. the chief bond between the sacrum and ilia and TABLE 2. MINIMUM AND MAXIMUM DIMENSIONS OF THE SACRAL has cranial and caudal bands. JOINT SURFACE. The iliolumbar, sacrotuberous, and sacrospinous Investigator Length (cm.) Width (cm.) ligaments are described as accessory ligaments. A Schunke 55.3 - 8.0 1.8 - 4.1 striking feature of all the accessory ligaments in Albee 196.0 - 8.0 2.5 - 3.0 the adult is their arrangement into two groups of Weis1 25.1 - 6.9 2.9 - 4.1 Simkens2° 4.0 - 6.5 2.3 - 3.0 fasciculi, one cranial and the other caudal.
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