Advanced Surgical and Therapeutic Trends in the Treatment of Chronic Sacroiliitis in Neurosurgery

C KURQLF VDFURLOLLWLV LV DQ LQÀDPPDWLRQ RI WKH VDFURLOLDF MRLQWV ZKLFK LV RIWHQ DVVRFLDWHG with diseases of the group of seronegative VSRQG\ORDUWKURSDWKLHV VXFK DV DQN\ORVLQJ VSRQG\- litis and psoriatic arthritis. The disease is character- L]HGE\SURORQJHGORZEDFNSDLQVWLႇQHVVDQGIXQF- WLRQDOOLPLWDWLRQWKDWFDQVLJQL¿FDQWO\LPSDLUSDWLHQWVµ TXDOLW\RIOLIH>@ 7UDGLWLRQDOO\ WUHDWPHQW LQFOXGHV FRQVHUYDWLYH PH WKRGVVXFKDVQRQVWHURLGDODQWLLQÀDPPDWRU\GUXJV 16$,'V SK\VLRWKHUDS\ DQG LPPXQRVXSSUHVVLYH WKHUDS\ > @ +RZHYHU LQ VRPH SDWLHQWV V\PS- tomatology remains persistent and more aggressive WKHUDSHXWLFDSSURDFKHVDUHUHTXLUHGLQFOXGLQJLQWUD articular administration of hyaluronic acid and corti- FRVWHURLG XQGHU LPDJHJXLGHG VXUJLFDO LQWHUYHQWLRQ >@2YHUWKHSDVWGHFDGHPHGLFDOVFLHQFHKDV made advances in both the diagnosis and treatment RIVDFURLOLLWLV7KHGHYHORSPHQWRIELRORJLFDJHQWVDV ZHOO DV PLQLPDOO\ LQYDVLYH VXUJLFDO WHFKQLTXHV KDV RSHQHG QHZ DYHQXHV IRU FRQWUROOLQJ LQÀDPPDWLRQ DQGLPSURYLQJIXQFWLRQDOFDSDFLW\>@ The aim of the present study is to analyze current trends in the therapeutic approach to chronic sacro- LOLLWLVIRFXVLQJRQWKHUROHRIVXUJLFDOWUHDWPHQWLQWKH comprehensive approach to the disease.

'XULQJ WKH SHULRG 0DUFK  ± 0DUFK   patients with chronic sacroiliitis were diagnosed in the Department of Neurosurgery at Pulmed Univer- sity Hospital by physical examination and diagnostic imaging. The latter were staged using the Oswestry 'LVDELOLW\,QGH[9$69LVXDO$QDORJXH6FDOHRI3DLQ and the „Facial Pain Rating Scale“. Only patients with involvement of both sacroiliac joints were included in the study. The values of the VAS scale and „Facial Pain Rating Scale“ were distributed in a scoring sys- tem as follows: ±QRSDLQQRSDLQQRGLႈFXOW\LQGDLO\OLIH ±OLWWOHSDLQGLႈFXOW\LQGDLO\OLIH ±PRGHUDWHPHGLXPSDLQGLႈFXOWLHVDQGRUOLPL- WDWLRQVLQGDLO\OLIH ±VHYHUHSDLQOLPLWDWLRQVLQGDLO\OLIH 7-9 – very severe pain (limitations and/or inability to IXQFWLRQLQGDLO\OLIH 9-10 – terrible/unbearable/unbearable pain (inability to function in daily life). 7KHGLVWULEXWLRQRISDWLHQWVE\VH[DJHDQGSDLQVH- YHULW\ DFFRUGLQJ WR WKH GLႇHUHQW VFDOHV FDQ EH SUH- sented graphically in the following table: Preoperative imaging by computer-assisted tomo- graphy (CAT) and magnetic resonance imaging (MRI) was also a consideration in the diagnosis of the patients. Each patient underwent an MRI of the lumbar spine and sacroiliac region to exclude pathol- RJ\LQWKHOXPEDUVSLQH7KHFKDUDFWHULVWLFLQÀDPPD- tory responses on the bone side in the presence of ankylosing spondylitis are presented in Figure 1. Male/female sex Ages Oswestry Disability Index pain score VAS pain assessment Pain assessment on a “Face scale” Men (12 patients) 63+/- 2 years old 21% – 40% moderate disability 5-7 severe pain (limitations in daily life) 3-5 moderate/medium SDLQGLႈFXOW\RU

in daily life) Women (16 patients) 66+/- 2 years old 21% – 40% moderate disability 5-7 severe pain (limitations in daily life) 5-7 severe pain (limitations in daily life) Table 1. 6KRZVWKHGLVWULEXWLRQRISDWLHQWVE\JHQGHUDJHDQGSDLQVHYHULW\ 3Advanced surgical and therapeutic trends... Fig. 1.5DGLRJUDSKDQG05,RIWKHOXPEDUVSLQHDQGVDFURLOLDFUHJLRQSUHVHQWLQJGHJHQHUDWLYHFKDQJHVLQWKHMRLQW ZRPHQ'XULQJWKHWKLUGWULPHVWHURIIROORZXSPHQ and 10 women were reported to have fully responded to the treatment. Interpretation of the results indicates that the best HႇHFW ZDV DFKLHYHG LQ WKH ¿UVW  PRQWKV DIWHU WKH PDQLSXODWLRQZDVSHUIRUPHG$WWKHVL[WKPRQWKWKH percentage of patients who had no pain remained KLJKDOWKRXJKEHWZHHQWKHWKDQGWKPRQWKVWKH study population that responded to the surgical treat- PHQWGURSSHGFRPSDUHGWRWKH¿UVWWULPHVWHU'HVSLWH WKHVHUHVXOWVRXUFRQFOXVLRQLVWKDWWKHPHWKRGXVHG shows good results for the treatment of chronic sac- URLOLLWLVLQERWKVH[HV*UDSKLFDOO\WKHUHVXOWVDUHSUH- sented in Figure 2.

$[LDO VSRQG\ORDUWKULWLV LV D FKURQLF V\VWHPLF LQÀDP- matory disease. Sacroiliitis is a part of these diseas- HVWKDWFDQKDYHGLႇHUHQWHWLRORJLHVDQGEHRIGLႇHU- HQWW\SHV>@7KHHPEU\RQLFGHYHORSPHQWRIWKH joint occupies an important place. The sacroiliac joint The treatment of the patients was performed using a PLQLPDOO\LQYDVLYHPHWKRGLQWKHRSHUDWLQJURRPRE- serving the rules of asepsis and antisepsis. Patients ZHUHDQHVWKHWL]HGE\ORFDOLQ¿OWUDWLRQZLWK/LGRFDLQH 20 mg/ml. The technique of the performed manipu- ODWLRQ FRQVLVWHG RI LQ¿OWUDWLRQ RI WKH VDFURLOLDF MRLQW XQGHU UDGLRORJLFDO FRQWURO IRU WKLV SXUSRVH SKDVH X-rays were used with a C-arm model „FYS3360A“ with a radiation source of 0.002 mGy/h) with the SODFHPHQW RI  PO RI K\DOXURQLF DFLG LQ HDFK MRLQW followed by 7 mg/ml. Flosterone. The manipulation ends with a sterile dressing of the surgical wounds. ,Q WKH WUHDWPHQW SURWRFRO ZH HVWDEOLVKHG SDWLHQWV had to perform bed rest for 30 to 60 minutes after the PDQLSXODWLRQ ZDV SHUIRUPHG DIWHU ZKLFK WKH\ ZHUH verticalized and ambulated independently.

3RVWRSHUDWLYHO\ SDWLHQWV ZHUH PRQLWRUHG DQG DV- sessed by applying the original pain rating scales. The study continued for 9 months after the manipula- tion. Patient assessment on day seven showed the following results: relative to the Oswestry Disability ,QGH[ERWKVWXG\JURXSVKDGDYHUDJHSDLQVHYHULW\ VFRUHV RI  PLQLPDO GLVDELOLW\ LQGLFDWLQJ WKH patients could manage activities of daily living. Simi- lar results were observed for the VAS and the „Facial 3DLQ5DWLQJ6FDOH³ZKHUHSDWLHQWVUDWHGWKHLUSDLQLQ WKHUDQJH±QRSDLQQRSDLQQRGLႈFXOW\LQGDLO\ activities). Similar results were observed in the study FRKRUWLQWKH¿UVWWULPHVWHU'XULQJWKHVHFRQGWULPHV- WHURIIROORZXSRIWKHPHQUHSRUWHGDQGZHUHDV- VHVVHGDVKDYLQJUHFXUUHQWSDLQDQGYDOXHVVLPLODU to baseline. Similar complaints were recorded in 2 Fig. 2. Graphical depiction of postoperative outcomes in treat- HGSDWLHQWVLQDEVROXWHYDOXHVDႇHFWHGE\WKHWUHDWPHQW 4 K. Bechev, N. Yotova, D. Markov et al. YLFJLUGOHORRVHQXQGHUWKHLQÀXHQFHRIWKHKRUPRQH relaxin. The range of motion in the joints increases >    @ 7KH VDFURLOLDF MRLQW KDV LPSRUWDQW relationships with neighboring organs. The internal and external iliac veins connect to form the common LOLDFYHLQLPPHGLDWHO\DQWHULRUWRWKHMRLQW7KXVWKH\ separate the joint from the bifurcation of the common LOLDFDUWHU\DQGPRUHDQWHULRUO\IURPWKHXUHWHU> @7KHOXPERVDFUDOWUXQNDQGQREWXUDWRULXVDUH located along the anterior surface of the joint behind the vessels. M. piriformis partially traps the anterior VXUIDFHRIWKHMRLQWFDSVXOHVHSDUDWLQJWKHMRLQWIURP WKHXSSHUSDUWRIWKHSOH[XVVDFUDOLV>@7KLVDQD- WRPLFDO SUR[LPLW\ LQÀXHQFHV WKH FOLQLFDO SLFWXUH DQG creates conditions for the involvement of adjacent anatomical elements. The close relationship of the joint with the neural elements also explains the irra- GLDWLRQRISDLQLQGLႇHUHQWGLUHFWLRQV>@ 'HSHQGLQJ RQ WKH HWLRORJ\ VDFURLOLLWLV FDQ EH UKHX- PDWLF LQIHFWLRXV GUXJLQGXFHG RU RQFRORJLFDO > @ $QN\ORVLQJ VSRQG\OLWLV SVRULDWLF DUWKURSDWK\ %HFKHWµV GLVHDVH K\SHUSDUDWK\URLGLVP DQG YDULRXV S\RJHQLF FDXVHV PD\ DFFRPSDQ\ LW ,QÀDPPDWRU\ VDFURLOLLWLVPD\EHVHFRQGDU\WRRVWHRDUWKULWLVSUHJ- QDQF\RUWUDXPD&OLQLFDOPDQLIHVWDWLRQVLQFOXGHORZ EDFNSDLQVWLႇQHVVDQGDWDODWHUVWDJHUHVWULFWLRQ of movement. Benjamin Buchanan and Matthew Var- acallo report that only 10% to 25% of all low back pain is due to sacroiliac pain. In up to 50% of these FDVHVWKHSDLQUDGLDWHVWRWKHORZHUH[WUHPLW\LQ LWUDGLDWHVWRWKHOXPEDUUHJLRQLQWRWKHLQJXLQDO UHJLRQDQGLQWRWKHORZHUDEGRPHQ>@3DLQ PRVW FRPPRQO\ UDGLDWHV WR WKH // GHUPDWRPHV EXW LW FDQ DOVR H[WHQG RYHU WKH / RU EHORZ WKH 6 GHUPDWRPHV 2YHU WKH \HDUV YDULRXV FULWHULD KDYH EHHQSXEOLVKHGIRUWKHGLDJQRVLV,QWKHOLWHUDWXUHWKH Rome criteria of 1961 and the New York criteria of 1984 are known. The discovery in 1973 of the close DVVRFLDWLRQ RI WKH +/$% OHXNRF\WH DQWLJHQ DQG VSRQG\ORDUWKULWLV ZDV YHU\ VLJQL¿FDQW > @ ,Q QHZ$PRUFULWHULDZHUHSXEOLVKHGDQGDGRSWHG by the European Spondyloarthropathy Association. 7KHPRUHLPSRUWDQWRQHVDUH>@ A. Past or present clinical manifestations %DFNSDLQDWQLJKWDQGRUPRUQLQJVWLႇQHVV 2. Asymmetric oligoarthritis 3. Permanent or alternating gluteal pain B. Detection of changes on imaging C. Predisposing genetic factors D. Positive reaction after administration of appropri- ate therapy :DOWHU0DNV\PRZ\FK5RHEHUW/DPEHUWHWDOUHSRUW- HGFDSVXOLWLVHQWKHVLWLVDQGOHVLRQVDQGHURVLRQVRI the tissue surrounding the joint. They also introduced LVIRUPHGLQWKHVHFRQGPRQWKRIJHVWDWLRQDODJHD WKLQ¿EURXVFDSVXOHLVIRUPHGLQWKH¿IWKPRQWKDQG LQWKHWKJHVWDWLRQDOZHHNWKHV\QRYLDOPHPEUDQH FRYHUVWKHMRLQWFDSVXOH7KH¿UVWGHFDGHRIDQLQGL- YLGXDOµVGHYHORSPHQWLVDVVRFLDWHGZLWKSURSRUWLRQDO JURZWK RI WKH MRLQW DQG WKH GHYHORSPHQW RI ¿EURXV FDUWLODJHZKHUHDVLQWKHVHFRQGDQGWKLUGGHFDGHV the articular surfaces begin to become uneven and SURPLQHQWHGJHVDSSHDURQWKHLOLDFVXUIDFHV>@ The sacroiliac joint is a semi-mobile joint that con- nects the sacrum to the two pelvic bones. The facies auricularis of the os sacrum and the facies auricu- laris of the os ilium serve as the articular surfaces. They correspond in shape and relief and are covered with hyaline cartilage. The cartilage of the os ilii is twice as thin and more often shows degenerative FKDQJHV>@7KHDUWLFXODUFDSVXOHLVVKRUWDQG attaches at the edges of the articular surfaces. The DUWLFXODUOLJDPHQWVDUHDQWHULRUSRVWHULRUDQGLQWHURV- seous. The anterior ones fuse with the superior and inferior regions of the joint. The posterior ones are PRUHQXPHURXVWKLFNHUDQGFRQVLVWRIVKRUWDQGORQJ bundles. The short bundles lie deep and attach to the SRVWHULRU VXUIDFH RI WKH VDFUXP SDUWLDOO\ FRYHULQJ WKHIRUDPLQDVDFUDOLDSRVWHULRUD>@7KHORQJOLJD- PHQWVDUHORFDWHGPRUHVXSHU¿FLDOO\7KH\GHVFHQG obliquely from the tuberositas iliaca to the middle part RIWKHFULVWDVDFUDOLVODWHUDOLVEHFRPLQJHQWZLQHGLQ WKH¿EHUVRIWKHOLJVDFURWXEHUDOH$VOLJLOLROXPEDOH DUHGHVLJQDWHGWKH¿EUHVZKLFKVWDUWIURPWKHSURFHV- sus costalis of the 5th lumbar vertebra and end at the crista iliaca. Deepest between the tuberositas sacra- lis and tuberositas iliaca are ligg. sacroiliaca interos- VHL>@7KHFDSVXOHRIWKHVDFURLOLDFMRLQWLVUHOD- WLYHO\WKLQDQGGHIHFWVDUHRIWHQVHHQKHUHWKURXJK ZKLFKV\QRYLDOÀXLGRUSXVOHDNVLQWRWKHVXUURXQGLQJ structures. The sacroiliac joint is subjected to con- tinuous stress and strain. It consists of two parts: the V\QGHVPRVLVDQGWKHV\QRYLDOSDUW>@ Fibrous adhesions and mild obliteration are seen LQ ERWK VH[HV HDUOLHU LQ PHQ DQG DIWHU PHQRSDXVH LQZRPHQ,WXVXDOO\RFFXUVDIWHUDJH>@,Q DGXOWLQGLYLGXDOVWKHMRLQWPD\EHFRPSOHWHO\¿EURVHG DQG VRPHWLPHV HYHQ RVVL¿HG &KDQJHV LQ WKH VDF- URLOLDF MRLQW FDQ FDXVH ORZ EDFN DQG VFLDWLF SDLQ >   @ 7KH GLDJQRVLV RI SDLQ RULJLQDWLQJ IURP WKLV MRLQW LV TXLWH GLႈFXOW EHFDXVH WKH VDPH FRPSODLQWV can be caused by disease of other anatomical struc- WXUHV8VXDOO\SDWLHQWVZLWKSDWKRORJ\LQWKHMRLQWUH- SRUWSDLQEHORZWKHOHYHORIWKHWKOXPEDUYHUWHEUD and most often it is localized around the position of the spina iliaca posterior superior. Similar complaints were reported by patients in our study group. Dur- LQJ SUHJQDQF\ WKH MRLQWV DQG OLJDPHQWV RI WKH SHO- 5Advanced surgical and therapeutic trends... D QHZ GH¿QLWLRQ LQFOXGLQJ VXEFKRQGUDO LQ¿OWUDWLRQ SUHVHQFHRIÀXLGLQWKHMRLQWHURVLRQRIWKHMRLQWFDY- LW\DQN\ORVLVDQGERQHEXGV>@ 7KH PRVW FRPPRQ V\PSWRP LV ORZ EDFN SDLQ ZLWK pain being strongest in the morning and diminishing DIWHU PRYHPHQW WKH ODWWHU LQFUHDVLQJ DIWHU VWDQGLQJ in a sitting position for a long time and when climb- ing stairs or crossing the legs. Most patients report DVKDUSGXOORUVWDEELQJSDLQWKDWVSUHDGVIURPWKH ORZHUEDFNWRWKHEXWWRFNDUHDDQGWKHUHLVRIWHQD IHHOLQJRIVWLႇQHVVLQWKHPRUQLQJWKDWODVWVIRUPRUH than an hour each time after waking. One of the PRVWFRPPRQV\PSWRPVLVDFKDQJHLQJDLW> @ 6DFURLOLLWLV LV GLႈFXOW WR GLDJQRVH DQG WKHUHIRUH UHVHPEOHV WKH V\PSWRPV RI OXPEDU GLVF KHUQLDWLRQ FR[DUWKURVLVDQGVFLDWLFQHUYHLQÀDPPDWLRQ$OOWKLV leads to incorrect treatment and delay in diagnosis >@ Diagnosis is made by a thorough physical examina- tion of the patient and the use of diagnostic imag- LQJPRGDOLWLHVWKHPRVWFRPPRQO\XVHGEHLQJSHO- YLF UDGLRJUDSK FRPSXWHG D[LDO WRPRJUDSK\ &$7 PDJQHWLF UHVRQDQFH LPDJLQJ 05, > @ 7\SLFDO ¿QGLQJV RQ VDFURLOLDF MRLQW UDGLRJUDSKV DUH VFOHUR- VLVHURVLRQSVHXGRGLODWDWLRQDQGERQHEULGJLQJ&7 GLDJQRVLVVKRZVVLPLODUFKDQJHVDVUDGLRJUDSKVEXW with much greater detail when illustrating bony struc- WXUHV6FOHURVLVQDUURZLQJRIWKHDUWLFXODUFOHIWHUR- sions and ankylosis are again seen. The greatest ad- vantage of the MRI scan is the clear visualization of GHWDLOHGDQDWRP\SDWKRORJLFFKDQJHVDQGWKHIRFXV RILQÀDPPDWLRQ7KHLPDJHWKDWLVREWDLQHGLQFOXGHV the abnormalities of the periarticular soft tissues that are only indirectly visible with other methods. Chronic structural changes of the bone and joint are very well YLVXDOL]HGVXFKDVSHULDUWLFXODUIDWW\WLVVXHDFFXPX- ODWLRQVXEFKRQGUDOHURVLRQVVFOHURVLVERQHEULGJHV and ankylosis. Detection of periarticular fatty tissue deposits is particularly important because other im- aging modalities do not visualize these deposits. MRI LVQRWDVVRFLDWHGZLWKUDGLDWLRQH[SRVXUHVRLWLVDS- SURSULDWH IRU \RXQJ ZRPHQ FKLOGUHQ DQG SDWLHQWV with more previous exposure. Patients diagnosed with sacroileitis are considered „MRI positive“ if more than one lesion is visible on a single slide. If only one OHVLRQLVSUHVHQWLWVKRXOGDOVREHSUHVHQWLQWKHQH[W WZRVOLGHV>@ Hyaluronic acid (HA) is one of the main components of the extracellular matrix that plays an important role LQWKHSUHVHQFHRIDVHSWLFLQÀDPPDWLRQLQMRLQWVDV- sociated with the accumulation of HA polymers and FHOOV RI FKURQLF QRQVSHFL¿F LQÀDPPDWLRQ7KH ODWWHU FRQWUROV WKH H[SUHVVLRQ RI LQÀDPPDWRU\ JHQHV DQG WKHUHOHDVHRIF\WRNLQHVLQWKHSURFHVVRILQÀDPPD- tion. It has been shown that upon local placement RI H[RJHQRXV +$ LQ WKH VDFURLOLDF MRLQW PHWDEROLF processes are initiated by synthesis and accumula- tion in the cartilaginous parts of the latter. In normal WLVVXHV+$LVLQWKHIRUPRIDKLJKPROHFXODUZHLJKW compound (HMW-HA) that inhibits angiogenesis by reducing the proliferation and migration of endothelial FHOOV DQG WKH H[SUHVVLRQ RI LQÀDPPDWRU\ UHDFWLRQV Research has shown that HMW-HA blocks T cell pre- FXUVRUVDQGSURGXFHV,/WKHUHE\UHGXFLQJWKHLQ- ÀDPPDWRU\UHVSRQVH>@

Surgical treatment of chronic sacroiliitis with intra- articular administration of corticosteroids and hyal- uronic acid has shown promising results in terms RISDLQUHGXFWLRQLPSURYHGIXQFWLRQDOFDSDFLW\DQG quality of life in patients. The combined approach DOORZV ERWK FRQWUROOLQJ WKH LQÀDPPDWRU\ SURFHVV through corticosteroids and hyaluronic acid and pro- viding structural and metabolic support of the joint. 'HVSLWHRXUFOLQLFDOREVHUYDWLRQVLQWKHVWXG\FRKRUW further randomized clinical trials with a larger num- ber of patients and long-term follow-up are needed WRYDOLGDWHWKHHႈFDF\DQGVDIHW\RIWKLVWKHUDSHX- WLF VWUDWHJ\ 6FLHQWL¿F HYLGHQFH VXJJHVWV WKDW WKH VDFURLOLDFMRLQWDQDWRP\LVXQGHUVHYHUHVWUHVVUH- VXOWLQJLQSDLQDQGVXEVHTXHQWGLVDELOLW\ZKLFKKDV EHHQVXFFHVVIXOO\DGGUHVVHGE\LQWUDDUWLFXODUÀXR- URVFRSLF QDYLJDWLRQ K\DOXURQLF DFLG DGPLQLVWUDWLRQ DQGÀRVWHURQH Author Contributions: All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Pulmed University Hospital for studies involving human subjects. Each of the patients included in the observational study gave their verbal consent to the treating physician that they agreed to be treated in the manner described, having been LQIRUPHG LQ DGYDQFH RI WKH EHQH¿WV DQG SRVVLEOH ULVNV RI the procedure. No complications were observed during or after the procedure. Informed consent statement: Verbal informed consent was obtained in the presence of each of the authors of the VFLHQWL¿FDUWLFOHIURPDOOSDUWLFLSDQWVLQWKHVWXG\ &RQÀLFWVRI,QWHUHVW7KHUHLVQRFRQÀLFWRILQWHUHVWLQWKH VFLHQWL¿FDUWLFOHSUHVHQWHG 6 K. Bechev, N. Yotova, D. Markov et al.

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