- Hammoudeh M.
- Khanjar I.
- Baronio M.
- Sadia H.
- Paolacci S.
- et al.
|Author year||Cases||Gender||Age (in years)||Kim Classification types||Duration from initial symptoms to final diagnosis||Clinical Presentation||Treatment||Follow-up||Fusion||Additional features|
|J Pouchot 1988|
|11||25–69 yrs (40.90)||7 M|
|1 wk to 13 mo.||All U/L, RT 5 LT 6|
MC buttock pain on the affected side.
Radicular pain in the lower back 7 cases
Tc 99 Scan uptake (10 cases)
|Pathology or bacteriology diagnosis only in 9 cases|
Arthrodesis in one case.
12–18 mo ATD
|Excellent out come in all||Healed in all||Pul Tb 4 cases,|
Tb spine 2 cases.
|Osman AA and Govinder S 1995|
|14||-||-||-||-||Low back pain buttock pain|
11 patient demineralization, hazineness and erosion
3 patients erosion with sclerosis
|2 patient abscess drainage|
18 Month ATD in all
|18 months to 4.5 year|
10 patients asymptomatic;
4 patients mild discomfort remained
|-||Concomitant chest and spine TB|
|Kim et al.|
|16||11-65 (32 yrs)||3 M|
|15–36 mo (8 mo)||Kim types Type 1: 2 Cases|
Type 2:1 cases
Type 3:6 cases
Type 4:7 cases
|One case B/L|
All patient buttock & LBP radicular pain(8 Cases), abscess
8 cases, sinus 2 cases
|Diagnosis confirmed only in 12 patients on pathology. Curettage or curettage and Arthrodesis if instability|
ATD 18 MO
Autologous BG (6 cases)
|2–3.7 yr (avg 2.5 yr)||Bony fusion achieved in 6 patients (18-26 mo);|
|Active Pul Tb in 5 cases,|
Tb spine 4 cases.
Complication one patient has draining sinus healed with sinus excision
|Mohammed Benchakroun 2004|
|4||Mean age 42||3 M|
|Mean 14 mo||All Aprin Stage 3 sacroiliitis||1 case B/L, 2 cases LT, 1 RT|
Case 1 LBP, buttock pain after prolonged sitting,
Case 2: sciatica and LBP gradual limp, wt loss
Case 3: LBP and sciatica
Case 4: LBP upon exertion 18 mo, difficult walking
|Surgical biopsy in all|
ATD in all
Case 1, 3, 4 only 6 mo
|Case 2 excellent 1 year later||Pos family history in case 2|
Mild pain upon exertion was the only residual symptom
|R J S Ramlakan 2007||15||15–60 yrs (mean: 27 yrs)||13 F|
|Range: 11 wk–39 wk (Mean: 18 wk).||14 U/L, 1 B/L,|
Persistent LBP and difficult walking
Loss of weight appetite and night sweats
Bone scans (Tc 99): increased uptake
X rays: jsw, joint margins sclerosis and periarticular osteopaenia
JSW, margins sclerosis, sequestra
|AFB: 9 cases open biopsy and Joint curettage Through PA|
Patients mobilised on crutches and ATD for 18 mo.
|3–10 years (mean: 5 years).||Bony healing radiologically evident at 2 yr||kk|
|Ahmed et al. 2013|
|Debridement and fusion Posterior Bone graft and screws|
|Pulmonary tuberculosis, epididymitis|
|42.4||F||Fistula Left, history of Multiple curettage operations before 6 months||Debridement and sequestrectomy, Posterior graft: None|
Rifampicin ? isoniazid (12 Mo)
|Lost follow up; out come not available||Spondylodiscitis L5–S1|
|56||M||Fistula right Multiple operations in SIJ||Debridement Posterior/posteriorb|
Rifampicin ? isoniazid 6Mo
|6 Mo; outcome: Poor||Psoas abscess|
Right Seven operations in SIJ before 30 years
|Debridement Posterior None Ciprofloxacin (4 Mo), ethambutol ? rifampicin ? isoniazid ? pyrazinamide (6 Mo)||86 Mo; Excellent out come|
|52.8||M||Bilateral Local pain||Debridement and fusion Posterior Bone graft Nitrofurantoin ? rifampicin ? isoniazid (6 Mo)||9 Mo; Poor out come||Spondylodiscitis L5–S1, psoas abscess, sacral decubitus ulcer|
|Gao 2011||15||17–64 yrs; mean 33.8||7 M|
|4–23 mo, mean (10.7 mo)|
Classified according to Kim Types
|Group A: 5 cases|
Group B 10 cases
|All U/L; RT 11 LT side|
Buttock pain and/or LBP, sciatica 4 cases, palpable mass or visible cutaneous fistulas 10 cases
|5 cases Group A Chemotherapy only|
Group B 10 cases Chemo and joint and sinus debridement surgery.
|30–87 mo (mean, 54 mo)||History of Corticosteroids use. pulmonary TB (two active and three old), old spine Tb in two and epididymis TB in one case|
|PRAKESH J 2014||35||22–55 yr (mean: 27 yR)||21 M|
|7 weeks–22 weeks (mean: 10 weeks)||Kim type|
6 type 1, 8 type 2, 7 type 3,
2 type 4
|3 case B/L; 32U/L|
Persistent low back pain and difficulty with walking
|ATD in all; surgical debridement in 9 patients||2 years (range 2–6 years||60% of patients bony ankylosis||13 patients history of TB contact|
4 patients MDR TB;
Past history PULTB 9, Potts spine 2, abdominal Koch's 3; incomplete DOTS 3; 4 tuberculosis in other region
|12||32.8 yr (range, 21–63 yr)||5 M|
|12.41 ± 4.36 months (range, 9–24 months)||1 case B/L, 11 cases U/L; persistent buttock or low back pain, a chronic sinus tract, and difficulty walking n all patients.||NPWT for an average of 18.33 ± 6.97 days (range, 14–35 days) with ATD||37.1 months||Bony fusion in 5 patients, and fibrous ankylosis in 7; healed in all||Recurrent TB of SIJ in one;|
Active TB in 2;
Spine TB in 2;
Intestinal TB in1
2 patients MDR TB
|Zhu et al. 2017||17||8 M|
|18 to 57|
|7 type II cases, 4 type III cases and 6 type IV cases||16.2 wk, Range: 6 wk to 15 mo||All cases U/L|
MC presentation LBP and buttock pain, difficulty walking
unable to ear weight (4 Cases), Sciatica (5 cases)
palpable inguinal mass (2 cases)
|11 type A: POWFD, BG and JF;|
4 type B: anterior abscess curettage before POWFD and JF;
2 type C: POWFD, JF and one-stage posterior lumbar focal lesion clearance, interbody fusion and IF.
|Avg. follow-up 36 mo|
Range: (26–45 mo)
|Bone fusion early on CT at 3 mo PO. All patients had solid joint fusion within 12 mo|
No complications or recurrence occurred.
|Pul TB in 4 cases|
2. Anatomic correlation, route, site, and spread of SIJ TB infection
- Garg R.K.
- Somvanshi D.S.
- Kramer L.
- Geib V.
- Evison J.
- Altpeter E.
- Basedow J.
- Brügger J.
- Seddon H.J.
- Strange F.G.
3. Clinical features of SIJ TB
3.1 Clinical presentation
3.2 Clinical assessment
3.3 Clinical diagnosis
- Mekhail N.
- Saweris Y.
- Sue Mehanny D.
- Makarova N.
- Guirguis M.
- Costandi S.
- A)Laboratory Investigations: The gold standard for diagnosing SI joint TB is by identification on culture and histopathological confirmation of Mycobacterium tuberculosis bacilli.
- a.Complete blood count, erythrocyte sedimentation rate (ESR), and C-Reactive Protein (CRP) are non-specific tests for diagnosing SI joint TB.
- b.A definitive diagnosis of SI joint TB requires confirmation with a microbiological identification of Mycobacterium tuberculosis bacilli and/or histopathological sample of involved tissue. As the SI joint is deeply placed, a Computed tomography (CT)-guided, Ultrasound (US) guided biopsy or open biopsy from the joint or synovial membrane can be undertaken for diagnosis. Pouchot et al. used needle biopsy to obtain tissue and noted a success rate of 81.8%.2However, an open biopsy may be needed when the aspirate yields no growth.
- c.Open Biopsy: A high yield can be obtained from an open biopsy, resulting in faster bone healing.15Kim et al. reported that a pathologic diagnosis could be made only in 75% of their cases.15Ramlakan and Govender yielded a pathologic diagnosis of Tuberculosis in 88% of patients using open biopsy through posterior approach.
- d.Microbiological examination includes identification of acid-fast bacillus (AFB) and mycobacterial culture on Lowenstein-Jensen (LJ) culture medium. However, the yield and culture growth is variable. Ramlakan and Govender were able to culture in 52% cases, whereas Luo et al. in 50% and Prakash et al. in 8% cases only.11,14,15
- e.Polymerase chain reaction (PCR) in synovial tissue or curette material allows amplification of the Mycobacterium tuberculosis genome and increasingly being used for diagnosis.7
- f.Histopathology usually reveals features suggestive of a granulomatous disease.14Other granulomatous diseases such as Brucellosis also affect the SIJ and should be excluded. Standard agglutination test (SAT) titre ≥1:160 favours the diagnosis of Brucellosis can be performed.27
- B)Imaging modalities for SIJ TB
- a.Plain Radiographs: Plain Radiographs in the initial stages may reveal haziness or loss of articular margins but later, as the disease progresses, joint widening, irregularity of articular surfaces and subchondral erosion is seen. (Fig. 1). If the disease process is halted (by treatment), narrowing of the joint space and marginal sclerosis is visible. However, if the disease progresses further, the erosive margins become distinct, and cavitation develops. Kim et al. have suggested a clinico-radiological classification of SIJ TB to guide treatment.
- b.Computed Tomography (CT) - CT demonstrates joint space widening, sequestrate and calcification more clearly than radiographs. Bony destruction, sclerosis and cavitation of the sacrum and fusion of the joint are better seen on CT.
- c.Ultrasound (US): US helps to locate the intrapelvic abscess and psoas abscess associated with SIJ TB and may guide diagnostic aspiration.28
- d.Magnetic resonance imaging (MRI)- MRI has been shown to be more sensitive than CT in early diagnosis and has superior ability to evaluate the integrity of the SIJ cartilage.29In the early stages of the disease, capsular distention is evident. Peri articular bone-marrow edema in the sacrum or ilium or both and soft tissue edema, joint space enlargement, joint effusion, small intraosseous abscesses, cold abscesses, destruction of iliac and sacral bones and sinus tracts are seen easily on MRI and these point towards infective pathology (Fig. 2, Fig. 3, Fig. 4).30Contrast MRI with Gadolinium-enhanced T1-weighted imaging shows typical peripheral rim enhancement of TB cold abscesses with central necrosis. It is difficult to differentiate pyogenic sacroiliitis from tuberculous sacroiliitis on MRI however features such as pre-existing osteomyelitis in ilium, wide joint space points towards the diagnosis of TB. Further, TB sacroiliitis will have thin, enhancing rim in comparison to the thick and irregular enhancing rim of pyogenic abscess.31MRI findings of periarticular muscle edema, thick capsulitis, extracapsular fluid collections and large bone erosion reliably differentiate infectious sacroiliitis from unilateral sacroiliitis associated with spondyloarthritis. The presence of iliac-dominant bone marrow edema and joint space enhancement supports the diagnosis of spondyloarthritis.32
- e.Isotope bone scanning (IBS): IBS is a helpful tool for diagnosis of sacroiliitis when the diagnosis is not clear with other modalities. Technetium-99 m methylene diphosphonate (Tc-99 m MDP) bone scintigraphy shows intense tracer uptake however can be non-specific. To increase specificity, newer scintigraphic techniques have been investigated. Single photon emission computed tomography/computed tomography (SPECT/CT) demonstrates a widened right SI joint with increased uptake. FDG Positron Emission Tomography (FDG-PET Scan) may be more sensitive, especially at early stages of inflammation due to physiological basis of the technique and improve diagnostic accuracy.21,33
- C)Clinico-Radiological classification for SIJ TB
- i)Kim et al. have classified SIJ TB into 4 categories based on severity of clinical and radiographic findings. This classification helps in guiding treatment in patients with SIJ TB.9(Fig. 5).
- ii)Zhu et al. on the other hand have proposed their classification based on the surgical method and radiological features in to 3 types.16(Fig. 6).
5. Treatment strategies in the management of SI joint tuberculosis
5.1 Non-operative management-
- Kumar S.
- Jain V.K.
5.2 Operative management options and clinical outcomes in literature
- 5.2.1.Surgical therapy includes debridement of infected joint material, drainage of abscesses, decompression, joint curettage, arthrodesis with or without bone grafts and spinal stabilization in cases of concomitant spinal TB.
- 5.2.2.Shi opined that the surgical approach should be chosen according to the location and size of abscess and the direction of fistula for SIJ TB. He indicated anterior approach for abscess in iliac fossa or with fistula in buttock; Posterior approach for cases with or without abscess and/or fistula of buttock and combined approach for the cases with large abscess and/or fistula both at iliac fossa and buttock region.36
- 5.2.3.About 75% of patients in Kim et al study were treated by surgical methods along with ATT. Authors suggest that surgery eradicates pus, granulation and necrotic tissue. They believe surgery improves the effectiveness of ATT by increasing blood flow to surgical site and reduces overall treatment period.
- 5.2.4.In about 46.6% of patients in Gao et al. series, debridement and arthrodesis was undertaken. The indication of arthrodesis was an unstable SI Joint due to extensive joint destruction. An additional iliac bone flap was pedicled with gluteus maximus to fill large tuberculous cavity and induce bony fusion.
- 5.2.5.Zhu et al have proposed a surgical approach method to treat SIJ TB based on their classification16(Fig. 5). They suggested that the surgical approach should be chosen according to the location and size of abscess and the direction of fistula. Type A patients were approached with posterior open-window focal debridement, autologous bone graft and joint fusion. They believe, posterior approach offers appropriate exposure of SI joint without risk of injury to neurovascular structures. Type B patients were treated first with anterior abscess curettage in supine then posterior open-window focal debridement and joint fusion in prone position. Further the Type C patients were operated with posterior open-window focal debridement, joint fusion and one-stage posterior lumbar focal lesion clearance, interbody fusion and internal fixation.
- 5.2.6.Use of Bone grafting: While Zhu et al used bone graft in all patients to achieve union, others have not routinely used it after joint curettage and debridement.9,11,13,
- 5.2.7.Use of OsteoSet: Li et al successfully treated SIJ TB by using bone graft interbody fusion along with rifampicin loaded OsteoSet after joint debridement. Bone union was observed at 10.5 months on average in about 90% patients.37
- 5.2.8.Minimally Invasive surgery: A minimally invasive retroperitoneoscopic technique has been used by Chandrasekhar et al in 2 patients of anterior sacroiliac joint tuberculosis. This technique helps to avoid sacral nerve roots injury and posterior cortex break with an advantage of providing early patient mobilization.38
- 5.2.9.Role of Negative Pressure Wound Therapy (NPWT): Luo et al. have successfully used NPWT therapy in all patients to treat chronic sinuses in SIJ TB. They concluded that the use of NPWT can decrease the mycobacterial load by removing pus, necrotic tissue and promote the proliferation of granulation tissue in the sinus tract.15
- 5.2.10.Role of Immobilization after surgery: Immobilization by bed rest and/or spica cast/orthosis/lumbosacral brace is recommended for patients with severe pain or after operative management by some authors.13,
6. Monitoring response to therapy
7. Prognostic factors in the outcome of SIJ TB
Statement of ethics
Declaration of competing interest
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