Background: Sacroiliac joint pain is increasingly recognized as a cause of low back pain. We compared the safety and effectiveness of minimally invasive sacroiliac joint arthrodesis using triangular titanium implants and conservative management in patients with chronic sacroiliac joint pain. Methods: This study was a prospective, multicenter randomized controlled trial of adults with chronic sacroiliac joint pain assigned to either conservative management or sacroiliac joint arthrodesis with triangular titanium implants. The study end points included self-rated low back pain (visual analog scale [VAS]), back dysfunction (Oswestry Disability Index [ODI]), and quality of life. Ninety percent of subjects in both groups completed the study. Results: Between June 6, 2013, and May 15, 2015, 103 subjects were randomly assigned to conservative management (n = 51) or sacroiliac joint arthrodesis (n = 52). At 2 years, the mean low back pain improved by 45 points (95% confidence interval [CI], 37 to 54 points) after sacroiliac joint arthrodesis and 11 points (95% CI, 2 to 20 points) after conservative management, with a mean difference between groups of 34 points (p < 0.0001). The mean ODI improved by 26 points (95% CI, 21 to 32 points) after sacroiliac joint arthrodesis and 8 points (95% CI, 2 to 14 points) after conservative management, with a mean difference between groups of 18 points (p < 0.0001). Parallel improvements were seen in quality of life. In the sacroiliac joint arthrodesis group, the prevalence of opioid use decreased from 56% at baseline to 33% at 2 years (p = 0.009), and no significant change was observed in the conservative management group (47.1% at baseline and 45.7% at 2 years). Subjects in the conservative management group, after crossover to the surgical procedure, showed improvements in all measures similar to those originally assigned to sacroiliac joint arthrodesis. In the first 6 months, the frequency of adverse events did not differ between groups (p = 0.664). By month 24, we observed 39 severe adverse events after sacroiliac joint arthrodesis, including 2 cases of sacroiliac joint pain, 1 case of a postoperative gluteal hematoma, and 1 case of postoperative nerve impingement. The analysis of computed tomographic (CT) imaging at 12 months after sacroiliac joint arthrodesis showed radiolucencies adjacent to 8 implants (4.0% of all implants). Conclusions: For patients with chronic sacroiliac joint pain due to joint degeneration or disruption, minimally invasive sacroiliac joint arthrodesis with triangular titanium implants was safe and more effective throughout 2 years in improving pain, disability, and quality of life compared with conservative management. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Purpose To compare the safety and effectiveness of minimally invasive sacroiliac joint fusion (SIJF) using triangular titanium implants vs conservative management (CM) in patients with chronic sacroiliac joint (SIJ) pain. Methods 103 adults with chronic SIJ pain at nine sites in four European countries were randomly assigned to and underwent either minimally invasive SIJF using triangular titanium implants (N = 52) or CM (N = 51). CM was performed according to the European guidelines for the diagnosis and management of pelvic girdle pain and consisted of optimization of medical therapy, individualized physical therapy (PT) and adequate information and reassurance as part of a multifactorial treatment. The primary outcome was the difference in change in self-rated low back pain (LBP) at 6 months. Additional endpoints included quality of life using EQ-5D-3L, disability using Oswestry Disability Index (ODI), SIJ function using active straight leg raise (ASLR) test and adverse events. NCT01741025. Results At 6 months, mean LBP improved by 43.3 points in the SIJF group and 5.7 points in the CM group (difference of 38.1 points, p \ 0.0001). Mean ODI improved by 26 points in the SIJF group and 6 points in the CM group (p \ 0.0001). ASLR, EQ-5D-3L, walking distance and satisfaction were statistically superior in the SIJF group. The frequency of adverse events did not differ between groups. One case of postoperative nerve impingement occurred in the surgical group. Conclusions In patients with chronic SIJ pain, minimally invasive SIJF using triangular titanium implants was safe and more effective than CM in relieving pain, reducing disability, improving patient function and quality of life.

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Our analysis shows that RLP is a frequent phenomenon in patients with SIJ-associated pain. At 6 months of follow-up, MISM helped relieve RLP more effectively than CM. Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique identifier: NCT01741025.

Study Design:Secondary analysis of data from a randomized controlled trial.Objectives:To identify risk factors for continued opioid use after conservative management (CM) or minimally invasive surgical management (MISM) of low back pain (LBP) originating from the sacroiliac joint.Methods:Patients were randomized either to CM (n = 49) or MISM (n = 52). We documented opioid use, pain intensity (visual analogue scale [VAS]), Oswestry Disability Index (ODI), and the Zung depression score (Zung Self-Rating Depression Scale) at baseline and at months 3 and 6 after treatment initiation.Results:Compared with opioid nonusers, opioid users at baseline had higher mean levels of disability (ODI 61.5, standard deviation [SD] 13.3 vs ODI 51.5, SD 12.8; P < .01) and higher depression scores (Zung 48.5, SD 8.5, vs Zung 42.2, SD 7.2; P < .01). At 6 months, opioid users had higher 6-month pain levels (VAS 60.4, SD 24.0, vs VAS 42.4, SD 28.2; P < .01), higher disability scores (ODI 50.5, SD 16.2, vs ODI 32.7, SD 19.3; P < .01) and higher depression scores (Zung 47.6, SD 8.0, vs Zung 38.8, SD 8.9; P < .01). Risk factors for continued opioid use at 6 months were patient age (odds ratio [OR] for age = 0.91; P = .02) and an increase in LBP (OR 1.08; P = .02) in the CM group and a lack of improvement in depression scores (OR 1.12; P = .03) in the MISM group.Conclusions:In our patient cohort, the risk of continued opioid use in the treatment of LBP increased not only with pain intensity but also with levels of depression during the course of treatment.

A 79-year-old female patient was referred to the radiology department because of a slowly enlarging bony mass on her left forehead. Neurological and systemic examinations were otherwise unremarkable.Computed tomography (CT) with bone window settings showed a broad based hyperostotic lesion on the tabula externa of the left frontal bone (asterisk) with associated sclerosis of the diploë (arrowheads) and an irregular delineation of the tabula interna (arrow) (Fig. A). Magnetic resonance imaging (MRI) also showed flat thickening of the dura that was slightly hyperintense to brain parenchyma on FLAIR (Fig. B, arrow). T1-weighted imaging (WI) after gadolinium contrast administration clearly revealed enhancement of the thickened dura adjacent to the skull lesion (Fig. C, arrow) and confirmed the overlying sclerosis (arrowhead) and hyperostosis (asterisk) depicted on CT. The imaging features were compatible with findings of meningioma en plaque (MEP).Resection of the tumor was performed with subsequent duraplasty and cranio plasty. Histological examination confirmed the MEP arising from arachnoid meningoendothelial cells. CommentMeningioma is the most frequently observed intracranial non glial tumor in the adult population (20%) with a female predominance. The tumor arises more frequently in African-Americans. Approximately 10% of the meningiomas are clinically silent.Typically, this tumor is slowly growing, sharply demarcated and surrounded by a capsule. Two main morphological configurations can be encountered: a spherical lobulated dural based one and a more sheetlike 'en plaque' configuration with dural and sometimes overlying bony infiltration. Although hyperostosis is a well known imaging characteristic of most meningiomas, this feature predominates in MEP.Both CT and MRI are useful imaging modalities for diagnosis of MEP. CT with bone window settings often demonstrates adjacent bony involvement such as erosions, sclerosis and hyperostosis. The degree of hyperostosis is usually disproportionate to the underlying size of the lesion. Sometimes a subdural plaque of ossification can be seen that is separated from the sclerotic or hyperostotic bone by a linear translucency corresponding to dura mater. On MRI the lesion is iso-to hypo-intense on T1-WI and has a variable appearance on T2-WI correlating to pathological features. A cerebrospinal fluid cleft can often be visualized on T2-WI which confirms its primary extra-axial localization. After contrast administration more than 95% of the lesions enhance vividly both on CT as on MRI.Multiple mechanisms are proposed for the hyperostosis associated with meningiomas but tumoral invasion of the overlying bony structures seems to be the most accepted theory.

Background:A 41-year-old woman without a relevant history was admitted to the emergency department after an epileptic seizure.

A 45-year-old, otherwise healthy women, was referred to our department for an MRI of the brain (Fig. 1), because of chronic headache. A subsequent CT scan ( Fig. 2) and cerebral angiogram was performed (Fig. 3). An endoscopic transsphenoidal biopsy of the clival lesion was performed, the histology of which is illustrated in Fig. 4. The diagnosis can be found at