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‘(‘1**-’(
.(
Io
I heir
I i- )(‘II I genogl-aplmic
(‘I i rmi(ItI i Iiil)O1’t
itfl(e
of
I ho-se
finohings
ii III
i’hie
afltelO-i1)feliOl’
1)one
tiate
SUrfaces
S
o’ighithm
iii
I omnat
an inch
facet
s riiav
joilmts.
‘l’Imeso’
rue
joiflt.
a.rt.icula.r-
(
of
D11II
Fig.
12)
but
lit tie
to
may
slIIfa(’es
joint..
The
remaining
5Vi(le, rtie connected
al)O\’e,
yraruse
has
appo’aIe(I
to
in
I he
anal.ornica.I
eoorohinate
serve
their
(lenu)nsl
portions,
1al
1he
0’
posterior
space
an(l
separate
vit.h
they
the
an(1
inimomni-
half of these
aoljs.eeni.
by a deep
cleft. ormi’sacro-iliae
ligaments.
one
separated
h)y the
eonohtion
sacrum
about
irt.iculatioiis,
nornml
the
of
Only
a briolge
across
tilLs
behimiol,
armol entirely
diarthl-o(lial
in
1i(’(/icine,
attempt
omatology
a(ljaeent
saero)-ihiae
dievelol)
aro- movable,
smu-fao-es
A.n
the
of
(‘Olittict.
of
recognized,
YORK
of
articulations.
(-at--shapedi
art.icular-
SII(’Ii)-iliIL(
form accessory
the true
sacro-
thus
from
joint
Spa(P,
he
should
capsule,
antI
considered
asymp-
n.
gr-I)lrj)
-‘
);i
actually
1 0) 0)ne-(ltIII1tel
I lowo-vei-,
iIiII(
he I inc
NEW
College
been
hi t lie svlnl)I
vit
$Iale
York
significance.
vicaril)tls
poit.ions
I
forni
clini(’al
Ali’IlCl’L..’l’IONS
SYRACUSE,
M.D.,
_\CU’
hOVe
jOiflts
i\-e
I(’ltlt
H.AI)LI’Y,
)-l Ll.\C
((,f .4 rialoiny,
SRO’!’O-thitt(
.\((‘(S-4I)1’\
.
LI:I:
liv
Ii I (‘III I rir’e
S.(’l(
I)eparliiienl
I/Il’
//()fl(
)lV
it nient
of
Aimal
oinioal
hmalf .saera
SI)eciIfleIiS---1S;)
New
onnv,
\ork
t
ate
College
of
ami(l 163
Medicine
ilia
fi-om
obt.aineol
-won-e
dissecte(l,
the
an(l
l)o--
roeril
-
FIG. 1
Articulated
specimen,
showing
bilateral
superficial
accessory
sacro-ihiac
articulations.
Fleets
on the posterior
superior
iliac spilmes articulate
with
corresponding
facets
on the sacrum.
These,
of the superficial
type,
are opposite
the secomid
Posterior
sacral
foramina.
The posterior
surface
of the facet
on the righmt side has beenl remoVc(1,
revealing
the edge of the articular
surface.
Tillforamenm
for branches
of the superior
gluteal
nerve
and artery
is clearly
shown
on the left side
u)et.w(-emm time accessory
and
true
saI’ro-ihiac
joints
(F).
The
(‘ircies,
as in all the illustrations,
enclose
time accessory
sacro-iliac
joints.
*
fornia,
501..
on exhibits
Based
June
34-A.
1950,
NO.
and
I, JANUARY
at
the
at the
1952
Annual
Americium
Meetinmg
Itoentgen
of the
Ray
Americali
Society,
Medical
St.
Louis,
Association,
Missouri,
San
(all-
}rancisco,
September
1950.
149
150
L.
A.
HADLEY
Fig.
2: A sacrum
viewed
from
the
right
side.
Note
the
round
facet
for an accessory
sacro-iliac
articulation
(arrow)
above
and
behind
the
true,
so-called
auricular,
sacro-iliac
articulation.
Note
also
the
space
between
these
articular
surfaces
1 1G. 3
for passage
of the nerve
and
blootl
vessels.
III all
of the cases
studied,
the accessory
arid the
true
sal-rn-iliac
joints
were
founld
t I) he sI-parate.
Fig.
3: Specimen
from
male,
aged
fifty, showing
superficial
accessory
sacro-iliac
joint
(arrow)
arthritic
spur
formation.
The
nutrient
foramen
shadow,
foreshortened,
is s-eI1
to the right
of and
the accessory
joint.
FIG.
Fig.
4 : half
sacrum
from
4
Fin.
a malo-,
age!!
sevelmty-four
years,
with
below
5
showing
ankylosed
superficial
accessor’
sacro-ihac
articulation
(arrow)
opposite
second
posterior
sacral
foramen.
The
normal
t-left hetween
the
iliac
crest
ani(l
the
posterior
surface
of the
sacrun
caim be seem above
thus i)ridgl-(1
jolllt
Fig.
5: Specimen
froni a Iiial(!, sevelmty-hvo
y(-ars
old. Deep
ty)e
of a(-cessl)ry
sacro-iliat:Irticulat.ionl
is seen
opl)osite
the first 1)osterior
sacral
foramen.
The
usual
(‘lIft
between
the ilium
and
Postel’ior
surface of the sacrum
is bridged
by thus vicarious
articulation
(arrosv).
The
articulation
is sI-I)arat(-(1
fronm
the true
sacro-iliac
by a passage
for the nerve
and
blood!
vessels.
Thmere is lit) cOnnectiOll
between
t.his
joint
and the old fractures
of the third
and fourth
vertebral
bottles
and
the right ilium,
svhicii occurrt-d
twenty-five
years
1)efore
death.
‘filE
JOURNAL
OF
III (NE
ANI)
JOINT
SURGERY
.C(ESSORY
S.\C1t()-1L1.(’
I’ll;.
1(1 )Illt
(I)lm11)Iaillt’Ii
:i(IlssOrV
ullIII-rlyilmg
hit iI)ns
without
‘Fillletters
jOillt.
(See
.\-I’a\’
of
arthritic
It
:ilso
of
llmI)Iltils.
and
I(,
fillmi
1
in
chiammges
ea(-ii
(lower
cir(’les).
case
appealoS’II’
7, 8, #{182}1,
and
Figs.
fl-Ill:!
‘lile
sixt
reveals
laterally
pl’ojectumg
ilmtl)
vt-a
V
rs
Vol..
34-A,
how(-ver,
011
a superficial
the
the
NO.
1. JANI’ARY
1952,
t he
lowl-l’
1)I)st
alld
t ul( left.
oi
sciatica
roelmt.gemiogralmi
surface
and
accessory
toor
port
11)11
of
shows
ei)urllatil)n
sacro-iliatill-
t rUI
I ‘atielit
dccl)
the
articua
of
saclo-iliac
10.)
adjacent
1, \\ll()
had
imall
accessory
nutri(-lmt
pailis
Saclo-ilial
foraniemi.
spill’
is on the
nudial
Si(le
of
to deep
I)r(-sstir(
over
tile
posterior
sul)l-rior
iliac
jI)ilit
011 tue
right
Si(1e sVImiCil shlows
little
evidence
(Xa nmlifled
ill Ma rcii
1943.
W’ hen mt (-ryml-wel
I sev-n
pamni,
but
only
after
heavy
lift ing.
sViliCii,
6
Iliale,
sixtv-t
ss’o years
old,
wit ui sacrl)-iliar
p:I Ill
of
a
(atcli
‘‘
OIl this
side Ul)I)Ii
st raigimt.-leg
raisilmg.
Time
joinmt with arthritic
clialmges,
i.e., irr(-gularity
of the articular
bone
(upper
circle).
The
patient
also has bilateral
superficial
g(-lmograni
151
#{149}‘lfl’1(t’I’I’IOX5
the
low back
and
timighms for Past.
t hree
oim time left side
svit.ii an arthritic
spur
(Compare
with specimen
showlm
in F’ig. 3 in
ill
tile
joilmt.)
spinme on the
[‘he
left
l)atient
side.
of artllrit
Ic cilange.
a rid a ha If years
later
COImil)iailme(1
There
Tue
she
of
tell(1(-rnmess
is also aim accessory
patient.
ss’as originally
still
had
some
low-back
152
L.
A.
HADLEY
I’IG. S
old.
1(I)entgenogralmi
of fermiale,
forty-six
yeals
I )fl t ime right
51(11- t here is a spur
)roje(-t.ing
foramen
landmark
cami be seerm just. within
Bilateral
supl-rh(-ial
alt
froni
time nie(Iial
side of t his
the circle
Oh tIle
1(11 sid(-.
FIn.
1(o(-nltg(-lll)gralii
sciatica,
anal
Ul)011
spur
forward
of
nmeralgia
helidirlg.
forniation.
articulations,
neural
arcimes.
As
with
Imiale,
sixtV-seVell
y(-ars
l)araest.iletica.
There
ilnpiligelnelit
Notching
amid
of
tue
lordosis
of time
ehurnation,
tips
:1
withi
:1I’(-(-SSI)l’y
ic
j 01
lIt
S:uI’o-mll!lIs
(a rrow
).
‘Fill-
9
showed
advanced
disc
ahld
(usc
thinmning,
there
of the
inferior
articular
(Continved
il
l’t 11 lit
olti.
‘File
l.ELti(llt
(-olmiplained
s’Its
a lordosis
svitim
imiaintenianmt-e
stu(Imes
Itoelltgenographmic
a result.
ill’it
developnienmt
on j). 153)
is
THE
JOURNAL
loss-hat-k
of
tiit-
with
of
against.
cimangls,
OF
BONE
latin,
lunmh:tr
degenieratioll
telescoping
processes
o)f arthritic
of
AND
iiiassive
thit- posterior
the
have
right.
curve
subjacent.
o-curred
JOINT
at
SURGERY
.(‘(‘ESSORY
S.(’1t()-1LIA(’
9.-((’oidinuedfrorn
p. 152)
Time interverteh)ral
foramirma
the patient’s
symptoms.
The
accessory
sacro-iliac.
The
left
I’IG.
t llese
l)I)ints
of impingenwnt
‘Fhesl
changes
were
compatible
only
as an example
of ankylosed
tially
normal.
(arrows).
with
right
10
svhmo (-on)plailled
FIG.
Ito(-llt.genogralml
1)11
of
left.
tue
The
l)atiemit.
t u:1 I is, eburmiatmon
tills
joint
and thie
I)vI-r
tills aI)normal
that
\Vitil
g(-nl)gI-;11n5
I ieiil
l\V()
ShiJ)(Ifi(itl
minI1
t
facets
iS
iL(Vft4OI’V
of
(lOS(’
It is s0l)ttItt0’(l
fi-om
gluteal
identifying
the
the
rtIi(I
The
I irber’o.sity
true
P1 )St (111)1’
5tL01I.l
‘Ehie
110111
t.lit
(Il)Vfl
to
the
trite
)ainm anmd
al-thritic
to ellge
of
pailm
of
scitttit:t
dccl)
imearly
hertessen-
changt-s.
i)etweell
of (‘ird-le)
Upon
an angle
forms
with
is
the
and,
pressure
60
200 consecutive
alentified.
The
posterior
(1(-grel-s
sacral
at these
points.
it may be t.endler
a foramen
through
constitutes
articulation.
It lies
joint.
lo’ss frequently
found,
smallei
develops
between
It
t.ul)erosity.
sa(-ral
the
is found
pa-
comnnun
iliac
foramen.
spine
Promi-
The
superficial
to deep
pressur-e.
which
a useful
between
This foramen
sacro-ihiac
piivat.e
more
superior
posterior
by
joint
artery.
accessory
the
the
second
ettitilage
develop
if arthritic,
surface
of
‘ere
between
seen
sacro-iliac
:uid
those
ai-t.iculat.ions
opposite
and
IieI’ve
iliun
and!
trite joint.
the second
1)1-oumile
This
may
posterior
simulates
may
ty)es
SlIl)tI’fioial
types
two
l)eeasionally
joint
loss’-h)ack
shiosvilig
upon.
pass branches
landmark
that. vicarious
large
r-oughened
opposite
the
for
first.
fom-amemm.
deep
tIme
SiI)ilally,
this
of
(oml)are(l
art.icular
SaUI’O-ihittC
the
l)Iamme
joint
articulation,
of
‘Fhie
srt’ittm,
I)u(ly
tIme
supei-fieial
oleep
sacro-iliac
boric.
Note
tht- foranid-Il
(close
Tue patit-nt
complaihme(1
bitto-rly
wer’e
h
to
of
a(-eessory
5toIl)-ilia(
I lie
surnnounte(l
slIpeI’iO)I
sul)erhcial
-U(’1)-ihiIt0
crest
of
time
a left
old,
have
been
emmcroached
roentgenogram
is shown
accessory
joint
appears
sa(-ro-ilm:u’.
sj:’o-inwns
ve!-y
y.-al’s
url(II-l’lying
these
a(0e.S501V
mmciii
joint..
of’ ti)l
t 1#{176}’ of
he lttt(ILLl
jOiflt
has
sixty-six
t rue sacro-ilmal’.
articUhutiOhi.
of the tru(-
of
s.
fennile,
i s:
AIt’rIoI’L.’’rloXs
fused
to
the
a large
the
encompass
foramen.
sacral
Articulation
appeaiance
of
together
occur
form
a third
in
accessory
the
an(1
tubero.sity
for
same
indlividilal.
sacro-iliac,
an
enlarged
articulation,
such
Oeoa-
entir-ely
separate
the crest
of the
fifth transverse
as
that
saerum
proce-
reported
by
(flraudi.
The
I)lafles
of
the
mioimal
and
the
accessory
articulations
ing to as
hmindrance
much
as 60 degrees.
The
resultant
sheering
to the customary
Irmovements
h)etween
the
contribute
in part
vom-.
34-A,
NO.
I, JANUARY
to the
1952
arthritic
changes
so frequently
may
form
an angle
stress
constitutes
a
ilium
and
the sacrum.
noted.
Complete
bony
amoumi
meclmanical
This
may
ankylos-is
I.-
154
L.
FIn.
A.
HADLI-Y
11
12
FIn.
1 1 : Itoelitgenograni
of’ felriale,
age(1
sixty
years.
Tue
1)atielit
hiad felt su(l(II-I1
511:11-I) 1)1li
in
low back
upomi
leaning
forsvard
five
sveeks
before
exarnirmation;
there
was
no imistorv
of injury.
Sue
indicated
the left posterior
superior
iliac spine
as tender
to deep
Pressure.
‘Fime 45-degi’o-toblique
i’oentgeiiogram
shoss’s
an arthritic
left accessory
sa(’ro-iliac.
Note
that
this
is (-Iitir(-ly
so-I)arate(I
from
the
true
sacro-iliac
(dotted
line)
by the tunnel
for passagoof the nerves
and
blood
lasso-Is.
The
posteroFig.
allterior
and
anteroposterior
true
.sacro-iliac
wo)uld
seem
to
joint.
Note
the
lation
(arrow).
hmas
also
l)ack
section
articulation
constitute
cartilagillous
been
pain,
tions
in
per
and
cent.,
with
spasm,
1)eri-y,
10.4
half
(‘Ondition
of
I 91 1
in
per
better
thme ohli(1ue
thali
at
s:u-runi
studies.
,
its
first
frequently
complain
or
teiulei’nio-ss
I o deep
;mitieulatioiis
of
notiomi,
i-eport.ed
oIl
respectively.
cent..
found
an incidence
of 36 pci’ cent.
lar facets
are covered
by hyaline
a
accessory
limitation
192 specimens
in Derry’s
time
left
foramen.
Tha- i)lalm(- of tioan angle
of 60 degrees
svith thie plalie
of tue acc-ssorv
joiimt.
This
disadvantage
to tue imornmaI
lflov(Imi(llts
I)f tue true sa(-ro-iliar
surfaces,
the joilmt space,
anmd the capsule
of t his vicarious
articil-
Patients
muso-le
show
the
(7’) forns
a nme-hamiical
articular
observed.
sciatica,
sixty-three
usually
throughi
the accessomy
joint..
Peterson,
in 1905, anol
over
16
views
12: Transverse
Fig.
Tiotter,
in
in(-i(Ien(-o-
tIme
Thie
958
of
Her findings
“suppoi-t.ed
cartilage
and separated
tu-cessoi-v
of
the joint
is surrounded
by a capsule”.
She also stated
that
articular
facets
was found
to increase
with increase
in age
Study
of the 185 specimens
of half sacra
i-evealed
accessoi’y
“the
ss’as
5(910’s
anatomical
the belief
that
by an articulat-
low-
ai-t icula-
mi Peter-sons
ino-idence
study
a
of
l)ressuIe
specimens.
the
.
.
(-avit.y
ineiolence
. ai-t.ieuand that
accessory
of
“.
cent.
Of
No
the
163
figures
ilia
are
roentgenogi-aphic
back
pain
sory
The
with
were
ol)viously
space,
available
bony
vertically
prominence
studies,
sits
preferably
joint
be
may
the
on the
dlownwar(I
of the
6
best
i)ei
end!
of
tovaroi
sacrum
with
per
most.
cent.
cent..
cent..
of
madle
were
and
el)urnation
with
the
svhiom
was
bilatei-al.
36
of
the
in eithei-
the
in the
axial
or tangential
1)ent.
foi-wai-d,
with
the
‘ill
lumbosacral
joint..
A large
san(l
lessen
fogging
from
scat
ter-ed
of
or
thme
pl)sition.
o-enti-al
l)ag
rad Ia
the
joint
1)0111-.
pI’olme
the
oent.
changes
u-regularity
sui)jac(-Imt
total
pcI’
lioent.genogr-aphmic
and
lovaect’s-
)f tue
(-lmalmges,
Bucky
shift
of
laive
(10-01).
time
per
consecutivo-
to
(-onohition
arthritic
thinning
patient
of 200
found
as
18
in
facets.
(‘limplaino-ol
svei-e
the
a longitudinal
table,
a i-eviev
of
ankylose(l.
were
is obtained
In
the
no
joints
ai-ticulai-
l)atient..s
showed
process
margins,
result
patients,
per
saei-o-iliac
accessol-y
cent.
of these
patients
four
times
as frequently
64
and
of
Roent.genograms
patient.
per
of an aithiit.ic
exostoses
Sometimes
33.5
about
joints,
arthritic,
revealed
indlividuals.
private
sciatica,
vicarious
cent.
asymptomatic
of
or without
as indicative
position.
the
for
joints.
In 42
type
occurredi
such
0)f
considered
16 per
examinations
sacro-iliac
superficial
number
examined,
placed
t it n
supine
1101-
ray
this,
directed!
agaiiist.
.
St ereoscopic
ai-e essential.
‘I’IIE
JOt’RNAI.
OF
itoNF;
AND
JOINT’
SURGERY
the
.\(‘CESSORY
S.CiI0)-ILIAC
I 55
ARTICULATIONS
SI’MMARY
A(’(’eS50)’Y
sacr-o)-iliac
(levelop
frequently
joints
posteriorly
betveen
the
ilium
anol
the
sacritm.
Both
deep
quently
the
and
sacrum.
These
superficial
seem
types
between
movable
They
the
have
diarthrodial
joints
to be compatible
may
with
.
Stella
New
on Accessory
Articular
Physiol.,
45: 202-210,
1911.
and
Contributo
G. :
GIRAUDI,
accessorie
3.
(Diartrosi
“
0.
PETERSON,
26: 521-524,
anatomico
TROT’FER,
MILDREn:
Accessory
6.
TROTFER,
MILDRED:
A
Surg.,
S.
22:
arthritic
latter
and
the
and
even
pain
occur
293-299,
LEWIS
A number
cause
for
theories
VARIATI(
the
Lovelace
local
recently,
der
and
of
ankylosed.
and
sciatica.
of
Anatomy,
of Medicmmme,
and
to
Syra-
the
Their
Significance.
“articulazioni
des
Anzeig.,
in
and
sacro-iliache
1936.
Hinterflflche
J.
Ilium,
delle
987-994,
Am.
Variation
IN
Tillill)
79:
Phys.
Os
sacrum.
225-241,
Sacro-iliac
Anat.
Anzeig.,
1935.
Anthrop.,
22:
Region.
AND
J.
Foundation
W.
for
have
called
and shoulder,
causes
THE
ARTI(TIATION
CERVICAL
VERTEBRAE
GROSSMAN,
Ih!edical
attention
chest,
and
along
with
of these,
Morton
dissected
M.D.,
Education
place
in the spine.
Their
reports
were
findings.
One of the authors
‘ reviewed
More
23:
Anat.
)NS
M.D.,
of authors
headaches
as to the
Sacrum
conoscenza
Articulatiomls.
AND
OVERTON,
From
alla
an
Anatomical
SECOND
M.
fre-
surface
247-261,
J.
Bone
1937.
amid
Joint
1940.
ICAL
THE
the
Med.,
acc(-ssoria.
Sacro-iliac
Common
Apr.
between
Radiol.
sacro-iliaca
more
posterior
ER EN CES
Articulationsfluichen
B. : Art.iculatio
ANATOM
taking
clinical
tfhe
spine
of low-back
radiologico
dorsali).
V. C. E. : tber
1905.
SELIGMANN,
mon
become
Fao-ets
e
sacro-iliache
4.
5.
BY
iliac
symptoms
D. E. : Note
DERRY,
J. Anat.
2.
observed.
superior
REF
I
been
posterior
The
author
is indebted
to Prof.
Philip
B. Armstrong
of time I)epartment
Zimmer
of the Department
of Photography,
of the New
York
State
College
York,
for assistance
in the preparation
of this
material.
NOTE:
Miss
(‘use,
and
develop
twenty
ALBUQUERQUE,
(And
Re-search,
to changes
in the
arm pains.
They
descriptions
based
these
cadaver
BETWEEN
NEW
Albuquerque
cervical
spine
have presented
of the
entirely
findings
MEXICO
as a cornvarious
pathological
changes
upon
roentgenographic
in a recent
article.
specimens
of the
cervical
and
spine.
He
reported
changes
in the vertebral
l)odies,
intervertebral
discs,
and
the foramina,
but he
did not mention
the variations
in the
apophyseal
articular
processes
between
the second
and third! cervical
vertebrae.
Josey
has presented
a series
of twenty
cases of headache
radiating
to the occipital
or
frontal
regions
which
was
associated
with
soreness
and stiffness
in the upper
portion
of
neck.
He found
in all cases.
the headache.
In
the
cervical
did not
spine
mention
in all,
any
from
*
of
VOL.
those
Material
Colorado
34-A.
of the
for
School
NO.’
over
this
thoracic
study
was
of Medicine,
1. JANUARY
1952
the
pressure
revealed
but showed
anomalies
studies
of the
Anatomical
ent
tenderness
most
instances,
Roentgenograms
third
cervical
applied
a loss
degenerative
or variations
cervical
spine
spine
obtained
Denver.
andl
through
the
nerve
as it. emerges
from
the
foramen
over the nerve
at this point
reproduced
of the normal
flexion
curve
in the upper
arthritic
changes
in only two.
However,
he
in the second
and third
cervical
articulations.
reveal
that
the cervical
vertebrae
are differlumbar
the
courtesy
spine
of the
and
that
I)epartment
the
differences
of Anatomy,
involve
lJniversity
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