The sacroiliac joint is approached, with the patient in prone position, via a direct posterior route under CT control (Fig. 20), which allows sampling of the joint space and both iliac and sacral subchondral bone (4). However, if only the anterior aspect of the joint is involved, it may be necessary to use a posterolateral route through the gluteal muscles and iliac bone under fluoro-scopic or CT guidance (Fig. 21) (7,8). The inferior portion of the sacroiliac joint, 1cm above the inferior margin of the joint, is usually the best site for biopsy with both approaches. At this level, the thickness of the iliac bone, which must be crossed prior to penetrating the sacroiliac joint, is much less than at a higher level and the joint space is simply anteroposteriorly oriented.
In the transiliac approach, the needle is inserted at 9 to 11 cm (usually 10 cm) from the midline, at an angle of 30° to 40° with the sagittal plane and advanced to the iliac bone, which is reached immediately laterally to the external margin of the sacroiliac joint, if fluoroscopic guidance is used. During the procedure, an arthrogram is performed to check that the joint space has been sampled.
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