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14 Articles in Volume 19, Issue #5
Agonism and Antagonism of the Muscles of the Shoulder Joint: An SEMG Approach
Analgesics of the Future: The Potential of IV Formulations for Post-Op Treatment of Pain
Blood Biomarkers Show Promise for Precision Pain Management
Can I Call Myself a “Pain Specialist?”
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control (Part 2)
Fear-Avoidance and Chronic Pain: Helping Patients Stuck in the Mouse Trap
How to Avoid Patient Alienation When Discussing Stress
Managing Phantom Limb Pain with Medication
Nerve Blocks Lead to Improved Quality of Life
Sacroiliac Joint Dysfunction: New Methods in Evaluation and Management
SCS Therapy in a Patient with Advanced Bilateral Kienbocks
Thoracic Epidural Abscess with Cord Compression Following a High-Frequency SCS Trial
What is the evidence to support clonidine as an adjuvant analgesic?
What’s In A Name? In This Case, That Which We Call Addiction Is Not Dependence

Sacroiliac Joint Dysfunction: New Methods in Evaluation and Management

Concepts in assessing and treating patients with various degrees of SIJ dysfunction, including presenting symptoms and pain referral patterns, the predictive values of unique tests, and the importance of guided injections.
Pages 37-40

The sacroiliac joint (SIJ) is a rather complex joint with multiple areas of potential pain generation. It represents the “crossroads” for weight transfer along the kinetic chain from the spine to the lower limbs and from the lower limbs to the spine. It is a very common pain generator, often overlooked in individuals with complaints of axial and even radicular pain complaints.

Epidemiology

The SIJ may be affected and become a pain generator at any age but is more commonly seen in the elderly and in young active individuals, affecting 15 to 30% of individuals with chronic non-radicular low back pain (LBP).
 Predisposing factors for the development of SIJ dysfunction and pain are listed in Table I.


Anatomy

The SIJ is the largest axial joint in the body. A diarthrodial joint, it forms the articulation of the lateral sacrum with the posteromedial ilium but is interestingly part synovial and part syndesmosis. The SIJ works in unison with the symphysis pubis. Although it allows very little movement and is semi-rigid (approximately 4 degrees of rotation / 1.6 mm gliding), it provides slight elasticity to the pelvic ring. Its stability is provided by several strong ligaments. The posterior sacroiliac ligament forms the syndesmosis and posterior border of the joint (there is no posterior capsule). There are no muscles that directly control the SIJ’s movement despite having a large number of muscles attaching somewhere on the pelvis. As we age, its articular surfaces become more irregular, further restricting movement and generally adding stability.

The innervation of the SIJ is still somewhat debated. Its posterior aspect is generally considered to be innervated by dorsal rami, specifically S1-S3 lateral branches (L5 and S4 in some individuals) and the L4-L5 medial branches. Its anterior aspect is believed to be innervated by the lumbosacral plexus (L2-S2 lateral branches). Possible contributions from other peripheral nerves, including the superior gluteal nerve, the obturator nerve, and other anatomical variations, have been described.2

Pathology and Pathophysiology

The primary function of the SIJ involves the absorption of mechanical forces from the lower limbs across the pelvic girdle. In that role, it is intimately involved with core stability. Dysfunction may occur when there is either abnormal stress on normal tissue or normal stress on abnormal tissue. Common tissue abnormalities are osteoarthritic changes, ligamentous laxity and defects due to repetitive strain, chondromalacia, and capsular disruption, among others.

A number of complex dynamic forces affect the SIJ during normal walking. At initial contact, there is posterior ilial rotation and a forward sacral torsion on the weight-bearing side. Simultaneously, there is no motion in the pelvis on the non-weight-bearing side as the ilium remains anteriorly rotated. At the mid-point of the cycle, the ilium on the weight-bearing side begins to move anteriorly, with the sacral torsion on that side at maximum. Then, as the opposite limb strikes the ground, the original weight-bearing side changes from posterior to anterior ilial rotation and sacral torsion is eliminated. Thus, during hip flexion there is ipsilateral compression of the sacrum as the ilium moves posteriorly and caudally. The opposite may occur with hip extension.

It is important for clinicians to consider SIJ dysfunction when evaluating low back pain. (Source: 123RF)

Clinical Evaluation

The most common symptom reported by patients with SIJ dysfunction is
axial low back pain, typically below the L5 vertebral level. Symptom presentation may involve the mid or upper buttock and the lateral proximal thigh, over the greater trochanter area. Some individuals may complain of sciatica-like symptoms. Symptoms of SIJ dysfunction may also overlap with other conditions, namely hip problems and lumbar facet pathology, lumbosacral herniated discs, and piriformis syndrome. It is common to attribute symptoms to other spinal pathology particularly when imaging abnormalities are present in the spine. Similarly, lack of SIJ imaging abnormalities may erroneously steer some practitioners away from identifying the sacroiliac joint as a pain generator.

On physical examination, it is common to detect tenderness over the affected side over the posterior and superior aspect of the joint. Neurological examination is expected to be normal. Several provocative maneuvers have been described. However, these generally lack diagnostic accuracy except when several are used in combination. The presence of at least three positive maneuvers (see Table II) have been reported to have a high degree of sensitivity (over 90%) although specificity remains below 80%.3

Imaging and Diagnostic Injections

Plain films, MRI, CT, and bone scans are generally useful in the setting of trauma, infection, or sacroiliitis associated with spondyloarthropathies (eg, sclerosis, erosions, ankylosis). Otherwise, correlation of imaging findings and patient pain is most of the times poor. Pain relief (50 to 75% reduction in pain) following image-guided diagnostic corticosteroid and local anesthetic injection is considered to be one of the most accurate diagnostic methods for SIJ dysfunction.4,5

Management Methods

Patient Education

Individuals with SIJ dysfunction should be asked to pay attention to their posture. Resting most of the weight on one foot while standing or on one hip while sitting tends to exacerbate pain. Taking uneven strides may also cause problems. Crossing the legs while sitting and sitting on a thick wallet may also contribute to the problem.

Physical Therapy and Manipulation

Similar to many other musculoskeletal ailments, physical therapy is generally considered to be an essential component for the management of SIJ dysfunction. It is often used as a first-line treatment, including various exercise methods aimed at restoring alignment and core stability along with multiple physical analgesic modalities. Another widely used interventions is kinesiotaping. Acupuncture and manual mobilization/manipulation (chiropractic/osteopathic) may also be used with good results demonstrated in many uncontrolled studies. There are different techniques for such manipulation, including High Velocity-Low Amplitude (HVLA), the Thompson’s Technique, and Muscle Energy, among others. For this particular ailment, each of these is considered to carry low risk and tend to be affordable.6

Interventional Procedures

Interventional procedures may include corticosteroid injections (CSIs), regenerative therapies, and neuroablative techniques. CSIs are by far the most commonly used interventional modality and generally considered to provide both diagnostic and therapeutic value. Accurate access to this narrow joint, however, may only be reasonably attained through the use of image-guided methods, in most cases, either fluoroscopy or ultrasound (see Figures 1-3). The choice of method depends greatly on the operator's level of comfort, experience, and availability. One study showed slightly better accuracy with fluoroscopy (98.2% vs. 87.3%). However, function and pain relief improved in both groups showing no significant difference.7 In experienced hands, the potential for complications when using CSIs is extremely low, the most common being vasovagal reactions. Injection site soreness is somewhat common with infection and facial flushing being relatively rare.8

Figure 1. Fluoroscopic injection technique showing needle and contrast in the sacroiliac joint.

Figure 2. Sacroiliac joint anatomy as seen in ultrasound. Arrows identify the ilium and sacrum while the space between these two landmarks is the joint and target for needle penetration.

Figure 3. Sacroiliac joint injection using ultrasound; the arrows point to the needle (an in-plane orientation).

A great deal of controversy exists between the use of intra-articular (IA) versus extra-articular (periarticular or PeriA) SIJ injections. Some low response rates to IA injections suggest significant extra-articular pain generators, namely the S1-3 lateral branches and the posterior SI ligaments. One method that may help to overcome some of these issues involves performing a two-portion injection. This approach generally uses the same volume as that used for IA injections but divides the injectate between IA and PeriA. In one study, this two-portion technique provided statistically significant improvements over IA injection alone, measured by greater than 50% pain relief at 3 months.9

Regenerative therapies for SIJ dysfunction management may include platelet-rich plasma (PRP) injections or proliferant therapy (prolotherapy). Purified amniotic membrane preparations and stem cells are becoming more popular. These therapies, however, tend to be quite expensive and generally lack solid scientific evidence. One small randomized controlled trial showed that prolotherapy, when compared to CSI, showed no difference in pain and disability scores at 2 weeks but significant pain relief at 15 months over CSI.10

SIJ injections using PRP have been reported mostly as case reports and case series. Concerns about publication bias abound. One randomized controlled trial compared CSI to PRP in 40 subjects. There were no differences between the two groups regarding pain and disability scores at 4 weeks. The only difference reported was persistence of improvement at 3 months in the PRP group.11

One very interesting concept involves injecting the SIJ with botulinum toxin (Botox) A prospective controlled study compared the use of periarticular Botox vs CSI. One month after the injection, pain control was similar in both groups but at 2 and 3 months, it persisted in the Botox group with high statistical significance.12

Neuroablative techniques may be considered following appropriate, yet short-lived, relief with CSIs. Multiple techniques have been described, including various types of radiofrequency (RF) such as conventional, bipolar, and cooled. Perhaps the quickest technique involves the use of a single multielectrode RF probe positioned percutaneously through a single-entry point along the sacrum lateral to the sacral foramina and medial to the sacroiliac joint. This technique may produce multiple RF lesions simultaneously. The effectiveness of neuroablative techniques for the management of SIJ-related pain was evaluated several years ago by a meta-analysis of 10 studies. The main outcome used as endpoint was the reduction of pain by 50% at 3 and 6 months after the procedure. The investigators concluded that RF techniques are effective but noted limited data and lack of randomized controlled studies.13 A systematic review of all interventional techniques concluded that the greatest evidence was that supporting cooled radiofrequency neurotomy of the lateral branches based on two randomized controlled trials and two observational studies.14

Surgery is generally considered a last option for SIJ dysfunction and is rarely performed except in traumatic cases with joint instability. Relatively new minimally invasive surgical options, such as the iFuse Implant System (SI-Bone), are designed to be easier and less invasive than traditional open surgical SIJ fusion.

Conclusion

It is imperative for clinicians to consider sacroiliac joint dysfunction when evaluating patients with low back pain. Complex neuroanatomical and spinal kinetic/postural chains are involved as potential causes of sacroiliac joint dysfunction. The clinical evaluation of patients with SIJ dysfunction should include a thorough history and physical examination, including several provocative maneuvers used in combination to improve the sensitivity and specificity of the diagnosis. Imaging studies generally play a minor role in the evaluation of SIJ dysfunction and various management strategies, from conservative to surgical, are available.

Last updated on: August 6, 2019
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Minimally Invasive SI Joint Fusion May Lessen Pain, Improve Quality of Life
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