Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain

5. Sacroiliac joint pain

INTRODUCTION

Sacroiliac (SI) joint pain is defined as pain localized in the anatomical region of the SI joint. The reported prevalence of SI joint pain among patients with mechanical low back pain varies between 15% and 30%.

METHODS

In this narrative review, the literature on the diagnosis and treatment of SI joint pain was updated and summarized.

RESULTS

Patient's history provides clues on the source of pain. The specificity and sensitivity of provocative maneuvers are relatively high when three or more tests are positive, though recent studies have questioned the predictive value of single or even batteries of provocative tests. Medical imaging is indicated only to rule out red flags for potentially serious conditions. The diagnostic value of SI joint infiltration with local anesthetic remains controversial due to the potential for false-positive and false-negative results. Treatment of SI joint pain ideally consists of a multidisciplinary approach that includes conservative measures as first-line therapies (eg, pharmacological treatment, cognitive-behavioral therapy, manual medicine, exercise therapy and rehabilitation treatment, and if necessary, psychological support). Intra- and extra-articular corticosteroid injections have been documented to produce pain relief for over 3 months in some people. Radiofrequency ablation (RFA) of the L5 dorsal ramus and S1-3 (or 4) lateral branches has been shown to be efficacious in numerous studies, with extensive lesioning strategies (eg, cooled RFA) demonstrating the strongest evidence. The reported rate of complications for SI joint treatments is low.

CONCLUSIONS

SI joint pain should ideally be managed in a multidisciplinary and multimodal manner. When conservative treatment fails, corticosteroid injections and radiofrequency treatment can be considered.

Diagnostic Accuracy of Clusters of Pain Provocation Tests for Detecting Sacroiliac Joint Pain: Systematic Review With Meta-analysis

OBJECTIVE

To assess the diagnostic test accuracy of pain provocation tests for the sacroiliac joint.

DESIGN

Systematic review of diagnostic test accuracy.

LITERATURE SEARCH

Seven electronic databases and reference lists of included studies and previous reviews were searched.

STUDY SELECTION CRITERIA

Studies investigating the diagnostic accuracy of clusters of clinical tests for sacroiliac joint pain were included.

DATA SYNTHESIS

Bivariate random-effects meta-analysis was employed. Risk of bias and applicability concerns were assessed using the revised Quality Assessment of Diagnostic Accuracy Studies tool, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was used to judge credibility of evidence.

RESULTS

From 2195 records identified in the search, 5 studies were included that assessed clusters of pain provocation tests for the sacroiliac joint. The estimated positive likelihood ratio was 2.13 (95% confidence interval [CI]: 1.2, 3.9), the negative likelihood ratio was 0.33 (95% CI: 0.11, 0.72), and the diagnostic odds ratio was 9.01 (95% CI: 1.72, 28.4). The GRADE ratings for the outcomes were of very low certainty. Assuming a point prevalence of sacroiliac joint pain of 20%, we calculated a positive posterior probability of 35% (95% CI: 32%, 37%) and negative posterior probability of 8% (95% CI: 6%, 10%).

CONCLUSION

A positive result on a sacroiliac joint pain provocation test cluster gives the clinician 35% certainty of having correctly identified sacroiliac joint pain. Clusters of pain provocation tests for the sacroiliac joint do not provide sufficient diagnostic accuracy for ruling in the sacroiliac joint as the source of pain. Clinicians can rule out the sacroiliac joint as the source of pain with more confidence: the negative posttest probability indicates that the clinician can conclude with 92% certainty that a negative test result is correct. J Orthop Sports Phys Ther 2021;51(9):422-431. Epub 1 Jul 2021. doi:10.2519/jospt.2021.10469.

Sacroiliac joint dysfunction: pathophysiology, diagnosis, and treatment

PURPOSE

To review the anatomy and function of the sacroiliac joint (SIJ), as well as the pathophysiology, clinical presentation, diagnostic criteria, and treatment options for SIJ dysfunction.

METHODS

The SIJ serves an extremely crucial function in mobility, stability, and resistance against shear forces. Joint mobility becomes increasingly limited with age-related cartilaginous changes that begin in puberty and continue throughout life. Pain can also be localized to the SIJ itself, known as SIJ dysfunction. A literature review was performed on the anatomy, etiology, risk factors, diagnostic modalities, and treatment options for SIJ dysfunction.

RESULTS

SIJ dysfunction is an under-recognized source of low back pain. Dysfunction can result from various clinical conditions, as well as abnormal motion or malalignment of the joint. Diagnosis and evaluation of SIJ dysfunction are difficult, with use of physical maneuvers and image-guided anesthetic injection. Non-operative treatment options are considered first-line due to high surgical complication rates. Such options include conservative management, radiofrequency treatment, nerve blocks, and articular injections. Surgical management involves open and percutaneous approaches.

CONCLUSION

With the aging nature of the population, SIJ dysfunction has emerged as an extremely prevalent issue. Current research into the pathophysiology and risk factors of SIJ dysfunction is extremely important for planning preventative and therapeutic strategies. Various treatment options exist including conservative management, radiofrequency, nerve blocks, intra-articular or peri-articular injections, and surgical fixation. Improved diagnostic methods in clinical practice are thus critical to properly identify patients suffering from SIJ dysfunction, plan early intervention, and hasten return to function.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Accuracy of the Diagnostic Tests of Sacroiliac Joint Dysfunction

Objective

The purpose of this study was to assess the reliability and validity of motion palpation and pain provocation compared with sacroiliac joint (SIJ) block as the gold-standard assessment method of patients with sacroiliac joint dysfunction (SIJD).

Methods

A cross-sectional study was conducted in the Department of Sports and Exercise Medicine at Rasool Akram Hospital. Forty-eight patients suspected of having SIJD were selected from a total of 150 patients on the basis of a combination of symptoms, physical tests, and magnetic resonance imaging findings. The patients suspected of having SIJD received the SIJ block, to which the accuracy of all the physical tests was compared. Sensitivity, specificity, and positive and negative predictive values were calculated for each test. The receiver operating characteristic curve and the area under the receiver operating characteristic curve were measured.

Results

The Flexion, Abduction and External Rotation (FABER) test had the highest specificity and positive predictive values of the physical tests. Furthermore, the combination of the FABER test and the thigh thrust test improved overall diagnostic ability more so than any of the other test combinations.

Conclusion

A combination of the motion and provocation tests increased specificity and positive predictive values, and the FABER test had the highest of these single values. The palpation tests did not change after the SIJ block, suggesting that their accuracy cannot be determined using this method.

Sacroiliitis in cancer patients: a review of current literature

The sacroiliac (SI) joint can be directly jeopardized by malignancy and indirectly by ergonomic changes of pelvic obliquity that introduces uneven weight distribution. Cancer treatment can exacerbate preexisting arthritis and cause diffuse arthropathies, but these are unlikely to be isolated to the SI joint. The cancer population is exposed to unique stressors that might facilitate development of SI joint pain that includes cancer itself and therapy-related complications. Like the general population, cancer patients are subject to aging and BMI and musculoskeletal structural changes that affect symmetric body functioning and posturing. No frank association between sacroiliitis and cancer has been identified. Therefore, we believe there is a need to characterize any relationship between cancer and SI joint dysfunction and pain.

Altered musculoskeletal mechanics as risk factors for postpartum pelvic girdle pain: a literature review

[Purpose] The aim of this literature review was to detect the factors associated with pelvic girdle pain persisting for over 3 months in the postpartum period. [Methods] We performed a broad literature search for eligible studies published before May 1, 2018 using electronic databases and processed the data using a review process. [Results] In the initial online search, we identified 12,174 potential studies. Finally, 22 studies met the specified criteria and were included for examination of risk factors for persistent pelvic girdle pain after delivery. Pain intensity and disability during pregnancy were risk factors for pelvic girdle pain persisting for over 6 months after delivery. The active straight leg raising test predicted the risk of persistent pelvic girdle pain after delivery. Dysfunction of the pelvic floor muscles was also a risk factor for persistent pelvic girdle pain. [Conclusion] Pain intensity and disability during pregnancy, positive provocation tests, active straight leg raising test, and musculoskeletal mechanics were positively associated with pelvic girdle pain persisting for over 3 months after delivery.

Sacroiliac joint pain following iliac-bone marrow aspiration and biopsy: a cohort study

Background: Sacroiliac joint (SIJ) pain is a common source of lower back pain; the factors associated have not been studied in cancer patients. Observing patients with bone marrow aspiration and biopsy (BMAB) who subsequently developed SIJ-pain led to this investigation. Aim: To investigate this possible relationship. Methods: A cohort study of cancer patients diagnosed with SIJ pain. The association of BMAB with SIJ pain was evaluated, as were variables that differed between the groups. Results: The prevalence of SIJ pain was 4.95% (231/4669). Among 231 patients with SIJ pain, 34% (78/231) did not have prior history of lower back pain and had undergone BMAB prior to their diagnosis of SIJ pain. A statistically significant association between BMAB-SIJ-pain was found (p < 0.01). Conclusion: We found linear correlation between BMAB and subsequent SIJ pain.

The sacro-iliac joint: A potentially painful enigma. Update on the diagnosis and treatment of pain from micro-trauma

The sacro-iliac joint (SIJ) located at the transition between the spine and the lower limbs is subjected to major shear forces. Mobility at the SIJ is very limited but increases during pregnancy and the post-partum period. Familiarity with the anatomy and physiology of the SIJ is important. The SIJ is a diarthrodial joint that connects two variably undulating cartilage surfaces, contains synovial fluid, and is enclosed within a capsule strengthened by several ligaments. This lecture does not discuss rheumatic or inflammatory diseases of the SIJ, whose diagnosis relies on imaging studies and blood tests. Instead, it focuses on micro-traumatic lesions. Micro-trauma causes chronic SIJ pain, which must be differentiated from hip pain and spinal pain. The diagnosis rests on specific clinical provocation tests combined with a local injection of anaesthetic. Findings are normal from radiographs and magnetic resonance imaging. Non-operative treatment with exercise therapy and stretching aims primarily to strengthen the latissimus dorsi, gluteus, and hamstring muscles to increase SIJ coaptation. Other physical treatments have not been proven effective. Radiofrequency denervation of the dorsal sensory rami has shown some measure of efficacy, although the effects tend to wane over time. Patients with refractory pain may benefit from minimally invasive SIJ fusion by trans-articular implantation of screws or plugs, which has provided good success rates.

Randomized Sham-controlled Double-Blind Multicenter Clinical Trial to Ascertain the Effect of Percutaneous Radiofrequency Treatment for Sacroiliac Joint Pain: Three-month Results

Objectives:

To investigate the effect of a percutaneous radiofrequency (RF) heat lesion compared with a sham procedure, applied to the lateral branches of L5, S1, S2, S3, and S4 nerve roots.

Materials and Methods:

Sixty patients aged 18 years and above with a medical history and physical examination suggestive for sacroiliac joint pain and a reduction of 2 or more on a numerical rating scale (NRS, 0 to 10) after a sacroiliac joint test block were included in this study. Treatment group: percutaneous RF heat lesion at the lateral branches of S1, S2, S3, and S4 nerve roots and the posterior ramus dorsalis of L5; sham group: same procedure as the treatment group except for the RF heat lesion. Primary outcome measure: pain reduction (NRS). Secondary outcome measure: Global Perceived Effect.

Results:

No statistically significant differences in pain level over time between the groups (Group×Period) (F_1,58=0.353; P=0.56) nor within the treatment Group (F_1,58=0.212; P=0.65) were found. The Period factor, however, yielded a significant difference (F_1,58=61.67; P<0.001), that is, when pooled together the mean pain level of the patients was significantly reduced at T1 compared with T0. In the crossover group, 42.1% experienced a reduction in NRS of 2 or more at 1 month (P=0.65). No statistically significant difference in satisfaction over time between the groups was found (F_1,50=2.1; P=0.15). The independent factors Group (F_1,50=2.02; P=0.16) and Period (F_1,50=0.95; P=0.33) also showed no statistically significant difference. The same applies to recovery: no statistically significant Group×Period effect (F_1,51=0.09; P=0.77) was found, neither an effect of Group (F_1,51=0.004; P=0.95) nor of Period (F_1,51=0.27; P=0.60).

Discussion:

The hypothesis of no difference in pain reduction or in Global Perceived Effect between the treatment and sham group cannot be rejected.

Level of Evidence:

Level 1A.

Sacroiliac Pain: A Clinical Approach for the Neurosurgeon

Pain originating from sacroiliac joint may also cause pain in the lumbar and gluteal region in 15% of the population. The clinical manifestation represents a public health problem due to the great implications on the quality of life and health-related costs. However, this is a diagnosis that is usually ignored in the general clinical practice; probably because of the unknown etiology, making harder to rule out the potential etiologies of this pathology, or maybe because the clinical criteria that support this pathology are unknown. By describing several diagnostic techniques, many authors have studied the prevalence of this pathology, finding more positive data than expected; coming to the conclusion that even though there is no diagnostic gold standard yet, an important amount of cases might be detected by properly applying several tests at the physical examination. Thus, it is necessary to have knowledge of the physiopathology and clinical presentation so that diagnosis can be made to those patients that manifest this problem. We present a clinical approach for the neurosurgeon.

Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain

BACKGROUND

It has been reported that in 13-32% of patients with chronic low back pain, the pain may originate in the sacroiliac (SI) joints. When treatment of these patients with analgesics and physiotherapy has failed, a surgical solution may be discussed. Results of such surgery are often based on small series, retrospective analyses or studies using a minimal invasive technique, frequently sponsored by manufacturers.

PURPOSE

To report the clinical outcome concerning pain, function and quality of life following anterior arthrodesis in patients presumed to have SI joint pain using validated questionnaires pre- and post-operatively. An additional aim was to describe the symptoms of the patients included and the preoperative investigations performed.

MATERIAL AND METHODS

Over a 6 year period we treated 55 patients, all women, with a mean age of 45 years (range 28-65) and a mean pelvic pain duration of 9.1 years (range 2-30). The pain started in connection with minor trauma in seven patients, pregnancy in 20 and unspecified in 28. All patients had undergone long periods of treatment including physiotherapy, manipulation, needling, pelvic belt, massage and chiropractic without success, and 15 had been operated for various spinal diagnoses without improvement. The patients underwent thorough neurological investigation, plain X-ray and MRI of the spine and plain X-ray of the pelvis. They were investigated by seven clinical tests aimed at indicating pain from the SI joints. In addition, all patients underwent a percutaneous mechanical provocation test and extra-articular local anaesthetic blocks against the posterior part of the SI joints. Before surgery all patients answered the generic Short-Form-36 (SF-36) questionnaire, the disease specific Balanced Inventory for Spinal Disorders (BIS) questionnaire and rated their level of pelvic and leg pain (VAS, 0-100). At follow-up at a mean of 2 years 49 patients completed the same questionnaires (89%).

RESULTS

At follow-up 26 patients reported a lower level of pelvic pain than before surgery, 16 the same level and six a higher level. Applying Svensson's method RP_{pelvic pain}=0.3976, with 95% CI (0.2211, 0.5740) revealed a statistically significant systematic improvement in pelvic pain. At follow-up 28 patients reported a higher quality of life and 26 reported sleeping better than pre-operatively. In most patients the character of the pelvic pain was dull and aching, often accompanied by a stabbing component in connection with sudden movements. Referred pain down the leg/s even to the feet and toes was noted by half of the patients and 29 experienced frequency of micturition.

CONCLUSIONS

It is apparent that in some patients the SI joints may cause long-term pain that can be treated by arthrodesis. We speculate that continued pain despite a healed arthrodesis may be due to persistent pain from adjacent ligaments. The next step should be a prospective randomized study comparing posterior fusion and ligament resection with non-surgical treatment.

IMPLICATIONS

Anterior arthrodesis can apparently relieve pain in some patients with presumed SI joint pain. The problem is how to identify these patients within the low back pain group.

Can hip abduction and external rotation discriminate sacroiliac joint pain?

AIM

The primary aim of the study is to determine if Hip Abduction and External Rotation (HABER) test is capable of reproducing familiar pain in individuals with low back pain (LBP) of sacroiliac joint (SIJ) origin (SIJ-positive) when compared with LBP of Non-SIJ origin (SIJ-negative). If so, the secondary aim is to determine the diagnostic accuracy of HABER test against the reference standard of pain provocation tests, and to determine which increments of the HABER test has highest sensitivity and specificity for identifying SIJ-positive individuals.

DESIGN

Single-blinded diagnostic accuracy study.

METHOD

Participants [n(122)] between ages of 18-50 y, suffering from chronic non-specific LBP (≥3 months) volunteered in the study. An experienced musculoskeletal physiotherapist evaluated and classified participants into either SIJ-positive [n(45)] or SIJ-negative [n(77)], based on reference standard of pain provocation tests [≥3 positive tests = SIJ-positive]. Another musculoskeletal physiotherapist, blinded to clinical groups, evaluated participants for reproduction of familiar pain during each increment (10°, 20°, 30°, 40°, and 50°) of HABER test.

RESULTS

The HABER test reproduced familiar pain in SIJ-positive individuals when compared with SIJ-negative individuals [p (0.001), R(2) (0.38), Exp(β) (5.95-10.32)], and demonstrated moderate level of sensitivity (67%-78%) and specificity (71%-72%) for identifying SIJ-positive individuals. Receiver operator curve analysis demonstrated that the HABER increments of ≥30° have the highest sensitivity (83%-100%) and specificity (52%-64%).

CONCLUSIONS

The HABER test is capable of reproducing familiar pain in SIJ-positive LBP individuals and has moderate levels of sensitivity and specificity for identifying SIJ-positive LBP individuals.

[Diagnostic test scale SI5: Assessment of sacroiliac joint dysfunction]

OBJECTIVE

Sacroiliac joint dysfunction is a known cause of low back pain. We think that a diagnostic score scale (SI5) may be performed to assess diagnostic utility of clinical signs of sacroiliac joint dysfunction. The primary aim of the present study was to conduct the pilot study of our new diagnostic score scale, the SI5, for sacroiliac joint syndrome.

MATERIAL AND METHODS

We reviewed the literature on clinical characteristics, diagnostic tests and imaging most commonly used in diagnosing sacroiliac joint dysfunction. Our group evaluated the diagnostic utility of these aspects and we used those considered most representative to develop the SI5 diagnostic scale. The SI5 scale was applied to 22 patients with low back pain; afterwards, the standard test for diagnosing this pathology (selective blockage of the SI joint) was also performed on these patients. The sensitivity and specificity for each sign were also assessed and the diagnostic scale called SI5 was then proposed, based on these data.

RESULTS

The most sensitive clinical tests for diagnosing SI joint dysfunction were 2 patient-reported clinical characteristics, the Laguerre Test, sacroiliac rocking test and Yeomans test (greater than 80% sensitivity). The tests with greatest diagnostic specificity (>80%) were the Lewitt test, Piedallu test and Gillet test. The proposed SI5 test score scale showed sensitivity of 73% and specificity of 71%.

CONCLUSIONS

Sacroiliac joint syndrome has been shown to produce low back pain frequently; however, the diagnostic value of examination tests for sacroiliac joint pain has been questioned by other authors. The pilot study on the SI5 diagnostic score scale showed good sensitivity and specificity. However, the process of statistical validation of the SI5 needs to be continued.

Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial

PURPOSE

The sacroiliac joint (SIJ) may be a cause of sciatica. The aim of this study was to assess which treatment is successful for SIJ-related back and leg pain.

METHODS

Using a single-blinded randomised trial, we assessed the short-term therapeutic efficacy of physiotherapy, manual therapy, and intra-articular injection with local corticosteroids in the SIJ in 51 patients with SIJ-related leg pain. The effect of the treatment was evaluated after 6 and 12 weeks.

RESULTS

Of the 51 patients, 25 (56 %) were successfully treated. Physiotherapy was successful in 3 out of 15 patients (20 %), manual therapy in 13 of the 18 (72 %), and intra-articular injection in 9 of 18 (50 %) patients (p = 0.01). Manual therapy had a significantly better success rate than physiotherapy (p = 0.003).

CONCLUSION

In this small single-blinded prospective study, manual therapy appeared to be the choice of treatment for patients with SIJ-related leg pain. A second choice of treatment to be considered is an intra-articular injection.

Sciatica-like symptoms and the sacroiliac joint: clinical features and differential diagnosis

PURPOSE

To compare the clinical features of patients with sacroiliac joint (SIJ)-related sciatica-like symptoms to those with sciatica from nerve root compression and to investigate the necessity to perform radiological imaging in patients with sciatica-like symptoms derived from the SIJ.

METHODS

Patients with pain radiating below the buttocks with a duration of 4 weeks to 1 year were included. After physical and radiological examinations, a diagnosis of SI joint-related pain, pain due to disk herniation, or a combination of these two causes was made.

RESULTS

Patients with SIJ-related leg pain (n = 77/186) were significantly more often female, had shorter statue, a shorter duration of symptoms, and had more often pain radiating to the groin and a history of a fall on the buttocks. Muscle weakness, corkscrew phenomenon, finger-floor distance ≥25 cm, lumbar scoliosis, positive Bragard or Kemp sign, and positive leg raising test were more often present when radiologic nerve root compression was present. Although these investigations may help, MRI of the spine is necessary to discriminate between the groups.

CONCLUSIONS

Sciatica-like symptoms derived from the SIJ can clinically mimic a radiculopathy. We suggest to perform a thorough physical examination of the spine, SI joints, and hips with additional radiological tests to exclude other causes.

Pain originating from the sacroiliac joint is a common non-traumatic musculoskeletal complaint in elite inline-speedskaters - an observational study

STUDY DESIGN

Observational study

OBJECTIVES

To investigate common non-traumatic musculoskeletal complaints of the low back in elite inline-speedskaters of the German national team.

SUMMARY OF BACKGROUND DATA

Traumatic injuries associated with falls or collisions are well documented in speedskaters but so far no studies have investigated non-traumatic low back pain. Previously, the sacroiliac joint was suspected as a frequent origin of complaint, we aimed to investigate this assumption.

METHODS

Two chiropractors examined elite inline-speedskaters of the German national team during three sports events between summer 2010 and 2011. A test cluster of five provocative tests for the sacroiliac joint was selected based on reliability and validity.

RESULTS

A total of 37 examinations were conducted on 34 athletes with low back pain during the three sport events. The reported pain intensities ranged from mild to moderate pain (VAS 23.4 ± 13.4 to 35.1 ± 19.2). About 90% of cases showed involvement of the SI joint of which again 90% presented with left sided symptoms.

CONCLUSIONS

Non-traumatic complaints of the low back originating from the left sacroiliac joint frequently occur in competitive inline speedskaters.

A finite element analysis of sacroiliac joint ligaments in response to different loading conditions

STUDY DESIGN

A finite element analysis of the sacroiliac joint (SIJ) and its associated ligaments utilizing a three-dimensional model constructed from computed tomography scans.

OBJECTIVE

To characterize the sacroiliac ligament strains in response to flexion, extension, and axial rotation loads and quantify the changes in SIJ stress and angular displacement in response to changes in ligament stiffness.

SUMMARY OF BACKGROUND DATA

The SIJ may be a major contributor to low back pain in up to 13% to 30% of patients. States of ligament laxity are often associated with hypermobility and possibly pain of SIJ origin. The mechanism by which the SIJ generates pain is both controversial and poorly understood.

METHODS

A finite element model of the human pelvis, SIJs, and sacroiliac ligaments was constructed from computed tomography scans. Ligament stiffnesses were altered and the SIJ stresses were compared with the original case. For simulated flexion, extension, and axial rotation scenarios, sacroiliac ligament strains were characterized and compared.

RESULTS

Sacroiliac joint stress and angular motion increases as ligament stiffness decreases. Periarticular intraligamentous strains vary depending on the magnitude and direction of the applied loads. Maximum ligamentous strains occur at the interosseous sacroiliac ligament.

CONCLUSION

The sacroiliac ligaments function to constrain the SIJ and decrease stress across the SIJ for different load scenarios. Decreasing sacroiliac ligament stiffness leads to both increased joint motion and stress.

Evidence-based diagnosis and treatment of the painful sacroiliac joint

Sacroiliac joint (SIJ) pain refers to the pain arising from the SIJ joint structures. SIJ dysfunction generally refers to aberrant position or movement of SIJ structures that may or may not result in pain. This paper aims to clarify the difference between these clinical concepts and present current available evidence regarding diagnosis and treatment of SIJ disorders. Tests for SIJ dysfunction generally have poor inter-examiner reliability. A reference standard for SIJ dysfunction is not readily available, so validity of the tests for this disorder is unknown. Tests that stress the SIJ in order to provoke familiar pain have acceptable inter-examiner reliability and have clinically useful validity against an acceptable reference standard. It is unknown if provocation tests can reliably identify extra-articular SIJ sources of pain. Three or more positive pain provocation SIJ tests have sensitivity and specificity of 91% and 78%, respectively. Specificity of three or more positive tests increases to 87% in patients whose symptoms cannot be made to move towards the spinal midline, i.e., centralize. In chronic back pain populations, patients who have three or more positive provocation SIJ tests and whose symptoms cannot be made to centralize have a probability of having SIJ pain of 77%, and in pregnant populations with back pain, a probability of 89%. This combination of test findings could be used in research to evaluate the efficacy of specific treatments for SIJ pain. Treatments most likely to be effective are specific lumbopelvic stabilization training and injections of corticosteroid into the intra-articular space.

Gynecological surgery and low back pain in older women: testing the association with sacroiliac joint stiffness and pelvic floor movements

OBJECTIVE

To determine sacroiliac joint compliance characteristics and pelvic floor movements in older women relative to gynecological surgery history and back pain complaints.

DESIGN

Single-visit laboratory measurement.

SETTING

University clinical research center.

PARTICIPANTS

Twenty-five women aged 65 years or older.

OUTCOME MEASURES

Sacroiliac joint compliance measured by Doppler imaging of vibrations and ultrasound measures of pelvic floor motion during the active straight leg raise test.

RESULTS

Doppler imaging of vibrations demonstrated test reliability ranging from 0.701 to 0.898 for detecting vibration on the ilium and sacrum sides of the sacroiliac joint. The presence of low-back pain or prior gynecological surgery was not significantly associated with a difference in the compliance or laxity symmetry of the sacroiliac joints. No significant difference in pelvic floor movement was found during the active straight leg raise test between subject groups. All P values were ≥.4159.

CONCLUSIONS

Prior gynecological surgery and low-back pain were not significantly associated with side-to-side differences in the compliance of the sacroiliac joints or in significant changes in pelvic floor movement during a loading maneuver in a group of older women.

Corticosteroid injection treatment to the ischiadic spine reduced pain in women with long-lasting sacral low back pain with onset during pregnancy: a randomized, double blind, controlled trial

STUDY DESIGN

Randomized double blind controlled clinical trial.

OBJECTIVE

To evaluate the pain relief effect of locally injected corticosteroid treatment in women with long-lasting sacral low back pain with onset during pregnancy.

SUMMARY OF BACKGROUND DATA

Pregnancy-related low back pain is a global problem. Almost 1 of 10 women still experienced disabling daily back pain 2 years after childbirth with high impact on the individual, family, and society. On spite of this, the sources of pain and effective treatment are uncertain.

METHODS

Thirty-six women were allocated to injection treatment, with slow-release triamcinolone and lidocaine or saline and lidocaine, given at the sacrospinous ligament insertion on the ischiadic spine bilaterally with 4 weeks follow-up time. Primary outcome measure was reported pain intensity on visual analogue scale and secondary outcome measures number of pain-drawing locations and pain-provoking test results. RESULTS.: The triamcinolone treatment group had significantly reduced pain intensity, number of pain locations, and pain-provoking test results between baseline and follow-up as compared with the saline treatment group. The absolute median change of visual analogue scale score in the triamcinolone treatment group was -24 mm and in the saline group +4.5 mm (P < 0.05). A reduced number of pain drawing locations was reported by 16 of 18 women in the triamcinolone group as compared with 10 of 18 in the saline group (P < 0.05). In the triamcinolone treatment group, 17 of 18 women had an improved pain provocation test result as compared with 9 of 18 in the saline treatment group (P < 0.01).

CONCLUSION

The anatomic region around the sacrospinous ligament insertion on the ischial spine is suggested to be one source of long-lasting sacral low back pain with onset during pregnancy. The pain was relieved by slow-release corticosteroid injection treatment to the ischial spine.

Interventional Management of Chronic Pain

Chronic non-cancer pain is a common clinical condition affecting a significant part of the population. This article aims to review the interventional options for non-cancer pain. Multiple searches using Medline were carried out and additional searches were made using reference lists of published papers and book chapters. The article discussed procedures ranging from selective nerve root or zygapophyseal (facet) joint block with local anaesthetics to irreversible neurodestruction with radiofrequency energy or neurolytic agents and neuromodulation with spinal cord stimulation. Other techniques include intraspinal delivery of analgesics. There is evidence that these interventional procedures are valuable both diagnostically and therapeutically. Key words: Intrathecal drug delivery, Neuropathic, Spine

Diagnostic validity of criteria for sacroiliac joint pain: a systematic review

A systematic literature review was conducted to determine the diagnostic validity of the criteria for sacroiliac (SI) joint pain as proposed by the International Association for the Study of Pain (IASP). Databases were searched up to September 2007. Quality of the studies was assessed using a Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Sensitivity, specificity, and diagnostic odds ratios (DOR) were calculated together with 95% confidence intervals (CI). Statistical pooling was conducted for results of provocative tests. Eighteen studies were included. Five studies examined the pattern of SI joint pain, whereas another 5 examined stressing test specific for SI joint pain. None of the studies evaluated the diagnostic validity of the SI joint infiltration or the diagnostic validity of the IASP criteria set as a whole. In all studies, the SI joint selective infiltration was used as a gold standard; however, the technique, medications, and required pain relief after the infiltration varied considerably between the studies. Taking the double infiltration technique as reference test, the pooled data of the thigh thrust test (DOR, 18.461; CI, 5.82 to 58.53), compression test (DOR, 3.88; CI, 1.7 to 8.9), and 3 or more positive stressing tests (DOR, 17.16; CI, 7.6 to 39) showed discriminative power for diagnosing SI joint pain.

PERSPECTIVE

This review of clinical studies focused on the diagnostic validity of the IASP criteria for diagnosing SI joint pain. A meta-analysis showed that the thigh thrust test, the compression test, and 3 or more positive stressing tests have discriminative power for diagnosing SI joint pain. Because a gold standard for SI joint pain diagnosis is lacking, the diagnostic validity of tests related to the IASP criteria for SI joint pain should be regarded with care.

Sciatica and the sacroiliac joint: a forgotten concept

The definition of sciatica is restricted to the pattern and localization of pain, although much emphasis is given to root compression as causative factor. Other sources of similar pain patterns are generally neglected. Despite absence of obligatory neurological signs in radicular syndromes, a number of patients are subjected to extensive, but redundant screenings. In this report, three patients are presented with presumed radicular pain syndromes, whose symptoms finally could be linked to the sacroiliac (SI) joint either via CT and MRI scans or via pain relief by intra-articular injection with local anaesthetics. Possible mechanisms of SI joint-related pain and difficulties in diagnostic specificity of signs and symptoms are discussed.

Structural and biomechanical aspects of equine sacroiliac joint function and their relationship to clinical disease

Pain originating from the sacroiliac joint (SIJ) in horses has long been associated with poor performance, yet specific diagnosis of sacroiliac dysfunction (SID) has been difficult to achieve. Clinical presentation of SID appears to fall into two categories. The first, presenting as pain and poor performance, is responsive to local analgesia of periarticular structures with poorly defined pathology. The second presents primarily as poor performance with bony pathological changes as a result of chronic instability. Diagnostic tests based on biomechanics as well as manual provocation for SIJ pain have formed the basis of tests currently used to diagnose SIJ dysfunction in humans. This review summarises the anatomy and biomechanics of the equine SIJ and current biomechanical, innervation and motor control concepts in human SID. The relationship between abnormal SIJ motion and altered neuromotor control with clinical disease of the equine SIJ are discussed. Future utilisation of these principles to develop new diagnostic and management tools for the equine SID is promising.