Sacroiliac joint pain referral zones

Full-Endoscopic Sacroiliac Joint Denervation for Painful Sacroiliac Joint Dysfunction: A Prospective 2-Year Clinical Outcomes and Predictors for Improved Outcomes

BACKGROUND AND OBJECTIVES

Full-endoscopic sacroiliac joint denervation (FE-SJD) is a novel technique for the management of pain secondary to sacroiliac joint dysfunction. The aim of this study was to assess the long-term efficacy, safety, clinical outcomes, and outcome predictors of uniportal full-endoscopic sacroiliac joint denervation.

METHODS

From 2019 to 2021, a total of 47 consecutive patients with pain secondary to sacroiliac joint dysfunction underwent uniportal FE-SJD through posterior approach by a single fellowship-trained spine surgeon. A retrospective analysis of perioperative parameters, complications, and clinical outcomes were obtained prospectively.

RESULTS

The patient cohort had a mean age of 59.4 ± 14.0 years, with 63.8% females. Symptom duration averaged 62.1 ± 53.7 months. The mean operative time was 57.1 ± 16.8 minutes. All patients were discharged on the same day of surgery. Significant improvement was noted in preoperative visual analog score (back) and Oswestry Disability Index scores at 3, 6, 12 months, and 2 years (P < .001). Thirty-four patients (72.3%) returned to normal functioning with an average of 82% pain relief and a satisfaction rate of 78.7% at a mean follow-up of 18.2 ± 13.1 months. There were no intraoperative complications. One patient had postoperative right L5 dysesthesia. Seven patients (14.9%) underwent contralateral FE-SJD due to satisfaction with the index procedure but residual pain on the contralateral side. Concomitant lumbar issues correlated with less functional improvement at 2 years (P = .009).

CONCLUSION

The long-term clinical results of FE-SJD are favorable. Endoscopic denervation of the dorsal rami branches supplying the sacroiliac joint represents a safe, effective, and durable option to address pain secondary to sacroiliac joint dysfunction. A significant factor that influences outcomes is the presence of concomitant lumbar pathology. Further research is needed to compare this technique with current available treatment options.

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.

A Novel Approach to Assessing and Conservatively Treating Anterior Cutaneous Nerve Entrapment Syndrome: A Case Study

Anterior cutaneous nerve entrapment syndrome (ACNES) is a common source of chronic abdominal pain and is often underdiagnosed despite numerous and potentially invasive diagnostic evaluations and tests. We present a case report describing a novel, conservative, and non-invasive approach to diagnose and treat recurrent ACNES in a young and active patient. We describe a treatment-based diagnostic approach to confirm potential ACNES pain generators while recording pre- and post-treatment pain scores. After each maneuver, the patient was reassessed which allowed the working diagnosis to clinically evolve demonstrating the pathologic interrelationship between different skeletal structures and myofascial tissues contributing to irritation of the anterior cutaneous nerve. This treatment-based technique also made it possible to identify referred pain from a condition with overlapping symptoms originating from a different anatomic site. Treatment consisted of sequenced osteopathic manipulation techniques, active release techniques, instrument-assisted soft tissue mobilization, directional cupping, stretching, and strengthening exercises. The combination of sequenced treatments over the course of six physical therapy visits spanning 10 weeks resulted in 100% pain reduction and complete resolution of functional limitations. The patient was able to complete all work requirements and physical activity without pain. A sequenced treatment-based diagnostic approach to this case allowed us to more accurately identify all involved anatomic regions of pain and anatomic segments of pathology that were contributing to the abdominal pain or referring pain. No diagnostic imaging, invasive test, or injection was needed to properly diagnose and treat this case of ACNES. A proper understanding and application of osteopathic manipulation, active release techniques, instrument-assisted soft tissue mobilization, cupping, and exercises successfully resolved the contributing pain conditions and provided the patient important and useful tools and strategies to prevent recurrence.

Referred pain: characteristics, possible mechanisms, and clinical management

Purpose of this review

Referred pain is a common but less understood symptom that originates from somatic tissues. A comprehensive recognition of referred pain is important for clinicians when dealing with it. The purpose of this study is to summarize the current understanding of referred pain, including its pathogenesis, characteristics, diagnosis, and treatment.

Recent findings

Referred pain arises not only from pathologies primarily involving local tissue but also from lesions in distant structures. Central sensitization of convergent neurons and peripheral reflexes of dichotomizing afferent fibers are two theories proposed to explain the pathological mechanism of referred pain. Because syndromes related to referred pain of different origins overlap each other, it is challenging to define referred pain and identify its originating lesions. Although various approaches have been used in the diagnosis and treatment of referred pain, including conservative treatment, blockade, radiofrequency, and surgery, management of referred pain remains a clinical challenge.

Summary

Unlike radicular pain and neuropathic pain, referred pain is a less studied area, despite being common in clinics. Referred pain can derive from various spinal structures, and blockage helps identify the primary pathology. Due to the heterogeneity of referred pain, treatment outcomes remain uncertain. Further studies are needed to improve our understanding of referred pain.

Ultrasound-guided lateral branch radiofrequency neurotomy for sacroiliac joint pain after lumbosacral spinal fusion surgery

Our study evaluated the clinical feasibility of ultrasound-guided lateral branch radiofrequency neurotomy for sacroiliac joint (SIJ) pain after lumbosacral spinal fusion surgery (LSFS). This prospective study included a total of 46 patients who were diagnosed with SIJ pain after LSFS, did not respond to conservative treatment and therefore underwent ultrasound-guided SIJ radiofrequency neurotomy (RFN) from January 2019 to January 2022. These patients were followed up for twelve months after the procedure. Patients were assessed with the Numeric Rating Scale (NRS) and the Oswestry Disability Index (ODI) preprocedural and postprocedural for 1 month, 6 months and 12 months follow-ups. There was a significant improvement in postprocedural NRS and ODI scores (p < 0.001). Thirty-eight patients (82.6%) had a satisfactory response and good global perceived effect (GPE) after twelve months. No significant complications were observed during the 12-month follow-up. The ultrasound-guided radiofrequency device designed as a safe, easily applied and encouraging method could avoid revision surgery. It is a promising technique and has shown good results in providing intermediate pain relief. In addition to the limited series reported in the literature, future studies will add meaning to this topic by including it in routine practice.

Magnetic resonance imaging findings related to sacroiliac joint pain in high-performance athletes

BACKGROUND

Sacroiliac joint (SIJ) dysfunction in athletes affects competitiveness. However, the pathology and imaging features have not been clarified.

OBJECTIVE

To clarify the association between SIJ pain and MRI findings in high-performance athletes.

METHODS

Fifty-two Japanese high-performance athletes with or without SIJ pain were recruited. MRI short tau inversion recovery (STIR) semi-coronal and semi-axial images of their SIJs were taken. The relationships between high-signal changes in MRI-STIR and SIJ pain and pain duration were investigated. Six athletes with continuous SIJ pain were prospectively followed.

RESULTS

The proportion of athletes with high-signal changes in the SIJ was significantly higher among athletes with SIJ pain for one month or more (76.9%, 10/13) than among athletes with SIJ pain for less than one month (18.2%, 2/11) and among athletes without SIJ pain (28.6%, 8/28). High-signal changes on painful SIJs were most often present in the sacrum. In three of the six athletes who were prospectively followed, the high-signal area and intensity on MRI both diminished as their symptoms improved.

CONCLUSIONS

High-signal changes of the SIJ on MRI-STIR images in high-performance athletes may reflect their SIJ pain.

What You Need to Know About Sacroiliac Dysfunction

Low back pain is the leading cause of disability worldwide, and sacroiliac dysfunction is estimated to occur in 15%-30% of those with nonspecific low back pain. Nurses are in the unique position to support and provide education to patients who may be experiencing sacroiliac dysfunction or possibly apply this knowledge to themselves, as low back pain is a significant problem experienced by nurses. A patient's clinical presentation, including pain patterns and characteristics, functional limitations, common etiologies and musculoskeletal system involvement, current diagnostic tools, and realm of treatments, are discussed along with their respective efficacy. Distinction is made between specific diagnosis and treatment of joint involvement and that of sacroiliac regional pain, as well as other factors that play a role in diagnosis and treatment for the reader's consideration.

Novel anatomical findings with implications on the etiology of the piriformis syndrome

PURPOSE

The cause of the piriformis-related pelvic and extra-pelvic pain syndromes is still not well understood. Usually, the piriformis syndrome is seen as extra-pelvic sciatica caused by the entrapment of the sciatic nerve by the piriformis in its crossing through the greater sciatic foramen. However, the piriformis muscle may compress additional nerve structures in other regions and cause idiotypic pelvic pain, pelvic visceral pain, pudendal neuralgia, and pelvic organ dysfunction. There is still a lack of detailed description of the muscle origin, topography, and its possible relationships with the anterior branches of the sacral spinal nerves and with the sacral plexus. In this research, we aimed to characterize the topographic relationship of the piriformis with its surrounding anatomical structures, especially the anterior branches of the sacral spinal nerves and the sacral plexus in the pelvic cavity, as well as to estimate the possible role of anatomical piriformis variants in pelvic pain and extra-pelvic sciatica.

METHODS

Human cadaveric material was used accordingly to the Swiss Academy of Medical Science Guidelines adapted in 2021 and the Federal Act on Research involving Human Beings (Human Research ACT, HRA, status as 26, May 2021). All body donors gave written consent for using their bodies for teaching and research. 14 males and 26 females were included in this study. The age range varied from 64 to 97 years (mean 84 ± 10.7 years, median 88).

RESULTS

three variants of the sacral origin of the piriformis were found when referring to the relationship between the muscle and the anterior sacral foramen. Firstly, the medial muscle origin pattern and its complete covering of the anterior sacral foramen by the piriformis muscle is the most frequent anatomical variation (43% in males, 70% in females), probably with the most relevant clinical impact. This pattern may result in the compression of the anterior branches of the sacral spinal nerves when crossing the muscle.

CONCLUSIONS

These new anatomical findings may provide a better understanding of the complex piriformis and pelvic pain syndromes due to compression of the sacral spinal nerves with their somatic or autonomous (parasympathetic) qualities when crossing the piriformis.

Effectiveness of motor control exercises versus other musculoskeletal therapies in patients with pelvic girdle pain of sacroiliac joint origin: A systematic review with meta-analysis of randomized controlled trials

BACKGROUND

Pelvic girdle pain represents a group of musculoskeletal pain disorders associated with the sacroiliac joint and/or the surrounding musculoskeletal and ligamentous structures. Its physical management is still a serious challenge as it has been considered the primary cause of low back pain.

OBJECTIVE

This review sought to determine the effectiveness of motor control exercises for two clinically relevant measures; i.e., pain and disability, on patients with pelvic girdle pain of sacroiliac joint origin.

METHODS

This review covered only randomized controlled studies. Online databases, such as PubMed, Embase, Scopus, and Cochrane Library, were searched from January 1, 1990, to December 31, 2019. PEDro scale was used to assess the methodological quality of included studies, while Review Manager was employed to synthesize data in view of meta-analysis. The PRISMA guidelines were applied for this review.

RESULTS

Twelve randomized controlled trials of moderate-to-high quality were included in this review. The studies involved 1407 patients with a mean age ranging from 25.5 to 42.1 years as well as intervention and follow-up durations from 1 week to 2 years. Motor control exercises alone for pelvic girdle pain of sacroiliac joint origin were not effective in terms of pain reduction (SMD = 0.29 [-0.64,1.22]) compared to control interventions whereas they were slightly effective in terms of disability reduction (SMD =-0.07 [-0.67, 0.53]) at short-term. The combination of motor control exercises with other musculoskeletal therapies, however, revealed to be more effective than control interventions in terms of pain reduction (SMD =-1.78 [-2.49, -1.07]; 95%CI) and lessened disability (SMD =-1.80 [-3.03, -0.56]; 95%CI) at short-term.

CONCLUSION

Motor control exercises alone were not found to be effective in reducing pain at short-term. However, their combination with other musculoskeletal therapies revealed a significant and clinically-relevant decrease in pain and disability at short-term, especially in peripartum period.

Radiculopathy with concomitant sacroiliac dysfunction and lumbosacral degenerative disease: illustrative case

BACKGROUND

The sacroiliac joint (SIJ) is an important cause of low back pain and referred leg pain (RLP). Pain from SIJ dysfunction may occur in isolation or may result from a combination with lumbosacral area–mediated pain. SIJ fusion is one treatment modality for medically refractory symptoms and may also have a role in the treatment of RLP.

OBSERVATIONS

The authors present a challenging case of concomitant lumbosacral degenerative disease and SIJ dysfunction in a patient with radiculopathy. They provide clinical characteristics and imaging findings and discuss difficulties in dealing with the intersection of these two distinct diagnoses. In addition, the authors offer a review of the relevant literature, elucidating the role of SIJ dysfunction in causing radicular lower extremity pain, the relationship to concomitant lumbosacral degenerative disease, and outcome data for SIJ fusion as it relates to RLP.

LESSONS

With increasing numbers of patients undergoing spinal instrumentation in the setting of degenerative lumbosacral arthritis, as well as randomized controlled trial data demonstrating the efficacy of SIJ fusion for medically refractory SIJ dysfunction, it is important to recognize the challenges in understanding how both of these patient groups may present with radiculopathy. Failure to do so may result in incorrect patient selection, poor outcomes, and increased morbidity for at-risk patients.

Infra-adjacent Segment Disease After Lumbar Fusion: An Analysis of Pelvic Parameters

STUDY DESIGN

Cross-sectional observational cohort study.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors associated with the development of sacroiliac joint (SIJ) dysfunction following lumbosacral fusion.

SUMMARY OF BACKGROUND DATA

Adjacent segment degeneration to both proximal and distal areas of spinal fusion is a postoperative complication of lumbar fusion. Various studies examined supra-adjacent degeneration following lumbar fusion, but few focused on infra-adjacent degeneration. In lumbosacral fusion, fusion extends to the sacrum, placing increased stress on the SIJ.

METHODS

A total of 2069 sequential patients who underwent lumbosacral fusion surgery from 2008 to 2018 at a single academic medical center were retrospectively reviewed. Patients who subsequently developed SIJ dysfunction were identified. SIJ dysfunction was defined as patients who met the diagnostic criteria with physical examination and received an SIJ injection with clinical evidence of improvement. Controls, without subsequent SIJ dysfunction, were matched with cases based on levels of fusion, age, sex, and body mass index. Pre-and postoperative pelvic parameters were measured, including pelvic incidence, pelvic tilt (PT), sacral slope, lumbar lordosis, lumbosacral angle, L4 incidence and L5 incidence.

RESULTS

Of 2069 patients who underwent lumbosacral fusion, 81 patients (3.9%) met criteria for SIJ dysfunction. Measurements were made for 47 of 81 patients who had SIJ dysfunction, that had both pre- and post-operative imaging. Measurements for 44 matched controls were taken. Postoperative PT was significantly lower in SIJ dysfunction patients compared to controls (20.82° ± 2.19° vs. 27.28° ± 2.30°; P < 0.05), as was L5 incidence (28.64° ± 3.38° vs. 37.11° ± 3.50°; P < 0.05).

CONCLUSION

Incidence of the SIJ dysfunction after lumbosacral fusion surgery was 3.9% and these patients had a significantly lower PT and L5 incidence compared to the control group. Significantly low PT may be derived from weak hamstring muscles, predisposing a patient to SIJ dysfunction. Therefore, hamstring muscle strengthening exercise for patients with decreased PT after lumbosacral fusion may decrease the incidence of SIJ dysfunction.Level of Evidence: 3.

Low back pain

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

A Current Update on Pelvifemoral Conditions That Should be in the Differential Diagnosis for Patients With Lower Extremity Radiculopathy

Patients presenting to an outpatient spine clinic frequently report symptoms of low back pain with associated buttock, groin, and lower extremity pain. While many of these individuals suffer from lumbar spine radiculopathy, a number of different orthopedic pathologies can mimic these symptoms. Management depends substantially on a detailed history and physical examination, in addition to working from a broad list of differential diagnoses when evaluating these patients. It is imperative that spine practitioners have a comprehensive understanding of the differential diagnoses that may mimic those originating from the lumbar spine, especially when a patient's symptoms are atypical from classic radicular pain. Misdiagnosis can lead to unnecessary testing and treatment, while delaying an accurate clinical assessment and treatment plan. This review highlights common orthopedic diagnoses that may present similar to lumbar spine pathologies and the evidence-based evaluation of these conditions.

Quantitative evaluation of the sacroiliac joint fixation in stress reduction on both sacroiliac joint cartilage and ligaments: A finite element analysis

BACKGROUND

The sacroiliac joint fixation is the last resort for patients with prolonged and severe joint pain. Although the clinical results of anterior fixations are conclusive, there exist several inevitable drawbacks with the surgical method such as the difficulty performing the surgery due to the presence of many organs. The posterior fixation technique has thus been developed to overcome those inconveniences. This study aims to assess in silico the mechanical environment following posterior and anterior fixations, focusing on stresses in both the sacroiliac cartilage and dorsal ligamentous part, as well as loads experienced by the pelvic ligaments.

METHODS

Sacroiliac joint cartilage, dorsal ligamentous part stresses and pelvic ligaments loads were evaluated with three types of fixation models. A vertical load of 600 N was applied, equally distributed via both acetabula when standing and sitting.

FINDINGS

Results show that the anterior sacroiliac joint fixation reduced von Mises stresses in the cartilage and dorsal ligamentous part and decreased ligaments loads more extensively than the posterior fixation when compared to the untreated model as a reference. However, the posterior fixation still remains the desirable and preferential treatment.

INTERPRETATION

The anterior sacroiliac joint fixation showed better performances compared to the posterior one; however, the lower invasive aspect of the latter is a fundamental clinical advantage which also has the possibility to be improved by considering various screws and cages configurations. This study provides a beneficial suggestion to improve the current fixation technique.

Enhanced Spinal Therapy: Extracorporeal Shock Wave Therapy for the Spine

Extracorporeal shock wave therapy (ESWT) is a non-invasive therapeutic method used for pain management and muscle strength improvement through the use of shock waves. In vitro studies have demonstrated that shockwave therapy induces fluctuation in redox reaction regulation and increases in Mitogen-Activated Protein Kinase (MAPK) signal transduction pathways, stimulating increased gene expression in the nucleus. ESWT has also been shown to upregulate angiogenesis and growth factors through activation of endothelial nitric oxide synthase (eNOS) and vascular endothelial growth factor (VEGF). The use of ESWT in the treatment of various musculoskeletal disorders was widely adopted throughout Europe, South America, and Asia before being introduced in the United States in 2000. Within the past 20 years, the clinical application of ESWT in the treatment of musculoskeletal and bone disorders has grown. This paper provides a comprehensive narrative review of applications and outcomes of ESWT in clinical spinal pathology and assesses reported efficacy as it relates to the pathology. A review of the literature yielded studies describing the use of ESWT in degenerative osteoporotic neuro-spinal pathology, heterotopic ossification due to spinal cord injury, cervical spondylosis, scoliosis, sacroiliitis, and coccydynia. The efficacy of ESWT as an adjunct treatment in patients with spinal cord pathologies varied with the specific pathology, however, all pathologies discussed in this review provided evidence of potential benefits with minimal adverse effects. While the use of ESWT for pain management has widely been established, further literature should aim to identify the long-term benefits of ESWT.

Criteria for Identifying Technically Difficult Cases when Performing Sacroiliac Intraarticular Injections Based on the Grade of Sacroiliac Arthrogram

OBJECTIVE

An intraarticular sacroiliac joint (SIJ) injection cannot always be performed successfully. Based on the patterns of the sacroiliac arthrogram, we explored possible indicators of technically difficult and technically easy injections into the SIJ including demographic features and anatomical features evident on preprocedural imaging.

DESIGN

Observational study.

METHODS

We evaluated 76 patients with painful SIJ (total 108 joints) diagnosed by SIJ injections. The sacroiliac arthrogram was graded as follows: Grade (G) 0 = the margin of the joint was partially outlined; G1 = the margin was completely outlined; G2 = intraarticular space was substantially outlined; and G3 = intraarticular space was fully outlined. Two multivariable ordered logistic regression analyses were performed to test the relationships between gender, age, and Grade, as well as between computed tomography (CT) findings and grade.

RESULTS

In men, the totals by Grade were G0 = 8 (joints); G1 = 33; G2 = 3; and G3 = 0. In women, these were G0 = 4; G1 = 28; G2 = 22; and G3 = 10. The Grade was significantly higher in women and was also higher with age (P < 0.05). Regarding morphological features in CT, minor osteophytes increased the odds in favor of better Grades of arthrogram (odds ratio = 3.50). Substantial vacuum phenomena strongly increased the odds of better arthrograms (20.52).

CONCLUSIONS

Outlining the SIJ cavity fully is significantly more difficult in male patients of any age than in aged female patients. The presence of minor osteophytes and substantial vacuum phenomena on preprocedure CT scans can be reasonably reassuring to the practitioner that they are unlikely to encounter difficulties during injection.

Diagnosis of Sacroiliac Joint Pain: Predictive Value of Three Diagnostic Clinical Tests

INTRODUCTION

To date, there have been no acceptable and accurate diagnostic criteria or standards of care for the management of sacroiliac joint (SIJ) pain. Several studies have yielded different contributions of clinical presentation, history, and physical examination in the diagnosis of SIJ pain. Our goal in this study was to assess the sensitivity and specificity of the diagnostic clinical tests and their predictive value in accurately diagnosing SIJ pain.

METHODOLOGY

Upon enrolling 200 eligible patients with SIJ pain as their primary diagnosis, they were re-evaluated and their verbal rating scale (VRS) pain scores and demographic data were obtained. Thereafter, three SIJ diagnostic tests were performed: the thigh thrust test, the Patrick test, and a modified version of the Gaenslen test that is referred to as the Mekhail test. Subsequently, the patients were taken to the procedure room to undergo SIJ injection, for which a confirmative result was ≥50% pain relief. The physicians performing the procedure were blinded of the results of the 3 tests performed. Results from the 3 tests were incorporated with the procedure results, from which we drew statistical and medical conclusions determining their predictive value and degree of aid to physicians in diagnosing SIJ pain.

RESULTS

We found that the cumulative effect of adding simultaneous tests increased the sensitivity of the testing but decreased the specificity, which generates a powerful screening tool. The combination of the Patrick and Mekhail tests demonstrated the best accuracy, with 94% sensitivity, 17% specificity, 81% positive predictive value, and 44% negative predictive value. The Patrick test was better than other tests for differentiating patients with SIJ pain from those with non-SIJ pain. No combination yielded both significant sensitivity and specificity. Generally, the overall predictive value of any of the tests on their own or their combination did not vary significantly from the predictive value of baseline demographics, including pre-injection pain score and pain referral diagram.

CONCLUSION

In conclusion, our study results were similar to those of previous investigators who found that physical examination plays a limited role in diagnosing SIJ pain. Specifically, we found that the clinical tests and/or their combinations added no significant predictive capacity compared to patients' baseline characteristics in predicting the response to diagnostic SIJ injection, albeit the combination of the Mekhail and Patrick tests yielded high sensitivity (94%), making them viable for consecutive screening, possibly reducing the unnecessary costs of diagnostic SIJ injection procedures.

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.

Prevalence of Hip or Groin Pain in Adolescents: A Systematic Review and Meta-Analysis

Musculoskeletal pain is a common cause of pain in adolescence and can be an important predictor of future pain. The prevalence of hip or groin pain that could potentially affect different adolescent populations has not yet been systematically reviewed. This systematic review aimed to determine the prevalence of hip or groin pain in this population. Five electronic databases were searched until January 2019 for eligible studies that included males and females 13 to 19 years of age. Study selection, data extraction, and risk of bias assessments were completed by 2 independent researchers. Based on inclusion criteria, 8 population-based, 8 clinical, and 4 sports populations were included. Studies were conducted in Europe, North America, and Australia. The prevalence was dichotomized into "0 to 3 months" and "3 months and above." Meta-analyses were performed to estimate the prevalence from 0 to 3 months, and individual estimates were reported for studies of 3 months and above. The overall prevalence of hip or groin pain in all adolescents from 0 to 3 months was 12% (95% confidence interval [CI] 6%, 23%) based on 10 studies, and was 7% (95% CI 6%, 10%) based on 7 population studies. Caution should be applied to these estimates due to substantial study heterogeneity. The pain prevalence in cerebral palsy from 0 to 3 months based on 4 studies was 13% (95% CI 10%, 15%). Individual prevalence estimates were 6% and 31% in obese and 4% in hypermobility populations, respectively, and ranged from 6% to 100% in 4 sports studies. The validity of these estimates is compromised by poor methodological quality.

Determination of the Prevalence From Clinical Diagnosis of Sacroiliac Joint Dysfunction in Patients With Lumbar Disc Hernia and an Evaluation of the Effect of This Combination on Pain and Quality of Life

STUDY DESIGN

A prospective cross-sectional study.

OBJECTIVE

To evaluate the prevalence of sacroiliac joint dysfunction in patients with lumbar disc hernia and examine the variations in clinical parameters cause by this combination.

SUMMARY OF BACKGROUND DATA

Although one of the many agents leading to lumbar pain is sacroiliac dysfunction, little progress has still been made to evaluate mechanical pain from sacroiliac joint dysfunction within the context of differential diagnosis of lumbar pain.

METHODS

Two hundred thirty-four patients already diagnosed with lumbar disc hernia were included in the study. During the evaluation, sacroiliac joint dysfunction was investigated using specific tests, pain levels with a Visual Analog Scale, and the presence of neuropathic pain using Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale. Other clinical assessments were performed using the Beck Depression Inventory, Health Assessment Questionnaire, and Tampa Kinesiophobia Scale.

RESULTS

63.2% of patients were female and 36.8% were male. Mean age was 46.72 ± 11.14 years. The level of sacroiliac joint dysfunction was 33.3% in the research population. In terms of sex distribution, the proportion of women was higher in the group with sacroiliac joint dysfunction (P < 0.05). No significant difference was observed in pain intensity assessed using a Visual Pain Scale between the groups (P > 0.05), but the level of neuropathic pain was significantly higher in the group with dysfunction (P < 0.05). In the group with sacroiliac joint dysfunction, the presence of depression was significantly higher (P = 0.009), functional capacity was worse (P < 0.001), and the presence of kinesophobia was higher (P = 0.02).

CONCLUSION

Our study results will be useful in attracting the attention of clinicians away from the intervertebral disc to the sacroiliac joint in order to avoid unnecessary and aggressive treatments.

LEVEL OF EVIDENCE

2.

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.

Technical variation of trans-articular sacroiliac joint (SIJ) fusion using three screws considering the effects of sacral dysplasia in patients with non-traumatic SIJ pain

Background

This study evaluated the technical adequacy of trans-articular sacroiliac joint (SIJ) fusion using three screws for non-traumatic SIJ pain, considering different grades of sacral dysplasia.

Methods

Cadaveric CT data of unilateral sacropelvic complexes for 72 individuals (53.4 ± 8.4 years) were selected. A 3D model was reformatted into the plain lateral radiograph to mark the articular surface of the SIJ. Subjects were classified into dysplastic (DYS) and non-dysplastic sacrum (NDS) groups. Proximal (PS), middle (MS), and distal screws (DS) with 10-mm diameter were virtually introduced to the iliac bone and the SIJ on the lateral image with a 5-mm safety margin. On a corresponding axial image, each screw was advanced vertically to the sagittal plane with the same safety margin. The entry points for each screw to the endplate of S1 (S2) and to the corresponding anterior sacral margin on the lateral image were measured, along with the maximal screw lengths on the axial image. Whether each screw passed through the SIJ was determined. Different types of sacral dysplasia and screws were compared statistically.

Results

Thirty-eight (26.4%) cases were DYS, and 106 (73.6%) were NDS. The entry points of all screws were significantly more distal in DYS than in NDS groups. The PS and MS screw lengths differed significantly between the 2 groups. Incidences of short sacral fixation (< 10 mm) were significantly higher for the DS in both NDS (38.7%) and DYS (39.5%) groups. Incidences of screw pass were lowest for the MS in both NDS (43.4%) and DYS (47.4%) groups.

Conclusions

Sacral dysplasia locates the SIJ more distally and therefore affects the entry point locations and screw lengths for all screws in trans-articular SIJ fusion, compared with a non-dysplastic sacrum. Moreover, three-screw fixation risks the development of unstable DS fixation and a high extra-articular fixation rate in MS.

Effect of repeated application of rigid tape on pain and mobility deficits associated with sacroiliac joint dysfunction

BACKGROUND

Sacroiliac joint dysfunction (SIJD) accounts for up to 30% of patients with low back pain. Rigid taping techniques are often used for conservative treatment of SIJD related symptoms; however, its effectiveness has not been systematically evaluated.

OBJECTIVES

The aim of our study was to investigate the effect of rigid tape on pain, malalignment and mobility deficits associated with anterior innominate SIJD.

METHODS

Two groups (n= 37; experimental and control) diagnosed with SIJD participated in a randomized, controlled trial. Tape was applied for 2 weeks in the experimental group, whereas the control group received no treatment. 2 × 2 (group × time) GLM-MANOVA assessed effects of tape on pain; innominate rotation; and hip rotation range of motion. Chi-square and McNemar tests assessed the effect of tape on Gillet and Sitting forward flexion mobility tests; the Patrick, Posterior shear and Gaenslen pain provocation tests were used to test pain. Variables were assessed before (PRE) and after (POST) two weeks.

RESULTS

No group differences were observed for any variable PRE. Pain intensity, innominate rotation (p< 0.05) and number of positive mobility and pain provocation tests (p< 0.05) decreased from PRE versus POST in the experimental group. No differences were observed in the control group.

CONCLUSION

Two weeks of rigid tape for anterior innominate correction successfully reduced symptoms related to SIJD.

Challenges in Diagnosing Sacroiliac Joint Pain: A Narrative Review

Accurate diagnosis of sacroiliac joint (SIJ) pain is challenging. Diagnosis can be aided by pain referral patterns, historical features, physical examination maneuvers, and imaging. However, all of these diagnostic tools have limitations. The most reliable clinical tools may be a combination of three or more positive physical exam maneuvers, although the evidence is inconsistent even for this strategy. Intra-articular diagnostic SIJ injections are often used as the reference standard for "true" sacroiliac pain. However, such injections do not consider extra-articular sources of pain that may also exist as part of the sacroiliac joint complex. Research has established the posterior sacral ligaments as a possible source of pain, and the innervation of these ligaments has been anatomically defined. It is possible that by expanding our focus from the articular portion of the sacroiliac complex structure to both the joint and extra-capsular ligaments, advancements in clinical diagnosis and treatment will be possible.

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.

Lumbosacral Radiculopathy: Inciting Events and Their Association with Epidural Steroid Injection Outcomes

Objective

Low back pain is the leading cause of worldwide disability, with lumbosacral radiculopathy accounting for over one-third of these cases. There are limited data on the relationship between etiologies and lumbosacral radiculopathy, and it is unknown whether specific causes predict treatment outcomes.

Design, Setting, and Subjects

This study explores patient-reported etiologies for lumbosacral radiculopathy in a chronic pain clinic between January 2007 and December 2015 and examines whether these causes affected epidural steroid injection outcomes.

Methods

We reviewed the medical records of 1,242 patients with lumbosacral radiculopathy who received epidural steroid injections. The recording of an inciting event was done contemporaneously based on note templates. A positive outcome following an epidural steroid injection was defined as ≥30% pain relief sustained for six or more weeks without additional intervention. Factors associated with epidural steroid injection outcome were analyzed by multivariable logistic regression.

Results

Fifty point seven percent reported an inciting event, and 59.9% of patients experienced a positive epidural steroid injection outcome. The most commonly reported causes were falls (13.1%), motor vehicle collisions (10.7%), and lifting (7.8%). Individuals with a herniated disc (56.3%) were more likely to report a precipitating cause than those with stenosis (44.7%) or degenerative discs (47.8%, P = 0.012). An inciting event did not predict treatment outcome. Factors associated with negative treatment outcome included opioid consumption (odds ratio [OR] = 0.61, 95% confidence interval [CI] = 0.39–0.95, P = 0.027), secondary gain (OR = 0.69, 95% CI = 0.50–0.96, P = 0.030), and baseline pain score (OR = 0.90, 95% CI = 0.84–0.97, P = 0.006). The number of levels injected was associated with a positive outcome (OR = 2.72, 95% CI = 1.28–6.47, P = 0.008).

Conclusions

Reported inciting events are common in patients with lumbosacral radiculopathy but are not associated with outcome following epidural steroid injection, and their occurrence is not always consistent with the purported mechanism of injury.

Fluoroscopically Guided vs Landmark-Guided Sacroiliac Joint Injections: A Randomized Controlled Study

OBJECTIVES

To determine the prevalence of intra- and extra-articular sacroiliac joint (SIJ) pain, which injection is more beneficial, and whether fluoroscopy improves outcomes.

PATIENTS AND METHODS

This patient- and evaluator-blinded comparative effectiveness study randomized 125 participants with SIJ pain from April 30, 2014, through December 12, 2017, to receive fluoroscopically guided injections into the joint capsule (group 1) or "blind" injections to the point of maximum tenderness using sham radiographs (group 2). The primary outcome was average pain on a 0 to 10 scale 1 month after injection. A positive outcome was defined as at least a 2-point decrease in average pain score coupled with positive (>3) satisfaction on a Likert scale from 1 to 5.

RESULTS

For the primary outcome, no significant differences were observed between groups (mean ± SD change from baseline, -2.3±2.4 points in group 1 vs -1.7±2.3 points in group 2; 95% CI, -0.33 to 1.36 points for adjusted difference; P=.23), nor was there a difference in the proportions of positive blocks (61% vs 62%) or 1-month categorical outcome (48% vs 40% in groups 1 and 2, respectively; P=.33). At 3 months, the mean ± SD reductions in average pain (-1.8±2.1 vs -0.9 ± 2.0 points; 95% CI, 0.11 to 1.58 points for adjusted difference; P=.02) and worst pain (-2.2±2.5 vs -1.4±2.0 points; 95% CI, 0.01 to 1.66 points for adjusted difference; P=.049) were greater in group 1 than 2, with other outcome differences falling shy of statistical significance.

CONCLUSION

Although fluoroscopically guided injections provide greater intermediate-term benefit in some patients, these differences are modest and accompanied by large cost differences.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02096653.

Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment

PURPOSE OF REVIEW

Low back pain encompasses three distinct sources: axial lumbosacral, radicular, and referred pain. Annually, the prevalence of low back pain in the general US adult population is 10-30%, and the lifetime prevalence of US adults is as high as 65-80%.

RECENT FINDINGS

Patient history, physical exam, and diagnostic testing are important components to accurate diagnosis and identification of patient pathophysiology. Etiologies of low back pain include myofascial pain, facet joint pain, sacroiliac joint pain, discogenic pain, spinal stenosis, and failed back surgery. In chronic back pain patients, a multidisciplinary, logical approach to treatment is most effective and can include multimodal medical, psychological, physical, and interventional approaches. Low back pain is a difficult condition to effectively treat and continues to affect millions of Americans every year. In the current investigation, we present a comprehensive review of low back pain and discuss associated pathophysiology, diagnosis, and treatment.

Diagnosing Sacroiliac Joint Pain

The sacroiliac joint (SIJ) is a diarthrodial joint that has been implicated as a pain generator in approximately 10% to 25% of patients with mechanical low back or leg symptoms. Unique anatomic and physiologic characteristics of SIJ make it susceptible to mechanical stress and also create challenges in the diagnosis of SIJ pain. A variety of inciting causes for SIJ pain may exist, ranging from repetitive low-impact activities such as jogging to increased stress after multilevel spine fusion surgery to high-energy trauma such as in motor vehicle accidents. Similarly, wide variability exists in the clinical presentation of SIJ pain from localized pain or tenderness around the SIJ to radiating pain into the groin or even the entire lower extremity. No pathognomonic clinical history, physical examination finding, or imaging study exists that aids clinicians in making a reliable diagnosis. However, imaging combined with clinical provocative tests might help to identify patients for further investigation. Although provocative physical examination tests have not received reliable consensus, if three or more provocative tests are positive, pursuing a diagnostic SIJ injection is considered reasonable. Notable pain relief with intra-articular anesthetic injection under radiographic guidance has been shown to provide reliable evidence in the diagnosis of SIJ pain.

Widespread pain in axial spondyloarthritis: clinical importance and gender differences

Background

There is a remarkable lack of detailed knowledge on pain areas in axial spondyloarthritis (axSpA), and their clinical relevance is largely unknown. Pain area may reflect local disease processes, but amplification of nervous system signalling may alter this relationship. Also, gender differences in pain area may exist in axSpA, possibly confounding disease activity outcomes. Therefore, we firstly detailed pain locations in axSpA and evaluated gender differences. Secondly, we explored the relationship of regional pain definitions with clinical outcomes. Finally, we explored the role of pain area in the assessment of disease activity.

Methods

Body charts informed on the presence of axial, peripheral articular and non-articular pain in 170 patients (108 men, 62 women) with axSpA. Multivariate Odds Ratios (ORs) were used to compare genders. General linear models were used to explore clinical differences in disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), activity limitations (Bath Ankylosing Spondylitis Functional Index [BASFI]), fear of movement (Tampa Scale for Kinesiophobia 11-item version [TSK-11]), anxiety (Hospital Anxiety and Depression Scale subscale anxiety [HADS-A]) and depression (HADS subscale depression [HADS-D]) between four subgroups classified by widespread non-articular pain (WNAP+/−) and physician global assessment of disease activity (PGDA+/−) (p < .05). Principal Component Analysis (PCA) was performed to explore gender differences in the structure of disease activity.

Results

Axial thoracic pain was least prevalent (lumbar, 74.4%; cervical, 47.6%; cervicothoracic, 47.6%; thoracic, 32.4%), but it was about three times more likely in women (OR, 2.92; p = .009). Axial cervicothoracic junction pain spread more diffusely in women (OR, 2.48; p = .018). Women exhibited a two- to threefold increased likelihood of widespread axial (OR, 3.33; p = .007) and peripheral articular (OR, 2.34; p = .023) pain. A subgroup of WNAP+/PGDA− combined with low PGDA (27% of all patients) was associated with worse BASFI, BASDAI, HADS-A and HADS-D in men and worse TSK-11 and HADS-A in women (p < .05). Disease activity outcomes showed a two-factor structure in women but not in men.

Conclusions

In patients with axSpA, the location and spread of pain was different between genders and was related to worse clinical status. On the basis of pain area and PGDA, clinical subgroups exhibiting a remarkably distinct health status were identified. Outcome instruments such as BASDAI should acknowledge gender differences to ensure structural validity.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1626-8) contains supplementary material, which is available to authorized users.

Management of a nonathlete with a traumatic groin strain and osteitis pubis using manual therapy and therapeutic exercise: A case report

INTRODUCTION

Without a definitive single pathoanatomical origin for groin pain, management is difficult. The purpose of this case report is to describe the differential diagnosis and management of an individual with a traumatic groin strain. Case Description: A 47-year-old sedentary male truck driver presented to physical therapy with a 2-month history of right medial groin pain. Pushing the gas pedal and sitting were painful activities. Pain was 3-8/10 on the Numeric Pain Rating Scale (NPRS). The patient reported 46/80 on the Lower Extremity Functional Scale. Examination: Tenderness was noted along the adductor longus muscle belly, right pubic ramus and hip range of motion was limited. Special tests directed at the hip and pelvic region indicated intraarticular and pelvic dysfunction. Treatment included hip and pubic symphysis joint mobilizations, lumbopelvic manipulation, adductor longus soft-tissue mobilization, and core strengthening. Outcome: 12 sessions of physical therapy resulted in LEFS to 80/80, Global Rating of Change (GROC) + 7, and NPRS 0/10 at worst. The patient returned to full work without restriction. Discussion: Groin pain has many pathoanatomical drivers. Management of a traumatic groin injury requires a thorough evaluation and a global treatment approach, in order to improve outcomes and reduce the risk of the pathology becoming chronic.

The impact of progressive pelvic floor muscle exercise and manual therapy in a patient postpartum who met the criteria for sacroiliac joint pain based on Laslett's cluster of provocation signs

Sacroiliac joint (SIJ) pain has been identified as a primary or contributing source of pain in patients with low back pain. The Laslett cluster of SIJ pain provocation tests has the strongest evidence for noninvasive clinical testing. The purpose of this report was to describe the impact of physical therapy treatments for a patient postpartum with SIJ pain who satisfied the Laslett cluster. Specifically, the goal was to assess the impact of progressive pelvic floor muscle exercise and manual therapy. The Modified Oswestry Low Back Pain Disability Questionnaire (MODI) was the primary outcome measure used in this case. In addition, the Numeric Pain Rating Scale (NRPS) and Global Rating of Change (GROC) were used as secondary outcome measures. In this case report, the patient responded to the combined interventions with decreases in MODI, NRPS and GROC. Further research is warranted to develop stronger evidence to identify specific interventions for the treatment of SIJ pain.

A Diagnostic Scoring System for Sacroiliac Joint Pain Originating from the Posterior Ligament

Objective

Sacroiliac joint (SIJ) pain originating from the posterior ligament manifests in not only the buttocks but also the groin and lower extremities and thus may be difficult to discern from pain secondary to other lumbar disorders. We aimed to develop a simple clinical diagnostic tool to help physicians distinguish between patients with SIJ pain originating from the posterior ligament and those with lumbar disc herniation (LDH) or lumbar spinal canal stenosis (LSS).

Design

Prospective case-control study.

Patients and Methods

We evaluated 62 patients with SIJ pain originating from the posterior ligament and 59 patients with LDH and LSS. Pain areas, pain increasing positions, provocation test, and tenderness points were investigated. A scoring system based on multivariate logistic regression equations using the investigated items was developed.

Results

Two pain areas (the posterosuperior iliac spine (PSIS) detected by the one-finger test and groin), pain while sitting on a chair, provocation test, and two tenderness points (PSIS and the sacrotuberous ligament) had high odds ratios (range, 25.87–1.40) and were used as factors in the scoring system. An integer score derived from the regression coefficient and clinical experience was assigned to each identified risk factor. The sum of the risk score for each patient ranged from 0–9. This scoring system had a sensitivity of 90.3% and a specificity of 86.4% for a positivity cutoff point of 4.

Conclusion

The scoring system can help distinguish between patients with SIJ pain originating from the posterior ligament and those with LDH and LSS.

Extracorporeal shock wave therapy for sacroiliac joint pain: A prospective, randomized, sham-controlled short-term trial

BACKGROUND

Sacroiliac joint (SIJ) pain can cause lower back pain and pelvic discomfort. However, there is no established standard treatment for SIJ pain. Extracorporeal shock wave therapy (ESWT) is a novel, non-invasive therapeutic modality for musculoskeletal disorders. The mechanism underlying shockwave therapy is not fully understood, but the frequency with which ESWT is applied clinically has increased over the years.

OBJECTIVE

We evaluated the efficacy of using ESWT to treating SIJ pain.

METHODS

Thirty patients with SIJ pain were assigned randomly to ESWT (n = 15) and sham control (n = 15) groups. The ESWT group received 2,000 shockwaves with energy set to the maximum level tolerable by the patient (energy density = 0.09-0.25 mJ/mm2). The probe was oriented perpendicular to the posterior SIJ line, and moved up and down along the joint line. The sham control group received 2,000 shockwaves with the probe oriented parallel to the posterior SIJ line. A 10-cm numeric rating scale (NRS) and the Oswestry Disability Index (ODI) scores were assessed before the intervention, and 1 and 4 weeks post-intervention. Participants were instructed to refrain from using any other conservative treatment, including anti-inflammatory medication and other physical modalities during the study.

RESULTS

In the ESWT group, NRS decreased significantly at post-treatment week 4 (3.64 (95% confidence interval, 2.29-4.99)) compared to baseline (6.42 (5.19-7.66); P < 0.05). ODI improved at 1 and 4 weeks compared to baseline, but not significantly. In the sham group, NRS and ODI did not differ at any post-treatment time point. There was a significant group difference in NRS at week 4 post-treatment (3.64 (2.29-4.99) in the ESWT group vs. 6.18 (5.34-7.02) in the sham control group; P < 0.05), but this was not the case for ODI.

CONCLUSIONS

ESWT represents a potential therapeutic option for decreasing SIJ pain.

Back Pain with Leg Pain

PURPOSE OF REVIEW

The clinical diagnostic dilemma of low back pain that is associated with lower limb pain is very common. In relation to back pain that radiates to the leg, the International Association for the Study of Pain (IASP) states: "Pain in the lower limb should be described specifically as either referred pain or radicular pain. In cases of doubt no implication should be made and the pain should be described as pain in the lower limb."

RECENT FINDINGS

Bogduks' editorial in the journal PAIN (2009) helps us to differentiate and define the terms somatic referred pain, radicular pain, and radiculopathy. In addition, there are other pathologies distal to the nerve root that could be relevant to patients with back pain and leg pain such as plexus and peripheral nerve involvement. Hence, the diagnosis of back pain with leg pain can still be challenging. In this article, we present a patient with back and leg pain. The patient appears to have a radicular pain syndrome, but has no neurological impairment and shows signs of myofascial involvement. Is there a single diagnosis or indeed two overlapping syndromes? The scope of our article encompasses the common diagnostic possibilities for this type of patient. A discussion of treatment is beyond the scope of this article and depends on the final diagnosis/diagnoses made.

Biomechanical study of different fixation techniques for the treatment of sacroiliac joint injuries using finite element analyses and biomechanical tests

The pelvis is one of the most stressed areas of the human musculoskeletal system due to the transfer of truncal loads to the lower extremities. Sacroiliac joint injury may lead to abnormal joint mechanics and an unstable pelvis. Various fixation techniques have been evaluated and discussed. However, it may be difficult to investigate each technique due to variations in bone quality, bone anatomy, fracture pattern, and fixation location. Additionally, the finite element method is one useful technology that avoids these variations. Unfortunately, most previous studies neglected the effects of the lumbar spine and femurs when they investigated the biomechanics of pelvises. Thus, the aim of this study was to investigate the biomechanical performance of intact, injured, and treated pelvises using numerical and experimental approaches. Three-dimensional finite element models of the spine-pelvis-femur complex with and without muscles and ligaments were developed. The intact pelvis, the pelvis with sacroiliac joint injury, and three types of pelvic fixation techniques were analyzed. Concurrently, biomechanical tests were conducted to validate the numerical outcomes using artificial pelvises. Posterior iliosacral screw fixation showed relatively better fixation stability and lower risks of implant failure and pelvic breakage than sacral bar fixation and a locking compression plate fixation. The present study can help surgeons and engineers understand the biomechanics of intact, injured, and treated pelvises. Both the simulation technique and the experimental setup can be applied to investigate different pelvic injuries.

Sacroiliac Joint Treatment Personalized to Individual Patient Anatomy Using 3-Dimensional Navigation

During the past 10 years, the sacroiliac (SI) joint has evolved from being barely recognized as a source of pain, to being a joint treated only nonsurgically or with great surgical morbidity, to currently being a joint treated with minimally invasive techniques that are personalized to the individual patient. The complex 3-dimensional anatomy of the SI joint and lack of parallel to traditional imaging planes requires a thorough understanding of the structures within and around the SI joint that may be at risk of injury. Thus, the SI joint is ideally suited for intraoperative 3-dimensional imaging and surgical navigation when being treated minimally invasively.

Referred leg pain originating from the sacroiliac joint: 6-month outcomes from the prospective randomized controlled iMIA trial

BACKGROUND

The first results from the randomized, controlled iFuse Implant System Minimally Invasive Arthrodesis (iMIA) trial showed that minimally invasive surgical management (MISM) of low back pain originating from the sacroiliac joint (SIJ) by placing transarticular triangular titanium implants reduced pain more effectively than conservative management (CM). We now conducted a separate analysis of the iMIA data to assess whether the referred leg pain (RLP) component of SIJ-associated pain may also be affected by MISM or CM.

METHODS

Data from 101 patients, recruited between June 2013 and May 2015 at nine European spine care centers, were included. Forty-nine patients were randomized to CM and 51 patients to MISM. RLP was defined as pain below the gluteal fold and assessed using the visual analogue scale (VAS). Changes in RLP over 6 months were the primary endpoint.

RESULTS

The prevalence of clinically significant RLP was 76.2 %. Over 6 months of follow-up, CM produced no significant change in RLP, which was 51.0 VAS points (interquartile range (IQR) 17.0-75.0) at baseline. In contrast, in the MISM cohort, we found a significant decrease in RLP from VAS 58.0 (IQR 24.5-80.0) at baseline to VAS 13.5 (IQR 0.0-39.3) after 6 months (p < 0.01). Improvement of RLP was associated only with the type of treatment (OR 5.04, p < 0.01), but not with patient age, sex, or different patterns of pain referral.

CONCLUSIONS

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.

SPECT/CT bone scintigraphy to evaluate low back pain in young athletes: common and uncommon etiologies

Low back pain of various etiologies is a common clinical presentation in young athletes. In this article, we discuss the utility of SPECT/CT bone scintigraphy for the evaluation of low back pain in young athletes. The spectrum of lower spine lesions caused by sports injuries and identifiable on bone scan is presented along with strategies to avoid unnecessary irradiation of young patients. Also covered are pitfalls in diagnosis due to referred-pain phenomenon and normal skeletal variants specific to this age group.