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

Incidence and risk factors of new-onset sacroiliac joint pain after spinal surgery: a systematic review and meta-analysis

Purpose

A systematic review and meta-analysis for incidence and risk factors of new-onset sacroiliac joint pain (SIJP) after spinal surgery aimed to provide evidence-based medical references for its early prevention, timely intervention, and appropriate treatment.

Methodology

The protocol of the systematic review and meta-analysis was registered in the International Prospective Register of Systematic Review (PROSPERO) with the PROSPERO ID (CRD42023463177). Relevant studies were searched to January 2024 from the databases of PubMed, Embase, Cochrane Library, and Web of Science, and the types of studies were cohort studies, case-control studies, and cross-sectional studies. Study quality was assessed using the Newcastle-Ottawa Scale (NOS) and the Cross-Sectional/Prevalence Study Quality recommended by the Agency for Healthcare Research and Quality (AHRQ). Two authors conducted studies search, data extraction, and quality assessment independently. Meta-analyses were done using Stata 14.0 software.

Results

Twelve observational studies with 3,570 spinal surgery patients were included. Ten were case-control studies, one was a cross-sectional study, and another was a cohort study, all of which were of moderate quality and above. The results of the meta-analysis showed that the incidence of new-onset SIJP after spinal surgery was 9.40%; females, no. of surgical segments, fusion to the sacrum, and postoperative pelvic tilt (PT) were significantly associated with the new-onset SIJP after spinal surgery. Meta-analyses for preoperative and postoperative controls of spondylopelvic parameters showed that postoperative lumbar lordosis (LL) in the SIJP group and postoperative LL and sacral slope (SS) of patients in the NoSIJP group had significant differences from preoperative.

Conclusion

Available evidence suggests that an increased risk of new-onset SIJP after spinal surgery is associated with sex, multi-segmental surgery, fusion to the sacrum, and greater postoperative PT.

Two Acute Stroke Patients Whose Lower Back and Lower Limb Pain Hampered Their Rehabilitation: The Effectiveness of Peripheral Nerve Blocks

Lower back and lower limb pain can hamper the rehabilitation of cerebral stroke patients. We report that peripheral nerve blocks enabled two patients to continue rehabilitation. Case 1 was an 83-year-old female with left hemiparesis due to cerebral infarction of the right basal ganglia. Rehabilitation started on the day after the stroke onset. On the 7th post-stroke day, she reported right buttock and dorsal thigh pain. Lumbar MRI demonstrated no lumbar spinal canal stenosis and no nerve impingement. The middle cluneal nerve block alleviated her buttock pain. On the 29th post-stroke day, she suffered severe pain on the medial side of the right knee. Blocking the infrapatellar branch of the saphenous nerve lessened that pain, she was able to walk without assistance, and rehabilitation was resumed. Case 2 was an 87-year-old female with sudden-onset left hemiparesis due to cardiogenic cerebral infarction. Intravenous thrombolysis and mechanical thrombectomy were performed. She presented with left hemiparesis due to infarcts at the right basal ganglia and the right temporal and parietal lobes. Her chronic low back pain worsened after admission and walking was difficult. Bilateral superior and middle cluneal nerve blocks improved her right lower back pain. Left low back pain was alleviated by sacroiliac joint blockage and rehabilitation was possible due to the absence of back pain. The strain on the lower back and lower limbs attributable to paresis due to stroke may lead to entrapment neuropathy. Peripheral nerve blockage is relatively simple and safe and may be useful in acute stroke patients whose rehabilitation is difficult due to pain.

Physical therapeutic options for residual sacrotuberous ligament pain after treatment of sacroiliac joint dysfunction

[Purpose] To evaluate the incidence of pain originating from the sacrotuberous ligament after sacroiliac joint treatment, and to determine effective physical therapeutic options for sacrotuberous ligament pain. [Participants and Methods] Among 303 patients with sacroiliac joint dysfunction, 57 patients (20 males, 37 females) with persistent lower-buttock pain after sacroiliac joint injections were included in the study. The incidence of sacrotuberous ligament pain and the physical findings from the first evaluation were investigated by physical therapists. [Results] Diagnostic sacrotuberous ligament injections identified lower-buttock pain originating from the sacrotuberous ligament in 57.9% of the patients (33 out of 57 patients) after treatment of sacroiliac joint dysfunction. Of these, 11 patients experienced relief after sacrotuberous ligament injection alone; the others required physical therapy. Sacrotuberous ligament relaxation alone was effective in eight patients; biceps femoris relaxation was required in eight patients; and gluteus maximus contraction exercise was required in six patients. [Conclusion] After sacroiliac joint treatment, the incidence of residual sacrotuberous ligament pain in the persisting lower-buttock pain was 57.9%. In addition to sacrotuberous ligament relaxation, biceps femoris relaxation was effective in patients who showed both higher differences in the straight leg raising test and biceps femoris tenderness, while gluteus maximus contraction exercises were effective in patients with gluteus maximus weakness.

Reliability and validity of manual palpation for the assessment of patients with low back pain: a systematic and critical review

BACKGROUND

Static or motion manual palpation of the low back is commonly used to assess pain location and reproduction in low back pain (LBP) patients. The purpose of this study is to review the reliability and validity of manual palpation used for the assessment of LBP in adults.

METHOD

We systematically searched five databases from 2000 to 2019. We critically appraised internal validity of studies using QAREL and QUADAS-2 instruments. We stratified results using best-evidence synthesis. Validity studies were classified according to Sackett and Haynes.

RESULTS

We identified 2023 eligible articles, of which 14 were low risk of bias. Evidence suggests that reliability of soft tissue structures palpation is inconsistent, and reliability of bony structures and joint mobility palpation is poor. We found preliminary evidence that gluteal muscle palpation for tenderness may be valid in differentiating LBP patients with and without radiculopathy.

CONCLUSION

Reliability of manual palpation tests in the assessment of LBP patients varies greatly. This is problematic because these tests are commonly used by manual therapists and clinicians. Little is known about the validity of these tests; therefore, their clinical utility is uncertain. High quality validity studies are needed to inform the clinical use of manual palpation tests.

Use of iliac screw associated with more correction of lumbar lordosis than S2-alar-iliac screw for adult spinal deformity

Background

To date, there is a paucity of reports clarifying the change of spinopelvic parameters in patients with adult spinal deformity (ASD) who underwent long segment spinal fusion using iliac screw (IS) and S2-alar-iliac screw (S2AI) fixation.

Methods

A retrospective review of consecutive patients who underwent deformity correction surgery for ASD between 2013 and 2017 was performed. Patients were divided into two groups based on whether IS or S2AI fixation was performed. All radiographic parameters were measured preoperatively, immediately postoperatively, and the last follow-up. Demographics, intraoperative and clinical data were analyzed between the two groups. Additionally, the cohort was subdivided according to the postoperative change in pelvic incidence (PI): subgroup (C) was defined as change in PI ≥5° and subgroup (NC) with change < 5°. In subgroup analyses, the 2 different types of postoperative change of PI were directly compared.

Results

A total of 142 patients met inclusion criteria: 111 who received IS and 31 received S2AI fixation. The IS group (65.6 ± 26°, 39.8 ± 13.8°) showed a significantly higher change in lumbar lordosis (LL) and upper lumbar lordosis (ULL) than the S2AI group (54.4 ± 17.9°, 30.3 ± 9.9°) (p < 0.05). In subgroup (C), PI significantly increased from 53° preoperatively to 59° postoperatively at least 50% of IS cohort, with a mean change of 5.8° (p < 0.05). The clinical outcomes at the last follow-up were significantly better in IS group than in S2AI group in terms of VAS scores for back and leg. The occurrence of sacroiliac joint pain and pelvic screw fracture were significantly greater in S2AI group than in IS group (25.8% vs 9%, p < 0.05) and (16.1% vs 3.6%, p < 0.05).

Conclusions

Compared with the S2AI technique, the IS technique usable larger cantilever force demonstrated more correction of lumbar lordosis, and possible increase in pelvic incidence. Further study is warranted to clarify the clinical impaction of these results.

Characteristics of the spinopelvic parameters of patients with sacroiliac joint pain

To evaluate the characteristics of the spinopelvic parameters on radiography in patients with sacroiliac joint pain (SIJP). Two hundred fifty patients were included and divided into the SIJP group (those diagnosed with SIJP based on physical findings and response to analgesic periarticular injections; n = 53) and the non-SIJP group (those with low back pain [LBP] because of other reasons; n = 197). We compared their demographic characteristics and spinopelvic parameters using radiography. All differences found in the patients' demographic characteristics and spinopelvic parameters were analyzed. More female participants experienced SIJP than male participants (P = 0.0179). Univariate analyses revealed significant differences in pelvic incidence (PI) (P = 0.0122), sacral slope (SS) (P = 0.0034), and lumbar lordosis (LL) (P = 0.0078) between the groups. The detection powers for PI, SS, and LL were 0.71, 0.84, and 0.66, respectively. Logistic regression analyses, after adjustment for age and sex, revealed significant differences in PI (P = 0.0308) and SS (P = 0.0153) between the groups, with odds ratios of 1.03 and 1.05, respectively. More female participants experienced SIJP than male participants. Higher PI and SS values were related to SIJP among LBP patients.

Surgical Outcomes of Patients with Sacroiliac Joint Pain: An Analysis of Patients with Poor Results Regarding Activities of Daily Living

Introduction

Sacroiliac joint (SIJ) arthrodesis is the last resort for patients with severe SIJ pain. However, this technique does not always provide good outcomes regarding activities of daily living (ADL). This study aims to reveal the preoperative clinical features associated with poor outcomes of SIJ arthrodesis.

Methods

Twenty-six consecutive patients who underwent SIJ arthrodesis between 2009 and 2018 were evaluated. Good-outcome was defined as ≥30% improvement in ADL, quantified by the Roland-Morris Disability Questionnaire (RDQ). The good-outcome group (17 patients; 10 men and 7 women, 42.5±8.4 years old) and the poor-outcome group (9 patients; 1 man and 8 women, 47.0±17.9 years old) were compared to identify the preoperative clinical features of poor surgical outcomes.

Results

No significant differences were observed between the two groups regarding age, preoperative RDQ score, time between onset and the confirmed diagnosis of SIJ pain, and the time between diagnosis and surgical treatment. The following preoperative clinical features associated with poor surgical outcomes were identified: female sex, pain in multiple regions, walking with a cane, and the use of a wheelchair before surgery (P<0.05).

Conclusions

The present study demonstrated that poor postoperative outcomes in patients with severe SIJ pain were associated with the following preoperative clinical features: female sex, pain in multiple regions, walking with a cane, or use of a wheelchair. Ample attention is warranted in patients with such features who are indicated for surgical treatments.

International Society for the Advancement of Spine Surgery Policy 2020 Update-Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity

The index 2014 International Society for the Advancement of Spine Surgery Policy Statement-Minimally Invasive Surgical Sacroiliac Joint Fusion-was generated out of necessity to provide an International Classification of Diseases, Ninth Revision (ICD-9)-based background and emphasize tools to ensure correct diagnosis. A timely ICD-10-based 2016 update provided a granular threshold selection with improved level of evidence and a more robust and relevant database (Appendix Table A1). As procedures and treatment options have evolved, this 2020 update reviews and analyzes the expanding evidence base and provides guidance relating to differences between the lateral and dorsal surgical procedures for minimally invasive surgical sacroiliac joint fusion.

Treatment of Coexisting Paralumbar Spine Diseases in Patients with Lumbar Disc Herniation

Lumbar disc herniation (LDH) elicits low back pain (LBP) and lower-limb symptoms. Paralumbar spine disease (PLSD), for example, superior cluneal nerve/middle cluneal nerve entrapment (SCN-EN, MCN-EN) and sacroiliac joint pain (SIJ), may be attributable to LDH whose treatment may not ameliorate their symptoms. We treated LDH patients and addressed their coexisting PLSDs. We retrospectively analyzed the effects of targeted block therapy for PLSD in 47 patients with LDH. They were 23 men and 24 women ranging in age from 21 to 79 years. They were seen between August 2014 and October 2018, within 3 weeks of LDH onset. PLSD was diagnosed based on the symptoms of patients whose pain was not controlled by oral medications. The treatment outcome was assessed by comparing the numerical rating scale (NRS) and the Roland-Morris Disability Questionnaire (RDQ) score recorded before and 2 weeks after last block treatment. Of the 47 patients with LDH, 2 suffered no LBP and 30 reported tenderness in the low back. We performed block therapy in 13 patients; 9 (19.1%) had concurrent PLSD and experienced pain relief. Their NRS improved from 8.1 ± 1.8 before- to 1.3 ± 0.9 after treatment; their RDQ score fell from 11.2 ± 6.0 to 0.9 ± 1.2 (both, p < 0.01). In an LDH patient with MCN-EN alone, MCN neurolysis was performed 2 weeks after a single MCN block proved to be only transiently effective. Paralumbar diseases may coexist in patients with LDH; treatment of the former may alleviate their LBP.

Characteristics of Low Back Pain due to Superior Cluneal Nerve Entrapment Neuropathy

Study Design

Retrospective analysis.

Purpose

The present study aimed to investigate the features of low back pain (LBP) due to superior cluneal nerve (SCN) entrapment neuropathy (SCN-EN) using the Roland Morris Disability Questionnaire (RMDQ), and to analyze the differences between LBP due to SCN-EN and lumbar spinal canal stenosis (LSS).

Overview of Literature

The SCN is derived from the cutaneous branches of the dorsal rami of T11–L5 and passes through the thoracolumbar fascia. LBP due to SCN-EN is exacerbated by various types of lumbar movement, and its features remain to be fully elucidated, often resulting in the misdiagnosis of lumbar spine disorder.

Methods

The present study included 35 consecutive patients with SCN-EN treated via nerve blocks or surgical release between April 2016 and August 2017 (SCN-EN group; 16 men, 19 women; mean age, 65.5±17.0 years; age range, 19–89 years). During the same period, 33 patients were surgically treated with LSS (LSS group; 19 men, 14 women; mean age, 65.3±12.0 years; age range, 35–84 years). The characteristics of LBP were then compared between patients with SCN-EN and those with LSS using the RMDQ.

Results

The duration of disease was significantly longer in the SCN-EN group than in the LSS group (26.0 vs. 16.0 months, p =0.012). Median RMDQ scores were significantly higher in the SCN-EN group (13 points; interquartile range, 8–15 points) than in the LSS group (7 points; interquartile range, 4–9 points; p <0.001). For seven items (question number 1, 8, 11, and 20–23), the ratio of positive responses was higher in the SCN-EN group than in the LSS group.

Conclusions

Patients with SCN-EN exhibit significantly higher RMDQ scores and greater levels of disability due to LBP than patients with LSS. The findings further demonstrate that SCN-EN may affect physical and psychological function.

The association between sacroiliac joint-related pain following lumbar spine surgery and spinopelvic parameters: a prospective multicenter study

PURPOSE

To prospectively calculate the incidence of postoperative sacroiliac joint-related pain (SIJP) and investigate the association between spinopelvic parameters and postoperative SIJP after lumbar spine surgery.

METHODS

We prospectively enrolled consecutive patients who underwent lumbar spine surgery. We defined postoperative SIJP as unilateral buttock pain according to fulfillment of the following criteria within 3 months of the surgery: a sacroiliac joint (SIJ) score higher than 4/9 postoperatively; positive response to analgesic periarticular SIJ injection with fluoroscopy; no other complications related to the surgery. The patients were divided into the SIJP group and non-SIJP group. We compared the background information and analyzed the differences in spinopelvic parameters in both groups. Additionally, receiver-operating characteristic curve analyses were performed to evaluate the cutoff values of spinopelvic parameters.

RESULTS

Of the 281 patients enrolled, 265 were included and eight developed postoperative SIJP (3.0%). There were no significant differences in the background information between groups. Preoperative and postoperative radiological evaluations revealed that the pelvic incidence (PI) in the SIJP group was significantly higher than that in the non-SIJP group, and there were no significant differences in lumbar lordosis (LL), pelvic tilt, sacral slope, and PI minus LL. For preoperative PI, the area under the curve, cutoff value, sensitivity, and specificity were 0.73739, 59, 62.5%, and 81.9%, respectively.

CONCLUSIONS

The incidence of postoperative SIJP after lumbar spine surgery was 3.0%. Higher PI values were associated with a higher risk of postoperative SIJP. These slides can be retrieved under Electronic Supplementary Material.

Validation study of a diagnostic scoring system for sacroiliac joint-related pain

Background

There are no specific radiological findings for the diagnosis of sacroiliac joint-related pain. A diagnostic scoring system had been developed in 2017. The score comprised the sum of scores of six items. The score ranged from 0 to 9 points, and the cutoff was calculated as 4.

Objective

To evaluate the validity of the diagnostic scoring system for sacroiliac joint-related pain.

Patients and methods

The sacroiliac joint-related pain group (n=31) comprised patients diagnosed with sacroiliac joint-related pain based on patient history, physical findings, and responses to analgesic periarticular injection. In addition, it was confirmed that they had no other lumbar or hip joint diseases. The non-sacroiliac joint-related pain group (n=123) comprised patients with low back pain due to a reason other than sacroiliac joint-related pain. We evaluated scores for all subjects. We analyzed the differences in each item between both groups and performed receiver-operating characteristic curve analysis to evaluate the score validity.

Results

There were no significant differences in patient characteristics between groups. There were significant differences for the following four of six items: one-finger test results (P<0.0001), pain while sitting on a chair (P=0.0141), sacroiliac joint shear test results (P<0.0001), and tenderness of the posterosuperior iliac spine (P<0.0001). The cut-off value was 5 points, the area under the curve was 0.80239, sensitivity was 77.4%, and specificity was 76.4%.

Conclusion

The score demonstrated moderate validity for diagnosing sacroiliac joint-related pain.

Sacroiliac joint pain after multiple-segment lumbar fusion: a long-term observational study-Non-fused sacrum vs. fused sacrum

INTRODUCTION

Sacroiliac joint pain (SIJP) after lumbar fusion surgery has recently gained attention as a source of low back pain after lumbar fusion. There are two risk factors for postoperative SIJP, i.e., fusion involving the sacrum and multiple-segment fusion. In this study, we examined whether SIJP could occur more frequently in patients with two risk factors (multiple-segment fusion to sacrum). Further, we examined SIJP after multiple-segment (≥3) lumbar fusion, focusing on the difference between floating fusion (non-fused sacrum) and fixed fusion (fused sacrum).

METHODS

Ninety-one patients who underwent multiple-segment lumbar fusion were included. Patients without preoperative clinical SIJP were considered. Of these, 17 developed new-onset SIJP. We investigated postoperative SIJP development, duration from surgery to SIJP onset, and postoperative treatment outcomes of SIJP patients using Japanese Orthopaedic Association (JOA) scores. We compared the findings between floating fusion group and fixed fusion group.

RESULTS

The incidence of SIJP was significantly higher with fixed fusion (32.1%) than with floating fusion (12.7%). The mean time of onset of sacroiliac joint pain was at 8.63 (2-13) months after surgery in the floating fusion group and 3.78 (1-10) months after surgery in the fixed fusion group, indicating that incidence occurred significantly earlier in the fixed fusion group. Our treatment outcome indicated that the mean JOA score significantly improved in the floating fusion group from 5.13 at the time of onset to 9.50 at the time of final follow-up; however, in the fixed fusion group, it improved from 5.78 at the time of onset to 7.33 at the time of final follow-up, indicating no significant improvement.

CONCLUSIONS

In multiple-segment lumbar fusion, fixed fusion (fused sacrum) has a very high risk of SIJP. In addition, the onset of SIJP in such cases may occur earlier. This aspect deserves consideration, given the difficulty of pain treatment.