Inciting Events Initiating Injection-Proven Sacroiliac Joint Syndrome

Effectiveness of lumbar motion style acupuncture treatment on inpatients with acute low back pain: A pragmatic, randomized controlled trial

BACKGROUND AND PURPOSE

This parallel, single-center, pragmatic, randomized controlled study aimed to investigate the effectiveness and safety of motion style acupuncture treatment (MSAT; a combination of acupuncture and Doin therapy) to reduce pain and improve the functional disability of patients with acute low back pain (aLBP) due to road traffic accidents.

MATERIALS AND METHODS

Ninety-six patients with aLBP admitted to the Haeundae Jaseng Hospital of Korean Medicine in South Korea due to traffic accidents were treated with integrative Korean medicine (IKM) with additional 3-day MSAT sessions during hospitalization (MSAT group, 48 patients) or without (control group, 48 patients), and followed up for 90 days.

RESULTS

The mean numeric rating scale (NRS) scores of low back pain (LBP) of the MSAT and control groups were both 6.7 (95% confidence interval [CI]: 6.3, 7.1) at baseline. After completing the third round of all applicable treatment sessions (the primary endpoint in this study), the mean NRS scores of the MSAT and control groups were 3.76 (95% CI: 3.54, 3.99) and 5.32 (95% CI: 5.09, 5.55), respectively. The difference in the mean NRS score between the two groups was 1.56 (95% CI: 1.25, 1.87).

CONCLUSION

IKM treatment combined with MSAT can reduce pain and improve the range of motion of patients with aLBP.

TRIAL REGISTRATION

This trial is registered at ClinicalTrial.gov (NCT04956458).

Chronic sacroiliac joint dysfunction and CT-guided percutaneous fixation: a 6-year experience

PURPOSE

Reporting the clinical outcomes, patient satisfaction, and complications following an imaging-guided percutaneous screw fixation in the treatment of sacroiliac joint dysfunction and evaluating the safety and effectiveness of this method.

METHODS

We performed a retrospective study on a prospectively gathered cohort of patients with physiotherapy-resistant pain due to sacroiliac joint incompetence that underwent percutaneous screw fixation, between 2016 and 2022 in our center. A minimum of two screws were used in all patients to obtain fixation of the sacroiliac joint, using percutaneous screw insertion under CT guidance, coupled with a C-arm fluoroscopy unit.

RESULTS

The mean visual analog scale significantly improved at 6 months of follow-up (p < 0.05). One hundred percent of the patients reported significant improvement in pain scores at the final follow-up. None of our patients experienced intraoperative or postoperative complications.

CONCLUSION

The use of percutaneous sacroiliac screws provides a safe and effective technique for the treatment of sacroiliac joint dysfunction in patients with chronic resistant pain.

Improved Outcomes with Concurrent Instrumentation and Fusion of the Sacroiliac Joint in Patients with Long Lumbosacral Constructs

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

Spinal fusion, specifically constructs connected to pelvic bones, has been consistently reported as a predisposing factor to sacroiliac joint (SIJ) pain. The aim of this study is to compare SIJ outcomes in patients with constructs to the pelvis following instrumentation vs instrumentation plus fusion of the SIJ.

METHODS

Data of study subjects was extracted from a prospectively maintained database as well as retrospectively collected from records at a tertiary academic medical center in the United States between 2018 and 2020.

RESULTS

A cohort of 103 patients was divided into 2 groups: 65 in Group 1 [S2AI screw without fusion device] and 38 in Group 2 [S2AI screw with fusion device]. None of the patients in Group 2 developed postoperative SIJ pain compared to 44.6% in Group 1. Sacroiliac joint fusion occurred in all Group 2 but none of Group 1 patients. The postoperative Visual Analogue Scale (VAS) for lower extremity (LE) pain (.8 vs .5; P = .03) and postoperative Oswestry Disability Index (ODI) (18.7 vs 14.2; P < .01) were significantly higher in Group 1. The rate of distal junctional break, failure, and/or kyphosis (DJBFK) and time to DJBFK were not significantly different between the two groups, and the rate of DJBFK did not change in the presence of multiple covariates.

CONCLUSION

The SIJs carry the heavy load of long lumbosacral fusion constructs extending to the pelvis. Simultaneous SIJ instrumentation and fusion decreases the risk of disability, prevents the development of postoperative SIJ pain, and may also protect the S2AI screw from loosening and failure.

Sacroiliac Joint Degeneration and Pain After Spinal Arthrodesis: A Systematic Review

STUDY DESIGN

This was a systematic review.

OBJECTIVE

The present study aims to review the available literature concerning sacroiliac joint (SIJ) pain and degeneration after lumbosacral fixation to identify the prevalence and potential risk factors.

SUMMARY OF BACKGROUND DATA

Although numerous factors can predispose patients to SIJ degeneration and pain various clinical studies indicate lumbosacral arthrodesis as a major cause.

MATERIALS AND METHODS

The PubMed-MEDLINE, Cochrane Central Registry of Controlled Trials, and Embase Biomedical database were searched. Peer-reviewed comparative studies, cohort studies, case series studies and case control studies, conducted either in a retrospective or prospective design, that registered data about SIJ pain and degeneration after lumbosacral fixation were included.

RESULTS

Twenty-one studies including 2678 patients met the inclusion criteria. The percentage of SIJ pain after lumbosacral fixation diagnosed with injections and physical examination varied widely, from 3% to 90%. Among patients who underwent spinal fusion, SIJ pain prevalence was higher when arthrodesis was fixed compared with floating fusions (59% vs. 10%, P -value >0.05). The prevalence of SIJ degenerative changes at computed tomography scan was more frequent in patients who underwent spinal arthrodesis than in those who did not (75% vs. 38.2%, P -value ≤0.05).

CONCLUSION

According to current evidence, patients who received lumbosacral fixation are at risk of SIJ pain. Number of fused levels, involvement of pelvis or sacrum in the arthrodesis area, inadequate lumbosacral sagittal alignment, and site of bone graft harvesting could be possible risk factor leading to sacroiliac degeneration and pain after lumbar spine fixation that should be investigated by physicians. However, there is a lack of homogeneity of the studies that address the problem, therefore, further prospective comparative studies, with a homogeneous architecture and cohorts are needed.

LEVEL OF EVIDENCE

Level III.

Auricular surface morphology and surface area does not influence subchondral bone density distribution in the dysfunctional sacroiliac joint

The subchondral lamella of the sacroiliac auricular surface is morphologically inconsistent. Its morpho-mechanical relationship with dysfunction (SIJD) remains unstudied. Here, the iliac and sacral subchondral bone mineralization is compared between morphological subtypes and in large and small surfaces, in SIJD joints and controls. CT datasets from 29 patients with bilateral or unilateral SIJD were subjected to CT-osteoabsorptiometry. Surface areas and posterior angles were calculated and surfaces were classified by size: small (<15 cm³ ) and large (≥15 cm³ ), and morphological types: 1 (>160°), 2 (130°-160°), and 3 (<130°). Mineralization patterns were identified: two marginal (M1 and M2) and two non-marginal (N1 and N2). Each sacral and iliac surface was subsequently classified. Dysfunctional cohort area averaged 15.0 ± 2.4 cm² (males 16.2 ± 2.5 cm² , females 13.7 ± 1.6 cm² ). No age correlations with surface area were found nor mean Hounsfield Unit differences when comparing sizes, sexes or morphology-type. Controls and dysfunctional cohort comparison revealed differences in female sacra (p = 0.02) and small sacra (p = 0.03). There was low-conformity in marginal and non-marginal patterns, 26% for contralateral non-dysfunctional joints, and 46% for dysfunctional joints. The majority of painful joints was of type 2 morphology (59%), equally distributed between small (49%) and large joints (51%). Larger joints had the highest frequency of dysfunctional joints (72%). Auricular surface morphology seems to have little impact on pain-related subchondral lamella adaptation in SIJD. Larger joints may be predisposed to the onset of pain due to the weakening of the extracapsular structures. Dysfunctional joints reflect common conformity patterns of sacral-apex mineralization with corresponding superior corner iliac mineralization.

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.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

K, A. P. K, J. P, B. A. Effect of Mulligan’s mobilization combined with motor control exercises on pain functional ability and muscle activity in sacroiliac joint dysfunction

Introduction and Aim: Sacroiliac joint dysfunction accounts 15% to 30% 0f low back ache conditions, If the SIJ is hypomobile, it cannot be effectively absorbed forces causing other body parts may be overstressed causing musculoskeletal dysfunction. This study’s aim is to identify the effect of mulligan’s joint mobilization techniques, motor control exercises and, aerobic exercises on pain functional ability and muscle activity in patients with SI joint dysfunction.   Methodology: Randomized controlled study was done by selecting patients with SI joint dysfunction. 185 participants with low back pain were evaluated and out of them 116 had positive SI joint dysfunction and 95 were selected based on selection criteria.  Computer- assisted randomization was done to divide the participants into three groups. Based on that group I has got 30, group II has 33, and group III has 32. Group I participants underwent Mulligan’s mobilisation for SI joint and followed by motor control exercises, Group II participants underwent motor control exercises and Group III participants underwent Aerobic exercises. All the treatment was given for 45 minutes 5 days per week for 6 weeks of duration. This study uses functional disability, Transverses abdominis muscle endurance, and pain measured using the Oswestry disability index, pressure biofeedback and numerical pain scale respectively.   Results:  On comparing group I and group II, the group I shows a significant improvement in all the outcomes. The ANOVA results show that the p-value is < .00001. The result is significant at p <0.05.   Conclusion: This study concludes that mulligans mobilization with motor control exercises would significantly improve pain, functional disability, and transverses abdominis muscle endurance.

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.

Minimally Invasive and Conservative Interventions for the Treatment of Sacroiliac Joint Pain: A Review of Recent Literature

Sacroiliac joint (SIJ) pain is responsible for approximately 15-25% of reported back pain. Patients with SIJ pain report some of the lowest quality of life scores of any chronic disease. Understanding of the physiology and pathology of the SI joint has changed dramatically over the years, and SI joint pain and injury can now be thought of in two broad categories: traumatic and atraumatic. Both categories of SI joint injury are thought to be caused by inflammation or injury of the joint capsule, ligaments, or subchondral bone in the SI joint. Treatment of SI joint pain usually involves a multi-pronged approach, utilizing both, multi-modal medical pain control and interventional pain/surgical techniques such as steroid injections, radiofrequency nerve ablation, and minimally invasive sacroiliac arthrodesis. Though conservative management through multi-modal pain control and physical therapy have their role as first line therapies, an increasing body of evidence supports the use of minimally invasive procedures, both as adjuvant treatments to conservative management and as second line therapies for patient's that fail first line treatment.

Review of Sacroiliac Joint Injection Techniques

PURPOSE OF REVIEW

The purpose of the review is to evaluate the current evidence on techniques for sacroiliac joint (SIJ) injections using landmark, ultrasound, fluoroscopy, and computed tomography (CT) guidance.

METHODS

A literature search was performed to find all relevant retrospective, prospective, and randomized controlled (RCT) studies where SIJ injections were performed under ultrasound, fluoroscopy, and CT guidance.

RECENT FINDINGS

A total of eight studies were identified with suitable data for inclusion. There were two RCTs, four prospective, and two retrospective studies included. Case reports or case series were excluded. A total of 420 patients were enrolled across all eight studies. CT guidance provided the most accurate needle placement in the SIJ injections followed by fluoroscopy, which was more accurate than ultrasound. Landmark-guided injections were not accurate. Accurate needle placement in SIJ confirms SIJ-mediated pain and injection of corticosteroids leads to improvement in pain and/or disability outcome measures regardless of guidance technique. Diagnostic CT-guided SIJ injections should be performed prior to consideration of SIJ fusion.

Minimally Invasive Sacroiliac Fusion-a Review

PURPOSE OF REVIEW

Sacroiliac dysfunction is an important cause of low back pain with significant impact on quality of life and daily activities. Minimally invasive sacroiliac joint fusion (MIS SI fusion) is an effective treatment for patients who failed non-surgical strategies. The purpose of this article is to review the clinical outcomes and complications of this surgical technique.

RECENT FINDINGS

For patients with SI joint dysfunction, MIS SI fusion reduced pain and disability as measured by Visual Analog Scale and Oswestry Index and improved quality of life as measured by Short-Form 36 and EuroQol-5D questionnaires. Satisfaction rates were higher in the SI fusion group when compared to the conservative management. In recent clinical trials, adverse events occurred with a similar rate in the first 6 months for patients assigned in the conservative management versus patients assigned to MIS SI fusion. MIS SI fusion is an effective and safe procedure for patients with sacroiliac dysfunction who failed non-surgical strategies. This procedure provides rapid as well as sustained pain relief, improvement in back function, high patient satisfaction, with low rate of complications.

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.

A Review and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain

INTRODUCTION

The sacroiliac joint (SIJ) has been estimated to contribute to pain in as much as 38% of cases of lower back pain. There are no clear diagnostic or treatment pathways. This article seeks to establish a clearer pathway and algorithm for treating patients.

METHODS

The literature was reviewed in order to review the biomechanics, as well as establish the various diagnostic and treatment options. Diagnostic factors addressed include etiology, history, physical exam, and imaging studies. Treatment options reviewed include conservative measures, as well as interventional and surgical options.

RESULTS

Proposed criteria for diagnosis of sacroiliac joint dysfunction can include pain in the area of the sacroiliac joint, reproducible pain with provocative maneuvers, and pain relief with a local anesthetic injection into the SIJ. Conventional non-surgical therapies such as medications, physical therapy, radiofrequency denervation, and direct SI joint injections may have some limited durability in therapeutic benefit. Surgical fixation can be by a lateral or posterior/posterior oblique approach with the literature supporting minimally invasive options for improving pain and function and maintaining a low adverse event profile.

CONCLUSION

SIJ pain is felt to be an underdiagnosed and undertreated element of LBP. There is an emerging disconnect between the growing incidence of diagnosed SI pathology and underwhelming treatment efficacy of medical treatment. This has led to an increase in SI joint fixation. We have created a clearer diagnostic and treatment pathway to establish an algorithm for patients that can include conservative measures and interventional techniques once the diagnosis is identified.

Etiopathogenesis of sacroiliitis: implications for assessment and management

The sacroiliac joints connect the base of the sacrum to the ilium. When inflamed, they are suspected to cause low back pain. Inflammation of the sacroiliac joints is called sacroiliitis. The severity of the pain varies and depends on the degree of inflammation. Sacroiliitis is a hallmark of seronegative spondyloarthropathies. The presence or absence of chronic sacroiliitis is an important clue in the diagnosis of low back pain. This article aims to provide a concise overview of the anatomy, physiology, and molecular biology of sacroiliitis to aid clinicians in the assessment and management of sacroiliitis. For this narrative review, we evaluated articles in English published before August 2019 in PubMed. Then, we selected articles related to the painful manifestations of the sacroiliac joint. From the retrieved articles, we found that chronic sacroiliitis may be caused by various forms of spondyloarthritis, such as ankylosing spondyloarthritis. Sacroiliitis can also be associated with inflammatory bowel disease, Crohn’s disease, gout, tuberculosis, brucellosis, and osteoarthritis, indicating common underlying etiological factors. The pathophysiology of sacroiliitis is complex and may involve internal, environmental, immunological, and genetic factors. Finally, genetic factors may also play a central role in progression of the disease. Knowing the genetic pre-disposition for sacroiliitis can be useful for diagnosis and for formulating treatment regimens, and may lead to a substantial reduction in disease severity and duration and to improved patient performance.

Exposure to a motor vehicle collision and the risk of future back pain: A systematic review and meta-analysis

OBJECTIVE

The purpose of this study is to summarize the evidence for the association between exposure to a motor vehicle collision (MVC) and future low back pain (LBP).

LITERATURE SURVEY

Persistent low back pain (LBP) is a relatively common complaint after acute injury in a MVC, with a reported 1 year post-crash prevalence of at least 31 % of exposed individuals. Interpretation of this finding is challenging given the high incidence of LBP in the general population that is not exposed to a MVC. Risk studies with comparison control groups need to be examined in a systematic review.

METHODOLOGY

A systematic search of five electronic databases from 1998 to 2019 was performed. Eligible studies describing exposure to a MVC and risk of future non-specific LBP were critically appraised using the Quality in Prognosis Studies (QUIPS) instrument. The results were summarized using best-evidence synthesis principles, a random effects meta-analysis and testing for publication bias.

SYNTHESIS

The search strategy yielded 1136 articles, three of which were found to be at low to medium risk of bias after critical appraisal. All three studies reported a positive association between an acute injury in a MVC and future LBP. Pooled analysis of the results resulted in an unadjusted relative risk of future LBP in the MVC-exposed and injured population versus the non-exposed population of 2.7 (95 % CI [1.9, 3.8]), which equates to a 63 % attributable risk under the exposed.

CONCLUSIONS

There was a consistent positive association in the critically reviewed literature that investigated the risk of future LBP following an acute MVC-related injury. For the patient with chronic low back pain who was initially injured in a MVC, more often than not (63 % of the time) the condition was caused by the MVC. These findings are likely to be of interest to clinicians, insurers, patients, governments and the courts. Future studies from both general and clinical populations would help strengthen these results.

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.

Pain and Functional Outcomes After Sacroiliac Joint Injection with Anesthetic and Corticosteroid at Six Months, Stratified by Anesthetic Response and Physical Exam Maneuvers

OBJECTIVE

To evaluate sacroiliac joint (SIJ) injection outcomes with local anesthetic and corticosteroid.

DESIGN

Prospective cohort.

SETTING

Single academic medical center.

METHODS

Thirty-four patients referred for SIJ injection with a clinical diagnosis of SIJ pain underwent injections with 1:1 mixture of 2% lidocaine and triamcinolone 40 mg/mL. Pain provocation physical exam (PE) maneuvers were recorded immediately before and after injection. Outcome measures at two to four weeks and six months included pain numeric rating scale (NRS) and Oswestry Disability Index (ODI).

RESULTS

For the analysis of outcomes by the overall group (not stratified by PE and/or anesthetic block), a 58.8% (95% confidence interval [CI] = +/-16.5%) ≥2 NRS reduction, a 32.4% (95% CI = +/-15.7%) ≥50% NRS reduction, and a 38.2% (95% CI = +/-16.3%) ≥30% ODI reduction were observed at two to four weeks, with similar improvements at six months. Outcomes stratified based on pre-injection PE did not reveal significant differences at either time point. The stratification based on the presence of 100% postinjection anesthetic response demonstrated a significant difference at two to four weeks for ≥50% NRS improvement. The true positive/true negative group (TP/TN) stratification demonstrated a significant difference for ≥50% NRS improvement at two to four weeks, whereas six-month outcomes for TP/TN demonstrated significant differences for ≥50% NRS and ≥30% ODI improvement. An increased injection response was observed with stratification of patients more likely to have true SIJ pain (i.e., TP), with TP/TN stratification demonstrating a 75% (95% CI = +/-30.0%) ≥2 NRS improvement and a 62.5% (95% CI = +/-33.5%) improvement of ≥50% NRS and ≥30% ODI for the TP group at two to four weeks, with similar results at six months.

CONCLUSIONS

SIJ steroid injection based on referral clinical diagnosis is unlikely to demonstrate true injection efficacy, and more specific selection criteria are warranted.

[Pain generator sacroiliac joint : Functional anatomy, symptoms and clinical significance]

BACKGROUND

The sacroiliac joint is a common cause of low back pain. Due to variable symptoms, the diagnosis is often very difficult. For diagnosis, systemic disease, as well as pathologies in the hips and lumbar spine must be excluded.

OBJECTIVES

To describe anatomy and function of the joint and underlying pathologies. To present the evidence of actual diagnostic and therapeutic options.

MATERIALS AND METHODS

An extensive literature research was carried out on PubMed.

RESULTS

The sacroiliac joint is an important and biomechanically complex joint. There are many controversial diagnostic tests to identify the sacroiliac joint as a source of pain. The cause of the dysfunction must be identified in order to treat it correctly and to prevent a chronification of the pain. The gold standard is conservative care.

CONCLUSION

The sacroiliac joint must be included in the differential diagnosis in patients with low back pain. Diagnostic tests are often insufficient for the diagnosis of sacroiliac joint pain. Many of the current diagnostic and therapeutic options present weak evidence.

Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area

The sacroiliac joint (SIJ) is often considered to be involved when people present for care with low back pain where SIJ is located. However, determining why the pain has arisen can be challenging, especially in the absence of a specific cause such as pregnancy, disease, or trauma, when the SIJ might be identified as a source of symptoms with the help of manual clinical tests. Nonspecific SIJ-related pain is commonly suggested to be causally associated with movement problems in the SIJ(s)-a diagnosis traditionally derived from manual assessment of movements of the SIJ complex. Management choices often consist of patient education, manual treatment, and exercise. Although some elements of management are consistent with guidelines, this Perspective article argues that the assumptions on which these diagnoses and treatments are based are problematic, particularly if they reinforce unhelpful, pathoanatomical beliefs. This article reviews the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction. In particular, it questions the continued use of assessing movement dysfunction despite mounting evidence undermining the biological plausibility and subsequent treatment paradigms based on such diagnoses. Clinicians are encouraged to align their assessment methods and explanatory models with contemporary science to reduce the risk of their diagnoses and choice of intervention negatively affecting clinical outcomes.

Sacroiliac Pain: Structural Causes of Pain Referring to the SI Joint Region

BACKGROUND

The currently reported incidence of primary sacroiliac joint (SIj) pathology ranges from 15% to 30%. The differential diagnosis of SIj region pain includes pain generated from the lumbar spine, the SIj, and the hip joint. The origins of SIj dysfunctions are controversial and pain generation from this joint has been questioned.

PURPOSE

Retrospectively analyze the relative incidence of lumbar spine, SIj, and hip joint etiologies in patients complaining of ≥50% SIj region pain.

STUDY DESIGN

This is a retrospective cohort case series.

METHODS

Inclusion criteria: chief complaint SIj pain (≥50% of overall complaint). In total, 124 patients charts were reviewed from a single spine surgeon's clinic. All patients were evaluated by the same 2 practitioners and all cases were reviewed for clinical examination findings, diagnostic tests performed, final diagnosis, treatment, and clinical follow-up.

RESULTS

After complete diagnostic workup, 112 (90%) had lumbar spine pain, 5 (4%) had hip pain, 4 (3%) had primary SIj pain, and 3 (3%) had an undetermined source of pain upon initial diagnosis. SIj pain generation was confirmed via fluoroscopy-guided diagnostic injections. Following designated treatment, 11 (9%) patients returned to clinic at an average of 2.4 years complaining of continued/recurrent SIj region pain. Further investigation revealed 6 patients had confirmed pain generation from the lumbar spine, 3 patients had confirmed pain generation from the SIj, and 2 patients had undetermined sources of pain.

CONCLUSIONS

The SIj is a rare pain generator (3%-6%) in patients complaining of ≥50% SIj region pain and is a common site of referral pain from the lumbar spine (88%-90%). Clinicians ought to quantify areas of pain (via percent of overall complaint) when interviewing their patients complaining of low back pain to distinguish potential pain generators. Recommended breakdown of areas of interest include axial low back, SIj region, buttock/leg, groin/anterior thigh.

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.

Lumbar Radiofrequency Rhizotomy in Patients with Chronic Low Back Pain Increases the Diagnosis of Sacroiliac Joint Dysfunction in Subsequent Follow-Up Visits

Chronic back pain is often a result of coexisting pathologies; secondary causes of pain can become more apparent sources of pain once the primary pathology has been addressed. The objective of our study was to determine if there is an increase in diagnosis of Sacroiliac joint pain following a Lumbar Rhizotomy. A list of patients who underwent Lumbar Radiofrequency during a 6-month period in our clinic was generated. Records from subsequent clinic visits were reviewed to determine if a new diagnosis of SI joint pathology was made. In patients who underwent a recent Lumbar Rhizotomy procedure to treat facetogenic pain, the prevalence of Sacroiliac joint pain increased to 70%. We infer that there is a significant increase in the diagnosis of Sacroiliac joint syndrome following a Lumbar Rhizotomy, potentially due to unmasking of a preexisting condition. In patients presenting with persistent back pain after Lumbar Rhizotomy, the clinician must have a high degree of suspicion for latent Sacroiliac joint pain prior to attributing the pain to block failure. It would be prudent to use >80% relief of pain after a diagnostic medial branch block as a diagnostic criterion for facetogenic pain rather than the currently accepted >50% in order to minimize unmasking of preexisting subclinical pain from the SI joint.

Reliability of MR-Based Volumetric 3-D Analysis of Pelvic Muscles among Subjects with Low Back with Leg Pain and Healthy Volunteers

AIM

Lately, the diagnostic value of magnetic resonance imaging, Lasègue sign and classic neurological signs have been considered not accurate enough to distinguish the radicular from non-radicular low back with leg pain (LBLP) and a calculation of the symptomatic side muscle volume has been indicated as a probable valuable marker. However, only the multifidus muscle volume has been calculated so far. The main objective of the study was to verify whether LBLP subjects presented symptomatic side pelvic muscle atrophy compared to healthy volunteers. The second aim was to assess the inter-rater reliability of 3-D manual method for segmenting and measuring the volume of the gluteus maximus, gluteus medius, gluteus minimus and piriformis muscles in both LBLP patients and healthy subjects.

METHOD

Two independent raters analyzed MR images of LBLP and healthy subjects towards muscle volume of four pelvic muscles, i.e. the piriformis, gluteus minimus, gluteus medius and gluteus maximus. For both sides, the MR images of the muscles without adipose tissue infiltration were manually segmented in 3-D medical images.

RESULTS

Symptomatic muscle atrophy was confirmed in only over 50% of LBLP subjects (gluteus maximus (p<0.001), gluteus minimus (p<0.01) and piriformis (p<0.05)). The ICC values indicated that the inter-rater reproducibility was greater than 0.90 for all measurements (LBLP and healthy subjects), except for the measurement of the right gluteus medius muscle in LBLP patients, which was equal to 0.848.

CONCLUSION

More than 50% of LBLP subjects presented symptomatic gluteus maximus, gluteus minimus and piriformis muscle atrophy. 3-D manual segmentation reliably measured muscle volume in all the measured pelvic muscles in both healthy and LBLP subjects. To answer the question of what kind of muscle atrophy is indicative of radicular or non-radicular pain further studies are required.

Chronic sacroiliac joint and pelvic girdle dysfunction in a 35-year-old nulliparous woman successfully managed with multimodal and multidisciplinary approach

BACKGROUND AND PURPOSE

Sacroiliac joint pain and dysfunction affect 15-25% of patients reporting low back pain, including reports of spontaneous, idiopathic, traumatic, and non-traumatic onsets. The poor reliability and validity associated with diagnostic clinical and imaging techniques leads to challenges in diagnosing and managing sacroiliac joint dysfunction.

CASE DESCRIPTION

A 35-year-old nulliparous female with a 14-year history of right sacroiliac joint dysfunction was managed using a multimodal and multidisciplinary approach when symptoms failed to resolve after 2 months of physical therapy. The plan of care included four prolotherapy injections, sacroiliac joint manipulation into nutation, pelvic girdle belting, and specific stabilization exercises.

OUTCOMES

The patient completed 20 physical therapy sessions over a 12-month period. At 6 months, the patient's Oswestry Disability Questionnaire score was reduced from 34% to 14%. At 1-year follow-up, her score was 0%. The patient's rating of pain on a numeric rating scale decreased to an average of 4/10 at 6 months and 0/10 at 1-year follow-up.

DISCUSSION

A multidisciplinary and multimodal approach for the management of chronic sacroiliac joint dysfunction appeared successful in a single-case design at 1-year follow-up.

Pelvic Belt Effects on Health Outcomes and Functional Parameters of Patients with Sacroiliac Joint Pain

Introduction

The sacroiliac joint (SIJ) is a common source of low back pain. However, clinical and functional signs and symptoms correlating with SIJ pain are widely unknown. Pelvic belts are routinely applied to treat SIJ pain but without sound evidence of their pain-relieving effects. This case-control study compares clinical and functional data of SIJ patients and healthy control subjects and evaluates belt effects on SIJ pain.

Methods

17 SIJ patients and 17 healthy controls were included in this prospective study. The short-form 36 survey and the numerical rating scale were used to characterize health-related quality of life in patients in a six-week follow-up and the pain-reducing effects of pelvic belts. Electromyography data were obtained from the gluteus maximus, biceps femoris, rectus femoris and medial vastus. Alterations of muscle activity, variability and gait patterns were compared in patients and controls along with the belts’ effects in a dynamic setting when walking.

Results

Significant improvements were observed in the short-form 36 survey of the SIJ patients, especially in the physical health subscores. Minor declines were also observed in the numerical rating scale on pain. Belt-related changes of muscle activity and variability were similar in patients and controls with one exception: the rectus femoris activity decreased significantly in patients with belt application when walking. Further belt effects include improved cadence and gait velocity in patients and controls.

Conclusions

Pelvic belts improve health-related quality of life and are potentially attributed to decreased SIJ-related pain. Belt effects include decreased rectus femoris activity in patients and improved postural steadiness during locomotion. Pelvic belts may therefore be considered as a cost-effective and low-risk treatment of SIJ pain.

Trial Registration

ClinicalTrials.gov NCT02027038

A Retrospective Outcomes Study of 20 Sacroiliac Joint Fusion Patients

Study Design

Retrospective case series.

Purpose

To report a novel approach to open posterior sacroiliac (SI) joint arthrodesis using a threaded titanium cage containing rhBMP­-2.

Materials & Methods

Twenty consecutive patients with a mean age of 57.7 years (range: 33­-84) underwent posterior SI joint fusion. Two closely related novel posterior oblique approaches were employed. Enrolled subjects included 17 females and three males. The mean follow­-up time for CT to assess fusion was 27 months (range: 17­-45 months). Insurance included a mixture of public and private payers. One of the patients (patient 19) was on worker’s compensation. During follow-­up, patients were assessed radiologically for radiographic bony union and asked to rate their satisfaction with the procedure. The Oswestry Disability Index (ODI) was applied on a one-time basis upon follow-up. All patients were diagnosed with sacroiliac joint pain based primarily on a positive response to fluoroscopically guided injections into the sacroiliac joint.

Results

Out of 20 patients, 33 SI joints were considered symptomatic and operated, and 32/33 joints successfully fused radiographically (a 96.9% fusion success rate). The average procedure satisfaction rating (PSR) was 7.25 out of a maximum 10 (range 1­-10). Seventeen patients responded to post-surgery ­follow-up questions, and 13 patients (76%), indicated they would elect to have the surgery again as well as recommend it to others. Average estimated blood loss was less than 50 mL, and average length of stay was one day.

Conclusions

Preliminary experiences with these novel posterior approaches to the SI joint described here seem to be safe and effective. The novel posterior approaches to the SI joint described here appear, preliminarily, to have many advantages over previously described procedures including markedly reduced surgical morbidity.

Short-term efficacy of sacroiliac joint corticosteroid injection based on arthrographic contrast patterns

OBJECTIVE

To determine the relationship between sacroiliac joint (SIJ) contrast dispersal patterns during SIJ corticosteroid injection and pain relief at 2 and 8 weeks after the procedure. The association between the number of positive provocative SIJ physical examination maneuvers (minimum of one in all patients undergoing SIJ injection) and the patient's response to the intervention was also assessed.

DESIGN

Retrospective chart review.

SETTING

Academic outpatient musculoskeletal practice.

PATIENTS

Fifty-four subjects who underwent therapeutic SIJ corticosteroid injection were screened for inclusion; 49 subjects were included in the final analysis.

METHODS

A retrospective review of electronic medical records identified patients who underwent SIJ corticosteroid injection. Fluoroscopic contrast flow patterns were categorized as type I (intra-articular injection with cephalad extension within the SIJ) or type II (intra-articular injection with poor cephalad extension). Self-reported numeric pain rating scale (NPRS) values at the time of injection and 2 and 8 weeks after the procedure were recorded. The number of positive provocative SIJ physical examination maneuvers at the time of the initial evaluation was also recorded.

MAIN OUTCOME MEASURES

The primary outcome measure was the effect of contrast patterns (type I or type II) on change in NPRS values at 2 weeks and 8 weeks after the injection. The secondary outcome measure was the association between the number of positive provocative SIJ physical examination maneuvers and decrease in the level of pain after the procedure.

RESULTS

At 2 weeks after the procedure, type I subjects demonstrated a significantly lower mean NPRS value compared with type II subjects (2.8 ± 1.4 versus 3.8 ± 1.6, respectively, P = .02). No statistically significant difference was observed at 8 weeks after the procedure. NPRS values were significantly reduced both at 2 weeks and 8 weeks, compared with baseline, in both subjects identified as having type I flow and those with type II flow (P < .0001 for all within-group comparisons).

CONCLUSIONS

Fluoroscopically guided corticosteroid injections into the SIJ joint are effective in decreasing NPRS values in patients with SIJ-mediated pain. Delivery of corticosteroid to the superior portion of the SIJ leads to a greater reduction in pain at 2 weeks, but not at 8 weeks. Patients with at least one positive provocative maneuver should benefit from an intra-articular corticosteroid injection.

Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment

Sacroiliac joint (SIJ) pain is an underappreciated source of mechanical low back pain, affecting between 15 and 30% of individuals with chronic, nonradicular pain. Predisposing factors for SIJ pain include true and apparent leg length discrepancy, older age, inflammatory arthritis, previous spine surgery, pregnancy and trauma. Compared with facet-mediated and discogenic low back pain, individuals with SIJ pain are more likely to report a specific inciting event, and experience unilateral pain below L5. Owing in part to its size and heterogeneity, the pain referral patterns of the SIJ are extremely variable. Although no single physical examination or historical feature can reliably identify a painful SIJ, studies suggest that a battery of three or more provocation tests can predict response to diagnostic blocks. Evidence supports both intra- and extra-articular causes for SIJ pain, with clinical studies demonstrating intermediate-term benefit for both intra- and extra-articular steroid injections. In those who fail to experience sustained relief from SIJ injections, radiofrequency denervation may provide significant relief lasting up to 1 year. This review covers all aspects of SIJ pain, with the treatment section being primarily focused on procedural interventions.

Spine-area pain in military personnel: a review of epidemiology, etiology, diagnosis, and treatment

BACKGROUND CONTEXT

Nonbattle illnesses and injuries are the major causes of unit attrition in modern warfare. Spine-area pain is a common disabling injury in service members associated with a very low return-to-duty (RTD) rate.

PURPOSE

To provide an overview of the current understanding of epidemiology, possible causes, and relative prognosis of spine-area pain syndromes in military personnel, including a discussion of various treatment options available in theaters of operation.

STUDY DESIGN

Literature review.

METHODS

Search focusing on epidemiology, etiology and associative factors, and treatment of spinal pain using electronic databases, textbooks, bibliographic references, and personal accounts.

RESULTS

Spine-area pain is the most common injury or complaint "in garrison" and appears to increase during training and combat deployments. Approximately three-quarters involve low back pain, followed by cervical and midback pain syndromes. Some predictive factors associated with spine-area pain are similar to those observed in civilian cohorts, such as psychosocial distress, heavy physical activity, and more sedentary lifestyle. Risk factors specific to military personnel include concomitant psychological trauma, g-force exposure in pilots and airmen, extreme shock and vibration exposure, heavy combat load requirements, and falls incurred during airborne, air assault, and urban dismounted ground operations. Effective forward-deployed treatment has been difficult to implement, but newer strategies may improve RTD rates.

CONCLUSIONS

Spine-area pain syndromes comprise a major source of unit attrition and are often the result of duty-related burdens incurred during combat operations. Current strategies in theaters of operation that may improve the low RTD rates include individual and unit level psychological support, early resumption of at least some forward-area duties, multimodal treatments, and ergonomic modifications.

Feasibility and accuracy of ultrasound-guided sacroiliac joint injection in dogs

Frozen cadaver specimens from three dogs were used to create a sectional anatomic atlas of the sacroiliac region. Frozen/thawed cadaver specimens from 12 dogs were used to develop an ultrasound-guided sacroiliac joint injection technique. Accuracy of the technique was tested in 15 additional canine cadaver specimens, using injectate containing blue dye and iodinated contrast medium. Sonoanatomic landmarks for consistently identifying a caudodorsal window into the canine sacroiliac joint space included the L7-S1 articular process joints, ilial wing, sacral wing, sacral lamina, and median sacral crest. Accuracy of ultrasound-guided sacroiliac joint injection was not significantly affected by operator, but was affected by the tissue location targeted and the reference standard used for calculations. Accuracy of the technique was good for placing injectate into either the synchondrosis component, dorsal sacroiliac ligament or ventral sacroiliac ligament; fair to poor for placing injectate into the synovial component; and poor for placing injectate into all four sacroiliac soft tissue structures. Concurrent placement of injectate into extraarticular tissues occurred frequently. We conclude that ultrasound-guided sacroiliac joint injection is feasible for evaluation as a treatment method for lumbosacral region pain in dogs, but is not sufficiently accurate for localizing pain to the sacroiliac joint alone.

Structural etiology of chronic low back pain due to motor vehicle collision

OBJECTIVE

To estimate prevalence rates of discogenic, facet, and sacroiliac joint pain, and describe clinical features of chronic low back pain patients whose symptoms were initiated by motor vehicle collisions.

DESIGN

Retrospective chart review.

SETTING

Academic spine center.

PATIENTS

Twenty-seven motor vehicle collision-induced chronic low back pain patients were included after undergoing diagnostic procedures.

INTERVENTIONS

Lumbar provocation discography, dual diagnostic facet joint blocks, and intra-articular sacroiliac joint injections.

METHODS

Enrolled patients underwent diagnostic procedures based on clinical presentation until the pain source was identified. The prevalence of each source of low back pain was estimated. Clinical, categorical, and continuous characteristics within the source groups were calculated with SAS v.9.2 (SAS Institute Inc., Cary, NC).

OUTCOME MEASURES

Etiology and prevalence were analyzed for each diagnosis group.

RESULTS

Of the 27 patients, 15/27 (56%) were diagnosed with discogenic pain, 7/27 (26%) with sacroiliac joint pain, and 5/27 (19%) with facet joint pain. Seventy-eight percent were female. Mean age was 42.5 years (standard deviation = 10.4) with median duration of symptoms of 24 months (interquartile range = 6-48).

CONCLUSIONS

Our study is the first to demonstrate that diagnostic spinal injections can identify particular spinal structures, namely the intervertebral disc, facet joint, and sacroiliac joint, as the specific source of chronic low back pain due to inciting motor vehicle collisions. The most common source of motor vehicle collision-induced chronic low back pain appears to be the disc followed by the sacroiliac and facet joints.