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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.
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10.1586/ERN.12.148
99
ISSN 1473-7175
© 2013 Expert Reviews Ltd
www.expert-reviews.com
Review
Sacroiliac joint (SIJ) pain is a common, yet
underappreciated cause of chronic low back
pain (LBP). In part because of its size and het-
erogeneity, there are myriad ways in which SIJ
pain can present, which makes the diagnosis
challenging. An understanding of the anatomy,
clinical presentation, diagnostic dilemmas
and treatment options can enhance the like-
lihood of an accurate diagnosis and o ptimize
outcomes.
Functional anatomy
The SIJ is a true diarthrodial joint, consisting of
two surfaces held together by fibrous capsule and
enjoined with synovial fluid. The average sur-
face area has been estimated to be approximately
17.5 cm
2
, although there is significant variability
between individuals regarding the shape and
size [1,2]. The sacral and ilial surfaces of the joint
are covered with hyaline and fibrocartilage,
respectively, and have rough and coarse textures
believed to be due to physiological adaptation to
stress [3].
SIJs must support the upper body and dampen
the impact of ambulation; ligaments that limit
the mobility of the joint also provide it with
strength. These include the anterior SI ligament,
dorsal SI ligament, sacrospinous ligament, sacro-
tuberous ligament and interosseus ligaments [4].
Together, from a functional standpoint, they
prevent separation of the joint and movement
of the pelvis along the various axes of the sacrum.
Ultimately, these ligaments act together to main-
tain bracing when weight is transferred from
the torso to lower extremities [5]. They work in
concert with muscular and fascial components,
including the thoracolumbar fascia, gluteus
maximus, piriformis and latissimus dorsi [6],
lending support and permitting movement.
Harrison et al. concluded that joint motion
was probably limited to translational and rota-
tional motions along 6 degrees of freedom [4].
Walker summarized prior studies from the
19th and 20th centuries, finding mean rotation
ranged between 1 and 1, and mean transla-
tion ranged between 3 and 16 mm, with the
Steven P Cohen*
1,2
,
Yian Chen
3
and
Nathan J Neufeld
4
1
Pain Medicine Division, Department
of Anesthesiology and Critical Care
Medicine, Johns Hopkins School of
Medicine, Baltimore, MD, USA
2
Walter Reed National Military Medical
Center, Uniformed Services University
of the Health Sciences, Bethesda, MD,
USA
3
Johns Hopkins School of Medicine,
Baltimore, MD, USA
4
Departments of Anesthesiology and
Critical Care Medicine, and Physical
Medicine and Rehabilitation, Johns
Hopkins School of Medicine, Baltimore,
MD, USA
*Author for correspondence:
scohen40@jhmi.edu
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.
Sacroiliac joint pain:
a comprehensive review of
epidemiology, diagnosis and
treatment
Expert Rev. Neurother. 13(1), 99116 (2013)
Expert Review of Neurotherapeutics
© 2013 Expert Reviews Ltd
10.1586/ERN.12.148
1473-7175
1744-8360
Review
Keywords: clinical diagnosis • diagnostic block • low back pain • radiofrequency • review • sacroiliac joint
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Expert Rev. Neurother. 13(1), (2013)
100
Review
caveat that measurements differed based on patient positions [7].
In a more recent in vivo analysis, Sturesson et al. reported even
smaller degrees of movements in all planes (mean rotation 2.,
mean translation 0.7 mm), with no differences found between
symptomatic and asymptomatic joints [8]. This led the authors to
conclude that 3D motion analysis is not a useful test in most indi-
viduals for identifying a painful SIJ(s). In summary, SIJ motion
is limited, with the primary function being
supportive.
The innervation of the SIJ is complex and
controversial. The posterior joint is better
understood and more relevant for treat-
ment purposes. Its innervation has been
described as arising mainly from the dorsal
rami of S1–S3, with contributions from L5
and S4 in many individuals [9,10]. Bernard
and Cassidy reported that branches from
the L4S3 dorsal rami contribute to the
nerve supply of the posterior SIJ [1]. Part
of this discrepancy may be due to the fact
that in individuals with sacralization of L5,
which predisposes patients to SIJ pain, L4
may play a role [Ramasubbu C, Cohen SP. Cooled
radiofrequency denervation of the lumbosacral
lateral branches for the treatment of pain sec-
ondary to metastatic tumor infiltration of the
sacroiliac joint: case report and focused litera-
ture review (2012), Submitted]
. The innervation
of the ventral joint is even more ambiguous,
with most studies reporting branches stem-
ming from the ventral rami of L5S2, and
possibly L4 [6,11] . Older literature cites contributions from the
superior gluteal and obturator nerves (Figures 1 & 2) [12] .
Prevalence
The prevalence of SIJ dysfunction has been mainly studied in
populations of patients presenting with nonspecific LBP, with
research groups using different selection criteria, different injec-
tion methods and different criteria to define
a positive response. Not surprisingly, this
has led to a wide range of prevalence rates.
In general, SIJ pain has a bimodal distribu-
tion, with higher prevalence rates occurring
in younger athletes and the elderly [13,14].
Studies using lower analgesic thresholds
(i.e., 50%) tend to report only slightly
higher prevalence rates than those using
more stringent cutoff thresholds (80%).
However, using ‘double’ or ‘confirmatory
blocks in an attempt to reduce the false-pos-
itive rate significantly lowers the estimated
prevalence rates compared with studies
using uncontrolled blocks, from 32–36 to
1521% [15].
In one of the earliest studies, Schwarzer
et al. estimated the prevalence rates of
patients presenting with LBP below L5S1
(n = 43) using three different criteria [16] .
They found a prevalence rate of 30% based
solely on the analgesic response (75%) to
a single lidocaine block. When the criteria
were tightened to pain relief and a ventral
Figure 1.Posterior view of the articulations and associated ligaments of the
sacroiliac joint and surrounding structures.
Drawing by Jee Hyun Kim. Adapted from
[9].
Supraspinous ligament
Ischiofemoral
ligament
Lateral
sacrococcygeal
ligament
Deep posterior
sacrococcygeal ligament
Superficial posterior
sacrococcygeal ligament
Sacrotuberous
ligament
Sacrospinous
ligament
Greater sciatic
foramen
Long and short
posterior sacroiliac
ligaments
Figure 2. Anterior view of the articulations and associated ligaments of the
sacroiliac joint and surrounding structures.
Drawing by Jee Hyun Kim. Adapted from
[9]
Anterior longitudinal ligament
Iliolumbar ligament
Anterior sacroiliac
ligament
Anterior and
lateral
sacrococcygeal
ligaments
Iliofemoral
ligament
Pubofemoral
ligament
Pubic symphysis
Acurate public
ligament
Sacrospinous
ligament
Sacrotuberous
ligament
Sacrospinous
ligament
Greater sciatic foramen
Cohen, Chen & Neufeld
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capsular tear on computed tomography (CT) imaging, the preva-
lence rate declined to 21%. Using the combination of analgesic
response, imaging abnormalities and concordant pain provocation
as criteria, the prevalence rate decreased to 16%. Maigne et al.
reported an 18.5% prevalence rate in 54 patients who failed epi-
dural steroid and facet injections, using an analgesic response to
a preliminary screening block with lidocaine followed by a con-
firmatory block with bupivacaine [17] . Irwin et al. found a 26.6%
prevalence rate in a retrospective review of 158 patients with
LBP and/or leg pain receiving initial and confirmatory injections
with lidocaine and bupivacaine, respectively [18]. Manchikanti
et al. reported a substantially lower prevalence rate of 10% in 20
patients who underwent double confirmatory blocks, reasoning
that their lower positive rate may have been because they focused
on a less targeted patient population [19] . In summary, although
there is some variation in reported prevalence rates depending
on the sample population and diagnostic criteria, it can be con-
cluded that the SIJ represents a major cause of mechanical LBP
in patients of all ages (Table 1).
Etiology
The mechanism of injury to the SIJ may best be described as a
combination of axial loading and rotation. Immunohistological
studies have demonstrated nociceptors to be present throughout
the joint capsule, ligaments and to a lesser extent subchondral bone,
suggesting that injury to any of the surrounding structures can be
a source of pain [20,21] . Bolstering this assertion is the observation
that clinical studies have documented pain provocation in asymp-
tomatic volunteers and patients using both capsular distension and
ligamentous probing [22,23]. Among intra-articular (IA) etiologies,
arthritis and spondyloarthropathies are the two most common
causes, though the latter may also be associated with extra-articular
(EA) pathology [24,25]. For EA etiologies, ligamentous and muscular
injuries and enthesopathy are likely the most frequent sources.
Numerous factors can predispose patients to SIJ pain. These
include true and apparent leg length discrepancies, transitional
anatomy, gait and biomechanical abnormalities, persistent
strain/low-grade trauma (e.g., jogging), scoliosis, pregnancy
and spine surgery [9]. Pregnancy can result in SIJ pain by vir-
tue of weight gain, exaggerated lordotic posture, third-trimester
hormone-induced ligamentous relaxation and the pelvic trauma
associated with parturition. In a large-scale study by Ostgaard et al.
(n = 855), the authors found a 49% 9-month period prevalence
rate for LBP among pregnant women, with SIJ pain comprising
a majority of cases [26]. In a more recent cohort study involving
313 pregnant women between 12 and 18 weeks gestation, Gutke
et al. found that 62% (n = 194) reported back pain [27]. Among
these, 54% had pelvic girdle pain situated around the SIJ(s), 17%
Table 1. Studies evaluating prevalence rates of sacroiliac joint pain.
Study (year) Subjects Interventions Diagnostic criteria Results Ref.
Maigne et al.
(1996)
54 patients with chronic
unilateral LBP with or
without radiation to
posterior thigh
Intra-articular blocks using 2 ml
of lidocaine and bupivacaine on
separate occasions. The authors
avoided anesthetizing
periarticular ligaments
75% pain relief, with the
bupivacaine block lasting
2 h
Prevalence rate 18.5%
False-positive rate
17%
[17]
Manchikanti
et al. (2001)
20 patients with chronic
LBP without neurological
deficits
Intra-articular blocks with
unspecified volume of lidocaine
and bupivacaine on separate
occasions
Not noted Prevalence rate 10%
False-positive rate
20%
[19]
Irwin et al.
(2007)
158 patients with chronic
LBP with or without lower
extremity pain
Intra-articular blocks with 2 ml of
lidocaine and 2 ml bupivacaine
and steroid on separate
occasions
70% pain relief, with the
bupivacane block lasting
4 h
Prevalence rate 27%
False-positive rate
43%
[18]
Laslett et al.
(2005)
48 patients with buttock
pain, with or without
lumbar or lower extremity
symptoms, without signs
of nerve root compression
Intra-articular blocks with
<1.5 ml of lidocaine + steroid
and bupivacaine on separate
occasions
80% pain relief with
lidocaine and bupivacaine
Prevalence rate 26%
False-positive rate 0%
[45]
van der Wurff
et al. (2006)
60 patients with chronic
LBP below L5 with or
without lower extremity
symptoms, without
neurological symptoms
Intra-articular blocks with 2 ml
lidocaine and bupivacaine on
separate occasions
50% pain relief with
lidocaine and bupivacaine,
with the bupivicaine block
lasting 4 h
Prevalence rate 45%
False-positive rate
12%
[46]
Liliang et al.
(2011)
52 patients with previous
spine fusion and pain
below L5
Intra-articular blocks with 2 ml of
lidocaine or bupivacaine +
steroid on separate occasions
>75% pain relief lasting
1–4 h. Those who had 1
positive and 1 negative block
underwent 3rd injection
Prevalence rate 40%
False-positive rate
27%
[132]
LBP: Low back pain.
Sacroiliac joint pain: acomprehensive review of epidemiology, diagnosis & treatment
Expert Rev. Neurother. 13(1), (2013)
102
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reported predominantly lumbar pain and the remainder (29%)
experienced combination pelvic girdle and lumbar pain. True and
functional leg length discrepancies can cause pain as a result of
increased stress and abnormal force vectors on the ipsilateral lower
extremity [28]. Friberg found that individuals with chronic LBP
were significantly more likely (75 vs 43.5%) to have a leg length
discrepancy of 5 mm than a matched cohort of asymptomatic
controls [29]. Spine surgery is a very common, yet underappre-
ciated source of SIJ pain, especially operations involving fusion
to the sacrum. Ivanov et al. used simulated surgical procedures
and a finite elemental spine-pelvis model to assess angular motion
and stress across the SIJ following spinal fusion [30]. They found
increased SIJ stress after surgery, which was least following L4–5
fusion and greatest after L4S1 fusion. These results are consist-
ent with those of Ha et al., who compared pre- and postsurgical
CT scans in 32 patients who underwent spinal fusions at different
levels with those of 34 matched controls [31]. The authors reported
a nearly twofold increase in SIJ degeneration in the fusion group
compared with the control patients (75 vs 38.2%), with the highest
incidence occurring in those with fusions extending to the sacrum.
Iliac crest bone graft procurement can also result in disruption
of the ligamentous and synovial portions of the SIJ [32]. These
findings are consistent with prevalence studies reporting that SIJ
pain occurs in between 32 and 61% of patients after fusion [33,34].
SIJ pain is more likely to ensue following an inciting event than
facetogenic and discogenic pain, which tend to be more insidi-
ous in onset. Studies have shown that between 40 and 50% of
patients with injection-confirmed SIJ pain can identify a specific
precipitating event. In descending order, the most frequent ante-
cedents for SIJ pain are motor vehicle collisions, falls, repetitive
stress and pregnancy [16,35,36].
Clinical findings
Pain patterns
The characteristics of SI-based pain vary from patient to patient,
rendering diagnosis difficult in the clinical setting. Because of its
size and heterogeneity, pain referral patterns in SIJ pain are very
variable. The magnitude of this variation can be gleaned from
the multitude of studies that attempt to correlate pain referral
patterns with either the reference standard of SIJ block, or pain
provocation with physical maneuvers. Studies have descriptively
and experimentally attempted to map the pain patterns associ-
ated with the SIJ. Fortin et al. challenged SIJs in asymptomatic
volunteers by injecting contrast and lidocaine in an attempt to
identify an SI pain pattern, generating a composite map on the
patients’ buttocks, inferior from the posterior inferior iliac spine
[22]. These findings were later confirmed in a clinical study that
found that those with buttock pain extending into the posterolat-
eral thigh experienced pain with SIJ provocation and had negative
facet blocks and discography [37]. Other investigators have also
found buttock pain extending into the posterolateral thigh to be
the most typical referral pattern. Two studies found the SIJs to
be the most likely source of pain when the worst area was located
within 10 cm of the posterior superior iliac spine [37,38]. Slipman
et al. mapped out pain referral patterns by characterizing the
distribution patterns in 50 patients who obtained 80% pain
relief following single SIJ blocks: 94% reported buttock pain,
72% lumbar pain, 50% experienced pain extending into the lower
extremity, 28% had pain below the knee, and groin pain was
reported in 14% of individuals [39] . The widespread variability in
this study may also be partially attributed to the observation that
the greater the intensity of mechanical spinal pain, the more distal
in the extremities it is referred. Depalma et al. [13] and Laslett [40]
have found that individuals with SIJ pain are more likely to report
lateral pain, rather than central pain. A cross-sectional prevalence
study by Schwarzer et al. found that the only pain referral pattern
that could reliably distinguish SIJ pain from other forms of LBP
was radiation into the groin [16] . Young et al. found pain arising
from sitting, unilateral pain and absence of lumbar pain were the
most reliable means to distinguish SI pain from facetogenic and
discogenic pain (Table 2) [41].
Physical examination findings
There is disagreement regarding the value of physical examination
techniques in diagnosing SIJ dysfunction. Dreyfuss et al. reported
that neither medical history nor physical examination maneuvers
were reliable in the diagnosis of SIJ pain, using response to a
joint block as the reference standard [42]. Slipman et al. reported
a 60% positive predictive value for response to a single SIJ injec-
tion in 50 patients selected based on 3 provocation maneuvers
and concluded that provocative tests should not be utilized as the
sole criteria for diagnosis [43]. However, several other investigators
have found that utilizing a battery of provocation tests may be
useful in identifying a painful SIJ. In a double-blind, placebo-
controlled study performed in 40 patients, Broadhurst and Bond
reported that Patricks, posterior shear and resisted abduction tests
had sensitivities ranging between 77 and 87%, with each having
100% specificity [44]. In a blinded validity study performed in
48 patients, Laslett et al. reported that the presence of three of
six provocation tests had 94% sensitivity and 78% specificity in
predicting a positive response to a single diagnostic SIJ injection
[45] . van der Wurff et al. [46] reported similar findings to those of
Laslett et al. [45], finding that the presence of three of five positive
provocation tests in 60 patients resulted in 85% sensitivity and
79% specificity using double confirmatory blocks as the diag-
nostic standard. Previous research has found provocation tests to
be more reliable than tests measuring motion for identifying a
painful SIJ [47,48]. In a recent systematic review by Szadek et al.,
the authors concluded that three positive provocation tests had
significant discriminative power (diagnostic odds ratio: 17.16) for
diagnosing SIJ pain using the reference standard of two positive
blocks [49]. In summary, the presence of three or more positive
provocative tests appears to have reasonable sensitivity and speci-
ficity in identifying those individuals who will positively respond
to diagnostic SIJ injections (Table 3).
Diagnostic imaging
A number of diagnostic imaging studies have been used to inves-
tigate SIJ pain with varying success. CT is a rapid test often
considered to be the gold standard for identifying bony pathology.
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In a retrospective study performed in 112 patients (62 of whom
had injection-confirmed SIJ pain), Elgafy et al. found that CT
was associated with a 57.5% sensitivity and 69% specificity using
diagnostic blocks as the reference standard [50]. Radionuclide bone
scanning has also been investigated in comparison with anesthetic
blocks but has been reported to have low sensitivity. Slipman
et al. [51] found 100% specificity but only 13% sensitivity for
radionuclide imaging in 50 patients who underwent diagnostic
SIJ injections, while Maigne et al. [52] reported 46.1% sensitiv-
ity and 89.5% specificity in a cohort of 32 patients. These low
sensitivities suggest that radionuclide imaging is a poor screening
tool for SIJ pain. MRI has been reported to be effective in detect-
ing early spondyloarthropathic SIJ pathologies with a sensitivity
exceeding 90% but is not useful in identifying noninflammatory
conditions (Table 4) [53] .
Treatment options
Conservative management
Although much of the literature regarding therapeutic options
has focused on interventional approaches to SIJ pain, conservative
management can provide a viable early option with fewer risks.
When evaluating physical therapy and rehabilitation studies,
it is important to note the distinction between pain and bio-
mechanical problems and strength and flexibility deficits, as the
latter do not necessarily result in pain, and pain is not always
accompanied by objective findings in tests designed to measure
Table 2. Studies evaluating physical findings in sacroiliac joint pain.
Study (year) Patients Findings suggestive of SI joint pain Ref.
Fortin et al. (1994) 10 volunteers and 16 patients with SI joint
pain
Point of maximum discomfort within 10 cm caudal and
3 cm lateral to PSIS
[22,37]
Murakami et al. (2008) 38 responders to periarticular injections Point of maximum discomfort within 3 cm from PSIS [38]
Schwarzer et al. (1995) 43 patients with axial LBP Radiation to groin [16]
Dreyfuss et al. (1996) 85 patients with axial LBP None [42]
Slipman et al. (2000) 50 patients with axial LBP 94% had buttock, 72% lumbar, 28% lower leg and
14% groin pain
[39]
van der Wurff et al. (2006) 60 patients with axial LBP None [46]
Jung et al. (2007) 160 patients with SI joint arthropathies Buttock pain alone, extending into posterolateral thigh,
or into groin
[133]
Laslett et al. (2003) 48 patients with axial LBP Non-centralizaton or peripheralization of pain. [134]
Depalma et al. (2011) 127 responders to IA SI joint blocks Lateral midline pain [13]
Young et al. (2003) 102 patients with nonradicular LBP Pain rising from sitting, non-midline pain below L5 [41]
Liliang et al. (2011) 130 patients evaluated for SI joint pain after
fusion
Unilateral pain, 3 provocative maneuvers,
postoperative pain different than preoperative pain
[132]
Ostgaard et al. (1991) 855 pregnant women Pain in the pubic symphysis [26]
Laplante et al. (2012) 153 patients with axial LBP None [14]
IA: Intra-articular; LBP: Low back pain; PSIS: Posterior superior iliac spine; SI: Sacroiliac.
Table 3. Predictive value of provocation testing for sacroiliac joint pain.
Study (year) Sensitivity Specificity (%) Number of
provocation tests
Ref.
van der Wurff et al. (2006) 85% 79 3 out of 5 [46]
Stanford and Burnham (2010) 82% 57 3 out of 6 [135]
Laslett et al. (2005) 94% 78 3 out of 6 [45]
Young et al. (2003) Phi coefficient 0.6, effect size
0.36
Not reported 3 out of 5 [41]
Broadhurst and Bond (1998) Range of 77–87% for each test 100 for each test 3 [44]
Liliang et al. (2011) p = 0.02 to distinguish from
<4 positive tests
Not reported 4 out of 6 [132]
Slipman et al. (1998) Not reported Positive predictive value 60 3 out of 6 [43]
Laslett et al. (2003) 91% 78, increased to 87 when patients whose
pain ‘peripheralized’ or ‘centralized’ were
excluded
3 out of 5
[134]
Sacroiliac joint pain: acomprehensive review of epidemiology, diagnosis & treatment
Expert Rev. Neurother. 13(1), (2013)
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biomechanical abnormalities and strength and flexibility limi-
tations. Nevertheless, strength and flexibility training can be
applied to correct the maladaptive biomechanical imbalance(s)
associated with injury that can worsen the injury and prevent
return to normal activities [54]. Most physical therapy tends to be
focused on core strengthening [55] , with many studies conducted
in peri- and postpartum women who routinely have SIJ dysfunc-
tion. There have been efforts to stabilize and rehabilitate the pelvic
joint through the use of devices such as pelvic belts in peripartum
women [56]. One study evaluating three different physical therapy
treatments in pregnant women diagnosed with SIJ pain based
on provocation maneuvers, found no difference between use of a
nonelastic SI belts, home exercise and a structured clinical exercise
program, with all groups demonstrating improvement between
38 weeks gestation and 12 months postpartum [57] . Ideally, the
use of a physical rehabilitation or exercise program designed to
alleviate pain and correct biomechanical deficiencies should be
individually tailored based on clinical findings, physical capacity
and anticipated compliance [58] .
Alternative treatments
Manual medicine
Manipulation (manual therapy, osteopathic manual treatment,
chiropractic adjustments) has been shown in uncontrolled or
poorly controlled studies to result in significant clinical improve-
ment of pain originating from the SIJ [5962]. However, these
studies have been performed using differing techniques and meth-
odology [9], and a well-designed cohort study failed to show an
association between spinal manipulation success and the presence
of a host of SIJ provocation maneuvers [63]. One comparative study
found the combination of high-velocity, low-amplitude SIJ and
lumbar manipulation to be superior to SIJ manipulation alone
[64]. SIJ bony asymmetries have been clinically shown in uncon-
trolled studies to resolve with manipulation [60,65]; however, a
study by Tullberg et al. [66] using roentgen stereophotogrammetric
analysis while standing showed no change in SIJ bony positioning
after manipulation, and an earlier study demonstrated no signifi-
cant correlation between ‘joint motion’ and response to diagnostic
blocks [42]. There are reports of improved tone and reduction in
pain involving SIJ-related soft tissues after manipulation, namely,
the quadriceps [67], abdominal musculature [68] and hamstrings
[65,69]. Despite the anecdotal nature of these reports, the low risks
associated with these noninterventional techniques warrant their
consideration by trained professionals [70].
Prolotherapy
Prolotherapy (also known as proliferative therapy) involves the
injection of otherwise nonpharmacological and nonactive irri-
tant solutions such as dextrose and platelet-rich plasma into the
body, usually around tendons or ligaments, in an attempt to
strengthen connective tissue and relieve musculoskeletal pain. It
is hypothesized to work by initiating an inflammatory process that
results in enhanced blood flow and accelerated tissue repair. In
the only randomized study evaluating prolotherapy for injection-
confirmed SIJ pain, Kim et al. compared up to 4 bi-weekly IA
dextrose 25% injections to steroids [71] . Although no differences
in short-term outcomes were noted with both the groups sig-
nificantly improving at 2 weeks, at 15 months post-treatment,
58.7% of patients who received prolotherapy continued to expe-
rience a positive outcome versus 10.2% in the IA steroid group.
An observational study by Cusi et al. evaluating three injections
of hypertonic dextrose into the SIJ ligaments reported similarly
auspicious outcomes, with success rates of 76, 76 and 32% at
3-, 12- and 24-month follow-up visits, respectively [72]. Despite
these results, the absence of placebo-controlled studies evaluating
prolotherapy for SIJ pain, and the negative results in high-quality,
controlled studies for back pain in general [73], warrant caution
when interpreting the results.
Interventional treatment
Nerve blocks
In deciding to initiate interventional treatment options, it is
important to consider the clinical evidence supporting a puta-
tive diagnosis, the evidence supporting the treatment and any
anatomical considerations that may affect the decision-making
process (e.g., spondyloarthropathy or multiple previously failed
interventions) [74]. SIJ pain disproportionately affects the elderly,
who tend to present with bilateral pain and have IA pathology
(i.e., arthritis), and young, active people who have are more likely
to present with unilateral pain caused by involvement of the soft
tissue structures (i.e., ligaments and muscles) that comprise the SI
articulation (i.e., EA pathology). Histological studies demonstrate
nociceptive innervation in the SIJ capsule, surrounding ligaments
and subchondral bone [20,21] . Depending on the patient, both IA
and EA injections may provide benefit.
EA steroid injections
There are two controlled trials evaluating EA injections, both
by the same group of investigators [24,25]. In the first study, 20
patients with seronegative spondyloarthropathy were randomized
to receive single peri-articular injections with 3 ml of steroid and
local anesthetic, or the same volume of saline and local anesthetic
[24]. At 2-month follow-up, those in the treatment group fared
better than those in the control group on pain and provocative
examination maneuvers. In the second study, Luukkainen et al.
Table 4. Imaging and diagnosis.
Imaging
modality
Accuracy
CT scan Good for already established bone changes. Does
not detect inflammation. 58% sensitive and 69%
specific in identifying symptomatic joint
MRI Treatment of choice. STIR and contrast-enhanced
superior. 85% sensitive for active sacroiliitis
Bone scans Low sensitivity, high specificity (>90%)
X-rays Very low sensitivity, high specificity
Ultrasound May be used to detect posterior ligamentous
pathology. Can be useful in pregnant women
STIR: Short TI inversion recovery MRI.
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randomized 24 patients with nonspondyloarthropathic SIJ pain to
the same injection scheme [25]. At 1-month follow-up, those who
received steroids experienced less pain than those who received
local anesthetic mixed with saline.
In a non-randomized, comparative effectiveness study,
Murakami et al. compared IA and EA injections in 50 patients
with pain in the SIJ region and three positive provocative tests
[75]. Patients received either IA lidocaine, or EA injections based
on pain provocation with hypertonic saline, and were assessed
5 min after the injection with range of motion exercises. The
authors reported that all patients in the EA group experienced
improvement versus nine out of 25 in the IA group [75]. In a study
by Borowsky and Fagen, the authors retrospectively compared the
outcomes of 80 patients who received IA SIJ blocks to 40 patients
who underwent combination IA and EA blocks to include the
lateral branches and posterior SI ligaments [76]. At 3 weeks (42.5 vs
27.5%) and 3 months (31.25 vs 12.5%), those in the combination
group were more likely to experience 50% pain relief than those
who received only IA injections. The main limitations to all of
these studies are that none prescreened patients with diagnostic
blocks, the short-term follow-ups and the lack of data evaluating
functional capacity.
IA steroid injections
The evidence supporting IA injections is weaker than that for
EA injections but still argues in favor of an effect. A prospective
investigation by Fischer et al. found CT-guided IA steroids to
be an effective long-term (mean duration of benefit: 12 months)
treatment in 56 children with juvenile spondyloarthropathy who
failed to respond to NSAIDs [77]. Hanly et al. compared the
response of IA steroids in 13 patients with inammatory spon-
dyloarthropathy and MRI evidence of sacroiliitis to that in six
patients devoid of radiological evidence of SIJ inammation
(mechanical back pain group) [78]. Both the groups demon-
strated significant improvements in pain scores and function
most prominent between 1 and 3 months, with no differences
noted between groups. In the only controlled study evaluating
IA steroid injections, Maugars et al. randomized ten patients
with spondyloarthropathy and sacroiliitis (13 injected joints)
to receive either IA steroids or saline [79]. At 1-month follow-
up, five of six steroid-injected joints improved by 70% versus
0 out of 7 in the control group. Six of the seven saline-injected
groups were then injected with steroids. Overall, 87.5% (12 out
of 14) injected joints were considered to respond positively at
1 month. At 3 and 6 months, success rates declined to 62 and
58%, respectively.
One possibility that has been entertained is that advanced
imaging capable of detecting inflammation, such as single pho-
ton emission CT or radionuclide bone scanning, may be able to
identify a subgroup of patients likely to respond to IA steroid
injections [80]. Although no study has evaluated the ability of these
diagnostic tools for SIJ pain, researchers have found a positive
association between positive single photon emission CT scans
and response to steroids injected into facet joints [81,82]. Overall,
there is moderate evidence supporting IA steroid injections for
spondyloarthropathy, and anecdotal evidence for a beneficial
effect in nonspondyloarthropathy SIJ pain. Despite positive results
being reported for blind injections [83], a study by Rosenberg et al.
found that only 22% of nonradiologically (i.e., landmark) guided
SI injections extended into the joint space [84].
Other IA injection therapy
Investigators have made several attempts to prolong the intrin-
sic short-term relief obtained with corticosteroid injections.
Theoretically, an IA injection of a neurolytic agent that diffuses
throughout the entire joint should provide long-standing relief for
those individuals suffering from IA SIJ pain. Ward et al. reported
a median 20.5 weeks pain relief in nine out of ten patients who
obtained good but short-term relief with IA steroid injections
who were subsequently treated with IA phenol [85]. However, the
high percentage of tears in the ventral capsule [16], and the high
frequency with which the injectate spreads into the epidural space
or sacral foramina [84] render this a high-risk procedure that is
rarely performed clinically.
Since the SIJ is a synovial joint, and controlled studies for knee,
hip and other forms of osteoarthritis have demonstrated interme-
diate-term benefit with hyaluronic acid [86,87], some have postu-
lated that viscosupplementation might be effective in a subgroup
of patients with degenerative SIJ arthritis. Srejic et al. reported
12–16 months of significant pain relief in four patients with SIJ
pain who underwent a series of three IA injections with hyaluronic
acid [88]. Three of these patients presented with postsurgical SIJ
pain, which is frequently accompanied by degenerative changes
in the SIJ [30,31] , while one suffered from severe osteoarthritis of
the spine. However, the treatment effect size for hyaluronic acid
is considered to be modest at best, and the treatment is likely to
benefit only those individuals suffering from degenerative SIJ
osteoarthritis.
Radiofrequency denervation
First described as a treatment for spinal pain in the early 1970s
[89], radiofrequency (RF) lesioning of the lateral branch nerves
innervating the SIJ has been used for over 10 years, with almost
universally positive results. But whereas controlled and uncon-
trolled studies have demonstrated benefit, none have compared
RF denervation to more conservative therapy. The best candidates
for SIJ denervation are those who have obtained effective but
short-term relief with SIJ blocks, and because the nerves amenable
to lesioning arise from the dorsal rami, those with pain arising
from the posterior joint. Dreyfuss et al. performed an elegant
randomized, double-blind study in 20 pain-free volunteers to
assess the innervation pattern of the lateral branch nerves [90] .
They found that multisite lateral branch blocks blocked ligamen-
tous probing in 70% of cases, but 86% of the time individuals
retained the ability to perceive capsular distension. This suggests
that lateral branch RF denervation should be more effective in
alleviating EA SIJ pain and that either lateral branch or EA blocks
would serve as better predictive tools than IA injections for RF
denervation response, though the latter contention has yet to be
evaluated in clinical trials.
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Expert Rev. Neurother. 13(1), (2013)
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Patient selection
The reasons for interventional treatment failure can be divided into
three main categories, which are outlined in Table 5. Thesinclude
poor patient selection, inaccurate diagnosis, and technical treat-
ment failures. Few studies have examined the factors affecting SIJ
RF denervation success. In a multicenter study by Cohen et al.,
higher preprocedure pain scores (i.e., greater disease burden),
regular opioid use and older age were associated with treatment
failure [36] . These results are consistent with other RF studies
suggesting opioid use and greater disease burden can predispose
patients toward treatment failure [91]. The most probable reason
as to why younger patients experienced higher success rates is that
they are more likely to have EA SIJ pathology (i.e., l igaments),
which includes the pain-generating structures innervated by
lateral branches.
A great deal of literature has been devoted to properly select-
ing patients for RF denervation procedures. Several investiga-
tors have advocated using double blocks to identify a painful SIJ
since single blocks are associated with a high false-positive rate
of around 20% [15] . All of these studies used comparative local
anesthetic blocks, arbitrarily defining a false-positive block as a
positive response to a screening block and a negative response
to a confirmatory block. However, it is likely that at least some
of negative confirmatory blocks actually represent false-negative
blocks. Reasons for false-negative blocks can include failure to
anesthetize the parts of the SIJ responsible for pain, and failure
of the patient to discount ‘procedure-related pain’. A multicenter
study by Cohen et al. evaluating predictors of SIJ RF denerva-
tion outcomes found no difference in success rates when only one
block, or more than one block was used [36]. In a randomized,
comparative cost–effectiveness study comparing zero, one and
two blocks before lumbar facet RF denervation, whereas two
blocks was associated with the highest RF denervation success
rate, the highest overall success rate and lowest cost per effective
procedure was noted in the zero-block group [92]. Reasons for
this finding, which is supported by theoretical computations [93],
include the absence of false-negative blocks and the high placebo
response rates for procedures [94] .
Since the lateral branches amenable to denervation innervate
the posterior ligaments but not the capsule or ventral support-
ing structures, one might surmise that performing lateral branch
screening blocks could improve outcomes. But whereas all studies
that performed lateral branch blocks achieved high success rates
[95–97], studies that have utilized SIJ blocks without lateral branch
blocks have reported equally positive outcomes.
Another area of controversy is the ideal cutoff threshold used to
designate an SIJ as ‘positive’. For facet blocks, the two most com-
monly used thresholds are 50 and 80% pain relief. In the only
study comparing the treatment results between cutoff thresholds
of 50 and 80% for SIJ pain, no difference was found between
RF denervation outcomes [36] . Similarly, no differences for cervi-
cal and lumbar facet RF denervation outcomes have been noted
when 50 and 80% cutoff thresholds were compared [91,98]. The
results for RF denervation are consistent with other treatments
that have found no differences in outcomes between using 50%
thresholds for screening procedures and more stringent reference
standards (Table 6) [99,100].
Types of RF denervation
Conventional RF
As alluded to earlier, not all people have innervation from L4, L5
and S4, and the decision to select which nerves to target should
be based on individual anatomy and clinical presentation (i.e.,
S4 when the foramen lies at a level parallel or above the lower
portion of the SIJ or the patient has distal radiation, and perhaps
L4 in individuals with sacralization of L5 or concomitant lumbar
pain). Multiple uncontrolled studies utilizing different selection
criteria, targeting different nerves, and employing various crite-
ria for success, follow-up periods and techniques, have reported
excellent success rates using conventional RF lesioning [101–103].
However, no controlled studies have been published evaluating
conventional RF denervation. There are two retrospective com-
parative studies that have compared conventional to cooled RF,
which reported conflicting results. In a study by Cohen et al. [36]
involving 77 patients with injection-confirmed SIJ pain, a trend
was noted whereby those individuals who underwent cooled RF
had better outcomes. In contrast, a recent study by Cheng et al.
performed in 88 patients showed no significant advantage for
cooled over conventional RF [104] .
The main limitation to conventional RF is that the small
lesions created (approximately 4 mm in horizontal diameter)
translate to a higher likelihood of missing nociceptive input, as
the lateral branches converging on the foramina are not visible
with imaging techniques. Anatomical studies have found that
the number and location of the lateral branches vary significantly
from patient-to-patient, side-to-side and level-to-level. In light of
the widespread variability in nerve location, we generally insert
curved electrodes at cephalad angles to maximize the surface
area of the active tips that are in contact with bone – similar to
what is generally recommended for lumbar facet joint RF den-
ervation [105] . Because of the small lesion
size, multiple lesions need to be created
around each foramen to interrupt all or
most of the nociceptive input transmit-
ted from the SIJ. Another technique often
used to amplify lesion size is fluid modu-
lation (i.e., injecting fluid before lesion-
ing), which likely acts via alterations
in thermal and electrical conductivity
properties [10 6,107].
Table 5. Reasons for interventional treatment failure.
Patient selection Inaccurate diagnosis Technical failure
Extensive disease burden False-positive block Poor lesion placement
Secondary gain
Social factors
High-dose opioid therapy
Coexisting psychiatric illness
Ventral or intra-articular SI joint pain
Coexisting pain generators
Procedural
complication
SI: Sacroiliac.
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Local anesthetic has been shown to enhance lesion diameter by
approximately 50% and has the additional benefit of diminishing
procedure-related pain. We generally mix 2% lidocaine with a
small dose of steroid before initiating RF since the latter has also
been shown to reduce the incidence of neuritis [108] .
Bipolar RF
In bipolar RF, a second electrode is placed in close proximity
to the first so that the current flows between the two electrodes
to create a continuous lesion. Several investigators have studied
the morphology of bipolar lesions using various mediums, from
animal tissue to egg white. Pino et al. examined bipolar RF lesion
patterns in egg white by heating 22-gauge electrodes in parallel
[109] . They reported that the optimum contiguous ‘strip’ lesion
occurred when the electrodes were placed 6 mm apart. Kang
et al. performed a similar study in egg white using water-cooled
bipolar RF, a technique permitting larger overall lesions through
prevention of tissue charring [110] . The authors reported that the
largest contiguous strip lesion was created when the leads were
placed 24 mm apart. Cosman and Gonzalez performed a series
of experiments in various types of animal tissue, concluding that
orientation, spacing, lesion time, electrode length and diameter
and tip temperature can all affect lesion formation [111]. When
considering these studies, one must recognize that egg white,
or even homogenous ex vivo animal tissue, does not necessarily
simulate conditions in heterogeneous human SI tissue.
In one of the earliest studies evaluating SIJ denervation,
Ferrante et al. conducted a retrospective study in 33 patients in
which bipolar electrodes were sequentially placed within 1 cm of
each other along the posteroinferior margin of the joint, permit-
ting lesions to form in strips [112] . They reported a 36.4% success
rate at 6-month follow-up based upon 50% decrease in visual
analog scale pain scores. The low success rate is not surprising,
considering this IA technique denervated only a small portion of
the posterior joint.
The conceptual appeal of bipolar RF denervation lies in its abil-
ity to maximize lesion size by use of an enclosed electrical circuit,
so that the placement of electrodes close to the foramen where the
lateral branches converge can theoretically interrupt all nocicep-
tive input. In a small observation study involving nine patients
who had experienced 50% pain relief following SIJ and lateral
branch nerve blocks, Burnham and Yasui created bipolar strip
lesions by sequentially leapfrogging 20-gauge electrodes around
the S1–3 foramina [96]. They reported a successful outcome
in 89% of subjects, with two-thirds continuing to experience
meaningful relief 1 year after treatment.
Cooled RF ablation
In comparison to conventional RF, cooled RF is a relatively new
technique, having been adapted from use in tissue ablation used
to treat tumors and cardiac arrhythmias [113–116]. The primary
feature of cooled RF is the internally cooled, large-bore electrodes.
Using irrigation-cooled electrodes allows the surrounding tissues
to slowly heat to neuroablative temperatures while maintaining
the directly adjacent tissue at a temperature that prevents tissue
charring, allowing for greater lesion expansion. The ablation
diameter (twofold increase over conventional RF), depth (3 cm
distal to the active tip) and area (eightfold increase) are therefore
increased substantially, promoting an increased likelihood of suc-
cessful neurotomy and pain resolution. Placing cooled electrodes
strategically around the sacral foramina (i.e., 1:30, 3:30 and 5:30
on the face of a clock for right-sided lesions) should theoretically
result in a continuous geometric strip lesion that completely severs
all nociceptive input from the SIJ.
Probe tip placement is similar to conventional RF, though
the technique needs to be adjusted somewhat. The electrodes
do not need to be inserted in a cephalo-caudal plane to maxi-
mize lesion area but instead can be placed directly perpendicu-
lar to the sacrum, thereby causing less tissue trauma. Because
the ablated area extends distal to the electrode tip, greater lesion
depth is obtained. In order to ensure that the temperature within
the sacral foramen does not exceed 45°C, for safety purposes the
electrodes need to be placed at a greater distance (7 mm) from
the foramina. Additionally, sensory stimulation is unnecessary
due to the fact that strategically placed electrodes should theoreti-
cally
create a continuous lesion that precludes missing individual
lateral branches.
Both controlled and uncontrolled studies support the use of
cooled RF in SIJ pain [97,117,118]. In a randomized, placebo-con-
trolled study conducted in 28 patients, Cohen et al. found that
64 and 57% of patients who underwent L4S3 or 4 denervation
after a positive IA injection experienced 50% pain relief at their
3 and 6-month follow-up visits, respectively, with comparable
improvements in function and medication reduction [118]. In an
open-label crossover arm, a slightly lower proportion of patients
experienced relief using conventional RF. In the subjects who
experienced a successful outcome, the median duration of benefit
was approximately 8 months.
Patel et al. performed a randomized cooled RF placebo-con-
trolled study on 51 patients [97]. Inclusion criteria were failure to
experience long-term relief with conservative measures including
IA injections, and two positive L5 dorsal ramus and S1–3 lateral
branch blocks. The patients were randomized in a 2:1 ratio to
receive either cooled or sham RF of L5S3, respectively. They
found statistically significant improvements in subjective pain,
physical function, disability and quality of life at 3-month fol-
low-up, with 47% of treatment patients experiencing a positive
Table 6. Causes of intra-articular and extra-articular
sacroiliac joint pain.
Intra-articular pain Extra-articular pain
Arthritis Ligamentous injury
Spondyloarthropathy Bone fractures
Malignancies Malignancies
Trauma Myofascial pain
Infection Enthesopathy
Cystic disease Trauma
Pregnancy
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Expert Rev. Neurother. 13(1), (2013)
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outcome (50% decrease in pain with comparable improve-
ments in either SF-36 bodily pain or functional capacity) versus
12% in the control group. At 6 and 9 months post-treatment, 38
and 59% of treatment patients continued
to have a positive outcome.
Although the use of techniques aimed
at amplifying lesion size has considerable
appeal for the SIJ wherein the number
and location of the nerves transmitting
pain signals vary considerably, they are
not devoid of drawbacks. Disadvantages
of cooled RF include the greater expense,
longer lesioning time and larger electrode
size, which enhances the risk of bleeding
and procedure-related pain. In view of the
fact that the larger lesions are more likely to
capture superficial branches, there is also a
higher incidence of cutaneous paresthesias
(Figures 3 & 4).
Combination ligamentous and neural
RF ablation
Similar to SIJ blocks, attempts have been
made to address multiple sources of SIJ
pain simultaneously with RF denervation.
In an observational study by Gevargez
et al., the authors used CT guidance to
lesion the L5 dorsal ramus and create
three lesions in the posterior interosseous
ligaments, in 38 patients with signs and
symptoms consistent with SIJ pain who
positively responded to intra-ligamentous
injections with definite but temporary
pain relief [119]. A total of 65% of patients
reported substantial pain relief lasting at
least 3 months. The main problem with this technique is that
it leaves a majority of the nerve supply, and large areas of tissue,
physiologically intact.
Pulsed RF
Pulsed RF (PRF) is a non-neuroablative
technique whose conceptual appeal is to
effect pain relief without injuring nerves.
Unlike conventional or cooled RF which
severs nerves resulting in Wallerian degen-
eration, PRF acts via the creation of an
electrical field, thereby inhibiting the
transmission of pain-transmitting A-delta
and C-fibers, and possibly by enhancing
descending modulatory systems [120,121] .
Therefore, the primary indication for PRF
is neuropathic pain, in which violation
of the nerve architecture can conceivably
exacerbate the underlying pain condition.
There is only one uncontrolled study
evaluating PRF for SIJ pain [122] . In a small
prospective observational study conducted
in 22 patients who obtained short-term
Figure 3. Schematic diagram depicting target points with anticipated lesions for
right-sided conventional radiofrequency of L4 and L5 and cooled-probe S1–S3
radiofrequency denervation.
Adapted from
[118].
Figure 4. Difference in lesion size between (A) cooled and (B) conventional
radiofrequency probes in chicken meat. Each small line represents a distance of 1 mm.
Adapted from
[118].
A
B
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benefit following SIJ blocks, 73% obtained at least 50% pain
relief and improvement in quality of life, with the median dura-
tion of benefit being 20 weeks in the responders. However, two
randomized studies comparing conventional denervation to PRF
in individuals with facetogenic pain both found conventional RF
to be superior [123,124]. In summary, there is scant evidence for the
use of PRF as a treatment for SIJ pain (Table 7).
Complications of RF ablation
Serious complications from neuroablative procedures are rare.
Postprocedure numbness and tingling are more common than
for facet denervation, affecting up to 20% of individuals, and are
believed to be due to the severing of cutaneous sensory branches.
This is rarely bothersome. The prophylactic administration of
steroids has been shown in a randomized study to reduce the
incidence of medial branch neuritis, though this has not been
formally studied for SIJ pain [108] . Bleeding and infection are
inherent risks of any percutaneous procedure, though the inci-
dence is very low. Misplaced electrodes can result in the ablation
of sacral spinal nerves leading to incontinence, worsening pain
or lower extremity weakness. This can be prevented by the use
of ‘finder’ needles placed into the foramina to ensure that the
active electrode tip is a safe distance. When intravenous agents are
administered, sedation protocols should be implemented.
Cryoanalgesia
Cryoanalgesia works by inducing ice crystal formation that dam-
ages the vasonervorum, leading to severe endoneurial edema and
disruption of neural transmission. In comparison to RF denerva-
tion, the main advantages of cryoanalgesia are a larger lesion size,
and the fact that it leaves the myelin sheath and endoneurium
intact. Disadvantages include a relatively shorter duration of benefit
and a possibly higher risk of bleeding and nerve injury. Currently,
there are no published studies evaluating cryoanalgesia for SIJ pain.
Other treatments
Neuromodulation
Spinal cord and peripheral nerve stimulation are generally
acknowledged to be more effective for neuropathic, than noci-
ceptive pain. There is currently only anecdotal evidence support-
ing neuromodulation for SIJ, with one investigator reporting good
results with S3 stimulation [125] and another report touting benefit
for S1 stimulation [126] .
Surgical intervention for SIJ pain
For nearly 100 years, surgical intervention has been offered to
patients whose symptoms are refractory to conservative man-
agement and nerve blocks. Most of the studies involve surgical
fusion of the SIJ and involve relatively small cohorts of patients.
A number have focused upon surgical intervention for SI disloca-
tion or fracture. Dabezies et al. described 11 patients with mainly
trauma-related SIJ disruption or fracture who received joint
reduction and stabilization with compression rods [127] . Although
they followed their patients for an average of 26.1 months, their
data are mostly limited to the technical aspects of surgery and
do not detail patient outcome, except for noting that several
patients had residual pain while one had extension of preop-
erative peroneal nerve palsy. Simpson et al. examined two dif-
ferent surgical approaches to pelvic stabilization in a series of
patients with mainly trauma-related SIJ disruption, but did not
include detailed outcome readouts from a clinical/functional
standpoint [128].
Interventions have also been used for non-traumatic SIJ pain.
Waisbrod et al. reviewed 22 surgeries over a 3.5-year period, defin-
ing ‘satisfaction’ as indicative of at least 50% reduction of pain,
no need for analgesics, and continuation of preoperative occupa-
tion [129]. They reported that 11 patients described satisfactory
results, and after excluding patients for psycho somatic pain, con-
cluded it was associated with a 70% success rate. Buchowski et al.
described a series of 20 patients who received SIJ arthrodesis after
failing conventional management, assessing their outcomes using
pre- and postoperative assessments with validated instruments
such as the SF-36 Health Survey as well as radiographic and clini-
cal data [130] . In the 15 patients who returned clinical outcome
surveys, statistically significant changes were noted in most cat-
egories of the SF-36, and for satisfaction, neurogenic symptoms
and functional capacity. The analysis of outcomes is confounded
by the 25% of patients who failed to respond to the survey. More
recently, Schütz and Grob reported on a cohort of 17 patients with
chronic lower back pain (12 idiopathic, five traumatic) who had
clinical signs and symptoms consistent with SIJ pain and a posi-
tive response to local anesthetic blocks, who underwent bilateral
SIJ fusion [131] . Their results were not encouraging. A total of
82% of patients were unsatisfied and perhaps more concerning,
65% required reoperation. The caveats for this study include the
disparate inclusion criteria and technical challenges of achieving
complete fusion in SIJs. Ultimately, surgical studies share cer-
tain confounding factors, such as an inability to blind patients
and variability in operative technique. In summary, whereas sur-
gery appears to be clearly indicated for fracture or dislocation, its
applicability to degenerative disease is less clear.
Conclusion
SIJ pain is an underappreciated source of mechanical LBP, affect-
ing up to 30% of individuals with chronic, nonradicular pain.
Whereas a combination of three or more provocation maneuvers
contain greater than 75% sensitivity and specificity according to
some studies for identifying a painful SIJ, the reference standard
for diagnosis remains low-volume anesthetic blocks. Uncontrolled
blocks are associated with a high false-positive rate, but using
controlled blocks increases the likelihood for a false-negative
result and has not been shown to improve treatment outcomes.
Although anecdotal evidence suggests that conservative and alter-
native therapies may benefit a subset of patients with biomechani-
cal or soft-tissue abnormalities, there are no studies evaluating
these treatments in patients with injection-confirmed SIJ pain.
Until such time as high quality RCTs are performed this cohort,
the benefit of these less expensive and invasive options will remain
unknown. Both IA and EA steroid injections may provide short-
term relief in a subset of patients with active inflammation, but
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Expert Rev. Neurother. 13(1), (2013)
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Table 7. Radiofrequency ablation studies.
Study (year) Study design Patients (n) SI joint
blocks
Cutoff
threshold (%)
Lateral
branch
blocks
Nerves
targeted
RF technique Follow-up
(months)
Success
rate (%)
Ref.
Ferrante et al.
(2001)
Retrospective 33 n = 1, 2 ml +
steroid
Not noted No Intra-articular Leapfrog bipolar 6 36
[112]
Gevargez et al.
(2002)
Prospective,
observational
38 n 1, 2 ml +
steroid
Not noted No CT: guided, L5 +
SI ligaments
Conventional 3 66 [119]
Cohen and Abdi
(2003)
Retrospective 9 n = 1, volume
not noted
80 for SI, 50
for LBP
1 L4–S3/4 Conventional 9 89 [95]
Yin et al. (2003) Retrospective 14 n = 2, 5 ml +
steroid,
extra-articular
70 No L5, S1, ± S2
and S3
Conventional 6 64
[102]
Buijs et al.
(2004)
Observational 38 n = 1, volume
not noted
50 No L4–S3 or S1–3 Conventional 4 67 [103]
Burnham and
Yasui (2007)
Prospective,
observational
9 n > 1, 2 ml +
steroid
50 1 at 4 sites L5–S3 Bipolar leapfrog 12 89 [96]
Vallejo et al.
(2006)
Prospective,
observational
22 n > 1, 2 ml +
steroid
75 No L4–S2 Pulsed 10 weeks 55 [122]
Kapural et al.
(2008)
Retrospective 26 n = 2, 3 ml +
steroid
50 No L5–S3 Cooled 3–4 69 [117]
Cohen et al.
(2008)
Randomized,
controlled
28 n = 1, 2 ml +
steroid
50 1 L4–S3/4 Cooled 6 57 [118]
Karaman et al.
(2011)
Prospective,
observational
15 n = 2, 2 ml 75 No L5–S3 Cooled 6 80 [136]
Speldewinde
(2011)
Prospective,
observational
20 n = 2, volume
not noted
80 No L5–S3 Conventional 2 80 [137]
Patel et al.
(2012)
Randomized,
controlled
51 n 1, volume
not noted.
Used intra- and
extra-articular
75 for lateral
branch blocks
2 L5–S3 Cooled 9 59
[97]
Cheng et al.
(2012)
Retrospective 88 n = 2, 3 ml +
steroid
50 No L4–S3 Cooled,
conventional
6 5060 at
6 months, 40
at 9 months
[104]
CT: Computed tomography; RF: Radiofrequency; SI: Sacroiliac.
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their long-term effectiveness remains unproven. In those indi-
viduals who obtain significant but transient relief with SIJ injec-
tions, RF ablation of the lower lumbar dorsal rami and S1–3(4)
lateral branches has been shown to provide pain relief lasting up
to 1 year.
Expert commentary
SIJ pain remains a significant challenge to clinicians, which stems
in part from the inherent difficulties surrounding diagnosis, the
heterogenous nature of the disorder, and the technical obstacles
involved in the treatment. Diagnostic injections are widely con-
sidered the reference standard for identifying a painful joint, but
in the absence of any confirmatory means for diagnosis, the accu-
racy of injections can never be truly known. Whereas the use of
the ‘double-block’ paradigm may reduce the ‘false-positive’ rate,
they inevitably result in more ‘false-negatives’, the consequences
of which may be more serious (i.e., misdiagnosing a treatable
condition) than treating patients without the index condition.
Currently, there are no well-designed studies evaluating conserva-
tive therapies. Steroid injections may provide temporary relief to
a subset of individuals with pain resulting from active inflamma-
tion, with stronger evidence supporting EA than IA blocks. In
those individuals who respond with significant albeit temporary
relief from blocks, RF denervation has been shown in controlled
studies to provide between 6 months and 1-year of relief. Whereas
the theoretical benefit of RF techniques that result in enhanced
lesion size (e.g., cooled or bipolar lesioning) is compelling for a
condition in which the number and location of nociceptive nerve
fibers vary from patient-to-patient, side-to-side and level-to-level,
controlled studies are needed to confirm this.
Five-year view
In recent years, our appreciation of the SIJ as a potential pain
generator has significantly grown, encompassing nearly all allied
health, medical and surgical specialties that treat this condi-
tion. Yet, there is still considerable room for improvement in our
knowledge regarding the mechanisms of injury, improvement in
diagnosis and refinements in treatment. With regards to the for-
mer, increased use of cadaveric experiments, computer-simulation
models and possibly ethical animal studies might shed light on
how an SIJ becomes painful. Currently, the analgesic response
to SIJ blocks performed with local anesthetic is considered the
reference standard for diagnosis, with many individuals advocat-
ing the use of multiple injections to ‘increase accuracy’. However,
a balance needs to be struck regarding the benefits of increased
specificity engendered by multiple injections, and the costs that
result from the inevitable diminished sensitivity associated with
this paradigm. For treatments, there is a glaring absence of well-
designed, controlled studies for noninterventional treatments, and
only a paucity of studies lacking long-term follow-up and second-
ary measures of improvement (e.g., function) evaluating steroid
injections. The evidence is somewhat stronger for RF denervation,
though studies evaluating conventional denervation (which is less
expensive and easier to perform than cooled or bipolar RF lesion-
ing) against sham procedures and other types of denervation are
desperately needed. Finally, the development of SIJ phenotypes,
which take into account demographic variables, clinical features
(e.g., pain descriptions and radiation patterns), and possibly sim-
ple experimental responses, may someday enhance diagnostic
accuracy and improve treatment outcomes.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
Sacroiliac joint (SIJ) pain may account for between 15 and 30% of nonradicular low back pain (LBP).
The SIJ is a major cause of LBP at any age but is more common in the elderly and younger active people.
A good physical exam is likely to demonstrate non-central, unilateral LBP without radiculopathy.
There is a high degree of accuracy for diagnosing sacroiliac pain with three or more provocation tests of the SIJ; however, diagnostic
blocks are the reference standard for identifying a painful joint(s).
Various pain generators surrounding the SIJ complex may need to be treated to maximize success, suggesting multimodal treatment is
ideal.
Treatment of SIJ pain should be individualized based on diagnostic tests and proper patient selection.
Both intra- and extra-articular steroid injections may provide intermediate-term relief depending on the pain generator.
Radiofrequency has proven to be a successful treatment for posterior SIJ pain.
References
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