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Sacroiliac Joint Dysfunction
Abstract
Sacroiliac joint (SIJ) arthropathy is a common cause of acute and chronic low back pain. It is estimated to be the cause of up to 30% of low back pain. In a recent multicentric study, Cher and colleagues found that the overall health burden endured by chronic SIJ pain sufferers was greater than cohorts with COPD, coronary artery disease, and asthma. The SIJ is a mechanical relay station – transmitting loads to and from the trunk and lower extremities while simultaneously providing logic functions as position sense and loading behavior. As such, it provides a unique role in human locomotion and serves as the driving impulse of truncal counterrotation. SIJ pathology is commonly associated with other conditions including: trauma to the pelvis, ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, inflammatory bowel disease, and pregnancy.
The development of the iliosacral joint (ISJ) in tetrapods represented a crucial step in the evolution of terrestrial locomotion. This structure is responsible for transferring forces between the vertebral column and appendicular skeleton, thus supporting the bodyweight on land. However, most research dealing with the water‐to‐land transition and biomechanical studies in general has focused exclusively on the articulation between the pelvic girdle and femur. Our knowledge about the contact between the pelvic girdle and vertebral column (i.e. the ISJ) at a tissue level is restricted so far to human anatomy, with little to no information available on other tetrapods. This lack of data limits our understanding of the development and evolution of such a key structure, and thus on the pattern and processes of the evolution of terrestrial locomotion. Therefore, we investigated the macro‐ and microanatomy of the ISJ in limb‐bearing squamates that, similar to most non‐mammalian, non‐avian tetrapods, possess only two sacral ribs articulating with the posterior process of the ilium. Using a combination of osteology, micro‐computed tomography and histology, we collected data on the ISJ apparatus of numerous specimens, sampling different taxa and different ontogenetic stages. Osteologically, we recorded consistent variability in all three processes of the ilium (preacetabular, supracetabular and posterior) and sacral ribs that correlate with posture and locomotion. The presence of a cavity between the ilium and sacral ribs, abundant articular cartilage and fibrocartilage, and a surrounding membrane of dense fibrous connective tissue allowed us to define this contact as a synovial joint. By comparison, the two sacral ribs are connected to each other mostly by dense fibrous tissue, with some cartilage found more distally along the margins of the two ribs, defining this joint as a combination of a syndesmosis and synchondrosis. Considering the intermediary position of the ISJ between the axial and appendicular skeletons, the shape of the articular surfaces of the sacral ribs and ilium, and the characteristics of the muscles associated with this structure, we argue that the mobility of the ISJ is primarily driven by the movements of the hindlimb during locomotion. We hypothesize that limited torsion of the ilium at the ISJ happens when the hip is abducted, and the joint is likely able to absorb the compressional and extensional forces related to the protraction and retraction of the femur. The mix of fibres and cartilage between the two sacral ribs instead serves primarily as a shock absorber, with the potential for limited vertical translation during locomotion. The iliosacral joint (ISJ) is the articulation between the ilium (pelvic girdle) and sacral ribs (sacral vertebrae). In tetrapods, this structure is responsible for transferring forces between the vertebral column and appendicular skeleton, thus supporting the bodyweight on land. Our knowledge about the ISJ at a tissue level is restricted so far to human anatomy, while in our study we analysed the ISJ in limb‐bearing lizards. We identified this contact as a synovial joint and argue that its mobility is primarily driven by the movements of the hindlimb during locomotion.
Background:
The sacroiliac joint (SIJ) is a major source of pain in patients with chronic low back pain. Radiofrequency ablation (RFA) of the lateral branches of the dorsal sacral rami that supply the joint is a treatment option gaining considerable attention. However, the position of the lateral branches (commonly targeted with RFA) is variable and the segmental innervation to the SIJ is not well understood.
Objectives:
Our objective was to clarify the lateral branches' innervation of the SIJ and their specific locations in relation to the dorsal sacral foramina, which are the standard RFA landmark.
Methods:
Dissections and photography of the L5 to S4 sacral dorsal rami were performed on 12 hemipelves from 9 donated cadaveric specimens.
Results:
There was a broad range of exit points from the dorsal sacral foramina: ranging from 12:00 - 6:00 position on the right side and 6:00 - 12:00 on the left positions. Nine of 12 of the hemipelves showed anastomosing branches from L5 dorsal rami to the S1 lateral plexus.
Limitations:
The limitations of this study include the use of a posterior approach to the pelvic dissection only, thus discounting any possible nerve contribution to the anterior aspect of the SIJ, as well as the possible destruction of some L5 or sacral dorsal rami branches with the removal of the ligaments and muscles of the low back.
Conclusion:
Widespread variability of lateral branch exit points from the dorsal sacral foramen and possible contributions from L5 dorsal rami and superior gluteal nerve were disclosed by the current study. Hence, SIJ RFA treatment approaches need to incorporate techniques which address the diverse SIJ innervation.
Objectives
The sacroiliac joint (SIJ) is an important and significant cause of low back pain. We sought to quantify the burden of disease attributable to the SIJ.
Methods
The authors compared EuroQol 5D (EQ-5D) and Short Form (SF)-36-based health state utility values derived from the preoperative evaluation of patients with chronic SIJ pain participating in two prospective clinical trials of minimally invasive SIJ fusion versus patients participating in a nationally representative USA cross-sectional survey (National Health Measurement Study [NHMS]). Comparative analyses controlled for age, sex, and oversampling in NHMS. A utility percentile for each SIJ subject was calculated using NHMS as a reference cohort. Finally, SIJ health state utilities were compared with utilities for common medical conditions that were published in a national utility registry.
Results
SIJ patients (number [n]=198) had mean SF-6D and EQ-5D utility scores of 0.51 and 0.44, respectively. Values were significantly depressed (0.28 points for the SF-6D utility score and 0.43 points for EQ-5D; both P<0.0001) compared to NHMS controls. SIJ patients were in the lowest deciles for utility compared to the NHMS controls. The SIJ utility values were worse than those of many common, major medical conditions, and similar to those of other common preoperative orthopedic conditions.
Conclusion
Patients with SIJ pain presenting for minimally invasive surgical care have marked impairment in quality of life that is worse than in many chronic health conditions, and this is similar to other orthopedic conditions that are commonly treated surgically. SIJ utility values are in the lowest two deciles when compared to control populations.
Study Design: Pain pattern mapping of the sacroiliac joint in asymptomatic volunteers was investigated. Prospective evaluation of 10 volunteers who received sacroiliac joint injections was performed. The injections consisted of contrast material followed by Xylocaine.
Objectives: To determine the pain referral pattern of the sacroiliac joint in asymptomatic individuals.
Summary of Background Data: All 10 individuals experienced discomfort upon initial injection, with the most significant sensation felt directly around the injection site. Subsequent sensory examination revealed an area of hypesthsia running caudally from the posterior superior iliac spine.
Methods: Volunteers were asked to describe the nature and location of the sensation upon sacroiliac injection. Sensory examination immediately followed the injection to determine referral patterns.
Results: Sensory examination immediately after sacroiliac injection revealed an area of buttock hypesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This area of hypesthesia corresponded to the area of maximal pain noted upon injection.
Conclusion: A pain referral map was successfully generated using provocative injections into the right sacroiliac joint in asymptomatic volunteers.
Simple and reliable diagnostic aids need to be available for clinicians to consider sacroiliac joint dysfunction in the differential diagnosis of low back pain. The Fortin finger test was used as a means to identify patients with low back pain and sacroiliac joint dysfunction. Provocation-positive sacroiliac joint injections were used to ratify or refute the applicability of this new clinical sign for identification of patients with sacroiliac joint dysfunction. Sixteen subjects were chosen from 54 consecutive patients by using the Fortin finger test. All 16 patients subsequently had provocation-positive joint injections validating sacroiliac joint abnormalities. A subset of 10 individuals underwent additional evaluation to exclude the possibility of confounding discogenic or posterior joint pain sources. All 10 patients had no indication of either discogenic or zygapophyseal joint pain generators. These results indicate that positive findings of the Fortin finger test, a simple diagnostic measure, successfully identifies patients with sacroiliac joint dysfunction.
Despite ongoing clinical suspicion regarding the relationship between sacroiliac joint (SIJ) dysfunction and lower extremity symptoms, there is a paucity of scientific literature addressing this topic. The purpose of this study was to describe patterns of contrast extravasation during SIJ arthrography and postarthrography CT in patients with lower back pain and to determine whether there are pathways of communication between the SIJ and nearby neural structures.
Fluoroscopically guided SIJ arthrography was performed on 76 SIJs. After the injection of contrast medium, anteroposterior, lateral, and oblique radiographs as well as 5-mm contiguous axial and direct coronal CT images were obtained. Contrast extravasation patterns were recorded for each joint. These observations included a search for contrast extravasation from the SIJ that contacted nearby lumbosacral nerve roots or structures of the plexus.
Sixty-one percent of all joints studied revealed one of five contrast extravasation patterns. Three of these observed patterns show a pathway of communication between the SIJ and nearby neural structures. These included posterior extravasation into the dorsal sacral foramina, superior recess extravasation at the sacral alar level to the fifth lumbar epiradicular sheath, and ventral extravasation to the lumbosacral plexus.
Three pathways between the SIJ and neural structures exist.
The nature, type and frequency of injuries occurring at a national figure skating competition were examined. Data was compiled from the medical history form of all 208 participants and the on-site evaluations of the 55 skaters who presented for treatment. Twenty-six percent of all the skaters were injured during the competition. Senior skaters accounted for more injuries than their junior counterparts. Pairs skaters appeared to be more susceptible to injury, incurring significantly more injuries than singles or dance skaters. As in other reports, injuries to the lower extremities predominated. Low back injury comprised 14.6% of all injuries. Thirty-five (64%) of the 55 injuries were exacerbations of a pre-existing injury and twenty (36%) were new ones. Most competitive figure skating injuries are of the overuse type, suggesting a need to evaluate predisposing factors and methods of rehabilitation.
In this brief study we provide evidence that earlier and more recent findings pertaining to the anatomy and physiology of the sacroiliac joint suggest that dysfunction in this joint could, similar to a herniated lumbar disc, produce pain along the sciatic nerve. These observations might explain some of the cases of sciatica in which no disc pathology can be found.
The presentation of a patient with primary spine pathology may be confounded by a myriad of symptoms that span many organ systems. Likewise, imaging findings are often diverse and may be as subtle as slight posterior joint asymmetry combined with paravertebral myofascial strain or as goss as fracture-dislocation with neurological sequelae. A systematic approach to selecting and applying the appropriate imaging study combined with a careful clinical history and examination will insure a more accurate diagnosis and proper treatment. The biomechanics of injury and the pathophysiology of the disease process in question should always be considered. This review discussed an algorithmic approach for understanding spine imaging with discussions of radiography, radionuclide scan, myelography, computed tomography scanning and magnetic resonance imaging.
We measured the load-displacement behavior of both single and paired sacroiliac (SI) joints in fresh cadaver specimens obtained from eight adults between the ages of 59 and 74 years. With both ilia fixed, static test loads were applied to the center of the sacrum along and about axes parallel and normal to the superior SI endplate. Test forces up to 294 N were applied in the superior, inferior, anterior, posterior, and lateral directions. Moments up to 42 N-m were applied in flexion, extension, lateral bending, and axial torsion. Displacements of the center of the sacrum were measured 60 s after each load increment was applied, using dial gauges and an optical lever system. The tests were then repeated with only one ilium fixed. Finally, the three-dimensional location and overall geometry of each SI joint were measured. For an isolated left joint at the maximum test loads, the mean (SD) sacral displacements in the direction of the force ranged from 0.76 mm (1.41) in the medial to 2.74 mm (1.07) in the anterior direction. The mean rotations in the directions of the moments ranged from 1.40 degrees (0.71) in right lateral bending to 6.21 degrees (3.29) in clockwise axial torsion viewed from above. We also examined load-displacement behavior under larger loads. Single sacroiliac joints resisted loads from 500 to 1440 N, and from 42 to 160 N-m without overt failure.
This retrospective study evaluated the diagnostic value of computed tomography in patients with sacroiliac pain. Computed tomography scans of the sacroiliac joints of 62 patients with sacroiliac joint pain were reviewed. The criteria to include the patient in the current study were pain relief after a local injection in the sacroiliac joint under computed tomography guidance, a physical examination consistent with a sacroiliac origin of the pain, and negative magnetic resonance imaging of the lumbar spine. A control group consisted of 50 patients of matched age who had computed tomography scans of the pelvis for a reason other than pelvic or back pain. Computed tomography scans showed one or more findings in 57.5% and 31% of the sacroiliac joints in the symptomatic and the control groups, respectively. The computed tomography scans were negative in 37 (42.5%) symptomatic sacroiliac joints with a positive sacroiliac joint injection test. The sensitivity of computed tomography was 57.5 % and its specificity was 69%. The finding of the current study suggests limited diagnostic value of computed tomography in sacroiliac joint disease because of its low sensitivity and specificity. With clinical suspicion of a sacroiliac origin of pain, intraarticular injection is currently the only means to confirm that diagnosis.
Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference standards. The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference standard. In a blinded concurrent criterion-related validity design study, 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection procedures were examined using a specific clinical examination and received diagnostic intraarticular sacroiliac joint injections. The centralisation and peripheralisation phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process. Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection. Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain. In the primary subset analysis of 34 patients, sensitivity, specificity and positive likelihood ratio (95% confidence intervals) of the clinical evaluation were 91% (62 to 98), 83% (68 to 96) and 6.97(2.70 to 20.27) respectively. The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac joints
Surgical treatment of chronic painful sacroiliac joint dysfunction
- M R Moore
- A Vleeming
- V Mooney
- T Dorman
- C Snijders
- R Stoeckart
- MR Moore
Diagnostic imaging of painful sacroiliac Jioints, editor. iSpine evidence-based interventional spine care
- Jd Fortin
- Se Wahezi
- D Mintz
- A Chang
editor. iSpine evidence-based interventional spine care
- J D Fortin
- S E Wahezi
- D Mintz
- A Chang
- JD Fortin