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Pain Practice - 2023 - Szadek - 5 Sacroiliac joint pain

December 2023
Pain Practice 24(4):1-20

DOI:10.1111/papr.13338

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CC BY-NC-ND 4.0

Authors:

Steven P Cohen

Johns Hopkins Medicine

Monique A H Steegers

Academisch Medisch Centrum Universiteit van Amsterdam

Jan Van Zundert MD, PhD, Fipp

Ziekenhuis Oost Limburg

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Introduction Sacroiliac (SI) joint pain is defined as pain localized in the anatomical region of the SI joint. The reported prevalence of SI joint pain among patients with mechanical low back pain varies between 15% and 30%. Methods In this narrative review, the literature on the diagnosis and treatment of SI joint pain was updated and summarized. Results Patient's history provides clues on the source of pain. The specificity and sensitivity of provocative maneuvers are relatively high when three or more tests are positive, though recent studies have questioned the predictive value of single or even batteries of provocative tests. Medical imaging is indicated only to rule out red flags for potentially serious conditions. The diagnostic value of SI joint infiltration with local anesthetic remains controversial due to the potential for false‐positive and false‐negative results. Treatment of SI joint pain ideally consists of a multidisciplinary approach that includes conservative measures as first‐line therapies (eg, pharmacological treatment, cognitive‐behavioral therapy, manual medicine, exercise therapy and rehabilitation treatment, and if necessary, psychological support). Intra‐ and extra‐articular corticosteroid injections have been documented to produce pain relief for over 3 months in some people. Radiofrequency ablation (RFA) of the L5 dorsal ramus and S1‐3 (or 4) lateral branches has been shown to be efficacious in numerous studies, with extensive lesioning strategies (eg, cooled RFA) demonstrating the strongest evidence. The reported rate of complications for SI joint treatments is low. Conclusions SI joint pain should ideally be managed in a multidisciplinary and multimodal manner. When conservative treatment fails, corticosteroid injections and radiofrequency treatment can be considered.

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Pain Practice. 2023;00:1–20.

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INTRODUCTION

This narrative review on sacroiliac (SI) joint pain is an

update of the article published in the series “Evidence-

based Interventional Pain Medicine According to

Clinical Diagnoses.”1 The SI joint has long been con-

sidered an important source of low back pain due to

the nociceptive innervation of the joint and empirical

findings that treatments targeting the SI joint can re-

lieve pain. The International Association for the Study

EVIDENCE- BASED REVIEW

Update of Evidence- Based I ntervent ional Pain Medicine According to Clinical Diagnoses

5. Sacroiliac joint pain

KarolinaSzadek MD, PhD, FIPP1 | Steven P.Cohen MD, FIPP2,3 |

Javierde AndrèsAres MD, PhD, FIPP4 | MoniqueSteegers MD, PhD, FIPP1 |

JanVanZundert MD, PhD, FIPP5,6 | Jan WillemKallewaard MD, PhD, FIPP7,8

DOI: 10.1111/papr.13338

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1Departme nt of Anes thesi ology an d Pain

Medic ine, A mste rdam Universit y Medic al

Centers, Amsterdam, The Netherlands

2Depa rtme nt of Anesthesiology,

Neurology, Physical Medicine &

Rehabi litat ion and Psychiat ry and

Behav ioral Scienc es, Nor thwest ern

University Feinb erg School of Med icine,

Chic ago, Illinois, USA

3Departme nt of Anes thesiology an d

Physic al Medi cine & Rehabil itation, Walter

Reed Nat ional Military Med ical C enter,

Unifor med Se rvices University of the

Health Scien ces, B ethesda, Ma ryland, USA

4Pain Un it Hospital Univer sitar io La Paz-

(Anesthesiology), Madrid, Spain

5Depa rtme nt of Anesthesiology,

Inten sive Car e, Emerg ency Me dici ne and

Multid iscip lina ry Pai n Cente r, Zieken huis

Oost- Limburg, Genk/ Lanaken, Belg ium

6Depa rtme nt of Anesthesiology and Pain

Medic ine, Ma astr icht University Medic al

Cente r, Maastr icht, The Netherland s

7Depa rtme nt of Anesthesiology and Pain

Medic ine, R ijnstate Zieke nhuis, Velp, The

Netherlands

8Departme nt of Anesthesiology and Pain

Medic ine, A mste rdam Universit y Medic al

Centers, Amsterdam, The Netherlands

Correspondence

Jan Van Zunde rt, De part ment of

Anes thesiology, Inte nsive Ca re, Eme rgency

Medicine and Multidisciplinary Pain

Cente r, Zieken huis Oost- Limburg,

Bess emer sstra at, Genk/L anake n 478 3620,

Belgium.

Emai l: jan.vanzundert@zol.be

Abstract

Introduction: Sacroiliac (SI) joint pain is defined as pain localized in the anatomical

region of the SI joint. The reported prevalence of SI joint pain among patients with

mechanical low back pain varies between 15% and 30%.

Methods: In this narrative review, the literature on the diagnosis and treatment of

SI joint pain was updated and summarized.

Results: Patient's history provides clues on the source of pain. The specificity

and sensitivity of provocative maneuvers are relatively high when three or more

tests are positive, though recent studies have questioned the predictive value of

single or even batteries of provocative tests. Medical imaging is indicated only

to rule out red flags for potentially serious conditions. The diagnostic value of SI

joint infiltration with local anesthetic remains controversial due to the potential

for false- positive and false- negative results. Treatment of SI joint pain ideally

consists of a multidisciplinary approach that includes conservative measures as

first- line therapies (eg, pharmacological treatment, cognitive- behavioral therapy,

manual medicine, exercise therapy and rehabilitation treatment, and if necessary,

psychological support). Intra- and extra- articular corticosteroid injections

have been documented to produce pain relief for over 3 months in some people.

Radiofrequency ablation (RFA) of the L5 dorsal ramus and S1- 3 (or 4) lateral

branches has been shown to be efficacious in numerous studies, with extensive

lesioning strategies (eg, cooled RFA) demonstrating the strongest evidence. The

reported rate of complications for SI joint treatments is low.

Conclusions: SI joint pain should ideally be managed in a multidisciplinary and

multimodal manner. When conservative treatment fails, corticosteroid injections

and radiofrequency treatment can be considered.

KEYWOR DS

cooled radiofrequency, evidence- bas ed medicine, low back pain, radiofrequenc y ablation, sacroiliac

joint

SACRO ILIAC J OINT PAI N

of Pain (IASP) has formulated criteria for the diagno-

sis of SI joint pain.2 According to these criteria SI joint

pain is defined as pain localized in the anatomical re-

gion of the SI joint, reproducible by performing spe-

cific SI joint provocation tests, or reliably relieved by

selective infiltration of the symptomatic SI joint with

a local anesthetic. Depending on the diagnostic crite-

ria employed (clinical examination, intra- articular test

blocks, medical imaging), the reported prevalence of

SI joint pain among patients with axial low back pain

varies between 15% and 30%.3–5

The SI joint is a diarthrodial synovial joint, that con-

nects the sacrum to the iliac bone. The antero- caudal

part of the SI joint is a true synovial joint, whereby the

facies auricularis of the sacrum is connected bilater-

ally to the facies auricularis of the iliac bones. Strong

ligaments support the joint, limiting its movement.

These ligaments can be divided into the ligamentum

sacroilacum interosseum, posterius, and anterius, and

three accessory ligaments—ligamentum sacrotuber-

ale, sacrospinale, and iliolumbale. The SI joint is en-

compassed by some of the most powerful muscles in

the body, including the erector spinae, psoas, quadra-

tus lumborum, piriformis, and gluteus. Yet, there are

no muscles explicitly intended for the active manipula-

tion of the SI joint.

The SI joint cannot function independently because

these muscles, together with the musculus piriformis,

are shared with the hip joint, and the erector spinae and

psoas muscles interact with the lumbar spine. The lig-

aments and the muscles support and inf luence the sta-

bility of the SI joint. The anterior part of the SI joint is

innervated by branches arising from the anterior ramus

of L4 and L5,6 or the lumbosacral trunk.7,8 Although

one detailed anatomical study describes the dorsal part

of the SI joint receiving innervation from the posterior

sacral network (PSN) formed by the lateral branches of

the posterior rami of S1–S3 (with variable contributions

from L5 and S4),9 findings from another study suggest

that these nerves innervate the posterior SI joint lig-

aments but do not reach the synovial part of the joint

posteriorly.10

SI joint pain can be divided into intra- articular

causes (infection, arthritis, spondyloarthropathies,

malignancies) and extra- articular causes (enthesop-

athy, fractures, ligamentous injuries, and myofascial

injuries). Frequently, no specific cause can be identi-

fied. Unidirectional pelvic shear stress, repetitive tor-

sional forces, and inflammation can all cause pain.

Risk factors include leg length discrepancy, abnormal

gait pattern, trauma, scoliosis, lumbar fusion surgery

with fixation to the sacrum, heavy physical exertion,

obesity, and pregnancy.11 –17 In patients suffering from

persistent low back pain after a technically success-

ful lumbar arthrodesis, a prevalence rate of SI joint

pain between 30% and 40% has been demonstrated

by means of diagnostic intra- articular blocks, with

the sole study that utilized double- blocks reporting a

true- positive rate of 40% and a false- positive rate of

26%.14,18,19 However, it remains unclear what percent-

age of these patients developed post- fusion SI joint

pain (eg, adjacent segment disease) due to increased

post- fusion stress on the SI joints20 versus individuals

with presurgical SI joint pain who underwent unneces-

sary fusion.

METHODOLOGY

This narrative review is based on the article “SI joint

pain” published in 2010.1 In 2015, an independent com-

pany, Kleijnen Systematic Reviews (KSR) performed a

systematic review of the literature for the period 2009–

2015 based on existing systematic reviews (SRs) and ran-

domized controlled trials (RCTs).21,2 2

For the current article, an updated search was con-

ducted for the period 2015–2023 using the terms “sacroil-

iac” and “joint” and “pain” in combination with specific

interventional pain management techniques, in this

case, “corticosteroid” or “steroid” and “injections”; “ra-

diofrequency” or “cooled radiofrequency.” Additionally,

authors selected relevant missing articles based on refer-

ence lists and precision literature reviews (eg, complica-

tions, arthrodesis).

DI AGNOSI S

History

Pain from the SI joint is generally localized in the glu-

teal region, below the L5 spinal level, where the pos-

terior elements of the SI joint are situated (94%).23

Referred pain from the intra- articular part of the

joint may also be perceived in the lower lumbar re-

gion (72%), groin (14%), upper lumbar region (6%), or

abdomen (2%). According to one study, pain referred

to the lower limb occurs in 28% of patients, with 12%

reporting pain in the foot.23 (Figure1). The posterior

extra- articular ligaments may also result in pain that

is referred into the lumbar area, lower extremity, and

into the groin. In one study, between 10% and 20% of

extra- articular SI joint pain was referred to the lower

extremity, with between 5% and 10% extending below

the knee.24 Upper extra- articular SI joint pain may be

more likely to extend into the groin, while middle and

lower extra- articular pathology may radiate into the

lower leg more than upper ligamentous pathology.24

Groin pain and anterior thigh pain may also occur in

individuals with ventral and occasionally even dorsal

SI ligamentous pathology, though epidemiological data

on this are lacking. If the pain is felt in the anatomical

region of the ischial tuberosity, it is less probable that

the patient suffers from SI joint pain.25

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SZADEK e tal.

Many investigators have emphasized that medical

history is important for correct diagnosis.20 Several in-

vestigators have found that radiation into the groin can

distinguish SI joint pain from other sources,4,24,26 while

others reported that proximity of the area of maximal

pain and/or tenderness to the posterior superior iliac

spine is predictive to response to injections.2 7,2 8 Yo u ng

etal.29 found positive correlations between SI joint pain

and worsening of symptoms when rising from a sitting

position, when symptoms are unilateral (particularly in

younger individuals with traumatic, extra- articular SI

joint pain), and with three or more positive pain prov-

ocation tests. Yet, other investigators have found no ag-

gravating or relieving factors to be helpful in identifying

a painful SI joint.30

Physical examination

Although solitary pain provocation maneuvers have no

pathognomonic value in identifying a painful SI joint,

two individual pain provocation tests- the compression

and thigh thrust test- may be helpful in diagnosing SI

joint pain.31 Patients with a positive thigh thrust test

or compression test may be more likely to suffer from

intra- articular SI joint pain [sensitivity 0.907 (0.78–

0.97), specificity 0.662 (0.53–0.77), diagnostic odds ratio

18.461 (5.82–58.53)]. Due to the size and the immobil-

ity of the SI interface, large forces are needed to stress

the joint, which can be a source of false negatives. In

addition, if forces are applied incorrectly, pain can be

provoked in neighboring structures, resulting in false-

positive tests. Both the sensitivity and specificity of the

clinical examination increases as a direct function of

the number of positive tests. Two studies found that

three or more positive provocative tests resulted in a

specificity and sensitivity of 79% and 85%, and 78% and

94%, respectively.32,33 This was confirmed by a meta-

analysis which showed that 3 or more positive stress

tests have discriminative power for diagnosing SI joint

pain.31 However, three recent studies call into question

the diagnostic value of individual or a battery of pro-

vocative tests.34–36 In a systematic review involving five

studies and 422 patients, Saueressig etal. found that a

battery of positive provocative SI joint maneuvers had

only a 35% certainty of identifying the SI joint as the

primary pain generator, but that a negative cluster of

tests is associated with a non- painful joint in 92% of

cases. {Saueressig, 2021 #12827}.

There is scant research on the association of histor-

ical and physical exam findings to predict response to

extra- articular injections, with one study finding an

association between a positive block and the patient

identifying the most painful point as being within 2 cm

of the posterior superior iliac spine. {Murakami, 2008

#12828} More research needs to be done on tests to

identify extra- articular pathology and distinguish be-

tween pathology involving different aspects of the SI

joint complex.

There are several clinical tests described in the liter-

ature: palpation tests to assess mobility and alignment,

and provocation tests to reproduce a patient's typical

pain. Herein we describe several of the more popular and

well- studied tests, with purported diagnostic validity.31

1. Fortin's finger test: The patient localizes the pain

with one finger, in the area immediately inferome-

dial to the posterior iliac spine (within 1 cm), and

consistently points to the same area.37

2. A combination of five provocation tests for SI joint

pain with a threshold of three or more positive tests,

including the compression, thigh thrust, distraction,

Gaenslen's, and Patrick's tests. Each of these purports

to reproduce a patient's typical pain.

FIGUR E 1 Typical pa in referral pattern of sacroiliac joint

pain (i llustration: Rogier Tromper t Medical Ar t http:// www. medic

alart. eu).

SACRO ILIAC J OINT PAI N

a. Compression test (Approximation test): The patient

lies on his/her side with the affected side up; the

patient's hips and knees are f lexed approximately

45° and 90°, respectively. The examiner stands be-

hind the patient and places both hands on the front

side of the iliac crest and then exerts downward

pressure.38

b. Thigh thrust test (POSH- Posterior Shear test,

Femoral Shear test): The patient lies supine with the

unaffected leg extended. The examiner stands next

to the affected side, then bends the leg at the hip

to an angle of approximately 90° with slight adduc-

tion while applying light pressure to the bent knee,

causing anterior- to- posterior shear in the affected

SI joint.38

c. Distraction test (Gapping test): The examiner

stands on the affected side of the patient who is

in the supine position with their arms crossed and

hands on the spinae iliaca anterior superior (SIAS).

The examiner applies pressure in the dorso- lateral

direction.38

d. Patrick's sign (FABER- Flexion Abduction External

Rotation test): The patient lies in the supine po-

sition with the examiner standing on the affected

side. The leg of the affected side is bent at the hip

and knee, with the foot positioned under the oppo-

site knee. The examiner fixes the contralateral SIAS

to prevent movement in the lower back. Downward

pressure is then applied to the knee of the affected

side.38

e. Gaenslen's test (Pelvic torsion test): The patient lies

in a supine position with the affected side on the

edge of the examination table. The unaffected leg

is bent at both the hip and knee, and maximally

flexed until the knee is pushed against the abdo-

men. The leg on the affected side is brought into

hyperextension whereby light pressure is applied to

the knee.38

3. The Gillet test, also known as the Stork test, is one of

the tests used in the assessment of SI and hip joint mo-

bility and alignment.39 The patient stands upright in a

comfortable posture, with both feet flat on the floor.

The examiner stands behind the patient to observe

their back and pelvis. Pelvic Movement Assessment:

Instruct the patient to lift one leg while flexing the knee

toward their chest, as if they were marching in place.

They can choose either leg for the initial assessment.

While the patient lifts their leg, palpate, and closely

observe the position of the iliac crest on the side of the

lifted leg (the ASIS—Anterior Superior Iliac Spine).

During normal hip flexion, the ASIS on the side of

the lifted leg should rise slightly or move upward sym-

metrically compared to the stationary ASIS on the op-

posite side. This is because the hip joint is flexing, and

the pelvis on the lifted side should rotate forward. If,

during the leg lift, the ASIS on the side of the lifted leg

does not move upward or moves downward compared

to the opposite side, it may indicate a lack of mobility

or dysfunction in the SI joint on that side. This can

suggest SI joint pathology or immobility. After assess-

ing one leg, repeat the test on the other leg to compare

mobility and symmetry.

Additional tests

Medical imaging is indicated only to rule out red flags

for potentially serious conditions.40

The choice of imaging depends on the patient's clin-

ical presentation. In various studies, the use of radiog-

raphy, computed tomography, single photon emission

computed tomography (SPECT), bone scans, and other

nuclear imaging techniques have been used to identify

specific disorders of the SI joint. As a sole diagnostic

tool, computed tomography (CT) is not helpful in diag-

nosing SI joint pain because of the high prevalence of de-

generative changes among asymptomatic individuals.41

This prevalence increases with age, whereby >85% of as-

ymptomatic patients over the age of 60 have radiological

evidence of SI joint degeneration. Degenerative changes

on the sacral surface generally lag years behind the oc-

currence on the iliac side, with the correlation between

clinical symptoms and imaging being poor.42 Similar to

CT scans, SI joint abnormalities are commonly observed

on magnetic resonance imaging (MRI) of asymptomatic

individuals and include bone marrow edema, erosions,

and sclerosis, with erosions being more specific in pa-

tients with low back pain.43

According to the Assessment of Spondyloarthritis

International Society (ASAS), MRI is the most adequate

imaging modality to detect sacroiliitis,44 but care must

be taken to distinguish between inf lammatory SI joint

pathology and non- inflammatory changes which may

resemble sacroiliitis.45,46 (s ee Ta ble1).

Diagnostic blocks

According to the 3rd IASP criterion, SI joint pain

should be completely relieved by selective infiltration

of local anesthetics into the symptomatic SI joint,2

whereby a local anesthetic is injected in the joint cavity.

Yet, this approach fails to consider both concomitant

pain generators and failure to achieve spread through-

out the entire SI joint complex. Several authors used a

single diagnostic block in clinical studies.4,23,47 Others

have used confirmatory (double) diagnostic blocks on

two separate occasions,5,25,32,33,48 –50 ideally using local

anesthetics of different durations of action, though the

sensitivity of the “comparative local anesthetic” para-

digm has been reported to be low in other contexts.51, 52

In six studies, corticosteroids were used in combina-

tion with local anesthetics.30,33,48,53,54 Although the

volume of local anesthetic used for infiltration has

SZADEK e tal.

varied between 1 mL4 and 4 mL,55 the capacity of the

intra- articular portion of the SI joint typically does not

excee d 2.7 mL27; hence, volumes too low can result in

false- negative blocks while excessive volumes can lead

to rupture of the joint capsule or extravasation outside

of the joint and false- positives. In individuals in whom

posterior extra- articular pathology is suspected (eg,

young individuals with unilateral pain after trauma

and prominent tenderness in the absence of significant

radiographic findings), either extra- articular injections

or lateral branch blocks may be employed, with the lat-

ter also being used as a prognostic tool before sacral

lateral branch RFA.56–58

The diagnostic value of SI joint infiltration with local

anesthetic remains controversial and difficult to cal-

culate due to the potential for false- positive and false-

negative results.59 Possible causes of inaccurate blocks

include dispersal of the local anesthetic to adjacent pain-

generating structures, (muscles, ligaments, nerve roots

through connections between the SI joint and upper

sacral foramina),60 the overzealous use of superf icial an-

esthesia or sedation, and failure to achieve infiltration

throughout the entire SI joint complex, with the latter

being a potential cause of a false- negative diagnosis. In

one study, three communication pathways between the

SI joint and adjacent neural structures were observed

that could increase the risk of a false- positive block: pos-

terior extravasation into the first dorsal sacral foramina,

superior recess extravasation at the sacral ala extending

to the fifth lumbar spinal nerve, and ventral extravasa-

tion reaching the lumbosacral plexus.60 The use of flu-

oroscopy or other imaging to guide needle placement

during SI joint blocks is strongly recommended. In stud-

ies evaluating the ability of blind injections to spread in-

side the joint, the accuracy has varied between 8% and

22%.56,61,62 CT- guided injections can be useful when the

SI joint cannot be accessed using f luoroscopy.63

Differential diagnosis

Spondyloarthropathy or axial spondyloarthritis is an in-

flammatory disease of the spine. It usually presents as

chronic low back pain before the age of 45 years, with

involvement of other joints and inf lammation observed

on imaging studies. Possible accompanying symptoms

TABLE 1 Differential d iagnosis for spondyloart hropathy and the major findings in MRI.

Conditions that resemble sacroiliac joi nt pain MRI f indings in SI joi nts46

Anatom ical variations involv ing the

cartilag inous or l igame ntous part of the

joint, including an ac cessory SI joi nt,

transitional vertebrae, hemisacralization

Small vessels locat ed in transitional cartilaginous- ligamentous portions which may simu late

bone marrow edema (BMO).

Osteoarth ritis/degenerative changes of the

SI joints and lower lumbar spine

Young (sports- active) indiv iduals: (BMO) in the SI joint s, minor erosion s, osteophytes, and

sclerosis.

Elderly w ith SI joint osteoarthr itis: BMO (often in the antero- superior part of the SIJs), minor

erosions.

Osteitis condensans ilii (OCI) Triangular- shape d, well- circumscribed, sub chondral sclerosis (anteriorly located, iliac side >

sacral) without gross erosions or SI joint nar rowing.

BMO surrounding sclerosis. If there is BMO surroundi ng fat metaplasia, this suggest s SpA

may coex ist with OCI.

Infectious sacroiliitis Anatom ic boundaries are not respected (involvement can be u nilateral or bilateral), usually

with large erosions, joint effusion, and more extensive BMO; soft tissue involvement, often

with abscess(es).

Tumors/pseudotumors Usu ally a straightforward imaging diagnosis

Diffuse idiopathic skelet al hyperostosis Evident, coars e bony/ossified bridges over the anterior and posterior SI joi nt articula r

margins and entheseal bridging.

Intra- articular ankylosis.

Hyperparathyroidism Subchondral resor ption with irregularity, gross erosions, and pseudo- w idening of the SI

joints (more pronounc ed on the i liac side).

Synovitis, acne, pustulosis, hyperostosis,

osteitis syndrome, and chronic recurrent

multifocal osteomyelitis

Osteit is/BMO (on either side of the SI joints) precede s erosive changes, sclerosis, and

hyperostosis in the SI joi nts (more marked on the iliac side).

Unilateral or bilateral asy mmet ric involvement of the SI joints mainly involving the iliac side,

with extensive osteosclerosis.

Gout Tophi may form in SI joints ( juxt a- articular, intra- art icular and sub chondral).

Paget's disease Must have other Pagetic changes in the pelvis.

Fusion of the SI joints is occa sionally observed in Paget's disease with c oexisting sacroiliitis.

Sarcoidosis May mimic SpA in radiographs. In the presence of k nown clinical sarcoidosis, the diagnosis of

bone sarcoidosis should be considered if there is concomitant involvement of the SI joints.

Abbrev iations: BMO, bone mar row edem a; OCI, Os teitis condensans i lii; SpA, spondyloart hropat hy.

SACRO ILIAC J OINT PAI N

include uveitis, psoriasis, and inf lammatory bowel

disease. Patients frequently carry the gene for human

leukocyte antigen (HLA)- B27, and those with active

inf lammatory disease often have evidence of elevated

acute phase reactants, including erythrocyte sedimenta-

tion rate and C- reactive protein (CRP).64

See also chapters on lumbosacral radicular syndrome

and lumbar facet joint pain.65,66

Hip pain is usually secondary to arthritis of the joint.

Patients usually present with pain in groin area but also

frequently have pain in the buttock and lateral hip which

can extend below the knee.67,6 8 Activity makes the pain

worse, and it may interfere with sleep. Plain radiography

is indicated.

Endometriosis69 is a common cause of pelvic, abdom-

inal, and low back pain caused by the implantation of

normal uterine endometrial mucosa in abnormal loca-

tions including the bowel, diaphragm, and pleural cavity.

The pain in endometriosis can be associated with other

symptoms such as dysmenorrhea, dyspareunia, and

dysuria.

Myofascial pain.70 is a relatively common source of

chronic pain caused by the presence of trigger points,

spasm or increased myoelectric tone, or even atrophy

within muscles. In addition to pain, it is associated with

restricted active movement in the affected area.71

Piri for mis72 syndrome is associated with pain in the

buttock, hip, and lower limb. Sciatic- like symptoms may

accompany piriformis syndrome and can be caused by

irritation of the sciatic nerve if the nerve passes through

the muscle or adjacent to the piriformis or neighboring

(eg, gemelli, obturator internis) muscle(s) anteriorly.

Entrapment of the sciatic nerve may develop following

excessive muscle strain, spasm or trauma to the buttocks

in patients with anatomical variations in which the sci-

atic nerve passes through or next to the piriformis muscle

(20%). Pathology involving the adjacent musculature of

the lateral rotator group (superior and inferior gemelli,

obturator internus) can also mimic SI joint pain.

Cluneal nerve entrapment syndrome is a medical con-

dition characterized by the compression or irritation of

the superior, middle and/or inferior cluneal nerves.73 In

all three categories of nerve involvement, individuals

typically experience pain in the lower back or buttocks,

along with dysesthesia or paresthesia. Symptoms are

typically exacerbated by lumbar movements or shifts in

posture, with numbness or radiating pain provoked when

pressure is applied over the relevant trigger point(s).

Symptomatic relief achieved through nerve blocks is

considered a diagnostic hallmark.

TREATMENT OPTIONS

Optimal treatment of SI joint pain consists of an in-

terdisciplinary approach and should include conserva-

tive (pharmacological treatment, cognitive- behavioral

therapy, manual medicine, exercise therapy, and reha-

bilitation treatment, and if necessary, psychological

evaluation and management) as well as interventional

pain management techniques.

A conservative management

Physical therapies primarily address the underlying

cause. In SI joint pain attributed to postural and gait

disturbances, targeted exercise therapy and manipula-

tion can reduce pain and improve mobility. There are

numerous randomized trials showing efficacy for mus-

cle relaxants, non- steroidal anti- inf lammatory drugs,

and antidepressants for back pain, but none have spe-

cifically addressed individuals with SI joint involvement.

Although anecdotal evidence supports spinal manipula-

tion, one study found that individuals with positive SI

joint provocation tests did not fare better than other pa-

tients with chronic low back pain.74 In patients with true

leg length discrepancies, partial correction with shoe in-

serts may provide benefit.75 One randomized study, per-

formed to evaluate whether radiofrequency denervation

added to a standardized exercise program and psycho-

logical support if indicated is more effective than only

standardized exercise and psychological support alone,

showed a statistically significant but clinically question-

able improvement in pain intensity 3 months after the in-

tervention for the SI joint treatment arm.76

Ankylosing spondylitis (M. Bechterew) is an inf lam-

matory rheumatological disorder that affects the verte-

bral column and the SI joint. Controlled studies have

demonstrated analgesic efficacy for immunomodulating

agents in ankylosing spondylitis and other spondylar-

thropathies. However, no conclusions can be drawn with

respect to their specific efficacy for SI joint pain.76

Interventional management

Patients with SI joint pain resistant to conservative treat-

ment are eligible for interventional management such as

intra- and peri- articular injections or radiofrequency ab-

lation (RFA) treatment.

Corticosteroid injections

Intra- articular injections

Randomized controlled trials evaluating intra-

articular injections report good pain relief for up to

6 months.77–79 Maugars et al.78 treated 13 SI joints in

10 patients: 6 joints with intra- articular corticoster-

oids, and seven joints with physiological saline solu-

tion. After 1 month, pain reduction of >70% was noted

for five of the six SI joints treated with corticosteroid,

whereas no benefit was noted in the placebo group.

SZADEK e tal.

Subsequently, all control group patients and two in

the treatment group who had short- term pain relief

received a repeat injection with corticosteroid. After

1, 3, and 6 months, significant pain reduction was ob-

served in 86%, 62%, and 58% of patients, respectively.

In a study by Visser etal.79 Fifty- one patients with SI

joint- related leg pain were randomized to treatment

with intra- articular corticosteroid injections (N = 18) ,

physiotherapy (N = 15), or manual therapy (N = 18) .

The effect of the treatment was evaluated after 6 and

12 weeks. Overall, 56% experienced a successful treat-

ment, with physiotherapy achieving success in 20% of

15 patients, manual therapy resulting in a 72% suc-

cess rate in 18 patients, and intra- articular injection

yielding a positive outcome in 50% of 18 patients.

However, in those treated with steroid injections, only

28% (N = 5) of patients experienced clinically relevant

pain relief after 12 weeks. Chen etal.77 compared intra-

articular SI joint platelet- rich plasma (PRP) injections

with intra- articular corticosteroids. Although pain

scores decreased over time for both the corticosteroid

and PRP groups, the corticosteroid group showed sta-

tistically significantly greater improvements in pain

than did the PRP group during the 6- month follow- up.

At 1 month, 80%, of participants in the corticosteroid

group reported ≥50% pain relief, and 70% at 3- month

follow- up.

Extra- articular and combination injections

There is similar, if not stronger evidence support-

ing peri- articular corticosteroid infiltrations.2 8,80 –82

Luukkainen etal.80 randomized 24 patients to receive

either peri- articular corticosteroid with local anes-

thetic (n = 13) or local anesthetic and saline (n = 11).

One month after the intervention, VAS pain scores

decreased significantly in the corticosteroid group

compared to the control patients. In an earlier double-

blind study, Luukkainen and colleagues demonstrated

superiority of periarticular SI joint injections to saline

2- month post- injection in 20 patients with spondy-

loarthropathy.81 In a large, double- blind comparative-

effectiveness study comparing landmark- guided to

fluoroscopically guided intra- articular injections,

Cohen et al.56 reported comparable benefit between

subjects with intra- articular and extra- articular spread

at 1- month, though on some outcome measures indi-

viduals in whom intra- articular spread was noted fared

better at 3 months. In this study, only 8% of landmark-

guided injections were intra- articular.

There have been several non- randomized trials com-

paring intra- articular to peri- articular injections. In an

observational study performed in 50 patients, Murakami

et al.83 reported superiority for peri- articular lidocaine

injections compared to intra- articular injections imme-

diately post- procedure. A quasi- randomized study (via

laterality) by Khalil etal.84 performed in 96 patients re-

ported superiority for peri- articular over intra- articular

injections through 3- month follow- up. Two studies that

included one small observational study and a retrospec-

tive analysis, reported comparable benefit for SI joint

injections administered within and outside of the joint

cav ity.85,86 Two other studies showed superiority for

combination intra- and extra- articular SI joint injections

with corticosteroid and local anesthetic compared to

intra- articular injections alone.82,87

Radiofrequency ablation (RFA) treatment

of the SI joint

The eff icacy of RFA treatments of the SI joint is dem-

onstrated by numerous observational,88–90 retrospec-

tive,91– 93 and randomized controlled studies.58 ,94 –10 0

However, the selection criteria, definitions of success,

RFA techniques (conventional monopolar, bipolar, mul-

tielectrode combination mono- and bipolar, and monop-

olar cooled), and parameters (ie, temperature, duration,

and location of RFA treatment), and imaging techniques

(fluoroscopy, CT, ultrasound) have varied widely be-

tween studies.

In one of the earliest attempts at SI joint denerva-

tion, Ferrante etal.91 performed multiple bipolar intra-

articular lesions at 90°C, reporting poor outcomes with

a technique that targets only the postero- inferior part of

the joint. A few years later, Gevargez etal.89 per for me d

three 90°C monopolar lesions in the ligamentum sacro-

iliacum posterior and one targeting the L5 ramus dorsa-

lis, which again resulted in poor outcomes. In the first

iteration of an extensive lesioning strategy targeting the

extrinsic nerve supply, Cohen and Abdi92 per for me d

single 80°C lesions of the L4- L5 rami dorsalis and the

S1–S3 (or S4) rami lateralis of the rami dorsalis. Despite

obtaining excellent results in this small observational

study, this technique would currently be considered

inadequate for severing most of the nociceptive input.

Several months later, Yin etal.57 published the descrip-

tion of a similar technique except that they excluded the

L4 ramus dorsalis and selected more caudal levels based

solely on concordant sensory stimulation. Burnham and

Ya s u i88 performed paraneuroforaminal bipolar RF strip

lesions at the level of S1–S3, and a monopolar RF treat-

ment at the level of the L5 ramus dorsalis. Two authors

described90,93 the effectiveness of a single strip lesion uti-

lizing a combination of both monopolar and bipolar cur-

rent transfer with the Simplicity III electrode positioned

lateral to S1, S2, S3, and S4 neuroforamina, whereby le-

sions were created at a temperature of 80–85°C for 60 s,93

and 85°C for 90 s.90 Cohen et al.101 investigated which

demographic and clinical variables could be used to pre-

dict SI joint RFA outcome. In multivariate analysis, pre-

procedure pain intensity, age 65 years or older and pain

referral below the knee were all statistically signif icant

predictors of failure, with a trend toward cooled RFA to

provide better outcomes than conventional denervation.

SACRO ILIAC J OINT PAI N

Younger patients may be more likely to benefit from L5

dorsal ramus and sacral lateral branch RF treatment

because they are more likely than older patients to have

an extra- articular, ligamentous source of SI joint pain,

which are innervated by the nerves being lesioned.

There are some reports on the use of pulsed radiof-

requency (PRF) therapy for the treatment of SI joint

pain.98,102 ,103 In study of Vallejo102 the L4, L5 rami

mediales and the S1, S2 rami laterales of the rami dor-

sales were treated with PRF using the parameters 45 V,

temperature of 42°C, for 120 s and temperature not ex-

ceeding 42°C. Although Dutta etal.103 treated the same

levels, they performed 3 PRF treatments on levels S1–

S3 and two at L4 and L5, with the time extended to 180 s

per cycle based on studies suggesting that longer heat-

ing times may be more effective for neuropathic pain.104

AboElafdl et al.98 used yet another approach, intraar-

ticular PRF, whereby 5 cycles of pulsed radiofrequency

for 120 s each were applied. Despite these uncontrolled

studies, randomized studies for lumbar facet joint pain

have consistently failed to demonstrate equivalence to

RFA treatment.10 5,106

To circumvent anatomical variations in innervations,

some investigators have employed internally cooled RF

electrodes, which increase the ablative area by mini-

mizing the effect of tissue charring that limits lesion ex-

pansion. An extensive lesioning strategy is particularly

important for SI joint pain given the widespread vari-

ability in the number and location of nerves receiving

and conveying nociceptive input. In the first study to

demonstrate efficacy with cooled RFA, Cohen et al.95

performed a randomized placebo- controlled study in

which a “classic” RFA procedure was performed on the

L4 and L5 dorsal rami and cooled RFA was applied to

the S1 to S3 or four lateral branches, with S4 being tar-

geted in individuals where the foramen was located level

with, below, or just above the bottom of the SI joint. One,

3- and 6 months post- treatment, 79%, 64%, and 57% of

patients reported ≥50% pain relief, respectively. In the

placebo group, only 14% experienced significant im-

provement at 1- month follow- up, and none experienced

significant benefit 3 months post- procedure. Patel etal.58

randomized 51 patients in a 2:1 ratio who responded to

two prognostic lateral branch blocks to receive either

cooled RFA or sham RFA of L5 dorsal ramus and S1- 3

lateral branches. At the 3- month primary endpoint, 47%

of patients in the RFA group experienced a positive out-

come, defined as ≥50% reduction in average pain coupled

with significant improvement in either the SF- 36 bodily

pain score or functional capacity measured by Oswestry

disability index, versus 12% in the control group. In their

most recent multi- center randomized controlled study

involving 210 patients who responded with short- term

relief to SI joint injections and experienced significant

benefit with prognostic lateral branch blocks, Cohen

etal.100 reported the superiority of the cooled RFA over

standard medical management, with 52% of patients in

the RFA group experiencing a positive categorical out-

come at the 3- month endpoint versus only 4% in the con-

trol group.

A detailed overview of RCTs evaluating RF tech-

niques and their effectiveness is provided in Table2.

Surgery

The use of SI joint fusion has increased dramatically

over the past 15 years. Older retrospective and ob-

servational studies of SI joint fusion reported good,

equivocal, and poor results for a variety of indications

including instability, malalignment, and degenerative

changes, but these studies were characterized by serious

methodological flaws including an incomplete descrip-

tion of diagnosis, including the parameters of diagnos-

tic blocks.107–109 Many earlier studies did not even use

blocks for diagnosis.110 –112

One rationale for the recent growth of minimally in-

vasive SI joint arthrodesis techniques is that while fu-

sion may benefit degenerative conditions, the trauma

of surgery in many cases outweighs the benefit. In one

systematic review that evaluated 40 studies (including 2

randomized controlled trials that compared iFUSE to

conservative management), Chang etal.113 reported sig-

nificant improvement across multiple domains lasting

greater than 1 year, with the 2 RCTs resulting in large

improvements in pain (mean difference − 40.5 mm, 95%

CI, −50.1 to −30.9; −38.1 mm) and function (mean dif-

ference in Oswestry Disability Index −25.4 points, 95%

CI, −32.5 to −18.3; −19.8 points). However, the 2 RCTs

contained multiple sources of bias and methodological

flaws including industry sponsorship, non- blinding of

patients (with most of the patients allocated to conser-

vative management receiving treatments they already

failed), and non- standardization of the diagnostic in-

jections, many of which were performed with high vol-

umes that exceeded the joint capacity.114 In another

systematic review that included six studies, f ive of which

were industry- sponsored, Abbas et al.115 reported more

modest differences in 6- month pain scores [standardized

mean difference − 1.5 (95% CI −1.8, −1.1)] and Oswestry

disability index [standardized mean difference − 1.1 (95%

CI −1.6, −0.5)] between SI joint arthrodesis and conser-

vative management.

Complications of interventional management

Although potential complications of intra- articular in-

jections and RF procedures include infection, hematoma

formation, neural damage, trauma to the sciatic nerve

during intra- articular injections or sacral spinal nerve

roots during the placement of “finder” needles dur-

ing RFA, vasovagal reactions, weakness secondary to

extra- articular extravasation to neural structures, and

SZADEK e tal.

TABLE 2 Su mmary of the evidence on efficacy of the RFA treatments according to RCTs results.

Author, Reference, Goal

Diagnostic/prognostic block

technique, Positive outcome RF technique Effect

Juch94

Efficacy of physiotherapy versus

RFA and physiotherapy.

Psychotherapy provided to

both groups as indicated.

25G need le ins erted 3–10 mm lateral

to the S1–S3 sac ral foramina

under f luoroscopic g uida nce.

After conf irmation of the need le

position in lateral view, 0.5 mL of

2% lidocaine was inje cted.

The dors al ramu s of L5 was blocked

using 0.5 mL of 2% lidocaine.

≥50% pain reduction within 30 to

90 min after the block.

Cooled RFA; 17G electrode; 3 lesions were created next to the S1, S2,

and S3 neuroforamina; 3 lesions were made for S1 and S2 and 2

lesions at S3. Temperature of 60°C for 2.5 min per lesion.

Simplicity; SIMPLICITY III prob e: was inserted at the lateral,

infer ior border of the sacrum, 10 mm below the S4 foramen

under f luoroscopic g uida nce. The electrode prob e was advanced

in a cephalad direction along the sacrum, lateral to the sacral

neurofora mina, medial to the sacroi liac joint and ventral to the

ileum. The correct position of the electrodes was checked and RF

lesions (85°C for 90 s per step) were created.

Bipolar palisade RFA: six 20G electrodes w ith 10 m m active tips were

placed para llel to each other 10 mm apart a nd per pend icular to the

sacr um. Then eight lesions (90°C, 180 s p er lesion) were made u sing

adjacent pairings of cannu las.

With all three tech niques, RF lesion of the ramus dorsalis of L5 was

carried out w ith a conventional monopolar electrode.

The mean dif ferenc e for the primar y

outcome, pain i ntensity at 3 months,

was −0.71 (95% CI, −1.35 to −0.06)

favoring the RFA group.

No significant differences between the

groups were found when success was

defi ned as greater than 30% or a 2-

point re duction in pai n at 3 months.

48 patients (49.48%) had >30% pain

reduction at 12 months.

57 patients (58.76%) had 2- poi nt or

great er pai n reduction at 12 months.

Salman96

Random ized, crossover study

comparing RFA and intra-

articular steroid injection.

Intra- articular SI joint block

with 3 mL solution contain ing

2 m L of lidocaine 2% and 1 mL

bupivacaine 0.5%.

≥75% pain relief for at least 3 h

post- block

RFA of the L4–5 primary dorsal rami and S1–S3 lateral sacral rami was

accomplished using a 20G ele ctrode with a 10 mm active tip, with

sensory electro- stimulation at 50 Hz. RFA lesion of 90 s at 80°C.

For S1 down to S3 lateral branch RFA, 22G electrodes with 5 m m active

tips, placed 3- 5 mm from the lateral border of the fora mina were

used. For S1 and S2, 3 monopolar thermal lesions were created, with

2 created at S3. Sensory sti mulation at each level was performed

for the fi rst lesion, eliciting concordant sensation at 0.5 V. 90 s 80°C

lesions.

At 1- , 3- , and 6- month p ost-

inter vention, 73%, 60% and 53% of

patients, respectively, experienced

≥50% pain relief in the RFA group.

In the steroid group, at 1- month

post- intervention, only 20%

exper ienc ed ≥50% pa in relief, with

no one havi ng improvement at 3-

and 6 - month follow- ups.

Zheng97

Random ized, open- lab el study

performed in SA patients

with sig nifica nt SI joint pain

using PSRN under c omputed

tomography guidance versus

celecoxib treatment.

Intra- articular injection

verified using arthrography.

Triamcinolone (40 mg) in 3 mL

0.5% bupivacaine was injected.

≥50% pain relief on VAS pain scale

6 h after diagnostic block

CT- guided strip bipolar lesions were created with a 20G electrodes

containing 5 m m active tips spaced 10 mm apart. Electrodes were

leapfrogged between adjacent pair s of cannulas, with lesions created

at 90°C for 3- min.

At week 12, pain reduction from

baseline was 65.3% versus 36.2%

in the PSRN and celecoxib arms,

respectively. At 24 weeks, pain

reduction was 61.1% versus 27.5%

in the PSRN and celecoxib arms,

re spe c ti ve ly.

Cohen95

Randomized, placebo- controlled

comparing cooled RF versus

sham procedure.

SI joint injection with 3 mL solution

containing 2 mL of bupivac aine

0.5% and 1 mL of 40 mg/mL of

depo- methylprednisolone.

≥75% pain relief lasting at least 3 h

after d iagnostic block

L4 and L5 dorsal rami were treated with 22G SMK- C10 cannula with

5- mm active tips. Sensory stim <0.5 V, with 90 s 80°C lesions created.

For S1–S3 lateral rami procedures, 17G 75 mm internally cooled

electrodes w ith 4 mm active tip s were inserted bet ween 3 and 5 m m

from the lateral border of the forami na at pre- designated position s.

Thre e per i- foraminal lesions were c reate d at S1 and S2, 2 at S3, and

1 at S4 (when tre ated). Sensory stimulation at ≤0.5 V. 2.5- m in lesions

were created at 60°C with the target tissue heate d to >75°C, resulting

in a lesion diameter ra nging b etween 8 and 10 mm.

One, 3- , and 6 - month post- procedure,

11 (79%), 9 (64%), and 8 (57%) of

radiofrequency treated patients

exper ienc ed ≥50% pa in relief and

significant functional improvement

versus 14% who experienced a

positive 1- month out come in the

sham g roup.

(Conti nu es)

SACRO ILIAC J OINT PAI N

Author, Reference, Goal

Diagnostic/prognostic block

technique, Positive outcome RF technique Effect

Patel 2012 and 201658,129

Cooled RF versus sham

inter vention for SI joint pain.

Lateral branches of S1–S3 were

targeted wit h 25G spinal needles,

advanc ed to the surface of the

sacr um 3–10 mm lateral to the

posterior sacral fora mina of S1–

S3; 0.5 mL of 0.5% bupivaca ine

was injected at each level. The

dorsal ramus of L5 was blocked

with 0.5 mL of bupivacaine 0.5%.

This block proto col was repeat ed

on a sepa rate day, after retu rn to

baseline pain. Subjects achiev ing

≥75% relief of thei r index pain

after b oth blocks were eligible for

enrollment.

The L5 dors al ramus was targeted between the sacral ala and ar ticular

process.

For S1 and S2, 3 lesions were created, for S3, 2 lesions were created. For

reference, right- sided S1 and S2 lesions corresponded to 2:30, 4:00,

and 5:30 positions on the face of a clock; for S3, right- sided lesions

corresponded to 1:30 and 3:00 on a clock face; left- sided le sions were

mirror images.

17G, 75 mm cooled elect rode with 4- mm active tips were used to create

lesions at all levels for 150 s at 60°C.

Position confirmed using epsilon marker.

Improvement in NRS pain score at

the 3- month t ime- point for the

treatment group was significantly

great er than that for the sham

group.

At 3- month follow- up, 47% of treated

patients and 12% of sham subjects

achieved pre- def ined treatment

succ ess, defined as ≥50% pain relief

with sig nifica nt improvement in

SF- 36 bodily pain or ODI. At 6 and

9 months, 38% and 59% of treated

subjects, respectively achieved

treatment success.

Mehta99

Randomized double- blind, sham-

controlled tr ial evaluating the

effectiveness of RFA using a

strip lesioning device for SI

joint pain

Double intra- articular, fluoroscopy-

guided blocks with 2 mL

of lidocaine. Patients were

deter mined to have SI joi nt pain

if they reported greater than 80%

pain relief i mmediately following

the diagnostic block on both

occasions.

RFA of the L5 prim ary dor sal ramus was performed usi ng a 22G 10 cm

electrode with a 10 mm active tip after sensory stimulation at <0. 5 V.

Simplicity st rip lesioning of the lateral branches of the S1, S2, and S3

was performe d using a n electrode that creates mono- and bipolar

lesions.

The sha m procedure was identical to RFA except no RF energ y was

applied.

At 3 months post- RFA, patients in the

active g roup reported a reduction

in the mean NRS pain score from

8.1 ± 0.8 to 3.4 ± 2.0. In the sham

group, the pre- randomiz ation mean

pain s core de creased from 7.3 ± 0.8

to 6.5 ± 2.0.

Cohen100

Randomized,

Comparative- effectiveness study

comparing cooled RF vs.

standard medical management

In patients with short- ter m relief

from SI joint i nject ions,

fluoroscopically guided lateral

branch blocks at S1–S3 (S4) and

L5 dorsal ramus block with local

anesthetic using a total volume

<2 m L were performed. Subjects

with bi lateral pain had bilateral

blocks.

Positive re spons e was ≥50% pain

relief.

N = 105: Fluoroscopica lly guided parafora minal lesions at the L5 dorsal

ramus and the S1–S3 (S4) lateral branches. Cooled RF ablation was

performed using 17G electrodes which were inser ted at 1:30, 3:30,

and 5:30 o'clock for right- sided lesions at S1 and S2, and at 1:00 and

3:00 o'clock at S3, with mir ror image posit ions for left- sided lesions.

L5 was targeted i n the groove lateral to the sacral articular proces s.

The 150 s lesions were created at a temperature of 60°C, resulting in a

target tissue temperature ≥ 80°C. Subjects with bilateral pain rec eived

cooled RF ablation treatment on both sides on the same occasion.

N = 105: Standard treatment included pharmacotherapy, physical and

chiropractic therapy, lifestyle changes, acupunct ure, yoga, and

therap eutic i njections into the sacroiliac ligaments or joint cavit y.

At 3 months, the mean NRS pain

score for the coole d RF ablation

group was 3.8 ± 2.4 with a mean

reduction in average NRS pain

score of 2.5 ± 2.5. In the control

group the mean NRS pain score at

3 month was 5.9 ± 1.7 with a 0.4 ± 1.7

reduction.

van Tilbu rg122

Randomized, sham- controlled

trial evaluating the efficacy

of RFA using a str ip lesion

device

60 patients who experienced ≥2- point

reduction in pain after an intra-

articular injection with 3 c c of 2%

lidocaine.

RFA of the L5 prim ary dor sal ramus was accompl ished using an

electrode (size not noted) w ith a 10 m m active tip.

Simplicity st rip lesioning of the lateral branches of the S1, S2, and S3

was performe d using a n electrode that creates mono- and bipolar

lesions. Each step was 85°C for 90 s, with a total of five st eps.

Sham group received an identical procedure except with no RF

lesioning.

No significant differences found for

pain reduction, positive outcome,

or satisfaction b etween groups 1-

month post- treatment.

Abbrev iations: CI, conf idence int erva l; NRS, nu meric rating s cale; ODI, O swest ry Dis ability Index; PSRN, palisad e sacroilia c radiofrequency neu rotomy; RFA, radiofrequency ablation; SA, spondyloar thros is; VAS,

visual analog scale.

TABLE 2 (C onti nued)

SZADEK e tal.

complications related to drug administration such as in-

travascular uptake, the reported rate of these complica-

tions in SI joint treatment is low.116

Luukkainen etal.80 ,81 reported no complications from

periarticular SI joint injections. For intra- articular injec-

tions, Maugars etal.78 reported only transient perineal

anesthesia lasting a few hours and mild sciatica lasting

3 weeks, but no information was given as to the number

of patients who reported these side effects. In the largest

randomized trial evaluating SI joint injections, Cohen

et al.56 reported a 6% adverse event rate in the fluoro-

scopically guided injection group and a 12% adverse

event rate in the landmark- guided group. These included

a 6.4% incidence of temporary neurological symptoms

(eg, weakness) attributed to sciatic nerve blockade.

For RF treatment of the SI joint, Cohen etal.95 noted

that the majority of 28 patients experienced temporary

worsening of pain 5–10 days after the procedure which

was attributed to procedure- related tissue trauma and

temporary neuritis. In a follow- up study, Cohen etal.101

reported five complications out of 77 treated patients.

These included three cases of temporary paresthesia,

one superficial skin infection that resolved with antibi-

otics and one case of hyperglycemia in a diabetic patient

requiring increased insulin use for 3 days. The latter

was caused by the corticoid used to prevent procedure-

related neuritis, which is a relatively common practice

recommended in the lumbar and cervical facet guide-

lines.117,118 In their study evaluating pulsed RF of the

SI joint, Vallejo etal.102 observed no complications or

worsening of pain. Transient buttock dys- or hypo-

esthesia and temporary worsening of pain have been

frequently reported in other studies evaluating heat ra-

diofrequency of the sacral lateral branches and is likely

related to denervation of branches to the skin.57,88,89,94

In one uncontrolled study evaluating cooled RF treat-

ment, post procedural hip pain lasting up to 5 days was

reported in most treated patients (N = 21) .119 In another

study, several patients reported soreness or numbness

at the introducer sites for up to 2 weeks after cooled RF

and one subject developed shingles at the introducer

site, though this complication was probably not di-

rectly related to treatment.58

Minimally invasive SI joint arthrodesis is considered

safer than open fusion, but still carries risks. In a sys-

tematic review evaluating 14 studies and 819 minimally

invasive fusions, Shamrock et al.120 reported an 11.1%

complication rate, with wound infection being the most

common. There was a 1.6% incidence of nerve entrap-

ment, and a revision rate of 2.6%.

In a large database review involving 469 patients,

Schoell et al.121 reported an overall complication rate

of 16.4% at 6 months, which did not include the 5.3% of

patients who developed novel lumbar pathology within

6 months of surgery.

EVIDENCE FOR INTERVENTIAONAL

MANAGEMENT

A summary of the available evidence for interventional

treatment of SIJ pain is provided in Ta ble3.

RECOMMENDATIONS IN 2023

The evidence evaluated in this review supports RFA as

an intervention to provide pain relief and functional ben-

efit in patients with chronic SIJ pain for periods ranging

between 3 months and 1- year post- treatment. Among 16

RCTs, 15 showed positive results. The only unequivocally

negative study was a small study by van Tilburg etal.88 that

enrolled over 75% of individuals screened and inexplicably

included patients with radiculopathy. Whereas the largest

randomized trial reached significance for the primary out-

come measure, the benefits at other points were small, and

76% of patients had a positive “diagnostic” block.94,12 2 In

one recent systematic review by Chappell etal.,123 the au-

thors reported a mean difference favoring RFA in both all

randomized trials [n = 5, (five trials, mean difference − 1.53,

95% CI −2.62 to 0.45)] and in just sham- controlled studies

(n = 4, mean difference − 1.89, 95% CI −3.45 to 0.34).

TABLE 3 Evidence of inter ventional pain management for SI joint pain.21

Technique

Recommendations

in 2010

GRADE level of

evidence in 2015

Recommendations

in 2018

Intra- articular corticosteroid injections 1B+Low We ak

Radiofrequency treatment of rami dorsalis and lateralis (palisade) 2C+Ver y low Ver y weak

Radiofrequency treatment of rami dorsalis and lateralis (palisade) SI

joint pain secondary to ankylosi ng spondylitis

Moderate Mo derate

Radiofrequency treatment of rami dorsalis and lateralis (simplic ity) Not graded Moderate against

Pulsed rad iofrequency treatment of ram i dorsalis and lateralis 2C+Not graded Ve r y w eak

Radiofrequency treatment of ramus dorsalis at L4–L5 and coole d

radiofrequency of the ramus lateralis

2B+Low Wea k

Cooled radiofrequency treatment of ra mus dorsalis at L 4–L5 and

ramus lateralis

Moderate Mo derate

SACRO ILIAC J OINT PAI N

The evidence supporting SI joint injections is less

robust. In one systematic review evaluating 15 studies,

only two of which were randomized, Kennedy et al.124

concluded the evidence supporting intra- articular SI

joint injections was moderate for short- term benefit. In

a narrative review that separated out intra- and extra-

articular injections, Gartenberg et al.125 recommended

consideration of extra- articular injections in individuals

who fail more conservative measures.

Although there are no guidelines on the use of mini-

mally invasive SI joint fusion, systematic reviews recom-

mend consideration of arthrodesis in individuals with

refractory SI joint pain secondary to degeneration, in-

stability, or malalignment.113,115

In summary, in patients with chronic low back com-

plaints possibly originating from the SI joint complex,

intra- and extra- articular injections with a local anes-

thetic and corticosteroids can be recommended. If this

fails or produces only short- term effects, radiofrequency/

palisade or cooled radiofrequency treatment of the lat-

eral branches of S1 to S3, (S4) can be considered in those

whose pain emanates primarily from extra- articular

sources. For individuals with SI joint degeneration or in-

stability, minimally invasive SI joint arthrodesis should

be considered.

Clinical practice algorithm

The practice algorithm is illustrated in Figure2.

TECHNIQUES

SI- joint infiltration technique126

The patient lies in a prone position. Using an AP fluoro-

scopic projection, the medial SI- joint line is formed by

the posterior joint articulation while the lateral open-

ing represents the anterior joint. Next, the C- arm is

rotated contralaterally until the medial cortical line of

the posterior articulation aligns with the lateral (ven-

tral) opening, thereby providing a clear soft- tissue tra-

jectory for the needle to penetrate ventrally. Tilting the

C- arm longitudinally in relation to the patient (cephalo-

caudally) can sometimes help the clinician distinguish

between the anterior and posterior articulations. Skin

puncture is 1–3 cm cranially from the lower edge of the

SI joint at the level of the zone of maximal radiographic

translucency. Penetration of the SI joint is character-

ized by a change in resistance and sometimes increased

procedure- related pain. The tip of the needle may ap-

pear to be slightly bent between the os sacrum and the

os ilium from needle distortion that occurs while tra-

versing the bony structures. On a lateral view, the needle

tip should appear anterior to the dorsal edge of the sa-

crum. Injection of contrast agent shows dispersal along

the articulation and a filling of the caudal joint capsule.

Use only 0.25–0.5 mL contrast agent. If this technique is

not successful, then approaching the joint from a more

rostral puncture point, or using computed tomography,

may facilitate penetration.

FIGUR E 2 Algorithm for the treatment of SI joint pain.

SZADEK e tal.

For peri- articular injections, the area(s) of maximal

pain and tenderness is targeted. Since the posterior liga-

ments are targets, there is no need to align the posterior

and ventral openings by obliquing the image intensifier.

Generally, higher volumes (up to 5 mL) are injected, with

contrast spread outlining ligamentous structures on

both the sacral and iliac sides.

Needle positioning for intra- articular SI joint injec-

tion is illustrated in Figure3A–C.

Lateral rami of S1–S3 (4) and dorsal ramus L5

(4) (LBB s)

Since lateral branches innervate the posterior ligaments

supporting the SI joint complex but not the capsule or

ventral soft tissue elements, they are sometimes used as

prognostic tests, but are not diagnostic. Some, but not

all randomized trials have used prognostic lumbar dor-

sal rami and sacral lateral branch blocks as predictive

tools before RFA.58,94,10 0

For the lateral rami of S1–S3, the image intensifier

may need to be angled cephalad so that it is perpendic-

ular to the posterior foramina, the targets for the finder

needles. For S1, further angling the image intensifier

ipslaterally often improves visualization of the poste-

rior opening. Since the ventral and dorsal foraminal

openings may be difficult to align, 25- or 22G finder

needles are placed into the S1–S3 foramina and with-

drawn to the posterior cortex, thereby forming an ori-

enting landmark. Since S4 provides innervation to the

joint in some people as described in a majority of the

anatomical studies, and others have found L4 inner-

vation to the upper SI ligaments in some individuals,

the lateral branches at S4 and the dorsal ramus at L4

may be targeted depending on presentation (eg, when

the S4 foramina lies at or above the level of the lower

margin of the joint).127,128 The relevant areas should be

marked on the skin, ideally somewhere between 7 and

10 mm from the lateral edge of the foramina. On the

face of a clock, levels may correspond to 2:00–2:30 and

5:00–5:30 at S1, 1:30 and 4:30 at S2, and 1:00–3:00 at S3

depending on foramen's opening relative to the infe-

rior SI joint margin. Thereafter a lateral image should

be obtained to confirm appropriate depth of needle

placement on the sacral surface, followed by infiltra-

tion of between 0.5 and <2 mL of a local anesthetic at

each level.

For the dorsal ramus of L5 and possibly L4, place the

needle in the notch between the sacral ala and the S1 ar-

ticular process, and at the junction between the upper

border of the transverse process where it intersects with

the superior articular process at L5, respectively, and in-

ject 0.5 mL of local anesthetic.

Various studies have defined different thresholds

for a prognostic block to be considered positive which

vary from ≥2 points.122 to ≥75% pain reduction on NRS

pain.5 8,129 As reductions in chronic pain intensity of at

least 50% are indicative of substantial improvements,130

we recommend at least 50% pain relief following the

prognostic blocks for a duration equal or longer than the

length of action of the local anesthetic.

Radiofrequency treatment technique of the

SI joint

RF treatment of the SI joint is performed with fluoro-

scopic imaging after a positive diagnostic/prognostic

block. The patient may be lightly sedated. The C- arm is

positioned in a similar fashion to that for lateral branch

blocks, with the same considerations for the nerves tar-

geted. For S1, slight ipsilateral oblique angulation can

often increase visualization of the posterior foramen.

Larger gauge electrodes are associated with increased

capture rates, which is important given the variability

in the location of lateral branches. Although sensory

electrostimulation at 50 Hz is often performed, because

there may be up to four lateral branches converging on

the sacral foramina, many physicians forego sensory

FIGUR E 3 (A, B) Intra- art icular injection of SI joint with contrast in anterior–posterior view. (c) Intra- articular inje ction of SI joint with

contrast shown in an oblique view.

SACRO ILIAC J OINT PAI N

stimulation and opt for an extensive lesioning strategy

that seeks to encompass the entire lateral margin of the

foraminal opening, as injecting local anesthetic before

lesioning at one area may prevent stimulation at other

areas. This may involve inserting RF cannulas at a

caudad- cephalad (longitudinal) angle so that the 10 mm

active tip envelops more of the lateral foraminal border.

Right S1 rami laterales are usually found between the “2

o'clock and 5:30 o'clock” positions on the lateral side of

the posterior neuroforamen, right S2 between 1:30 and

5:30, and right S3 rami laterals between 1:00 and 3:30.

For S4, the nerve target is generally high on the forami-

nal border, for example, between 12:30 and 2:00. In view

of the small lesion size created by conventional elec-

trodes, and the widespread variability in the location

and number of nerves converging on each foramen, mul-

tiple lesions are usually necessary. Before performing the

RF treatment, motor stimulation should be performed

to ensure the absence of leg or sphincter contraction.

If present, the needle position is too close to the spinal

nerve root and repositioning is necessary. After correct

positioning of the electrode, the RF probe is inserted and

a 120 s RF treatment at 80°C is made.92

The bipolar RF palisade technique131

The palisade technique is performed after a positive di-

agnostic/prognostic block. In an AP fluoroscopic view,

a cranio- caudal line is marked on the skin between the

lateral aspect of the sacral foramina and the SI joint line.

In a lateral fluoroscopic view, six 20G electrodes with

10 mm active tips are placed parallel to each other per-

pendicular to the sacrum, approximately 10 mm apart. If

different needle sizes and dimensions are used, the dis-

tance between the needles may be adjusted accordingly

(ie, closer for smaller lesions and active tips). The elec-

trode position is checked in an AP view to confirm

placement of the needles lateral to the sacral foramina,

but close enough to capture the afferent input (around

10 mm from the lateral edge). Motor stimulation up to

2.0 V can be used to confirm an absent motor response.

Thereafter, five bipolar lesions (90°C, 180 s per lesion)

are created using adjacent electrode pairings. The needle

positioning is illustrated in Figure4A,B.

Cooled RF of the SI joint132,133

Cooled RF treatment of the SI joint is performed after

a positive diagnostic/prognostic block. The patient can

be lightly sedated. C- arm f luoroscopy is used to visual-

ize the sacrum in a manner similar to that used for lat-

eral branch blocks and conventional RFA. The target

nerves are the same as those outlined for conventional

RFA, except that the morphology of the lesion (ie, cir-

cular instead of elliptical, extending past the distal tip

of electrode) dictates a perpendicular approach. The RF

electrode, which is subsequently inserted via the same

introducer, is 2 mm shorter than the stylet, but extends

2 mm beyond the tip of the cannula which has implica-

tions for sensory (if performed) and motor stimulation

and allows the lesion, which projects distal to the active

tip, to encompass a larger area down to bone. To maxi-

mize encasement of the lateral branches of the S1 to S3

(S4) dorsal rami and prevent inadvertent injury to spinal

nerves, the electrode is placed 8–10 mm from the lateral

edge of the posterior sacral foramina. Thereafter, three

lesions are created at S1 and S2, 2 lesions at S3 and if

applicable, a single lesion at S4. Typically, these lesions

are spaced about 1 cm apart from one another, creat-

ing a continuous strip of ablated tissue lateral to each

FIGUR E 4 (A) AP view of the palisade te chnique. (B) Lateral view of the palisade technique.

SZADEK e tal.

foramen. The dorsal rami of the L5 and L4 spinal nerves

may be targeted in a classical manner with traditional

electrodes or using cooled RFA.

Figures5 and 6 illustrate the performance of cooled

RF lesions at S1, S2, and S3.

Images from left to right A: Lateral f luoroscopic view

demonstrating “finder” needles in the S1, S2, and S3 fo-

ramina. B: Antero- posterior f luoroscopic view demon-

strating f inder (thin) needles in the S1–S3 foramina with

cooled RF electrodes positioned at the 10:30, 9:00, and

7:00 positions on the face of a clock around the S1 fora-

men. C: Depiction of bipolar cooled RF lesions in red at

the 9–11 o'clock and 7–9 o'clock positions around S1 left

foramen. The thin needles are spinal “finder” needles

while RF cannulas are thicker.

Images from left to right A: Depiction of bipolar

cooled RF lesions around the S1, S2, and S3 foramina

in red (anteroposterior view). B: Lateral view of SI joint

bipolar cooled RF. The finder needles at the S1, S2, and

S3 foramina appear thin and traverse each foramen,

while the thicker needs are RF cannulas. C: Photograph

of SI joint bipolar cooled RF of the left sacral lateral

branches. Notice the bipolar lesioning forming between

the first two needles at the 9–11 o'clock positions around

the S1 foramen and the black hub of the finder needles.

Note

According to recent changes in local coverage determi-

nation (LCD), the diagnosis of SI joint pain is contingent

on clinical evaluation and positive provocative maneu-

vers, with diagnostic injections recommended for con-

firmation due to inconsistencies in diagnostic criteria.

Many payers require a cutoff of 75% or higher for pain

improvement, although there is ongoing debate about the

ideal threshold and the IMMPACT guidelines and re-

sponder analyses in U.S. Food and Drug Administration

and European Medicines Agency studies use thresholds

ranging from 30% to 50%.130 The long- term effective-

ness of therapeutic SI joint injections remains unclear,

with repetitive corticosteroid injections posing cumula-

tive risks. Guidelines recommend a multidisciplinary

approach for long- term management and suggest con-

sideration of controlled injections when used to guide

invasive treatment, emphasizing the importance of ac-

curate diagnosis.

The frequency and duration between treatments

lack clarity in the literature, with guidelines suggest-

ing injections at a minimum of 2–3 months apart and

a maximum of four injections over a 12- month period.

Intra- articular injections may not be optimal for se-

lecting candidates for radiofrequency ablation (RFA)

with lateral sacral branch blocks suggested as an alter-

native, though this recommendation lacks validation

in studies.

Although there is clear evidence supporting RFA for

SI joint pain, the literature faces challenges in meta-

analysis and other evidence- based reviews due to small

sample sizes, high heterogeneity, and methodolog-

ical f laws in existing studies. Overall, the evidence for

RFA compared to placebo for SIJ pain is deemed to be

FIGUR E 5 (A–C) Cooled RF with finder needles, coole d RF probe, and bipolar coole d RF lesions.

SACRO ILIAC J OINT PAI N

low- quality, highlighting the need for further research

with improved study designs and larger sample sizes.

It is noteworthy that the U.S. Centers for Medicare &

Medicaid Services no longer considers SI joint denerva-

tion essential as a treatment option despite the advent of

unique Current Procedural Technology (CPT) codes for

lateral branch blocks and RFA in 2020. These changes

are specific to the United States and may not be globally

relevant. More information can be found at the following

link: https:// www. cms. gov/ medic are- cover age- datab ase/

view/ lcd. aspx? lcdId= 39383 & ver= 9.

SUMMARY

The SI joint is responsible for 15%–30% of axial low

back complaints predominantly below L5 and can be

difficult to distinguish from other forms of low back

pain which often co- exist. The results of clinical ex-

amination and radiological imaging are of limited di-

agnostic value. Several studies demonstrate that having

at least three positive SI joint pain provocation tests is

associated with high sensitivity and specificity (≥ 75%)

for diagnostic intra- articular blocks, though some re-

cent studies question this. Furthermore, there is scant

evidence on the ability of provocative maneuvers to

identify extra- articular pathology, which appears to be

similar in prevalence to intra- articular etiologies of SI

joint pain. Given the high incidence of false- positive

and false- negative results, the outcome of diagnostic

blocks should be interpreted with caution. There is

evidence for both intra- and peri- articular SI joint in-

jections to provide >1 month of pain relief, with some

studies suggesting that combination injections are more

effective than either stand- alone procedure. In indi-

viduals who fail conservative treatment, L5 dorsal rami

and sacral lateral branch RFA can be considered, par-

ticularly in individuals with a prominent component of

extra- articular joint pain. For refractory patients with

degenerative changes and/or instability, minimally in-

vasive SI joint arthrodesis has potential, but further re-

search is warranted.

AUTHOR CONTRIBUTIONS

Karolina Szadek performed the literature search and

review and wrote the article. Steven P. Cohen provided

additional references and comments and also edited the

paper. Javier de Andrès Ares provided additional com-

ments and also edited the paper. Jan Willem Kallewaard

provided additional references and comments and also

edited the paper. Jan Van Zundert controlled the paper,

provided comments, and had full responsibility for the

end product. Monique Steegers assisted Karolina Szadek

and edited the manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

DATA AVAILA BI LIT Y STATE MEN T

This narrative review is based on the existing literature,

therefore data on the used publications are available

through PubMed and libraries.

FIGUR E 6 (A–C) Bipolar cooled RF arou nd S1, S2, and S3.

SZADEK e tal.

ORCI D

Monique Steegers htt ps://orcid.

org/0000-0003-0812-5089

Jan Van Zundert htt ps://orcid.

org/0000-0002-5389-2036

Jan Willem Kallewaard https://orcid.

org/0000-0002-7681-1796

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How to cite this article: Szadek K, Cohen SP, de

Andrès Ares J, Steegers M, Van Zundert J,

Kallewaard JW. 5. Sacroiliac joint pain. Pain

Pract. 2023;00:1–20. https://d o i.or g / 10 .1111 /

papr.13338

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Sep 2024

Background and Aims: Low back pain is a prevalent condition affecting 60–85% of individuals during their lifetime. Despite various proposed mechanisms, the etiology of low back pain remains unclear. This study aims to evaluate the effectiveness of combining ultrasound-guided infiltrations with early rehabilitation in reducing pain and improving functional limitations in patients with chronic nonspecific low back pain. Methods: A retrospective observational study was conducted, reviewing data from January to April 2024 involving 40 patients with chronic nonspecific low back pain. Each patient received two cycles of ultrasound-guided lidocaine and corticosteroid infiltrations at the level of the posterior lower iliac spine, followed by 10 rehabilitation sessions. Patients were assessed at baseline (T0), after the first treatment cycle (T1), and after the second cycle (T2) using the Oswestry Disability Index, Quebec Back Pain Disability Scale, Roland Disability Questionnaire, and Numeric Rating Scale. Results: Significant improvements were observed across all assessment scales. The ODI scores decreased from 33.5 at baseline to 3.5 after treatment (p < 0.001). Similar reductions were noted in the QBPDS (from 61.5 to 10.3), RDQ (from 18 to 3.4), and NRS (from 7.4 to 1.3). The combination of ultrasound-guided infiltrations and early rehabilitation resulted in a significant reduction in pain and disability, with the most notable improvements occurring after the second treatment cycle. Conclusions: The integration of ultrasound-guided infiltrations with early rehabilitation is highly effective in managing chronic nonspecific low back pain, significantly reducing both pain and functional limitations.

Radiofrequency for chronic lumbosacral and cervical pain: Results of a consensus study using the RAND/UCLA appropriateness method

Article

Full-text available

Apr 2024
Pain Pract

Background Despite the routine use of radiofrequency (RF) for the treatment of chronic pain in the lumbosacral and cervical region, there remains uncertainty on the most appropriate patient selection criteria. This study aimed to develop appropriateness criteria for RF in relation to relevant patient characteristics, considering RF ablation (RFA) for the treatment of chronic axial pain and pulsed RF (PRF) for the treatment of chronic radicular pain. Methods The RAND/UCLA Appropriateness Method (RUAM) was used to explore the opinions of a multidisciplinary European panel on the appropriateness of RFA and PRF for a variety of clinical scenarios. Depending on the type of pain (axial or radicular), the expert panel rated the appropriateness of RFA and PRF for a total of 219 clinical scenarios. Results For axial pain in the lumbosacral or cervical region, appropriateness of RFA was determined by the dominant pain trigger and location of tenderness on palpation with higher appropriateness scores if these variables were suggestive of the diagnosis of facet or sacroiliac joint pain. Although the opinions on the appropriateness of PRF for lumbosacral and cervical radicular pain were fairly dispersed, there was agreement that PRF is an appropriate option for well‐selected patients with radicular pain due to herniated disc or foraminal stenosis, particularly in the absence of motor deficits. The panel outcomes were embedded in an educational e‐health tool that also covers the psychosocial aspects of chronic pain, providing integrated recommendations on the appropriate use of (P)RF interventions for the treatment of chronic axial and radicular pain in the lumbosacral and cervical region. Conclusions A multidisciplinary European expert panel established patient‐specific recommendations that may support the (pre)selection of patients with chronic axial and radicular pain in the lumbosacral and cervical region for either RFA or PRF (accessible via https://rftool.org ). Future studies should validate these recommendations by determining their predictive value for the outcomes of (P)RF interventions.

RF001 / #55 APPROPRIATENESS CRITERIA FOR RADIOFREQUENCY INTERVENTIONS IN CHRONIC LOW BACK AND NECK PAIN: EUROPEAN CONSENSUS AND E-HEALTH TOOL

Article

Dec 2023

B10 Developing appropriateness criteria for radiofrequency in chronic low back and neck pain: a RAND/UCLA appropriateness study

Conference Paper

Jun 2022

Background and Aims Despite routine use of radiofrequency (RF) for the treatment of chronic low back and neck pain, there remains uncertainty on the most appropriate patient selection criteria. This study aimed at developing appropriateness criteria for RF (ablation and pulsed) in relation to relevant patient characteristics. Methods The RAND/UCLA Appropriateness Method (RUAM) was used to reach an expert consensus on the appropriateness of RF for a variety of clinical scenarios. A panel consisting of 13 European RF experts rated the appropriateness of RF for a total of 1,296 clinical scenarios, divided over two indication areas: chronic low back and neck pain. The results from the first rating round were discussed during a panel meeting held on March 4th, 2022. Results During the first rating round, RF was considered appropriate in 9% of the clinical scenarios and was associated with specific patient characteristics. The appropriateness of RF was strongly determined by the response to a diagnostic/prognostic block. The second most determining factor of appropriateness was the location of tenderness on palpation for chronic low back pain and the predominant pain trigger for chronic neck pain. Conclusions The RUAM proved to be useful to identify patient-specific criteria for RF in chronic low back and neck pain. The initial scenarios will be refined in the second rating round and embedded in an educational e-health tool, aiming to support patient selection and application of the RF technique.

The sacroiliac joint

Article

Nov 2024
Pain Pract

E V I D E N C E -B A S E D R E V I E W 1. Lumbosacral radicular pain

Article

Full-text available

Nov 2023
Pain Pract

Introduction Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. Methods The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. Results Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short‐term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well‐selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. Conclusions The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.

Pain Practice - 2023 - Van den Heuvel.pdf 3. Pain originating from the lumbar facet joints

Article

Full-text available

Aug 2023
Pain Pract

Jan Willem Kallewaard

Introduction: Pain originating from the lumbar facets can be defined as pain that arises from the innervated structures comprising the joint: the subchondral bone, synovium, synovial folds, and joint capsule. Reported prevalence rates range from 4.8% to over 50% among patients with mechanical low back pain, with diagnosis heavily dependent on the criteria employed. In well-designed studies, the prevalence is generally between 10% and 20%, increasing with age. Methods: The literature on the diagnosis and treatment of lumbar facet joint pain was retrieved and summarized. Results: There are no pathognomic signs or symptoms of pain originating from the lumbar facet joints. The most common reported symptom is uni- or bilateral (in more advanced cases) axial low back pain, which often radiates into the upper legs in a non-dermatomal distribution. Most patients report an aching type of pain exacerbated by activity, sometimes with morning stiffness. The diagnostic value of abnormal radiologic findings is poor owing to the low specificity. SPECT can accurately identify joint inflammation and has a predictive value for diagnostic lumbar facet injections. After "red flags" are ruled out, conservatives should be considered. In those unresponsive to conservative therapy with symptoms and physical examination suggesting lumbar facet joint pain, a diagnostic/prognostic medial branch block can be performed which remains the most reliable way to select patients for radiofrequency ablation. Conclusions: Well-selected individuals with chronic low back originating from the facet joints may benefit from lumbar medial branch radiofrequency ablation.

Cooled radiofrequency ablation versus standard medical management for chronic sacroiliac joint pain: a multicenter, randomized comparative effectiveness study

Article

Full-text available

Jul 2023

Introduction Low back pain is the leading cause of disability worldwide, with sacroiliac joint pain comprising up to 30% of cases of axial lower back pain. Conservative therapies provide only modest relief. Although placebo-controlled trials show efficacy for sacral lateral branch cooled radiofrequency ablation, there are no comparative effectiveness studies. Methods In this randomized, multicenter comparative effectiveness study, 210 patients with clinically suspected sacroiliac joint pain who obtained short-term benefit from diagnostic sacroiliac joint injections and prognostic lateral branch blocks were randomly assigned to receive cooled radiofrequency ablation of the L5 dorsal ramus and S1–S3 lateral branches or standard medical management consisting of pharmacotherapy, injections and integrative therapies. The primary outcome measure was mean reduction in low back pain score on a 0–10 Numeric Rating Scale at 3 months. Secondary outcomes included measures of quality of life and function. Results 3 months post-treatment, the mean Numeric Rating Scale pain score for the cooled radiofrequency ablation group was 3.8±2.4 (mean reduction 2.5±2.5) compared with 5.9±1.7 (mean reduction 0.4±1.7) in the standard medical management group (p<0.0001). 52.3% of subjects in the cooled radiofrequency ablation group experienced > 2 points or 30% pain relief and were deemed responders versus 4.3% of standard medical management patients (p<0.0001). Comparable improvements favoring cooled radiofrequency ablation were noted in Oswestry Disability Index score (mean 29.7±15.2 vs 41.5+13.6; p<0.0001) and quality of life (mean EuroQoL-5 score 0.68±0.22 vs 0.47±0.29; p<0.0001). Conclusions In patients with sacroiliac joint pain, cooled radiofrequency ablation provided statistically superior improvements across the spectrum of patient outcomes compared with standard medical management. Trial registration number NCT03601949 .

Sacroiliac innervation

Article

Full-text available

Aug 2022
EUR SPINE J

Purpose To investigate the innervation pattern of the sacroiliac region, especially with regard to the sacroiliac joint (SIJ). Dorsal SIJ innervation was analyzed and described. Our main hypothesis was that nerves reach the SIJ dorsally, passing ligamental compartments, as this would explain dorsal SIJ pain. Methods To examine sacroiliac innervation, we followed the nerves in over 50 specimens over several years. Plastinated slices were evaluated, nerves in the region were stained histologically, and the data were summarized as 3D models. Results The Rami communicans and posterior branches of the spinal nerves and their branches that form a dorsal sacral plexus and communicating branches, together with corresponding vessels, were observed to form neurovascular bundles embedded by tiny fatty connectives in gaps and tunnels. Branches of L5-S1 pass the inner sacroiliac ligaments (the interosseous sacroiliac ligament and axial interosseous ligament). The outer sacroiliac ligaments (posterior sacroiliac ligaments, long posterior sacroiliac ligament, sacrotuberal ligament, thoracolumbar fascia) are passed by the S1-S4 branches. However, although the paths of these nerves are in the direction of the SIJ, they do not reach it. It is possible that impingement of the neurovascular bundles may result in pain. Moreover, the gaps and tunnels connect to the open dorsal SIJ. Conclusion Our findings suggest that Bogduk’s term “sacroiliac pain” correlates to “sacroiliac innervation”, which consists of “inner-” and “outer sacroiliac ligament innervation”, and to ventral “SIJ pain”. The watery gaps and tunnels observed could play a significant role in innervation and thus in the origins of SIJ pain. Level of evidence Individual cross-sectional studies with consistently applied reference standard and blinding.

The efficacy of primary sacroiliac joint fusion for low back pain caused by sacroiliac joint pathology: a systematic review and meta-analysis

Article

Full-text available

Jun 2022
EUR SPINE J

Purpose Conduct a systematic review to quantify the effect of primary sacroiliac joint fusion (SIJF) for the treatment of sacroiliac (SI) joint pathology on patient reported outcomes. Methods Medline, Embase, Cochrane, PubMed, and Scopus databases were searched prior to August 18th, 2020 for all English-Language studies involving the treatment of SIJ pathology through SIJF and/or conservative management (CM). The quality of included studies was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Primary outcome measure was the Visual Analogue Scale (VAS) for low back pain. Secondary outcome measure was the Oswestry Disability Index (ODI) and the incidence of adverse reactions. Results A total of 564 patients and six studies were included. The overall quality of evidence analyzed by this review was low (GRADE = 0). Five out of the six studies were industry funded. The VAS standardized mean difference (SMD) between SIJF and CM at three months and six months follow-up was − 1.4 [95% confidence interval − 2.3, − 0.6] and − 1.5 [95% CI − 1.8, − 1.1]. The ODI SMD between SIJF and CM scores at three months and 6 months follow-up was − 0.9 [95% CI − 1.1, − 0.7] and − 1.1 [95% CI − 1.6, − 0.5]. The odds ratio of adverse reactions due to SIJF compared to CM was 1.9 [95% CI 0.1, 42.8]. Conclusion Based on the limited number of independent trials with long-term follow-up, SIJF shows potential as a surgical treatment option for SIJ pathology. PROSPERO registration CRD42020206149 (25th September 2020).

Patient-perceived duration of effect of lidocaine and bupivacaine following diagnostic medial branch blocks; a multicenter study

Article

Full-text available

Mar 2022

Objective To quantify the duration of pain relief reported in association with lidocaine and bupivacaine in patients suffering from axial back pain, who reported a response of >80% relief lasting at least 30 minutes following medial branch blocks(MBB). Design A retrospective review. Methods Setting & Subjects: Four academic medical centers utilized a uniform pain diary. It was administered to consecutive patients after undergoing MBB. This pain diary included NRS pain score and percentage of pain relief (PPR) at 12 designated time points. Results One hundred and fifty pain diaries were collected and analyzed. 42 blocks were performed in the cervical spine, 7 in the thoracic spine, and 101 in the lumbar spine. By NRS, 32% of pain diaries indicated that the patient experienced ≥ 80% pain relief at the 30-minute and 42.7% (64/150) did so by PPR. Mean duration of >80% pain relief as measured by NRS in the bupivacaine subgroup was 3.5 hours (SD 8.7, 95% CI 0.6-6.5) versus mean duration of 16.4 hours (SD 19.6, 95% CI 5.4-27.4) in the lidocaine subgroup. Mean duration of >80% pain relief as measured by PPR in the bupivacaine subgroup was 19.2 hours (SD 19.2, 95% CI 13.3-25.1) versus mean duration of 12.2 hours (SD 15.9, 95% CI 5.6-18.8) in the lidocaine subgroup. Conclusions This study demonstrates that there is no discernable or statistically significant difference in the duration of effect when comparing lidocaine to bupivacaine in patients that experience 80% or more relief following a medial branch block. This data suggests any emphasis on concordant duration of relief from specific anesthetics utilized for diagnostic medial branch blocks should be reconsidered.

Efficacy of Peri-Articular Versus Intra-Articular Sacroiliac Joint Blocks under Fluoroscopy Guidance: A Multicentric Study

Article

Full-text available

Mar 2022