The sacroiliac joint (SIJ) is a putative source of low back pain. The objective of this article is to provide clinicians with a concise review of SIJ structure and function, diagnostic indicators of SIJ-mediated pain, and therapeutic considerations. The SIJ is a true diarthrodial joint with unique characteristics not typically found in other diarthrodial joints. The joint differs with others in that it has fibrocartilage in addition to hyaline cartilage, there is discontinuity of the posterior capsule, and articular surfaces have many ridges and depressions. The sacroiliac joint is well innervated. Histological analysis of the sacroiliac joint has verified the presence of nerve fibers within the joint capsule and adjoining ligaments. It has been variously described that the sacroiliac joint receives its innervation from the ventral rami of L4 and L5, the superior gluteal nerve, and the dorsal rami of L5, S1, and S2, or that it is almost exclusively derived from the sacral dorsal rami. Even though the sacroiliac joint is a known putative source of low back and lower extremity pain, there are few findings that are pathognomonic of sacroiliac joint pain. The controlled diagnostic blocks utilizing the International Association for the Study of Pain (IASP) criteria demonstrated the prevalence of pain of sacroiliac joint origin in 19% to 30% of the patients suspected to have sacroiliac joint pain. Conservative management includes manual medicine techniques, pelvic stabilization exercises to allow dynamic postural control, and muscle balancing of the trunk and lower extremities. Interventional treatments include sacroiliac joint, intra-articular joint injections, radiofrequency neurotomy, prolotherapy, cryotherapy, and surgical treatment. The evidence for intra-articular injections and radiofrequency neurotomy has been shown to be limited in managing sacroiliac joint pain.
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"Several sources of innervation have been suggested, including the ventral rami of L4 and L5, the superior gluteal nerve, and the dorsal rami of L5, S1 and S2 . One group has argued that the innervation of the joint derives almost exclusively from the sacral dorsal rami, while another has also identified nerve fibers within the surrounding ligaments, and within the joint capsule itself  . "
[Show abstract][Hide abstract] ABSTRACT: Background: The sacroiliac joint (SIJ) is an important cause of chronic low back pain, implicated in 15% - 30% of all cases. While radiofrequency neurotomy (RFN) is the interventional treatment of choice for spinal pain originating from the facet joints, fewer studies have investigated its potential for treating SIJ pain, and its long-term efficacy is unknown. Objectives: To obtain a real-world view of RFN treatment outcomes for SIJ pain by conducting an observational study within a community pain practice, among a heterogeneous patient group receiving standard-of-care diagnostic workup and treatment. Study Design: A prospective, observational study, with data collection over five years, was conducted at the authors' private practice. Patients & Methods: A cohort of 215 patients underwent fluoroscopically guided SIJ RFN of the dorsal and lateral branches of S1-S3 and the descending branch of L5. All patients had previously had their diagnosis of SIJ pain confirmed by controlled comparative analgesic blocks of relevant nerves, and recorded pre-procedure pain levels on the 11-point Numerical Rating Scale (NRS). Outcome measures included pain, and a Likert scale to measure alterations to analgesic use, changes to paid employment status and patient satisfaction. Results: We demonstrate an average pain reduction of 2.3 ± 2.1 NRS points following RFN (baseline pain score of 6.9 ± 1.7 to a follow-up average of 4.6 ± 2.7 NRS points; p ≤ 0.01). At a mean follow-up period of 14.9 ± 10.9 months (range 6 - 49 months), an overall 42.2% of patients reduced their analgesic use. Of the patients for whom employment capacity was applicable (82 patients), 21 patients reported an improvement. Overall, 67% of patients were satisfied with their outcome of post-RFN treatment. No complications occurred. Limitations: This observational study had no independent control group and only included a single study site. Conclusions: RFN is a safe and effective treatment for pain confirmed to originate from the sacroiliac joint.
"It has been reported that the evaluation of the main pain source in cases of spine degenerative diseases could be associated with certain difficulties. Because of the same segmental innervation, the patterns of pain originating from different structures could bear some resemblance.39–45 Furthermore, every movement of the lumbar spine involves all vertebral segments, therefore clinical provocative tests without application of diagnostic interventions can hardly determine the cause of pain syndrome.17,46–48 "
[Show abstract][Hide abstract] ABSTRACT: To study the possible effects of various diagnostic strategies and the relative contribution of various structures in order to determine the optimal diagnostic strategy in treating patients with noncompressive pain syndromes.
Prospective, nonrandomized cohort study of 83 consecutive patients with noncompressive pain syndromes resistant to repeated courses of conservative treatment. The follow-up period was 18 months.
Nucleoplasty was effective in cases of discogenic pain; the consequences related to false positive results of the discography were significant. The most specific criterion was 80% pain relief after facet joint blocks, whereas 50% pain relief and any subjective pain relief were not associated with a significant increase in the success rate. A considerable rate of false negative results was associated with 80% pain relief, whereas 50% pain relief after facet joint blocks showed the optimal ratio of sensitivity and specificity. Facet joint pain was detected in 50.6% of cases (95% confidence interval 44.1%-66.3%), discogenic pain in 16.9% cases (95% confidence interval 9.5%-26.7%), and sacroiliac joint pain in 7.2% cases (95% confidence interval 2.7%-15%). It was impossible to differentiate the main source of pain in 25.3% of cases.
It is rational to adjust the diagnostic algorithm to the probability of detecting a particular pain source and, in doing so, reduce the number of invasive diagnostic measures to evaluate a pain source. False positive results of diagnostic measures can negatively affect the overall efficacy of a particular technology; therefore, all reasons for the failure should be studied in order to reach an unbiased conclusion. In choosing diagnostic criteria, not only should the success rate of a particular technology be taken into consideration but also the rate of false negative results. Acceptable diagnostic criteria should be based on a rational balance of sensitivity and specificity.
Full-text · Article · Apr 2013 · Journal of Pain Research
"The sacroiliac joint is a complex diarthrodial joint, consisting of bilateral asymmetric and incongruent corresponding joint surfaces of the ilium and the sacrum. Its multiplanar orientation, irregular joint gap, facultative accessory auricular surfaces or partial ankylosis make blind and fluoroscopy-guided intra-articular injections difficult.10,11 The joint is partly synovial and partly a syndesmosis, surrounded by thick dorsal and interosseous ligaments.12 "
[Show abstract][Hide abstract] ABSTRACT: The sacroiliac (SI) joint is frequently the primary source of low back pain. Over the past decades, a number of different SI injection techniques have been used in its diagnosis and therapy. Despite the concerns regarding exposure to radiation, image-guided injection techniques are the preferred method to achieve safe and precise intra-articular needle placement. The following study presents a comparison of radiation doses, calculated for fluoroscopy and CT-guided SI joint injections in standard and low-dose protocol and presents the technical possibility of CT-guidance with maximum radiation dose reduction to levels of fluoroscopic-guidance for a precise intra-articular injection technique.
To evaluate the possibility of dose reduction in CT-guided sacroiliac joint injections to pulsed-fluoroscopy-guidance levels and to compare the doses of pulsed-fluoroscopy-, CT-guidance, and low-dose CT-guidance for intra-articular SI joint injections.
Comparative study with technical considerations.
A total of 30 CT-guided intra-articular SI joint injections were performed in January 2012 in a developed low-dose mode and the radiation doses were calculated. They were compared to 30 pulsed-fluoroscopy-guided SI joint injections, which were performed in the month before, and to five injections, performed in standard CT-guided biopsy mode for spinal interventions. The statistical significance was calculated with the SPSS software using the Mann-Whitney U-Test. Technical details and anatomical considerations were provided.
A significant dose reduction of average 94.01% was achieved using the low-dose protocol for CT-guided SI joint injections. The radiation dose could be approximated to pulsed-fluoroscopy- guidance levels.
Radiation dose of CT-guided SI joint injections can be decreased to levels of pulsed fluoroscopy with a precise intra-articular needle placement using the low-dose protocol. The technique is simple to perform, fast, and reproducible.
Full-text · Article · Aug 2012 · Journal of Pain Research