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Sacroiliac Joint Pain, A Review. Ahmad Al-khayer SpR Rehabilitation Medicine. Controversies. Anatomy SIJ movements Do clinical tests have a role? Is imaging conclusive? Is SIJ intraarticular injection conclusive? Treatment??. Controversies. Anatomy SIJ movements

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Sacroiliac joint pain a review

Sacroiliac Joint Pain, A Review

Ahmad Al-khayer

SpR Rehabilitation Medicine


Controversies
Controversies

  • Anatomy

  • SIJ movements

  • Do clinical tests have a role?

  • Is imaging conclusive?

  • Is SIJ intraarticular injection conclusive?

  • Treatment??


Controversies1
Controversies

  • Anatomy

  • SIJ movements

  • Do clinical tests have a role?

  • Is imaging conclusive?

  • Is SIJ intraarticular injection conclusive?

  • Treatment??

  • The diagnosis of SIJ pain is in itself controversial!!!


Aims

  • History

  • Anatomy, Biomechanics, Movements

  • Pathophysiology

  • Diagnosis (Pain Distributions, Clinical & Radiological Tests, Intraarticular injection)

  • Treatment (Conservative, Minimally Invasive, Surgical)


History
History

  • Hippocrates observed that a woman’s pelvis separated during labour and remained so after birth. Lynch 1920 (Surg Gynecol Obstet 575-580)


History1
History

  • Hippocrates observed that a woman’s pelvis separated during labour and remained so after birth. Lynch 1920 (Surg Gynecol Obstet 575-580)

  • Albee 1909 (JAMA 53;1273-67), Smith-Paterson 1926 (JBJS 8;118-136), Campbell 1927(Surg Gynecol Obstet 45;218-9)


History2
History

  • Hippocrates observed that a woman’s pelvis separated during labour and remained so after birth. Lynch 1920 (Surg Gynecol Obstet 575-580)

  • Albee 1909 (JAMA 53;1273-67), Smith-Paterson 1926 (JBJS 8;118-136), Campbell 1927(Surg Gynecol Obstet 45;218-9)

  • Development of discectomy surgery by Mixter and Barr 1934 (New Engl J Med 211;210-15)


History3
History

  • Hippocrates observed that a woman’s pelvis separated during labour and remained so after birth. Lynch 1920 (Surg Gynecol Obstet 575-580)

  • Albee 1909 (JAMA 53;1273-67), Smith-Paterson 1926 (JBJS 8;118-136), Campbell 1927(Surg Gynecol Obstet 45;218-9)

  • Development of discectomy surgery by Mixter and Barr 1934 (New Engl J Med 211;210-15)

  • Schwarzer 1995 (Spine 20;31-7), Maigne 1996 (Spine 21:1889-92), Katz 2003 (J Spinal Disord Tech 16;96-9). The cause of chronic low back pain in 13-30% of patients.


Anatomy

C or Ear shaped by adulthood.

Fibrous capsule; thin anteriorly, absent posteriorly

Synovial (75% of its superior part is not)

Anatomy


Anatomy1

C or Ear shaped

Fibrous capsule; thin anteriorly, absent posteriorly

Synovial (75% of its superior part is not)

True diarthrodial joint: The concave sacral surface is covered with thick hyaline cartilage, the convex iliac surface is covered with fibrocartilage

Anatomy


Anatomy2

Ant Post

Anatomy


Anatomy3

The morphology of the SIJ changes with age;

Flat until puberty

By 30 bony ridges on the ilium side

By fourth decade ridges on both sides

Anatomy


Anatomy4

The morphology of the SIJ changes with age;

Flat until puberty

By 30 bony ridges on the ilium side

By fourth decade ridges on both sides

Anatomy

  • It varies greatly in size, shape, contour from side to side and between individuals


Anatomy5

The morphology of the SIJ changes with age;

Flat until puberty

By 30 bony ridges on the ilium side

By fourth decade ridges on both sides

Anatomy

  • It varies greatly in size, shape, contour from side to side and between individuals

  • The synovial cleft narrows with age;

    1-2mm in individuals aged 50 to 70

    0-1mm in over 70





Biomechanics
Biomechanics

  • “Keystone in an arch”effect; the greater the force the greater the resistance


Biomechanics1
Biomechanics

  • “Keystone in an arch”effect; the greater the force the greater the resistance

  • Triplanar shock absorber, base of spine

  • Transmits and dissipates upper trunk loads


Movements
Movements

  • Powerful ligament (interosseous)

  • Different and variable shape

  • Keystone


Movements1
Movements

  • Powerful ligament (interosseous)

  • Different and variable shape

  • Keystone

    Does it actually move?


Movements2
Movements

  • Many type of movements have been described by Weisl 1955, Mitchell 1979, Beal 1982, Woerman 1982, Aitken 1986, Bernard 1987, Lee 1989, Shaw 1992, Oldrieve 1996)


Movements3
Movements

  • Many type of movements have been described by Weisl 1955, Mitchell 1979, Beal 1982, Woerman 1982, Aitken 1986, Bernard 1987, Lee 1989, Shaw 1992, Oldrieve 1996)

  • Movement of ilium on the sacrum (upslip, downslip, outflare, inflare, anterior torsion, posterior torsion)

  • Movement of sacrum on the ilium (nutation, counter-nutation, sacral side bending, rotation)


Movements4
Movements

  • “Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis”. Sturessone et al 1989, (Spine 14(2): 162-5)

  • 25 patients (21F: 4M). Physiological and extreme physiological positions. Mean rotations around axial axis 2.5 degrees (0.8 degree-3.9 degrees). Mean translation was 0.7 mm (0.1-1.6 mm).


Movements5
Movements

  • The two most common types of motion are nutation (backward rotation of the ilium on the sacrum) and counternutation (forward rotation)

  • SIJ motion progressivelydecreases in men aged between 40 and 50 and in women aged over 50. Dreyfuss 1995 (Spine 6;785-813)


Pathophysiology
Pathophysiology

  • Multiple theories:

  • Ligamentous or Capsular tension

  • Bony arthritis

  • Synovial inflammation

  • Extraneous compression or shear forces

  • Hypo or hypermobility

  • Abnormal mechanics

  • Myofascial


Pathophysiology1
Pathophysiology

  • SIJ dysfunction (postpartum, limb length discrepancy, repetitive minor trauma)

  • Infection (haematogenous)

  • Spondyloarthropathies (Ank spond, Reiter’s)

  • Degenerative arthritis

  • Post traumatic arthritis (insufficiency factures, major trauma)

  • Previous spinal surgery (lumbar stabilisation....)


Pathophysiology less frequent
Pathophysiology (less frequent)

  • Metabolic and endocrine disorders (crystal induced joint disorders, hyperparathyroidism)

  • Primary tumors (chondrosarcoma, giant cell tumors...)

  • Mets to pelvis

  • Idiopathic

  • Rare causes (iatrogenic, psychogenic).


Pathophysiology2
Pathophysiology

  • Dreyfuss 1995 (Clin N Am 6;785-813)

  • Intraarticular sources: Spondyloarthropathies, OA, infection, metabolic

  • Extraarticular sources: ligamentous sprain, SIJ fractures, insufficiency fractures, ligamentous, tendious, fascial attachment

  • Tumors

  • Iatrogenic


Pathophysiology3
Pathophysiology

  • Dreyfuss 1995 (Clin N Am 6;785-813)

  • Intraarticular sources: Spondyloarthropathies, OA, infection, metabolic

  • Extraarticular sources: ligamentous sprain, SIJ fractures, insufficiency fractures, ligamentous, tedious, fascial attachment

  • Tumors

  • Iatrogenic

  • Could the above be relevant for treatment?


Diagnosis
Diagnosis

Pain distribution

Clinical Tests

Radiological Investigations

Intraarticular Injection


Pain distributions
Pain Distributions

  • Fortin et al 1994 (Spine;19:1475-82).

    10 asymptomatic volunteers, SIJ injection with contrast material followed by Xylocaine. Buttock hypoesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This corresponded to the area of maximal pain noted upon injection. SIJ pain referral map was generated.


Pain distributions1
Pain Distributions

  • Fortin et al 1994 (Spine;19:1483-9).

    54 patients completed pain diagrams. Two blinded clinicians selected 16 patients whose diagrams most represented the SIJ referral diagrams from study 1. 100% of these 16 had pain provocation with SIJ injection.


Pain distributions2
Pain Distributions

  • Fortin et al 1994 (Spine;19:1483-9).

    54 patients completed pain diagrams. Two blinded clinicians selected 16 patients whose diagrams most represented the SIJ referral diagrams from study 1. 100% of these 16 had pain provocation with SIJ injection.

    How many of the remaining could have had SIJ pain too?


Pain distributions3
Pain Distributions

  • Slipman et al 2000 (Arch Phys Med Rehabil 81;334-8)

    50 (18M:32F) patients. All demonstrated a positive diagnostic response to a fluoroscopically guided SIJ injection. Each patient's preinjection pain description was used to determine areas of pain referral.


Pain distributions4
Pain Distributions

  • Slipman et al 2000 (Arch Phys Med Rehabil 81;334-8)

    50 (18M:32F) patients. All demonstrated a positive diagnostic response to a fluoroscopically guided SIJ injection. Each patient's preinjection pain description was used to determine areas of pain referral.

    47 buttock pain, 36 lower lumbar pain. 7 groin pain. 25 lower-extremity pain. 14 leg pain distal to the knee, and 6 patients reported foot pain.


Pain distributions5
Pain Distributions

  • Slipman et al 2000 (Arch Phys Med Rehabil 81;334-8)

    50 (18M:32F) patients. All demonstrated a positive diagnostic response to a fluoroscopically guided SIJ injection. Each patient's preinjection pain description was used to determine areas of pain referral.

    47 buttock pain, 36 lower lumbar pain. 7 groin pain. 25 lower-extremity pain. 14 leg pain distal to the knee, and 6 patients reported foot pain.

    18 potential pain-referral zones were established.



Pain distributions7
Pain Distributions

Only 4% of patients

mark any pain above L5 on

self reported Pain drawings.

Dreyfuss 1996

(Spine, 21:2594-2602)


Pain distributions8
Pain Distributions

Many diseases mimic SIJ pain:

Spinal disorders

Non- spinal disorders:

Gastrointestinal

Genitourinary

Pubic symphysis motion

Myofascial imbalances

Aberrant gait

Hip joint disorders


Clinical tests
Clinical Tests

  • Pain provocative tests

  • Palpation tests

  • Motion demands tests


Clinical tests1
Clinical Tests

  • Pain provocative tests

    • Patrick’s test 77% sensitivity, 100 % specificity*. (FABER)

    • Thigh thrust test 80% sensitivity, 100% specificity*. (Post shearing stress applied to SIJ through Femur)

    • * (Broadhurst 1998, J Spinal Disord 11;341-345)

  • Palpation tests

  • Motion demands tests


Clinical tests2
Clinical Tests

  • Pain provocative tests

  • Palpation tests

    • The midline sacral thrust test 89% sensitivity, 14% specificity (patient prone, post ant force)

    • (Dreyfuss 1996 Spine 21:2594-2602)

  • Motion demands tests


Clinical tests3
Clinical Tests

  • Pain provocative tests

  • Palpation tests

  • Motion demands tests

    Sitting tolerance 78% sensitivity, 58% specificity (Stark et al)

    Standing, Flexion


Clinical tests4
Clinical Tests

Partick’s test

Yeaoman’s test

Lewin Ganslen’ test

Pelvic rock’ test

Stretch test


Clinical tests5
Clinical Tests

  • Clinical examination cannot definitely confirm that the SIJ is the source of patient’s pain

    *Dreyfuss P et al; Spine 1996; 21(22): 2594–602. Van der Wurff P et al ; Man Ther, 2000; 5(1): 30-6. Van der Wurff P et al ; Man Ther, 2000; 5(2): 89-96*


Radiological investigations
Radiological Investigations

  • X-rays, CT, MRI, and bone scan do not provide consistent findings that can be used for the diagnosis

    *Prather H; Clin J Sport Med, 2003; 13(4): 252-5, Dreyfuss P et al; Am Acad Orthop Surg. 2004; 12(4):255-65, Rothschild BM et al; Clin Exp Rheumatol, 1994; 12(3): 267-74*


Intraarticular injection
Intraarticular Injection

  • LA

  • Gold standard for diagnosis of intraarticular SIJ pain

  • 70-80% relief of pain is diagnostic

    *Dreyfuss P et al; Am Acad Orthop Surg. 2004; 12(4):255-65, Maldjian C et al; Radiol Clin North Am, 1998; 36(3): 497-508. Maigne JY et al; Spine, 1996; 21(16): 1889-92. Luukkainen RK et al; Clin Exp Rheumatol. 2002; 20(1):52-4*


Intraarticular injection the technique
Intraarticular InjectionThe Technique

  • Dussault et al 2000(Radiology, 214:273-7)

    Patients prone.

    C-arm fluoroscope angled 20 to 25 in a caudal direction.

    Straight needle is advanced perpendicular to the table aiming to post inf part of SIJ.

    97% success rate reported.


Intraarticular injection the technique1
Intraarticular InjectionThe Technique

  • Buchowski et al 2005 (The Spine Journal, 520-528) Patients prone.

    C-arm fluoroscope angled 20 to 25 in a caudal direction and away from the side to be injected.

    Spinal needle is advanced in the direction of the beam aiming for the post inf aspect of the joint.



Treatment
Treatment

Conservative

Minimally invasive

Surgical


Conservative treatment
Conservative Treatment

  • Medications (NSAID, opiate, antidepressants)

  • Physical therapy (aerobic conditioning, activity modification, posture education, early mobilisation..)

  • Orthotics and shoe modification

  • Others (rest, heat, manipulation, chiropractic)


Minimally invasive treatment
Minimally Invasive Treatment

  • Intraarticular Injections: LA and corticosteroid

    -Braun 1996. 30 SPA, CT guided Intra SIJ. Statistically significant improvement 5 m.(J Rheumatol 23;659-64)

    -Hanly 2000. 13 SPA & 6 non SPA. CT guided intra SIJ injection. Transient improvement at 1-3 m. No significant improvement at 6 m. (J Rheumtol 27;719-22)

    -Slipman 2001. Retrospectively 31 non SPA. Fluoroscopic guided Intra SIJ. Average 2.1 injectio. Average follow up 94.4 w. Significant reduction in Oswestry & VAS. Work status & medication consumption improved. (Am J Phys Med Rehabil, 80(6): 425-32)


Minimally invasive treatment1
Minimally Invasive Treatment

  • Periarticular Injections: LA and corticosteroid.

    - Luukkainen 2002. 24 non SPA patients. Double blind controlled. 13 with MP & LA and 11 of NACL & LA. Significant improvement of MP over NACL at one month.(Clin Exp Rheumtol 20;52-54)


Minimally invasive treatment2
Minimally Invasive Treatment

- Murakami 2007.

Pain provocation test identified pain in SIJ area. Intraarticular injection for the first 25 patients and extraarticular for the second 25.

LA. Restriction of activities of daily life scale. Improvement in 9 out of 25 intra and 25 out of 25 extra.

The 16 intra were then injected extra and showed improvement.

Extra is easier and should be tried first. (J Orthop Sci, 12(3): 274-80)


Minimally invasive treatment3
Minimally Invasive Treatment

  • Prolotherapy: Phenol, glycerine, dextrose, glucose into surrounding ligaments produce extra collagen. Strengthen SIJ. (Keating 1999, Movement, Stability and Low Back Pain 573-586)

  • Neuroaugmentation: Electrical stimulation to spinal cord or deep brain. (Calvillo, 1998, Spine 23;1069-1072)

  • Viscosupplementation: Hyaluronic acid into SIJ. Lubricant. (Calvillo1998, Spine 23;1069-1072)

  • Radiofrequency neurotomy: Heat to S1, S3. (Yin 2003, Spine 28;2419-2425)


Surgical treatment
Surgical treatment

21 surgical technique were identified in 2007


Surgical treatment1
Surgical treatment

All the identified papers were case reports, case series, or technique papers.

Only four papers collected the data prospectively

Sample size ranged from 1 to 172

Follow up period ranged from 6 weeks to 9 years

Minimal statistical analysis.

Lack of information on functional outcome.

SIJ arthrodesis was only considered when conservative treatment failed

(Al-khayer 2007, J Back Musculoskeletal Rehab, 20;135-141)


Summary
Summary

  • SIJ is an important cause of low back pain

  • Referral zones are wide

  • Clinical tests can be used as screening tool

  • The gold standard test for diagnosis of intraarticular SIJ pain is is Intraarticular injection of LA

  • Treatment is multidisciplinary, and it is affected by the source of pain

  • Research



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