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 Do clinical tests have a role? Is imaging conclusive? Is SIJ intraarticular injection conclusive? Treatment?? The diagnosis of SIJ pain is in itself controversial!!!

History

Anatomy, Biomechanics, Movements

Pathophysiology

Diagnosis (Pain Distributions, Clinical & Radiological

Tests, Intraarticular injection)

Treatment (Conservative, Minimally Invasive,

Surgical)

Aims

History Hippocrates observed that a woman’s pelvis

separated during labour and remained so after birth.

Lynch 1920 (Surg Gynecol Obstet 575-580)

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)

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)

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 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 Ant Post

Anatomy 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 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

It varies greatly in size, shape, contour from side to

side and between individuals

Anatomy 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

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

Anatomy

Anatomy

The old bridge of Stirling, built about 1550

Both Highland troops and the British army tried to

cross during the 1745 Jacobite rebellion

Biomechanics “Keystone in an arch”effect; the

greater the force the greater the

resistance

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Biomechanics “Keystone in an arch”effect; the

greater the force the greater the

resistance

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Triplanar shock absorber, base of spine

Transmits and dissipates upper trunk loads

Movements Powerful ligament (interosseous)

Different and variable shape

Keystone

Movements Powerful ligament (interosseous)

Different and variable shape

Keystone

Does it actually move?

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)

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)

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).

Movements The two most common types of motion are nutation

(backward rotation of the ilium on the sacrum) and

counternutation (forward rotation)

SIJ motion progressively decreases in men aged

between 40 and 50 and in women aged over 50.

Dreyfuss 1995 (Spine 6;785-813)

Pathophysiology Multiple theories:

Ligamentous or Capsular tension

Bony arthritis

Synovial inflammation

Extraneous compression or shear forces

Hypo or hypermobility

Abnormal mechanics

Myofascial

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)

Metabolic and endocrine disorders (crystal induced

joint disorders, hyperparathyroidism)

Primary tumors (chondrosarcoma, giant cell

tumors...)

Mets to pelvis

Idiopathic

Rare causes (iatrogenic, psychogenic).

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

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

Pain distribution

Clinical Tests

Radiological Investigations

Intraarticular Injection

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 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 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 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 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 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 Distributions

Pain Distributions

Only 4% of patients mark any pain above L5 on self reported Pain drawings.

Dreyfuss 1996 (Spine, 21:2594-2602)

Pain Distributions

Many diseases mimic SIJ pain:Spinal disorders

Non- spinal disorders:GastrointestinalGenitourinary

Pubic symphysis motionMyofascial imbalances

Aberrant gaitHip joint disorders

Clinical Tests

Pain provocative tests Palpation tests Motion demands tests

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 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 Tests

Pain provocative tests Palpation tests Motion demands tests

Sitting tolerance 78% sensitivity, 58%

specificity (Stark et al)

Standing, Flexion

Clinical Tests

Partick’s test

Lewin Ganslen’ test Yeaoman’s test

Pelvic rock’ test Stretch test

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

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

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 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 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.

Intraarticular InjectionThe Technique

Treatment

Conservative

Minimally invasive

Surgical

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 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 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 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 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)

Arthrodesis or stabilisation

Open procedures& bone graft

PercutaneousNo bone graft

Metal work No metal work

Surgical treatment21 surgical technique were identified in 2007

Surgical treatment1. All the identified papers were case reports, case

series, or technique papers.

2. Only four papers collected the data prospectively

3. Sample size ranged from 1 to 172

4. Follow up period ranged from 6 weeks to 9 years

5. Minimal statistical analysis.

6. Lack of information on functional outcome.

7. SIJ arthrodesis was only considered when

conservative treatment failed

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

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

Questions