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Discover effective pain management techniques for Sacroiliac Joint Arthropathy at our APA Pain Management Course. Learn how to alleviate pain and improve mobility.
Introduction:
Sacroiliac Joint (SIJ) pain significantly contributes to low back pain, and treatments targeting the SIJ have proven effective. The International Association for the Study of Pain (IASP) defines SI joint pain as localized in the SI joint region, reproducible through stress tests, and alleviated by selective infiltration with a local anesthetic. Prevalence, depending on diagnostic criteria, ranges from 16% to 30% in axial low back pain patients. The SI joint, a diarthrodial synovial joint, comprises a true synovial joint anteriorly and a syndesmosis posteriorly involving ligaments and muscles. Innervation is through sacral dorsal rami. SI joint pain categories include intra-articular (infection, arthritis) and extra-articular causes (fractures, myofascial issues), often idiopathic. Contributing factors involve pelvic shear stress, torsional forces, and inflammation, with risk factors including leg length discrepancy, abnormal gait, trauma, scoliosis, lumbar fusion, exertion, and pregnancy. Persistent post-arthrodesis low back pain shows a 32%-35% prevalence in diagnostic intra-articular blocks.
The sacroiliac joint receives its primary nerve supply from the lateral branches of the dorsal rami of spinal nerves L4 to S3, with additional innervation from the ventral rami of L4 to S2 spinal nerves. The variability in nerve supply among individuals contributes to diverse patterns of pain referral from the joint.
Diagnosis of Sacroiliac Arthropathy -
History: Typically, pain originating from the SI joint is primarily localized in the gluteal region (94%). Referred pain may also manifest in the lower lumbar region (72%), groin (14%), upper lumbar region (6%), or abdomen (2%). Approximately 28% of patients experience referred pain in the lower limb, while 12% report pain extending to the foot.
Physical Examination:
Individual provocative maneuvers exhibit limited diagnostic value. The size and immobility of the SI interface demand substantial forces to stress the joint, potentially leading to false negatives. Moreover, incorrectly applied forces can induce pain in adjacent structures, yielding false-positive test results. Nevertheless, the clinical examination's sensitivity and specificity increase proportionally with the number of positive tests. Two studies indicate that achieving three or more positive provocative tests enhances both specificity and sensitivity to an acceptable level. Young et al. identified a positive correlation between SI joint pain and exacerbated symptoms during rising from a sitting position, unilateral symptoms, and the presence of three positive provocative tests. The following are the seven most critical clinical tests, positive when replicating a patient's typical pain.
Compression Test (Approximation Test):
During this test, the patient assumes a side-lying position with the affected side facing upward. The hips are flexed at 45°, and the knees are flexed at 90°. The examiner stands behind the patient, applying downward and medial pressure with both hands on the front side of the iliac crest.
Distraction Test (Gapping Test):
In this examination, the examiner positions themselves on the affected side of the supine patient. Placing hands on both anterior superior iliac spines with a crossed hand technique, the examiner applies pressure in the dorso-lateral direction.
Patrick’s Sign/FABER Test (Flexion Abduction External Rotation Test):
In this test, the patient lies supine while the examiner stands alongside the affected side. The leg on the affected side is flexed at the hip and knee, with the foot placed beneath the opposite knee. The examiner applies downward pressure to the knee of the affected side.
Gaenslen Test (Pelvic Torsion Test):
During this examination, the patient assumes a supine position with the affected side positioned at the edge of the examination table. The unaffected leg is bent at both the hip and knee, maximizing flexion until the knee contacts the abdomen. Simultaneously, the contralateral leg (on the affected side) is brought into hyperextension, with gentle pressure applied to the knee.
Thigh Thrust Test (Posterior Shear Test):
During this test, the patient is supine with the unaffected leg extended. The examiner, positioned beside the affected side, flexes the extremity at the hip to around 90° with slight adduction. Simultaneously, light pressure is applied to the bent knee.
Fortin’s Finger Test:
In this test, the patient consistently points to the location of pain using one finger, positioned inferomedially to the posterior superior iliac spine.
Gillet/Stork Test:
To conduct this assessment, the patient stands while the examiner uses one thumb to palpate the posterior superior iliac spine (PSIS) and the other thumb to palpate the sacral base, positioned medially to the PSIS. The patient is then instructed to stand on one leg while pulling the hip of the palpated side into 90° or more of hip flexion. This process is repeated on the opposite side, allowing for a bilateral comparison. The examiner evaluates each side for the quality and amplitude of movement. In a normally functioning pelvis, the side being palpated should exhibit posterior rotation, causing the PSIS to descend or move inferiorly. Symmetry in movement between the left and right SIJ should be observed. A positive outcome occurs when the PSIS on the ipsilateral side of the knee flexion moves minimally downward, remains static, or is associated with pain, indicating sacroiliac joint hypomobility.
Investigations -
Medical imaging is primarily recommended to exclude potential "red flags." Numerous studies have employed various techniques such as radiography, computed tomography (CT), single-photon emission CT, bone scans, and other nuclear imaging methods to identify specific disorders related to the SI joint. Despite these efforts, a consistent correlation between imaging findings and SI joint pain confirmed through injections has not been established. Magnetic resonance imaging (MRI) is limited in assessing normal anatomy; however, in cases of spondylarthropathy, it can detect inflammation and cartilage destruction even in the absence of abnormal clinical presentations.
Diagnostic Blocks:
According to IASP criteria, the disappearance of pain following intra-articular SI joint infiltration with local anesthetic is essential for confirming the diagnosis. While some authors rely on a single diagnostic block for clinical studies, others advocate confirmatory (double) diagnostic blocks involving two different local anesthetics with varying durations of action. However, the diagnostic value of SI joint infiltration with local anesthetic remains controversial due to the potential for both false-positive and false-negative results. Factors contributing to inaccurate blocks include the dispersion of local anesthetic to adjacent pain-generating structures (muscles, ligaments, nerve roots), excessive use of superficial anesthesia or sedation, and the failure to achieve infiltration throughout the entire SI joint complex. The use of fluoroscopy or other imaging techniques to guide needle placement during SI joint blocks is strongly recommended.
Differential Diagnosis of Sacroiliac Arthropathy :
• Spondyloarthropathy (including ankylosing spondylitis, reactive arthritis, psoriatic arthritis, etc.).
• Lumbosacral Radicular Pain due to Nerve Root Compression
• Facet Joint pain.( Specially L5 - S1 facet joint Pain)
• Pain originating from the hip Joint.
• Myofascial pain.
• Piriformis syndrome.
Treatment Options:
The management of SI joint pain is most effective when approached through a multidisciplinary strategy, encompassing both conservative and interventional pain management techniques.
Conservative Management:
Conservative treatments primarily address the underlying causes. For SI joint pain related to postural and gait issues, exercise therapy and manipulation prove effective in reducing pain and enhancing mobility. In cases of ankylosing spondylitis, an inflammatory rheumatological disorder affecting the vertebral column and SI joint, immunomodulating agents have demonstrated efficacy. The conservative approach includes pharmacological treatment, cognitive-behavioral therapy, manual medicine, exercise therapy, rehabilitation treatment, and, if necessary, psychiatric evaluation.
Interventional Management:
Patients with SI joint pain resistant to conservative measures may opt for intra-articular injections or radiofrequency (RF) treatment. Intra-articular injections, involving local anesthetic and corticosteroids, can offer substantial pain relief for up to one year. While intra-articular injections are commonly assumed to yield superior results compared to peri-articular infiltrations, studies have shown that the latter can provide effective short-term pain relief, highlighting the significance of extra-articular sources of SI pathology. Controlled studies support the idea that both intra- and extra-articular injections may be beneficial. RF treatment, including conventional thermal, pulsed, cooled, and bipolar thermal approaches, has demonstrated efficacy in several studies. Targeting the L4–L5 dorsal rami and the S1 to S3 (or S4) lateral branch of dorsal rami has been attempted with limited success.
SI Joint Intraarticular Steroid Injection
SI joint injections combining local anesthetic and corticosteroids offer effective pain relief for up to a year. While intra-articular injections are assumed to yield superior results, peri-articular infiltrations have shown significant short-term pain relief in double-blind studies, highlighting the relevance of extra-articular sources in addressing SI pathology.
The injection is typically guided by imaging techniques, such as fluoroscopy or ultrasound, to ensure accurate placement of the needle into the targeted joint space. The local anesthetic provides immediate pain relief, and the corticosteroid works to reduce inflammation and provide more sustained relief over a more extended period.
In the classical SI Joint Infiltration Technique, the patient assumes a prone position. Using anterior-posterior fluoroscopic projection, the posterior joint articulation forms the medial SI joint line. The C-arm is rotated contralaterally until the medial cortical line of the posterior articulation is focused. Skin puncture, 1 to 2 cm cranially from the SI joint's lower edge, is guided by the zone of maximal radiographic translucency. Penetration, indicated by a change in resistance, occurs with the needle tip slightly curved between the os sacrum and os ilium. Contrast injection reveals dispersal along the articulations and caudal joint capsule filling. Adjustments, including a more rostral puncture or CT guidance, may be considered if needed.
Drug injected - Depot Methyl Prednisolone or Triamcinolone 20-40 mg with Local anaesthetic lignocaine or bupivacaine in a total volume of 3-4 ml
Complications of SI Joint Intraarticular Steroid Injection -
While intra-articular steroid injections for the sacroiliac joint (SI joint) can be beneficial for managing pain, there are potential complications associated with the procedure. It's important to note that complications are relatively uncommon but can occur. Some possible complications include:
1. Infection: There is a risk of infection at the injection site. Providers typically use sterile techniques to minimize this risk, but infections can still occur.
2. Bleeding: Some patients may experience bleeding at the injection site. This is usually minimal, but in rare cases, it may require medical attention.
3. Nerve Injury: There is a slight risk of injuring nearby nerves during the injection, which could lead to pain, numbness, or tingling. This risk is minimized by using imaging guidance, such as fluoroscopy, to ensure accurate needle placement.
4. Allergic Reaction: While uncommon, some individuals may have an allergic reaction to the injected steroid medication. This can include redness, swelling, or itching at the injection site.
5. Changes in Blood Sugar Levels: In individuals with diabetes, intra-articular steroid injections may cause temporary increases in blood sugar levels. It's essential for individuals with diabetes to monitor their blood sugar closely after the procedure.
6. Flare-Up of Symptoms: In some cases, rather than providing relief, the injection may initially cause a temporary exacerbation of pain before the intended therapeutic effect takes place.
SI Joint Conventional Radiofrequency (RF) Denervation -
In Radiofrequency (RF) Treatment of the SI Joint, conducted under fluoroscopic imaging post a positive diagnostic block, the patient receives light sedation. The C-arm is positioned to achieve either a slightly oblique projection (L4 ramus dorsalis), an anterior-posterior projection (L5 ramus dorsalis and rami laterales), or a cephalo-caudal projection (S1 to S3 rami laterales). For enhanced visualization of the posterior foramen in S1, a slight ipsilateral oblique angulation is often applied. A 22G SMK-C10 cannula with a 5-mm active tip is inserted until bone contact is confirmed at the target nerve level. Electrostimulation at 50 Hz is used to confirm the correct needle position, with paresthesia felt in the painful area at thresholds <0.5 V. Lesion creation may necessitate multiple treatments due to electrode size limitations and the variable nerve convergence on each foramen. Prior to RF treatment, motor stimulation ensures no leg or sphincter contraction, indicating correct positioning. The RF probe is then inserted, and a 90-second RF treatment at 80°C is administered.
SI Joint Conventional Radiofrequency (RF) Denervation -
A cooled RF treatment for the SI joint is administered following a positive diagnostic block, with the patient receiving light sedation. C-arm fluoroscopy is utilized to visualize the sacrum through the L5/S1 disk space. The targeted areas include the L5 ramus dorsales and S1 to S3 rami laterales. An introducer with a stylet is inserted to the bone endpoint of the posterior sacrum, where the stylet extends 6 mm beyond the introducer tip. The subsequent insertion of the RF probe through the same introducer extends only 4 mm beyond the introducer tip. To ensure maximum encasement of the lateral branches of the S1 to S3 (S4) nerves, the electrode is positioned 8 to 10 mm from the lateral edge of the posterior sacral foramina, with the tip approximately 2 mm proximal to the surface. Two or three lesions are created at each sacral level, spaced about 1 cm apart, forming a continuous strip of ablated tissue lateral to each foramen. RF energy is delivered for 2 minutes (30 seconds per lesion) with a target electrode temperature of 60°C. The dorsal branch of the L5 nerve is targeted using classical techniques.
SI Joint Cryaablation -
SI joint cryoablation is a minimally invasive procedure that uses extreme cold to freeze and destroy the nerves that transmit pain from the sacroiliac joint.. SI joint cryoablation is an alternative to radiofrequency ablation. There are a few advantages over radiofrequency denervation. Due to large lesion size the success rate os higher with si joint cryoablation. you can read our article on cryoablation. Sahoo RK, Das G, Pathak L, Dutta D, Roy C, Bhatia A. Cryoneurolysis of Innervation to Sacroiliac Joints: Technical Description and Initial Results-A Case Series. A A Pract. 2021 Mar 30;15(4):e01427. doi: 10.1213/XAA.0000000000001427. PMID: 33783380.
Summary -
The sacroiliac (SI) joint contributes to a significant portion (16% to 30%) of axial low back complaints and can pose challenges in differentiation from other types of low back pain. Both clinical examination and radiological imaging have limited diagnostic efficacy. Interpretation of diagnostic blocks should be approached with caution due to the common occurrence of both false-positive and false-negative results. Presently, prevailing scientific evidence supports the use of intra-articular SI joint infiltrations for achieving short-term improvement. In cases where such interventions prove ineffective or yield only temporary relief, the recommendation is to consider radiofrequency (RF) treatment if it is available.
About the Authors -
Dr. Debjyoti Dutta, a renowned pain specialist and author, is Director and Consultant at Samobathi Pain Clinic and Fortis Hospital in Kolkata. As a registrar at the Indian Academy of Pain Medicine, he specializes in musculoskeletal ultrasound and interventional pain management. Dr. Dutta has made significant contributions through impactful publications like "Musculoskeletal Ultrasound in Pain Medicine" and "Clinical Methods in Pain Medicine." Serving as a faculty member for the Asian Pain Academy Courses, he plays a crucial role in providing high-quality pain management fellowship training in Kolkata, India.
Dr. Chinmoy Roy is a highly accomplished Director and Consultant at Rajahart Pain Clinic, Kolkata, West Bengal, and a Visiting Consultant at B.R. Singh Hospital, Kolkata. With an MD and certifications in pain management, rheumatology, and musculoskeletal ultrasound, he's a recognized authority. Dr. Roy is an executive committee member of the Indian Society for the Study of Pain, Scientific Secretary of the International Society for Musculoskeletal Ultrasound in Pain, author, co-editor, reviewer, and an experienced educator in pain medicine and ultrasound.
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