Published on February 25, 2014
REVIEW ARTICLE Sacroiliac Joint Dysfunction Evaluation and Management Boris A. Zelle, MD, Gary S. Gruen, MD, Shervondalonn Brown, MD, and Susan George, PT Abstract: Sacroiliac joint dysfunction is believed to be a signiﬁcant source of low back and posterior pelvic pain. Methods: To assess the clinical presentation, diagnostic testing, and treatment options for sacroiliac joint dysfunction, a systematic literature review was performed using MEDLINE. Results: Presently, there are no widely accepted guidelines in the literature for the diagnosis and treatment of sacroiliac instability. Establishing management guidelines for this disorder has been complicated by the large spectrum of different etiologic factors, the variability of patient history and clinical symptoms, limited availability of objective testing, and incomplete understanding of the biomechanics of the sacroiliac joint. Conclusions: A reliable examination technique to identify the sacroiliac joint as a source of low back pain seems to be pain relief following a radiologically guided injection of a local anaesthetic into the sacroiliac joint. Most patients respond to non-operative treatment. Patients who do not respond to non-operative treatment should be considered for operative sacroiliac joint stabilization. Key Words: sacroiliac joint, pain, review (Clin J Pain 2005;21:446–455) T he sacroiliac joint (SIJ) has been implicated as the primary pain source in 10% to 25% of the patients with low back pain.1,2 During pregnancy, 20% to 80% of the women experience low back or posterior pelvic pain frequently arising from the SIJ.3–10 Despite its frequency, the diagnosis and treatment of SIJ dysfunction has been poorly deﬁned in the literature. Many studies on the treatment of SIJ dysfunction have limitations, such as lack of randomization and heterogenous patient population. Therefore, the guidelines for the diagnosis and treatment of SIJ dysfunction remain controversial. Various factors contribute to this controversy. First, the patient history and the presenting symptoms vary, and the historical information is often nonspeciﬁc. The diagnosis is often complicated by Received for publication November 28, 2003; revised March 28, 2004; accepted April 18, 2004. From the Department of Orthopaedic Surgery, Division of Orthopaedic Traumatology, University of Pittsburgh Medical Center, Pittsburgh, PA. Reprints: Gary S. Gruen, MD, Professor, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Building, Suite 1010, 3471 Fifth Avenue, Pittsburgh, PA 15213 (e-mail: email@example.com). Copyright Ó 2005 by Lippincott Williams & Wilkins 446 concomitant discogenic pain or facet joint arthritis. These structures may refer pain to the SIJ or SIJ dysfunction may develop as a result of adaptive changes. Several reported examination techniques for diagnosing SIJ dysfunction have shown a low sensitivity and speciﬁcity in clinical trials. In addition, the availability of objective testing is limited, and radiological studies in patients with SIJ dysfunction are often difﬁcult to interpret. This article will review the anatomy of the SIJ as well as the etiology, diagnosis, and management of SIJ dysfunction. ANATOMY OF THE SACROILIAC JOINT The pelvis is formed by the 2 ilia and the sacrum. The sacrum is composed of 5 fused vertebrae and forms the posterior pelvic column. The adult SIJ is an auricular C-shaped joint. The anterior sacral side of the joint is lined by thick hyaline cartilage, whereas the posterior iliac side of the joint is lined by ﬁbrocartilage. The SIJ has been described as a true synovial joint. Many ligaments affect the stability of the SIJ. Simonian et al performed a cadaveric study in order to access the ligamentous contribution to pelvic stability.11 They described increased SIJ motion after the anterior and posterior interosseous ligaments were sectioned. The accessory ligaments, which include the iliolumbar, sacrotuberous, and sacrospinous ligaments, are also important stabilizers of the sacrum. Numerous sources innervate the SIJ. The synovial capsule of the SIJ and ligaments have unmyelinated free nerve endings that transmit pain and thermal sensation. The SIJ capsule is innervated by encapsulated and unencapsulated nerve endings. The posterior joint receives innervation from L3–S3, and the anterior joint receives innervation from L2– S2.12 Nerve innervation to the posterior ligaments arises from the lateral branches of the posterior primary rami L4–S1 and anterior rami L2–S2. Because there are various levels of innervation, pain from the SIJ may present in a varied pattern. DIFFERENTIAL DIAGNOSIS Pain at the SIJ may arise from various etiologies. Besides SIJ dysfunction, other conditions may affect the SIJ including inﬂammatory disease, infection, tumor, metabolic disorders, degenerative disease, iatrogenic conditions, referred pain, and trauma.13–16 Anky-losing spondylitis is the most common inﬂammatory condition that affects the SIJ. A febrile course in a patient with sacroiliac signs may be indicative of infection, particularly in a patient with a history of intravenous drug abuse.13 Primary or metastatic disease to the region of the SIJ Clin J Pain Volume 21, Number 5, September/October 2005
Clin J Pain Volume 21, Number 5, September/October 2005 Sacroiliac Joint Dysfunction will generally manifest with radiographic changes. The SIJ is a synovial joint and may be affected by metabolic conditions such as gout or pseudogout. Osteoarthritis may affect the SIJ and has a typical radiographic appearance. Degenerative changes on the radiograph are often coincidental because the discomfort produced by osteoarthritis is generally far less impressive than are the radiographs.17,18 Iatrogenic conditions include SIJ pain following bone graft harvesting procedures.14 The sacroiliac ligaments are among the strongest ligaments in the body, and the forces required to disrupt them are considerable. Therefore, most cases of traumatic SIJ dislocation result from high-energy trauma, and many patients have associated life-threatening injuries (ie, intra-abdominal injuries, pelvic bleeding).19 provoke pain in the SIJ.24,25 Due to the multiseg-mental innervation of the SIJ, pain arising from the SIJ may refer to various anatomic regions and diverse pain patterns have been described. Dreyfuss et al documented the pain referral pattern in 45 patients with low back pain with a positive response to a diagnostic SIJ block as well as the pain referral pattern in 40 patients with low back pain with a negative response to a diagnostic SIJ block.21 These authors reported that both patient populations described various and broad patterns of referred pain that encompassed the buttocks, the groin, and the entire lower limb. However, Dreyfuss et al noted that pain referral above the L5 level was not found in patients with pain originating from the SIJ and suggested this ﬁnding as a possibly discriminating feature.21 In a study by Fortin et al, the SIJ of asymptomatic volunteers were subjected to stress by ﬂuoroscopy-guided joint injections.26 Although various pain patterns were found, these authors established a composite drawing and identiﬁed an area extending 10 cm caudally and 3 cm laterally from the posterior superior iliac spine common to every volunteer. Based on these results, Fortin et al performed a consecutive study in which they identiﬁed 16 patients with low back pain with a pain referral pattern consistent with SIJ pain.2 Each of these patients had a provocative positive ﬂuoroscopy-guided injection of the SIJ. Therefore, we conclude that pain arising from the SIJ may radiate into various anatomic regions including the buttocks, the groin, and the entire lower limb. If the pain is referred above the ﬁfth lumbar level, it is unlikely that the SIJ is the source of pain. In patients with SIJ dysfunction, it can be expected that the pain referral pattern includes an area extending 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. ETIOLOGY OF SACROILIAC JOINT DYSFUNCTION A clear predisposition to SIJ dysfunction has not been identiﬁed. However, several factors such as degenerative joint disease, joint laxity, and trauma have been implicated in the etiology. The concept of degenerative conditions resulting in SIJ dysfunction is poorly reported in the literature. Anatomical investigations have shown that degenerative changes in aging SIJ are a common ﬁnding,20 and the grade of degeneration is usually not correlated with the clinical symptoms.17,18 The concept that ligamentous laxity may be a signiﬁcant contributor has been reinforced by the higher incidence in women as well as the increased prevalence during pregnancy. Additionally, SIJ dysfunction is also associated with a history of minor direct trauma such as a fall onto the buttocks. Bernard and Cassidy reported that 58% of those with SIJ dysfunction by history and physical examination presented with a history of minor trauma.13 Therefore, it could be assumed that a minor trauma may reveal clinical symptoms in patients with an individual predisposition to SIJ dysfunction. EVALUATION The clinical presentation of SIJ dysfunction varies, and several clinical tests for SIJ dysfunction have been shown to have limited validity.21–23 In addition, the evaluation is frequently complicated by associated spinal lesions. Bernard and Kirkaldy-Willis reported on a series of 336 patients with SIJ dysfunction; 39% were diagnosed having an associated spinal disorder. Among those associated spinal disorders, facet joint syndrome (41%) and spondylolisthesis (29%) were the most common.1 Clinical Presentation SIJ dysfunction often becomes symptomatic following a minor traumatic event. The typical scenario includes a fall onto the buttocks or a slip while pushing a heavy object. Pain arising from the SIJ may be described as aggravated by transitional activities such as climbing stairs, getting up from a chair, or getting out of a car. In particular, activities requiring asymmetrical loading through the lower extremity or pelvis such as skating, gymnastics, golﬁng, and step aerobics may q 2005 Lippincott Williams & Wilkins Physical Examination and Clinical Tests The physical examination includes an evaluation of the lumbar spine, hips, and pelvis. One of the most consistent physical ﬁndings in patients with SIJ dysfunction is point speciﬁc tenderness over the sacral sulcus as well as the posterior sacroiliac spine. In the diagnosis of SIJ dysfunction, there are several clinical tests used which, in general, can be divided into motion palpation tests and pain provocation tests. The motion palpation tests are designed to detect asymmetric SIJ motion. The Gillet test is the most frequently studied motion palpation test and is performed with the patient standing. One of the examiner’s thumbs is placed on the second sacral spinous process and the other thumb on the posterior superior iliac spine. The patient is asked to raise the involved leg, which maximally ﬂexes the hip. Usually the posterior superior iliac spine moves inferiorly in relation to the second sacral spinous process. However, in patients with dysfunction of the SIJ, the posterior superior iliac spine remains at the level of the second sacral spinous process, and the maneuver is usually painful. The pain provocation tests are based on reproducing the pain arising from the SIJ area. The Gaenslen test is performed with the patient supine on the examining table. One hip joint is maximally ﬂexed, whereas the other is maximally extended simultaneously. The test will stress both SIJ simultaneously. If the patient has posterior pelvic pain, the test is considered positive. The Patrick, or FABER (ﬂexion abduction and external rotation), test stresses the hip and SIJ. The test is performed by 447
Zelle et al moving the ﬂexed, abducted, and externally rotated hip to an extended position. If the test is positive, the patient describes pain at the posterior superior iliac spine and the SIJ. The POSH (posterior shear) or thigh thrust test is performed by ﬂexing the hip to 90°, adducting the femur to the midline, and applying axial pressure along the femur. This maneuver causes posterior shear forces on the ilium and therefore results in pain over the SIJ in symptomatic patients. The REAB (resisted abduction) test is done with the patient supine and the fully extended leg in 30° abduction. The patient is pushing the leg laterally while the examiner holds the leg by the ankle. This test reproduces the patient’s SIJ pain by stressing the cephalic aspect of the SIJ. The Yeoman test is performed with the patient prone. The test is performed by extending the hip and rotating the ilium. Usually, the patient will report pain over the posterior SIJ. It is important that the clinical SIJ tests used are reproducible so that they are capable of producing meaningful results. However, the reliability of the different SIJ tests is variable.21,27,28 It seems that the Gaenslen test, the FABER test, and the POSH test are the are the most reliable examination techniques with an acceptable clinical reliability of greater than 80%.21,28 However, both valid and reliable test results are necessary to support the quality of a diagnostic test. Regarding the validity of the SIJ tests, it seems that only the POSH test reaches an acceptable sensitivity and speciﬁcity of higher than 80% and therefore appears to be superior to other clinical SIJ tests.29,30 Due to the limited reliability and validity of most clinical SIJ tests, various combinations of clinical tests have been suggested for the diagnosis of SIJ dysfunction.27,29 Cibulka et al examined the clinical usefulness of a cluster of SIJ tests. They reported 0.82 sensitivity, 0.88 speciﬁcity, 0.86 positive predictive value, and 0.84 negative predictive value when a combination of tests was used.27 Broadhurst and Bond evaluated the sensitivity and speciﬁcity of the FABER, POSH, and REAB tests for the diagnosis of SIJ dysfunction.29 Their study indicated that the 3 tests in combination had a high predictive value for identifying patients with pain arising from the SIJ. Moreover, the sensitivity ranged from 70% to 80% and the speciﬁcity was 100%. Intra-articular injection of the SIJ are a useful technique in establishing the SIJ as a source of pain and can be considered the diagnostic gold standard for SIJ dysfunction.23,31 The patient’s response should be monitored as should the duration of pain relief. A positive response is recorded when there is greater than 90% relief of pain initially and at 2 weeks.32 Radiological Evaluation The radiological evaluation of the SIJ remains challenging. No studies have clearly documented radiographic abnormalities in SIJ dysfunction. However, imaging assessment of the SIJ in patients with persistent SIJ pain is important to rule out sacroiliitis, fractures, or tumors. In these patients, the most commonly used techniques include conventional radiography, computed tomography (CT), magnetic resonance imaging (MRI), and scintigraphy. Thermography, conventional tomography, and arthrography of the SIJ have been described but are of limited use.33 The anatomical complexity of the joint, its structure, individual variation, and location have led to the development 448 Clin J Pain Volume 21, Number 5, September/October 2005 of a number of radiographic techniques designed to reveal particular aspects of SIJ pathology. The conventional posteroanterior projection technique in the prone position with the tube rotated oblique by 25° to 30° is recommended in order to obtain an image of the SIJ tangential to the beam of radiation.34 Alternatively, a Ferguson view (anteroposterior with the tube angled 30° cephalad) projects the beam at a right angle to the sacrum, allowing better visualization of the anterior and posterior SIJ lines.34,35 A recent retrospective study indicates that radiographs in the prone position in addition to conventional pelvic or lumbar spine views did not provide signiﬁcant additional information in most patients.36 The CT scan can deﬁne early joint narrowing and bony abnormalities such as fractures that are sometimes not visible on conventional radiographs. However, it has been noted that subchondral sclerosis, joint space narrowing, and osteophytes are natural aging phenomena.34,37 Recent studies have indicated that the MRI is useful in the detection of early sacroiliitis and neoplastic lesions.38–40 However, there are no reports regarding the use of the MRI in the evaluation of patients with SIJ dysfunction. We therefore suggest that MRI in the diagnosis of SIJ dysfunction plays a limited role and should be mainly used to rule out inﬂammatory, traumatic, or neoplastic sources of SIJ pain. Bone scintigraphy41–45 and single photon emission computed tomography (SPECT)45–47 of the SIJ are feasible screening methods for demonstrating inﬂammation, stress fracture, or neoplasm involving the SIJ. In addition, there is evidence that quantitative scintigraphy could be an objective test for diagnosing SIJ dysfunction because there is increased uptake on the symptomatic side.48,49 Slipman et al reported that in patients with SIJ dysfunction, the sensitivity of a bone scan can be as low as 12.9%.50 Finally, it has been our experience that scintigraphy for the detection of SIJ dysfunction is limited and is not routinely performed. MANAGEMENT The treatment of sacroiliac dysfunction remains controversial. The osteopathic approach incorporates joint-speciﬁc manipulative techniques in order to restore normal joint dynamics.51–54 Physical therapy strategies emphasize manual correction of SIJ asymmetry, lumbopelvic stabilization, and correction of muscle imbalance.55 However, outcome data following management of SIJ dysfunction are limited and, to our knowledge, randomized clinical trials comparing different treatment methods have not been reported. Physical Therapy Prather discussed the nonoperative approach to SIJ dysfunction, as divided into an acute phase, a recovery phase, and a maintenance phase.24,25 In the acute setting (1–3 days), antiinﬂammatory medications, relative rest, and icing are helpful. Activities requiring single-leg stance such as skating, gymnastics, golﬁng, or step aerobics should be avoided. Asymmetries in muscle strength, muscle stiffness, and anatomical leg length discrepancies should be addressed within pain-free limits. In the recovery phase (3–8 days), the correction of biomechanical deﬁcits becomes the focus of treatment. To address muscle q 2005 Lippincott Williams & Wilkins
Clin J Pain Volume 21, Number 5, September/October 2005 imbalances affecting the pelvic ring mobility, muscle length and ﬂexibility must ﬁrst be restored to shortened muscles. Commonly shortened muscles affecting pelvic ring mobility may include the erector spinae, iliopsoas, rectus femoris, hip abductors including the tensor fascia late, hip adductors, quadratus lumborum, and deep hip external rotators including the obturator internus and piriformis muscles.24,25,55–57 After ﬂexibility has been established, strengthening exercises should be added to the therapy protocol. SIJ belts for additional stability as well as SIJ injections for additional pain relief can be used as an adjunct to physical therapy. During the maintenance phase (beyond 8 weeks), retraining of multiple muscle groups to work in coordination becomes more important. According to Prather, advanced proprioceptive reeducation is the key to a successful complete recovery. Lumbopelvic stabilization exercise assists the patient in developing appropriate muscle awareness and effective patterns of muscle ﬁring between the ‘‘inner core muscles’’ and ‘‘outer core muscles’’ in order to stabilize the pelvic ring. Research thus far suggests that the postural inner core muscles increase their level of recruitment prior to initiation of movement regardless of movement direction to stabilize the load transfer through the pelvic ring.58–60 The outer core muscles synergistically ﬁre after the inner core muscles to enhance stabilization. The inner core muscles consist of the transverse abdominus, deep ﬁbers of the multiﬁdus, diaphragm, and levator ani. The outer core muscles include the oblique abdominals, latissimus dorsi, erector spinae, biceps femoris, hip adductors and adductors, gluteus maximus, medius, and minimus. The balanced actions of theses muscles limit the shearing forces at the SIJ and symphysis pubis.58 Patients with low back pain experience signiﬁcantly delayed transverse abdominus contraction and multiﬁdus inhibition.61,62 Initial ﬁndings suggest that facilitated exercise of the multiﬁdus and transverse abdominis signiﬁcantly reduces the return of low back pain after an acute low back pain episode.58 The development of these motor-planning strategies, which train inner unit activation prior to outer unit movement, seems to provide the patient and the physical therapist with promising tools to effectively stabilize their pelvic ring. In a cadaveric study, Vleeming et al demonstrated the importance of the outer system comprised of the gluteus maximus muscle and the contralateral latissimus dorsi muscle for the stabilization of the SIJ.63 These muscles are coupled through the posterior layer of the thoracolumbar fascia and create forces perpendicular to the SIJ. Therefore, the combined forces of these 2 muscles are hypothesized to play an important role for stabilizing the SIJ, especially during rotation of the trunk. Based on this reciprocal anatomical relationship, Mooney et al conducted an electromyographic study conﬁrming the functional reciprocal gluteus-latissimus relationship.57 Interestingly, these authors also observed electromyographic hyperactivities of these muscles in symptomatic patients. These electromyographic hyperactivities as well as the clinical symptoms decreased under a rotary strengthening exercise program. These anatomical and clinical ﬁndings suggest a rational base for strengthening exercise programs. In addition to physical therapy, SIJ stabilization can also be achieved or augmented by orthotic devices such as q 2005 Lippincott Williams & Wilkins Sacroiliac Joint Dysfunction sacroiliac belts. This therapy may provide additional pain control secondary to external stabilization of the SIJ . Vleeming et al documented that prolonged external stabilization with a brace or a SIJ belt is a reliable treatment method for instability caused by ligamentous damage in multiparous women.64 Most patients with SIJ dysfunction respond to physical therapy. In a prospective study, Sasso et al reported functional improvement in 95% of the patients with SIJ dysfunction following physical therapy at a 2-year follow-up.65 Inferior results were obtained in 25% of patients with chronic symptoms. Their physical therapy program consisted of patient education, lumbopelvic stabilization exercises, abdominal strengthening, and joint mobilization with adjustments in the training program according to age, body habits, and mobility. Manipulation In general, manipulative therapies can be divided into 2 categories: the nonimpulse-based therapies and the impulsebased therapies. The nonimpulse-based therapy includes lowforce and low-velocity procedures such as trigger point therapies and muscle energy techniques. Most reports dealing with joint manipulation focus on impulse-based therapies. In these techniques, the therapist uses high velocity and high force, and these procedures are usually associated with an audible release. The therapeutic effect of this treatment is still unclear. Most investigations on the mechanics of joint manipulations were performed on metacarpophalangeal joints.66–70 As suggested by several experimental studies, the audible crack during manipulation is probably generated from a cavitation mechanism within the joint because of a drop in the internal joint pressure.66,68–70 This pressure drop results in the release of dissolved gasses (mainly carbon dioxide) within the synovial ﬂuid, as evidenced by postmanipulation radiographs.67–70 Due to its elastic recoil, the capsule snaps back, increasing the volume of the capsule. Based on neurophysiological studies, it is assumed that the therapeutic effect of joint manipulation relies on the stress on the ligaments and other periarticluar structures during the joint manipulation, which causes ﬁring of high-threshold afferent muscle/joint mechanoreceptors.71 According to this theory, the stimulation of muscle and joint afferents causes a reﬂex relaxation of muscles as well as reﬂex actions that inhibit pain receptors on the segmental level. The current literature suggests that most patients with a SIJ dysfunction beneﬁt from manipulation. Bernard and Cassidy reported a series of 258 patients with SIJ dysfunction treated with manipulations. Excellent results were obtained in 95% of the patients.13 However, no long-term follow-up was presented in this series, and it remains unclear in how many percent the symptoms recur. Osterbauer et al treated a series of 10 patients with SIJ dysfunction with short-lever manipulation 3 times per week for 5 weeks.54 A 1-year follow-up was obtained for 6 patients who reported satisfying results. Herzog et al followed a series of 11 patients who were treated with spinal manipulations 3 times per week over a 2-week period.52 Although pain, joint mobility, and the Oswestry score improved in most patients until the end of the treatment, most patients worsened within the ﬁrst 2 weeks posttreatment. We conclude that manipulations appear to be successful in many patients suffering from SIJ dysfunction; however, it remains uncertain 449
Zelle et al if pain recurrence can be prevented using this treatment approach. Injection Therapy The safety, efﬁcacy, and reproducibility of injection therapy have been demonstrated in both spondyloarthropathy and patients with SIJ dysfunction.72–78 SIJ injections are of therapeutic as well as diagnostic value. In patients with low back pain, the injection of corticosteroids has shown to improve the pain for several months.73–76,78 However, the anti-inﬂammatory effect is not permanent, and the injections do not offer an opportunity to stabilize an incompetent joint.74,77 Because signiﬁcant pain relief can usually not be recorded at 6 months postinjection,74 repeated injections are often required in order to obtain continuous pain relief.78 On the other hand, SIJ injections represent an important diagnostic tool. It is widely accepted that the identiﬁcation of the SIJ as the primary source of pain requires a signiﬁcant pain relief following the injection of a local anaesthetic.2,23,79 Due to the complex anatomy of the SIJ, intra-articular injections should be performed under radiographic control.1,2,26,74–78,80 Fluoroscopy-guided injections, as the standard technique, are usually effective for the majority of patients and successful results have been reported.2,26,75,76,78,80 Computed tomographyguided injections seem to be helpful in cases with severe sclerotic changes and narrowing of the joint space.74,77,81 In addition, we perform CT-guided injections if the diagnostic SIJ injection is part of the workup for a possible surgical intervention. In cases where the radiation exposure is undesireable (for example, young women), MRI-guided corticosteroid injection of the SIJ is a feasible option and the reported experiences are promising.33,73 As an alternative to intra-articular SIJ injections, Cohen and Abdi recently suggested lateral branch blocks as a treatment option for SIJ pain.82 In this pilot study, the authors investigated the efﬁcacy L4 and L5 dorsal rami and S1–S3 lateral branch blocks and reported that some pain relief was obtained in 17 of 18 patients. However, only 13 of 18 patients obtained more than 50% pain relief. Therefore, Cohen and Abdi suggested further controlled clinical trials in order to evaluate the clinical outcomes. It can be speculated, however, that the success rates of lateral branch blocks are limited by the various innervation patterns of the SIJ. We therefore conclude that SIJ denervation cannot be recommended as a standard technique until the success rates have been established in further clinical trials. Prolotherapy The concept of ligament stimulation by connective tissue proliferant injection in order to stabilize the incompetent SIJ has gained recent interest. In a prospective, randomized, double-blind study in patients with low back pain, Ongley et al performed 6 consecutive injections of dextroseglycerin-phenol at weekly intervals as well as Xylocaine injections in a control group. At 6 months posttreatment, signiﬁcantly greater improvements of pain and disability were recorded in the proliferant group.83 Similar results were reported by the same group 6 years later.84 However, the value of their outcomes was 450 Clin J Pain Volume 21, Number 5, September/October 2005 limited by a relatively short follow-up and the concomitant treatment consisting of regular exercise, spinal manipulation, and injections of local anesthetics. In addition, these studies were performed in patients with low back pain. Although it can be inferred that patients with SIJ dysfunction may also beneﬁt from the joint stabilizing effect, speciﬁc outcomes that can be achieved in this patient population need to be investigated. Operative Treatment Surgical treatment options include SIJ denervation and SIJ arthrodesis. The injection of 96% ethanol is questionable as an effective method for denervation, as it may also cause damage to the surrounding tissue. Radiofrequency denervation seems to be a more precise option because the damage to the surrounding bone and soft tissue can be minimized by ﬂuoroscopic85 or CT86 guidance. Although long-term results following radiofrequency SIJ denervation have not been published, previous publications suggest that many patients have recurrent symptoms within the ﬁrst 6 months following the denervation and that also the number of responders is limited.85,86 We therefore assume that radiofrequency denervation is complicated by the complex innervation of the SIJ. In order to optimize the treatment results, Cohen and Abdi suggested radiofrequency denervation for those patients who have responded to a local anesthetic nerve blockade.82 In their pilot study, Cohen and Abdi performed radiofrequency denervation in 9 patients who had responded to previous local anesthetic nerve blockades. They reported a successful outcome in 8 of 9 patients at 9 months follow-up. Therefore, these authors recommended that the success rates of this treatment approach warrants further evaluation with randomized controlled clinical trials. Various surgical techniques have been described for SIJ arthrodesis. These techniques have been mainly used in patients with dislocation and fracture dislocation of the SIJ. The anterior approach proceeds along the inner table of the ilium to the SIJ, denuding the cartilage, bone grafting, and internally ﬁxing with plates and screws.87–89 Posterior ﬁxation includes transiliac bars, double cobra plates, tension bend plates/transiliac reconstruction plates, and iliosacral screws.90–92 In addition, percutaneous ﬁxation with screws or bars using ﬂuoroscopic or CT guidance has been widely used in recent years.19,93,94 Outcome studies on patients with SIJ dysfunction undergoing surgical SIJ stabilization are limited, because most patients seem to respond to nonoperative treatment. Shuler and Gruen reported the successful sacroiliac arthrodesis and remittance of pain in a patient with chronic postpartum pelvic pain.95 Berthelot et al reported a successful outcome in 2 patients undergoing SIJ fusion using autogenous bone grafting and iliosacral screw ﬁxation.96 Belanger and Dall reported successful clinical and radiographic fusion in 4 patients followed for up to 9 years.97 In a series of 22 patients, Waisbrod et al reported satisfactory results in 50% of the patients at 30 months after surgery using a bone grafting technique without instrumentation.98 Two nonunions were recorded in their series. Lippitt presented a series of 23 patients with isolated SIJ dysfunction. Although 48% had complete q 2005 Lippincott Williams & Wilkins
Clin J Pain Volume 21, Number 5, September/October 2005 Sacroiliac Joint Dysfunction relief of pain by transﬁxing the SIJ with 3 percutaneous screws, 3 of the patients had no relief at all.99 There was no incidence of nonunion, device failure, or infection. Finally, Moore reported the outcome of 38 patients undergoing SIJ fusion using a screw ﬁxation technique.100 In this study, 35 patients were available for follow-up at 20 months. The workers’ compensation patients reported an average improvement of 32%, whereas the nonworkers’ compensation patients reported an average improvement of 61%. Four nonunions were recorded in this series. In order to obtain satisfactory clinical results, optimal patient selection is required. Waisbrod et al emphasized the importance of thorough patient evaluation leading to purposeful selection and recommended a surgical fusion be performed only if each of the following mandatory criteria was fulﬁlled: constant lower back pain of prolonged duration, pain with radiation into the groin or thigh without radicular pain pattern, positive radiological ﬁndings, positive scintigraphy, positive pain provocation test, pain relief following inﬁltration, and no psychosomatic disorders.98 Based on our experience and the current literature, the following algorithm for patients presenting with posterior pelvic pain is utilized (Fig. 1). Initially, the primary source of pain should be identiﬁed through a detailed history and clinical exam. If the SIJ appears to be the main source of pain, the patient is enrolled in a 6-week treatment program utilizing physical therapy, aquatherapy, and anti-inﬂammatory medication. If no signiﬁcant improvement in pain relief is achieved, a CT-guided injection of the SIJ using a local anaesthetic combined with a longacting corticosteroid is performed. The diagnosis of SIJ dysfunction is established if the patient experiences both immediate and signiﬁcant pain relief. The intraarticular injections can be repeated once if temporary pain relief has been obtained by the ﬁrst injection. In our protocol, patients are only considered for surgical stabilization if they meet all of the following inclusion criteria: appropriate history and physical ﬁndings, unresponsive pain to speciﬁc physical therapy, immediate complete pain relief following CT-guided injections, followed by a recurrence of pain after 2 to 3 weeks. For SIJ fusion, iliosacral screw ﬁxation remains our preferred technique because it has been shown to be a safe and reliable technique,19 and fusion rates of greater than 90% are achieved. However, we emphasize that the patient selection is of paramount importance in order to ensure satisfactory clinical outcomes following SIJ fusion. Therefore, we adhere to a careful selection algorithm (Fig. 1) and achieve satisfactory clinical results in approximately 80% of the patients undergoing surgical SIJ arthrodesis. FIGURE 1. Algorithm for the management of sacroiliac joint pain. q 2005 Lippincott Williams & Wilkins 451
Zelle et al POSTERIOR PELVIC PAIN DURING PREGNANCY The incidence of pelvic and/or low back pain in pregnancy varies between 20% and 80%.3–10 The onset of pregnancyrelated low back and pelvic pain occurs between the 18th and the 24th week of pregnancy.4,101 The symptoms often disappear within the ﬁrst 2 months following childbirth.102–104 However, approximately 20% of the women with low back and pelvic pain during pregnancy and 5% of all pregnant women have persistent complaints at 3 years following delivery.104 Reported risk factors for developing pregnancy-related low back and pelvic pain include increased body mass index,4,102 number of previous pregnancies,4,9,105 young age,4,106 low education level,106 back pain prior to pregnancy,9 and poor muscle function.104 Hormonal, biomechanical, circulatory, and psychosocial changes during pregnancy may play a role in the etiology of pregnancy-related low back pain. Ostgaard et al reported that biomechanical factors such as sagittal and transverse abdominal diameter or lumbar lordosis could predict the occurrence of low back and pelvic pain.107 However, pregnancyrelated pain cannot be explained solely by biomechanical changes during pregnancy. Evidence of systemic causes includes the early onset of pain during pregnancy that does not parallel the weight gain.4 MacLennan et al were the ﬁrst to show a correlation between symphyseal pain and relaxin values.108 Relaxin is an ovarian peptide hormone of the insulin-like growth factor family. In women, circulating relaxin shows a marked increase in early pregnancy and peaks around the 12th to 14th gestational week.109–111 Although the physiologic effect of relaxin in humans is not completely understood, it can be assumed that it plays a role for the connective tissue remodeling in pregnant women.112 These alterations may inﬂuence the ligament apparatus and make the low back more vulnerable to loading. We therefore assume that pregnancyrelated low back and pelvic pain is probably a result of the interaction of hormonal changes during pregnancy and increased biomechanical loads on the pelvis. This assumption is also consistent with the results from anatomic investigations, which showed variably deep bony pits and craters at the insertions of the ligaments at the posterior part of the os pubis, at the anterior part of the os ileum and the os sacrum in previously pregnant women, but they have not been shown in nulliparous women or in men.113,114 Because diagnostic options are limited during pregnancy, the identiﬁcation of the SIJ as the primary source of posterior pelvic pain is complicated. Therefore, the diagnosis is usually based on the patient history, pain drawings, clinical provocation tests, and pain relief by a sacroiliac belt.4,8,101 In the history, a pregnant woman with pain arising from the SIJ will describe pain in the posterior pelvis and the deep gluteal area. The pain is often exacerbated by prolonged walking or standing. A pain diagram will show markings of stabbing pain in the buttock and eventually the posterior aspect of the ipsilateral thigh.115 The most commonly recommended clinical examination technique seems to be the POSH test, which is easy to perform even late during pregnancy and has shown sensitivity, speciﬁcity, and interexaminer agreements of greater than 80%.30,115–117 In addition, the FABER test has shown satisfactory results,116 and it has been suggested that the 452 Clin J Pain Volume 21, Number 5, September/October 2005 best discriminatory power can be achieved by combining different pain provocation tests.117 Education is a crucial part of managing pregnancyrelated low back and pelvic pain. Women should be aware that their symptoms are a common ﬁnding secondary to biomechanical and hormonal factors. They should also understand that they are at risk for residual pain after pregnancy and recurrent symptoms during consecutive pregnancies. Physical therapy should be based on stabilizing treatment. Noren et al identiﬁed poor muscle function as a signiﬁcant risk factor for persistent postpartum low back and pelvic pain,104 indicating that in this patient population, strengthening exercise should be a primary goal of physical therapy. Additional stability can be obtained by the use of a sacroiliac belt, and relief of symptoms may be provided by its application.24,25,64 Manipulation treatment should be avoided during pregnancy. Although acetaminophen can be taken to relieve pain, nonsteroidal anti-inﬂammatory agents are generally contraindicated during pregnancy. CONCLUSIONS Although SIJ dysfunction is a common problem in the outpatient setting, widely accepted diagnostic and treatment guidelines have not been established in the literature. Most patients respond to nonoperative treatment, and few patients require surgery. A thorough selection protocol should be followed prior to using more invasive treatment methods. Based on previous literature reports and our own experience, we utilize the following treatment algorithm (Fig. 1). All patients presenting with clinical symptoms undergo a thorough clinical examination. The POSH test seems to be a useful clinical test for the diagnosis of SIJ dysfunction. However, we recommend a combination of different clinical SIJ tests in order to reliably establish the SIJ as pain source. In addition, conventional radiographs are recommended in order to screen for traumatic and neoplastic lesions. If the clinical evaluation suggests SIJ dysfunction, the patient is enrolled in a 6-week program of physical therapy. In those patients who do not respond to nonoperative treatment methods, a CT-guided local anesthetic/steroid injection is indicated in order to establish the SIJ as the primary source of pain. Only the patients who experience signiﬁcant relief of pain for 2 to 3 weeks following the injection are candidates for a surgical SIJ arthrodesis. In these patients, we recommend an iliosacral screw ﬁxation in order to obtain a surgical ﬁbroarthrodesis of the SIJ. However, it must be emphasized that most patients respond to nonoperative treatment. Invasive procedures are rarely required and should only be performed if the diagnosis of SIJ dysfunction has been well established and thoroughly addressed nonoperatively. REFERENCES 1. Bernard TN, Kirkaldy-Willis WH. Recognizing speciﬁc characteristics of nonspeciﬁc low back pain. Clin Orthop. 1987;217:266–280. 2. Fortin JD, Aprill CN, Ponthieux B, et al. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. 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