Sacroiliac Joint: Review of the Literature and Current Treatments

Educational Objectives

The goal of this program is to improve the treatment of patients with pain in the sacroiliac (SI) joint. After hearing and assimilating this program, the clinician will be better able to:

1. Cite current literature about diagnosis and management of SI joint pain.
2. Select appropriate therapies for patients with SI joint pain.

Summary

Background: surgical fusion of sacroiliac (SI) joint first reported in early 1900s; anterior approach described in 1920s; pain related to SI joint subsequently overshadowed by other pathologies

Anatomy: anatomy of SI joint variable; synovial part of joint typically includes S1 and S2 but may also include S3; 75% of joint fibrous and ligamentous; shape of synovial joint variable; additional research required to determine proportion of pain generated by ligaments, muscles, or nerves as opposed to articular surface or joint itself

Shape: large variety of shapes of SI joint observed on computed tomography (CT) in patients without pain; patients with C-shaped or boomerang-shaped SI joint, compared with broader articular surface, on CT more likely to have pain; observation supported mathematically by statistical shape-modeling

Movement: SI joint historically thought not to move; literature shows at least several degrees of motion; investigation of flexion-extension x-rays in speaker’s patients showed large variability in motion of SI joint; range of motion in SI joint varies up to ±10° in some patients; center of rotation variably posterior and inferior to joint itself; motion more nutation (as opposed to rotation)

Fortin et al (1994): performed provocative injections on normal volunteers and evaluated pattern of pain; Fortin finger test based on study; in secondary study, Fortin et al (1994) performed anesthetic injections in patients with pain in low back and area of SI joint; majority of relief located in lower buttocks (Fortin area); majority of patients with pain related to SI joint experience pain in Fortin area and variably in other areas; Fortin et al (1994) used relief of pain as diagnostic criterion; sensitivity and specificity for SI joint not currently known

Findings on physical examination: based on use of injection studies as diagnostic test; ≥3 positive tests required for reasonable sensitivity and specificity; multitest regimens most conclusive; physical examination involves evaluation of intra- and periarticular pathology

Specificity of injections: test-retest evaluations currently available in literature; rate of false-positive results 11% to 22% for intra-articular injections; false positives call into question use of intra-articular injection as gold standard for diagnosis; amount of pain relief required to qualify as positive response remains undefined

Injections of steroids: literature unclear about benefit of intra-articular injection of steroids; Liliang et al (2009) found >75% relief of pain in 39 out of 150 patients; 26 patients experienced relief lasting >6 wk; other investigators showed similar results; speaker concludes intra-articular steroids worth trying but may not provide lasting relief

Prolotherapy: involves injection of dextrose or other irritants to simulate inflammatory response; Kim et al (2010) found prolotherapy, compared with injection of steroids, associated with more sustained relief at >12 mo

Manipulation: many uncontrolled studies; few long-term conclusions; considered low risk and generally beneficial

Radiofrequency (RF): broad categories include conventional, bipolar, and cooled RF; Patel et al (2016) showed >50% relief of pain in 79% of patients at 1 mo, 64% at 3 mo, and ≈50% at 6 mo; RF shows potential for relief of pain; data limited, but risk appears relatively low; long-term data currently lacking

Open surgery: early reports on fusions showed relatively mediocre rates of success and high rates of nonunion, high morbidity, and long stays in hospital; more recent reports using open posterior approaches and posterolateral windows in ilium showed rates of success ≈50%, with high rates of nonunion and morbidity

Minimally invasive treatments: initial data show greater improvement with minimally invasive treatments, compared with open techniques; Cross et al (2018) showed high rate of successful fusion using technique incorporating decortication, screws, and bone grafting in 19 patients with follow-up of 24 mo; using same technique, Araghi et al (2017) showed 72% rate of success at 6 mo in 50 patients

Distraction arthrodesis: Fuchs et al (2018) showed robust rate of success at 2 yr in 171 patients; another study incorporating distraction arthrodesis showed rate of fusion 79%, with significant improvements in Oswestry Disability Index (ODI) and Visual Analog Scale (VAS); using posterior lateral oblique and posterior medial oblique approaches with bone morphogenetic protein, Beck et al (2015) reported rate of fusion 97% in study of 20 patients (33 SI joints)

Triangular implants: trials showed significant improvements in SI joint-related pain (based on VAS and ODI) and significant improvements, compared with nonsurgical treatments

Lasting relief: data show more lasting relief, suggesting solid fusion or at least stabilization of joint; superiority of fusion vs stabilization remains to be established; lasting benefits for relief of pain shown for fusion compared with RF denervation or conservative management; fusion decreases use of opioids

Readings

Araghi A et al: Pain and opioid use outcomes following minimally invasive sacroiliac joint fusion with decortication and bone grafting: the Evolusion clinical trial. Open Orthop J 2017;11:1440-8; Beck CE et al: A retrospective outcomes study of 20 sacroiliac joint fusion patients. Cureus 2015 Apr;7(4):e260;Cross WW et al: Minimally invasive sacroiliac joint fusion: 2-year radiographic and clinical outcomes with a principles-based SIJ fusion system. Open Orthop J 2018;12:7-16; Fortin JD et al: Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. part II: clinical evaluation. Spine (Phila Pa 1976) 1994 Jul 1;19(13):1483-9; Fortin JD et al: Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. part I: asymptomatic volunteers. Spine (Phila Pa 1976) 1994 Jul 1;19(13):1475-82; Fuchs V et al: Distraction arthrodesis of the sacroiliac joint: 2-year results of a descriptive prospective multi-center cohort study in 171 patients. Eur Spine J 2018 Jan;27(1):194-204; Kim WM et al: A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med 2010 Dec;16(12):1285-90; Liliang PC et al: The therapeutic efficacy of sacroiliac joint blocks with triamcinolone acetonide in the treatment of sacroiliac joint dysfunction without spondyloarthropathy. Spine (Phila Pa 1976) 2009 Apr 20;34(9):896-900; Patel N: Twelve-month follow-up of a randomized trial assessing cooled radiofrequency denervation as a treatment for sacroiliac region pain. Pain Pract 2016 Feb;16(2):154-67.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Patel was recorded at the 3rd International Conference on Sacroiliac Joint Surgery, held February 21-24, 2018, in Tampa, FL, and presented by the University of South Florida Department of Continuing Education. For information about upcoming CME opportunities from the University of South Florida, please visit www.usf.edu/continuing-education/. The Audio Digest Foundation thanks the speakers and the University of South Florida for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR411302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.