Diagnosis and Differential Diagnosis of Sacroiliac Joint Pain

Educational Objectives

The goal of this program is to improve management of sacroiliac joint-related pain. After hearing and assimilating this program, the clinician will be better able to:

1. Apply principles and techniques to optimize outcomes after radiofrequency neurotomy.
2. Determine whether the sacroiliac joint is the source of a patient’s low back pain.

Summary

Diagnosis of source of low back pain: Spratt et al (1990) stated precise diagnosis unknown in 80% to 90% of patients with disabling low back pain; concept derived from paper by Dillane et al (1966); authors unable to identify cause of low back pain in 79% of men and 89% of women; statement no longer considered accurate

Prevalence: published estimates of prevalence of pain in sacroiliac (SI) joint 13% to 30%; DePalma et al (2011) showed SI joint accounted for 18.2% (confidence interval [CI] 13%-24.7%) of cases of chronic low back pain; mean age of patients with pain in SI joint 61 yr (CI 55-68 yr); younger patients tended to have painful disc; older patients tended to have painful joint (eg, facet, SI); age strongly associated with source for pain in back (likelihood of pain in SI joint increases with increasing age)

Lumbosacral fusion: studies showed prior lumbar or lumbosacral fusion increased prevalence of painful SI joint to 32% to 35%; low back pain after fusion that differs from preoperative low back pain may suggest SI joint as source; time from fusion to onset of new pain >3 mo consistent but not predictive of pain in SI joint

DePalma et al (2011): investigated patients with chronic low back pain and history of lumbar fusion; 43% had painful SI joint (CI 26.5%-60.9%); statistically, history of lumbar or lumbosacral fusion in patients with chronic low back pain associated with higher prevalence of pain in SI joint, compared with patients without fusion; surgical construct extending to sacrum also risk factor for pain in SI joint after fusion; computer model demonstrates increase in sacral angular motions and stress on articular surface of SI joint after surgical construct extending to sacrum; moments increase linearly as fusion extends to sacrum

Features of low back pain predictive of SI joint as source: pain related to SI joint typically does not occupy midline; DePalma et al (2011) showed midline low back pain moderately reduced statistical likelihood of SI joint as source of pain; DePalma et al (2012) observed probability of SI joint-related pain increased with increasing age and decreasing body mass index (BMI), primarily in female patients; probability of SI joint-related pain increases with female sex, low BMI, and increasing age; changes in hormone levels may affect ligamentous laxity; bleeding within SI joint during peripartum and postpartum periods speculated to potentially predispose patient to symptoms over time; strain on SI joint may be increased in patients with low BMI because weight line ventral to pelvis

Referral pattern: referral to groin consistent pattern for SI joint (also indicative of intra-articular pathology of hip joint); SI joint rarely causes pain above level of L5; piriformis syndrome typically presents with more medial, gluteal pain, with referral to posterolateral thigh and/or leg; SI joint-related pain more axial paramidline lumbosacral; referral pattern with piriformis syndrome may more closely resembles that for inflamed nerve root; L5 or S1 radicular pain or radiculopathy can present similarly to SI joint-related pain

Readings

DePalma MJ et al: What is the source of chronic low back pain and does age play a role? Pain Med 2011 Feb;12(2):224-33; DePalma MJ et al: Etiology of chronic low back pain in patients having undergone lumbar fusion. Pain Med 2011 May;12(5):732-9; DePalma MJ et al: Multivariable analyses of the relationships between age, gender, and body mass index and the source of chronic low back pain. Pain Med 2012 Apr;13(4):498-506; DePalma MJ et al: Does the location of low back pain predict its source? PM R 2011 Jan;3(1):33-9; Dillane JB et al: Acute back syndrome-a study from general practice. Br Med J 1966 Jul 9;2(5505):82-4; 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; Irwin RW et al: Age, body mass index, and gender differences in sacroiliac joint pathology. Am J Phys Med Rehabil 2007 Jan;86(1):37-44; Spratt KF et al: A new approach to the low-back physical examination. behavioral assessment of mechanical signs. Spine (Phila Pa 1976) 1990 Feb;15(2):96-102

Disclosures

For this program, the following has been disclosed: Dr. DePalma reported nothing to disclose. The planning committee reported nothing to disclose.

Acknowledgements

Dr. DePalma 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:

OR411403

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.

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