Download The Painful Sacroiliac Joint

6/1/2013
The Painful Sacroiliac Joint
MYTHS, DOGMA, AND THE EVIDENCE
Disclosures
None.
ALAN B.C. DANG, MD
June 1, 2013
SI joint surgery is currently being
marketed to patients.
New devices are on their way to market.
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DOES SI JOINT PAIN COME
FROM THE SI JOINT?
YES
NO
It’s a diarthrodral joint; all joints can develop arthritis.
Patients with inflammatory arthritis develop pannus.
Patients respond to local anesthetic injections/surgery
Articular cartilage is only present on sacral side.
Precise innervation is still debated.
There are no pathognomonic exam findings or
radiographic signs for SI joint dysfunction.
Anatomy
Articular cartilage on sacral surface.
Fibrocartilage on iliac surface.
This mismatch may contribute to degeneration of the joint.
Marginal osteophytes can be seen > 50 years old.
Incidental MRI changes can be seen > 30 years old.
Radiographic changes can be asymptomatic.
Anterior third of the joint has synovial membrane.
Posterior portion of the joint is purely ligamentous.
Symptomatic Sacroiliac Joints
have abnormal range of motion
MYTH
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Last year, NASA sent two probes to the moon.
Differences in position/velocity from small variations in gravity
were used to create a 3-D gravity map.
STEREOPHOTOGRAMMETRIC ANALYSIS
A pair of X-rays can be used to do the same thing in
ROENTGEN STEREOPHOTOGRAMMETRIC ANALYSIS (RSA)
No difference in the movement of
symptomatic and asymptomatic
SI joints.
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No difference in the position of the
SI joints with manual manipulation.
FACT
There is not a lot of motion at the SI joint
No difference in the position of the
SI joints with standing hip flexion test
on physical exam.
Intra-articular injections & nerve blocks
are reliable diagnostic tools for
sacroiliac joint dysfunction
MYTH
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PROSPECTIVE DOUBLE BLIND STUDY
PROSPECTIVE DOUBLE BLIND STUDY
L5 Dorsal Ramus + S1-S4 Lateral Branch Block
followed by ligamentous probing/capsular distension
L5 Dorsal Ramus + S1-S4 Lateral Branch Block
followed by ligamentous probing/capsular distension
CONTROL GROUP
LIDOCAINE GROUP
100%
60%
REPORTED PAIN
REPORTED PAIN
Patient-to-Patient Variability?
MAYBE
Technical Difficulty of Injections?
DEFINITELY
ANATOMIC STUDY
Fluoroscopically guided S1 and S2
lateral branch blocks with green dye
in cadavers followed by dissection
(n = 11)
36%
ACCURACY
no single finding, or constellation of examination
findings predicts a positive or negative response to
SI joint block from local anesthetic
inadequate physical exam
vs.
inadequate “gold standard”
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Is there even any evidence supporting
SI joint dysfunction as a “real diagnosis”?
YES
Intra-articular injections & nerve blocks
are reliable diagnostic tools for
sacroiliac joint dysfunction
MYTH
Intra-articular injections & peri-articular
blocks provide 6 to 12 months of pain
relief from sacroiliac joint dysfunction
TRUE
RADIOFREQUENCY ABLATION
Multiple studies including randomized, doubleblind placebo-controlled studies and single-blind
placebo-controlled studies show superior pain
relief with steroid injections for SI joint
pain vs. placebo.
STUDIES ARE HETEROGENOUS
Mix of CT and Fluoroscopy
Mix of intra-articular and peri-articular injections
Only targets the posterior portion of the joint
(whereas the “degenerating” synovial portion is anterior).
TRUE
Provides relief of SI joint pain at 3 and 6 months
in a formal meta-analysis
TRUE
Aydin SM, Gharibo CG, Mehnert M, and Stitik TP.
TP The role of radiofrequency ablation for sacroiliac joint pain: a meta-analysis. PMR 2: 842-851, 2010.
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SI joint dysfunction must exist.
Superior pain relief with some therapeutic
interventions over placebo
Early Industry-Funded Studies
Support Surgical Intervention
Literature supports efficacy of
non-surgical therapies.
Including a handful of double-blind placebo
controlled randomized studies
NON-RANDOMIZED INDEPENDENT CHART REVIEW
n = 31
NON-RANDOMIZED CASE-SERIES
n = 52
85%
would have surgery again
when asked 6 months later
75%
had improvement in pain
52%
COMPLETE PAIN RELIEF
67%
COMPLETE/EXCELLENT PAIN RELIEF
unclear if surgeon-defined or patient-defined
97%
COMPLETE/EXCELLENT/GOOD PAIN RELIEF
unclear if surgeon-defined or patient-defined
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Inclusion Criteria
Pain unresponsive to “prolonged" non-operative
treatment and had complete or near complete pain
relief with CT-guided sacroiliac injection.
The Challenge in
SI Joint Dysfunction
is Accurate Diagnosis
THIGH THRUST TEST
91% sensitivity
66% specificity
Positive response to double infiltration
treated as reference standard.
The patient is placed in the supine
position and the examiner flexes and
adducts the patient’s hip.
Pressure is then applied as an axial
load to the femur in order to produce a
posterior shear stress on the SI joint
IMAGE PROVIDED BY SI-BONE
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COMPRESSION TEST
69% sensitivity
63% specificity
The patient is placed in the supine
position and the examiner applies
pressure to spread the anterior
superior iliac spines.
IMAGE PROVIDED BY SI-BONE
3 or more positive
provocative tests
Distraction Test
FABER (Patrick Test)
Gaenslen Test
Thigh Thrust Test
Compression Test
Distraction Test
Patient in lateral decubitus position. Examiner provides a compressive
downward portion.
FABER (Patrick Test)
Hip flexion, abduction, and external rotation
Gaenslen Test
Patient supine at the edge of examination table with one leg dangled
over the side of the table and contralateral leg actively flexed and held
close to the chest. Examiner applies a downward force on the extended
leg to stress both SI joints.
NONE OF THESE ARE INDEPENDENTLY VALID
85%
sensitivity
76%
Summary
specificity
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SI joint dysfunction is a difficult diagnosis to make due to
limitations in diagnostic tools.
NSAIDs, non-opiate analgesics should be first-line therapy.
Physical therapy is a reasonable option although there are no
prospective, controlled studies.
Thanks.
Steroid injections and RFA have proven benefits, but localization
is difficult. Consider CT guidance for non-responsive individuals.
Surgical treatment will likely be more prominent in the future.
Randomized trials are currently on-going.
The Rosette Nebula
SAN FRANCISCO, CA
February 9, 2013
Canon EOS-60Da / ISO 1600 / 400mm F5.6 L / Celestron CG5-GT
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