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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. 1 6/1/2013 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 2 6/1/2013 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. 3 6/1/2013 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 4 6/1/2013 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” 5 6/1/2013 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. 6 6/1/2013 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 7 6/1/2013 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 8 6/1/2013 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 9 6/1/2013 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 10