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Szadek K, Cohen SP, de Andrès Ares J, Steegers M, Van Zundert J, Kallewaard JW. 5. Sacroiliac joint pain. Pain Pract 2024; 24:627-646. [PMID: 38155419 DOI: 10.1111/papr.13338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Sacroiliac (SI) joint pain is defined as pain localized in the anatomical region of the SI joint. The reported prevalence of SI joint pain among patients with mechanical low back pain varies between 15% and 30%. METHODS In this narrative review, the literature on the diagnosis and treatment of SI joint pain was updated and summarized. RESULTS Patient's history provides clues on the source of pain. The specificity and sensitivity of provocative maneuvers are relatively high when three or more tests are positive, though recent studies have questioned the predictive value of single or even batteries of provocative tests. Medical imaging is indicated only to rule out red flags for potentially serious conditions. The diagnostic value of SI joint infiltration with local anesthetic remains controversial due to the potential for false-positive and false-negative results. Treatment of SI joint pain ideally consists of a multidisciplinary approach that includes conservative measures as first-line therapies (eg, pharmacological treatment, cognitive-behavioral therapy, manual medicine, exercise therapy and rehabilitation treatment, and if necessary, psychological support). Intra- and extra-articular corticosteroid injections have been documented to produce pain relief for over 3 months in some people. Radiofrequency ablation (RFA) of the L5 dorsal ramus and S1-3 (or 4) lateral branches has been shown to be efficacious in numerous studies, with extensive lesioning strategies (eg, cooled RFA) demonstrating the strongest evidence. The reported rate of complications for SI joint treatments is low. CONCLUSIONS SI joint pain should ideally be managed in a multidisciplinary and multimodal manner. When conservative treatment fails, corticosteroid injections and radiofrequency treatment can be considered.
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Affiliation(s)
- Karolina Szadek
- Department of Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Steven P Cohen
- Department of Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | | | - Monique Steegers
- Department of Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Department of Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Klessinger S, Casser HR, Gillner S, Koepp H, Kopf A, Legat M, Meiler K, Norda H, Schneider M, Scholz M, Slotty PJ, Tronnier V, Vazan M, Wiechert K. Radiofrequency Denervation of the Spine and the Sacroiliac Joint: A Systematic Review based on the Grades of Recommendations, Assesment, Development, and Evaluation Approach Resulting in a German National Guideline. Global Spine J 2024:21925682241230922. [PMID: 38321700 DOI: 10.1177/21925682241230922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
STUDY DESIGN Systematic review of the literature and subsequent meta-analysis for the development of a new guideline. OBJECTIVES This manuscript summarizes the recommendations from a new clinical guideline published by the German Spine Society. It covers the current evidence on recommendations regarding the indication, test blocks and use of radiofrequency denervation. The guidelines aim is to improve patient care and efficiency of the procedure. METHODS A multidisciplinary working group formulated recommendations based on the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. RESULTS 20 clinical questions were defined for guideline development, with 87.5% consensus achieved by committee members for one recommendation and 100% consensus for all other topics. Specific questions that were addressed included clinical history, examination and imaging, conservative treatment before injections, diagnostic blocks, the injected medications, the cut-off value in pain-reduction for a diagnostic block as well as the number of blocks, image guidance, the cannula trajectories, the lesion size, stimulation, repeat radiofrequency denervation, sedation, cessation or continuation of anticoagulants, the influence of metal hardware, and ways to mitigate complications. CONCLUSION Radiofrequency (RF) denervation of the spine and the SI joint may provide benefit to well-selected individuals. The recommendations of this guideline are based on very low to moderate quality of evidence as well as professional consensus. The guideline working groups recommend that research efforts in relation to all aspects of management of facet joint pain and SI joint pain should be intensified.
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Affiliation(s)
- Stephan Klessinger
- Neurochirurgie Biberach, Biberach, Germany
- Universitätsklinikum Ulm, Ulm, Germany
| | | | | | - Holger Koepp
- Wirbelsäulenzentrum, St Josefs-Hospital, Wiesbaden, Germany
| | - Andreas Kopf
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | | | - Matti Scholz
- ATOS Orthopädische Klinik Braunfels GmbH & Co KG, Braunfels, Germany
| | | | | | - Martin Vazan
- Wirbelsäulen- und Rückenzentrum Dresden, Praxis für Neurochirurgie, Dresden, Germany
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Chen X, Wang L, Zhang Y, Sun Q, Yuan S, Tian Y, Liu X. Sacroiliac joint degeneration in degenerative lumbar spondylolisthesis and related risk factors: a retrospective study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1375-1382. [PMID: 36826600 DOI: 10.1007/s00586-023-07558-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/25/2022] [Accepted: 01/22/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE This study was performed to evaluate the degree of radiological sacroiliac joint (SIJ) degeneration in patients with degenerative lumbar spondylolisthesis (DLS). The related risk factors for SIJ degeneration were also investigated. METHODS We retrospectively analyzed the lumbar and pelvic computed tomography (CT) scans of 303 patients with DLS admitted from January 2018 to December 2021. One hundred and fifty-six age-, gender-, and body mass index-matched patients without lumbar anomality who underwent lower abdominal or pelvic computed tomography scans were included in the control group. Sagittal parameters were measured on full-length lateral radiographs. Two protocols (Backlund's grade and Eno's classification) were used to assess SIJ degeneration. Univariate analysis and bivariate and multivariate regression analysis were performed to identify the factors affecting SIJ degeneration in patients with DLS. RESULTS According to Backlund's grade and Eno's classification, SIJ degeneration was more severe in the DLS group than in the control group (P < 0.001). Multi-segment degenerative changes (P = 0.032), two-level DLS (P = 0.033), a history of hysterectomy (P < 0.001), lower extremity pain (P = 0.016), and pelvic pain (P = 0.013) were associated with more significant SIJ degeneration as assessed by Backlund's grade. The results of Pearson's correlation analysis showed positive correlation between the sagittal vertical axis and SIJ degeneration (r = 0.232, P = 0.009). The multivariate linear regression analysis showed that a history of hysterectomy was significantly correlated with SIJ degeneration in patients with DLS (r = 1.951, P = 0.008). CONCLUSIONS SIJ degeneration was more severe in patients with than without DLS. We should take SIJ degeneration into consideration when diagnosing and treating DLS especially those who had undergone previous hysterectomy or showed sagittal malalignment.
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Affiliation(s)
- Xing Chen
- Department of Orthopedics, Qilu Hospital of Shandong University, 107 Wenhua Road, Jinan, 250012, Shandong, People's Republic of China
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Lianlei Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, 107 Wenhua Road, Jinan, 250012, Shandong, People's Republic of China
| | - Yuchen Zhang
- Department of Orthopedics, Qilu Hospital of Shandong University, 107 Wenhua Road, Jinan, 250012, Shandong, People's Republic of China
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Qingyu Sun
- Department of Orthopedics, Qilu Hospital of Shandong University, 107 Wenhua Road, Jinan, 250012, Shandong, People's Republic of China
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Suomao Yuan
- Department of Orthopedics, Qilu Hospital of Shandong University, 107 Wenhua Road, Jinan, 250012, Shandong, People's Republic of China
| | - Yonghao Tian
- Department of Orthopedics, Qilu Hospital of Shandong University, 107 Wenhua Road, Jinan, 250012, Shandong, People's Republic of China
| | - Xinyu Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, 107 Wenhua Road, Jinan, 250012, Shandong, People's Republic of China.
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China.
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Sacroiliitis: A Review on Anatomy, Diagnosis, and Treatment. Adv Orthop 2022; 2022:3283296. [PMID: 36620475 PMCID: PMC9812593 DOI: 10.1155/2022/3283296] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/09/2022] [Accepted: 12/13/2022] [Indexed: 12/29/2022] Open
Abstract
Introduction Sacroiliitis is an inflammation of one or both of the sacroiliac (SI) joints, most often resulting pain in the lower back that can extend down the legs. Pain arising from the SI joint can be difficult to diagnose and treat due to the intricate surrounding ligamentous structure, nerve innervation, and its role in transferring weight from the upper body to the lower limbs. SI joint dysfunction accounts for up to 25% of cases of lower back pain and has a debilitating effect on patient functionality. This review aims to provide comprehensive coverage of all aspects of SI joint pain, with a specific focus on differential diagnosis and treatment. Methods Current literature on SI joint pain and inflammation, other etiologies of lower back pain, and new treatment options were compiled using the databases PubMed and Cochrane and used to write this comprehensive review. There were no restrictions when conducting the literature search with regard to publication date, study language, or study type. Results The diagnosis protocol of SI joint pain arising from sacroiliitis usually begins with the presentation of lower back pain and confirmatory diagnostic testing through fluoroscopy joint block. Reduction in pain following the anesthetic is considered the golden standard for diagnosis. The treatment begins with the conservative approach of physical therapy and analgesics for symptom relief. However, refractory cases often require interventional methods such as corticosteroid injections, prolotherapy, radiofrequency ablation, and even SI joint fusion surgery. Conclusion SI joint pain is a complex problem that can present with varying patterns of pain due to uncertainty regarding its innervation and its prominent surrounding structure. It is therefore especially important to obtain a thorough history and physical on top of diagnostic tests such as a diagnostic block to properly identify the source of pain. Conservative treatment options with physical therapy and analgesics should be attempted first before interventional strategies such as ablation, injections, and prolotherapy can be considered. SI joint fusion surgery is a solution to cases in which previous methods do not provide significant relief.
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Lorio M, Kube R, Araghi A. International Society for the Advancement of Spine Surgery Policy 2020 Update-Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity. Int J Spine Surg 2020; 14:860-895. [PMID: 33560247 DOI: 10.14444/7156] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The index 2014 International Society for the Advancement of Spine Surgery Policy Statement-Minimally Invasive Surgical Sacroiliac Joint Fusion-was generated out of necessity to provide an International Classification of Diseases, Ninth Revision (ICD-9)-based background and emphasize tools to ensure correct diagnosis. A timely ICD-10-based 2016 update provided a granular threshold selection with improved level of evidence and a more robust and relevant database (Appendix Table A1). As procedures and treatment options have evolved, this 2020 update reviews and analyzes the expanding evidence base and provides guidance relating to differences between the lateral and dorsal surgical procedures for minimally invasive surgical sacroiliac joint fusion.
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Affiliation(s)
- Morgan Lorio
- Advanced Orthopedics, Altamonte Springs, Florida
| | - Richard Kube
- Prairie Spine & Pain Institute, Peoria, Illinois
| | - Ali Araghi
- The CORE Institute, Sun City West, Arizona
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Schenker A, Schiltenwolf M, Schwarze M, Pepke W, Hemmer S, Akbar M. [Pain generator sacroiliac joint : Functional anatomy, symptoms and clinical significance]. DER ORTHOPADE 2019; 49:1000-1005. [PMID: 31811321 DOI: 10.1007/s00132-019-03843-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The sacroiliac joint is a common cause of low back pain. Due to variable symptoms, the diagnosis is often very difficult. For diagnosis, systemic disease, as well as pathologies in the hips and lumbar spine must be excluded. OBJECTIVES To describe anatomy and function of the joint and underlying pathologies. To present the evidence of actual diagnostic and therapeutic options. MATERIALS AND METHODS An extensive literature research was carried out on PubMed. RESULTS The sacroiliac joint is an important and biomechanically complex joint. There are many controversial diagnostic tests to identify the sacroiliac joint as a source of pain. The cause of the dysfunction must be identified in order to treat it correctly and to prevent a chronification of the pain. The gold standard is conservative care. CONCLUSION The sacroiliac joint must be included in the differential diagnosis in patients with low back pain. Diagnostic tests are often insufficient for the diagnosis of sacroiliac joint pain. Many of the current diagnostic and therapeutic options present weak evidence.
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Affiliation(s)
- A Schenker
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, Heidelberg, Deutschland
| | - M Schiltenwolf
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, Heidelberg, Deutschland
| | - M Schwarze
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, Heidelberg, Deutschland
| | - W Pepke
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, Heidelberg, Deutschland
| | - S Hemmer
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, Heidelberg, Deutschland
| | - M Akbar
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, Heidelberg, Deutschland.
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