Fluoroscopically Guided Diagnostic and Therapeutic Intra-Articular Sacroiliac Joint Injections: A Systematic Review

Spinal Cord Stimulation for Intractable Pain Caused by Sacroiliac Joint Dysfunction: A Case Report

Sacroiliac joint dysfunction is one of the causes of lower back pain, and although it has characteristic pain locations and aggravating factors, it is difficult to diagnose and is often overlooked. A case of relief of typical pain symptoms due to sacroiliac joint dysfunction by spinal cord stimulation is presented. A 60-year-old woman presented with severe chronic pain in the left lumbar, lower buttock, iliac, and groin areas that worsened even when sitting for short periods, as well as numbness in the right lower extremity. The patient had chronic lower back pain since experiencing acute lumbosacral sprains in her 20s and 40s, and her symptoms worsened without any trigger in her 60s. Standard imaging examinations showed no lesions that could be causing the pain, and blood tests showed no inflammation or other abnormalities. Although pharmacological treatment did not provide sufficient analgesia, sacroiliac joint block provided a significant analgesic effect, leading to a definitive diagnosis of sacroiliac joint dysfunction. A spinal cord stimulation trial was performed using percutaneous 8-contact leads placed at the thoracic vertebra 8-11 level, and pain relief was confirmed. One month later, 2 new percutaneous 16-contact leads and an implantable pulse generator were implanted simultaneously. One month after implantation, the visual analog scale and the quick inventory of depression symptomatology scores decreased dramatically from 83 to 8 and from 16 to 4, respectively. In addition, the numbness of the right lower extremity disappeared. These analgesic effects were sustained for 12 months.

Cooled radiofrequency ablation provides extended clinical utility in the management of chronic sacroiliac joint pain: 12-month follow-up results from the observational phase of a randomized, multicenter, comparative-effectiveness crossover study

INTRODUCTION

Sacroiliac joint (SIJ) pain comprises up to 30% of cases of mechanical low back pain (LBP), the leading cause of disability worldwide. Despite sacral lateral branch cooled radiofrequency ablation (CRFA) showing efficacy in clinical trials, there is a lack of comparative-effectiveness long-term follow-up.

METHODS

In this randomized, multicenter, comparative-effectiveness study, 210 patients with injection-confirmed SIJ pain who responded to prognostic lateral branch blocks were randomly assigned to receive CRFA of the L5 dorsal ramus and S1-S3/4 lateral branches or standard medical management (SMM) consisting of pharmacotherapy, physical therapy, injections, and integrative therapies. Patients were followed up at 1, 3, 6, 9, and 12 months, with participants reporting unsatisfactory SMM outcomes being allowed to crossover (XO) and receive CRFA at 3 months. The primary outcome measure was the mean change in average LBP score on a 0-10 Numeric Rating Scale (NRS), with secondary outcomes including measures of quality of life (QoL) and function. A responder was defined as a participant who experienced a ≥30% or ≥2-point decrease in average daily NRS pain score coupled with a score ≥5 out of 7 (moderately better) on the Patient Global Impression of Change scale.

RESULTS

At 12 months, the mean NRS pain score declined from a baseline of 6.4±1.4 to 3.5±2.6, with 57.4% (35/61) of participants in the randomized CRFA cohort experiencing a ≥2-point or 30% decrease in average LBP from baseline. In the crossover cohort, 35/63 (55.6%) subjects had the same experience 12 months following the XO procedure; in the XO group, the mean LBP decreased from 6.1±1.5 to 3.4±2.5. Patients also experienced clinically meaningful improvements in QoL via EuroQoL-5D-5L at 12 months (mean change of +0.22±0.27 in the originally-treated CRFA group and +0.21±0.33 in the XO group). Oswestry Disability Index (ODI) scores also improved by 12.4%±14.7 (CRFA) and 13.7%±17.1 (XO) from baseline at study-end. No serious adverse events related to the CRFA procedure were reported.

CONCLUSION

CRFA in patients with SIJ pain provided clinically significant and sustained improvements for 12 months following a single CRFA treatment, regardless of previous SMM treatment.

TRIAL REGISTRATION NUMBER

NCT03601949.

Motor Control Exercises and Their Design for Short-Term Pain Modulation in Patients with Pelvic Girdle Pain: A Narrative Review

Background: Pelvic girdle pain (PGP) is described in the literature as a subgroup of low back pain (LBP), characterized by pain localized between the posterior iliac crest and the gluteal fold, particularly near the sacroiliac joints. This condition can manifest in different forms non-specific PGP, occurring during pregnancy or postpartum (pregnancy-related PGP), which represents the most prevalent form and non-pregnancy-related PGP, resulting from mechanical alterations caused by trauma or microtrauma. Specific PGP, associated with identifiable causes such as fractures, infections, or arthritis. Over the years, research has focused on identifying the most effective approaches for managing this condition and addressing its associated biopsychosocial impairments. The aim of this narrative review is to determine the types of motor control exercises (MCEs) used to reduce short-term pain in patients with PGP and to assess whether these exercises are designed in accordance with the principles of motor control (MC) theories. Methods: A narrative review was conducted through searches in various medical and rehabilitation databases, including MEDLINE (via PubMed), PEDro, Scopus, and Web of Science. The inclusion criteria of the review encompassed case studies, case reports, editorials, original research articles, randomized controlled trials (RCTs), and systematic reviews (SRs). Results: Six articles met the eligibility criteria, comprising two SRs and four RCTs, all of which were included in the qualitative analysis. Among these, two studies examine MCEs for non-pregnancy-related PGP, while all the other studies focus on pregnancy-related PGP. The exercises described focused on lumbar-pelvic stabilization or deep spinal muscle activation. Among the six included studies, five did not report statistically significant changes in pain outcomes, while only one study demonstrated a statistically significant improvement. Conclusions: The analysis highlighted that the exercises currently employed are generally unspecific and not systematically structured according to the principles outlined in MC theories. The available evidence, combined with the incorrect design of these exercises, does not allow for definitive conclusions regarding the efficacy of MCEs in reducing short-term pain in patients with both pregnancy-related and non-pregnancy-related PGP.

Utility of minimally invasive percutaneous arthrodesis of the sacroiliac joint for the treatment of low back pain: systematic review of the literature

BACKGROUND

The surprising increase observed in recent years in the use of minimally invasive sacroiliac joint arthrodesis techniques as a treatment for low back pain justifies an objective review of this results.

PURPOSE

carry out a systematic review of the literature to evaluate the clinical results of patients with low back pain treated with percutaneous arthrodesis of the SIJ.

STUDY DESIGN

Systematic review.

METHODS

Systematic search of the medical literature. The words used in the Search were: "Hollow screw system", "percutaneous sacroiliac joint stabilization", "sacroiliac joint", "minimally invasive", "sacroiliac pain", "sacroiliac dysfunction". With logical connectors such as "and", "not" and "or".

DATABASES

Pubmed, Scopus, Embase, Ovid, EBSCO host and google scholar. The search extended from the beginning of the databases until September 2024. The "Rayyan" program was used to collect the information and facilitate the analysis process.

INCLUSION CRITERIA

Systematic review from the literature, clinical trials, observational studies and case series. They followed PRISMA principles.

RESULTS

661 articles were found, of which 108 articles were duplicates. The criteria (Inclusion/Exclusion) were applied to the 553 articles identified based on the independent reading of the summaries by each of the authors on the Rayyan platform and 434 articles were excluded. The 119 selected articles were completely reviewed to finally obtain 102 articles included in the review. Epidemiological data were extracted into an Excel table, methodological and related to clinical results and safety of procedures made. The Prisma checklist for systematic reviews was applied in each article. The epidemiological quality of the articles was evaluated based on the checklists STROBE and CONSORT. The results regarding clinical improvement were overwhelming. However, most of the studies were sponsored by industry and with a limited population and follow-up not always prolonged.

CONCLUSIONS

Although the clinical results regarding the effectiveness of SIJ fusion are forceful for their effectiveness, we recommend considering some aspects for their analysis and especially long-term studies.

Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

This study examined the efficacy of manual therapy for pain and disability measures in adults with sacroiliac joint pain syndrome (SIJPS).

METHODS

We searched six databases, including gray literature, on 24 October 2023, for randomized controlled trials (RCTs) examining sacroiliac joint (SIJ) manual therapy outcomes via pain or disability in adults with SIJPS. We evaluated quality via the Physiotherapy Evidence Database scale and certainty via Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) in post-treatment pain and disability scores were pooled using random-effects models in meta-regressions.

RESULTS

We included 16 RCTs (421 adults; mean age = 37.7 years), with 11 RCTs being meta-analyzed. Compared to non-manual physiotherapy (i.e. exercise ± passive modalities; 10 RCTs) or sham (1 RCT) interventions, SIJ manual therapy did not significantly reduce pain (SMD: -0.88; 95%-CI: -1.84; 0.08, p = 0.0686) yet had a statistically significant moderate effect in reducing disability (SMD: -0.67; 95% CI: -1.32; -0.03, p = 0.0418). The superiority of individual manual therapies was unclear due to low sample size, wide confidence intervals for effect estimates, and inability to meta-analyze five RCTs with a unique head-to-head design. RCTs were of 'good' (56%) or 'fair' (44%) quality, and heterogeneity was high. Certainty was very low for pain and low for disability outcomes.

CONCLUSION

SIJ manual therapy appears efficacious for improving disability in adults with SIJPS, while its efficacy for pain is uncertain. It is unclear which specific manual therapy techniques may be more efficacious. These findings should be interpreted cautiously until further high-quality RCTs are available examining manual therapy against control groups such as exercise.

REGISTRATION

PROSPERO (CRD42023394326).

The effectiveness of sacral lateral branch radiofrequency neurotomy for posterior sacroiliac joint complex pain in patients selected by dual sacral lateral branch blocks; A real-world cohort study

Background

Previous study of spinal neurotomy procedures indicates that stringent block selection improves outcomes. However, this pattern is not established for sacral lateral branch radiofrequency neurotomy (SLBRFN). Few SLBRFN studies have used stringent block selection criteria such as ≥80 % pain reduction following dual sacral lateral branch blocks (SLBB).

Objective

Evaluate the effectiveness of SLBRFN in patients with ≥80 % pain relief following dual SLBBs.

Methods

Retrospective single-arm cohort study of consecutive patients from two Canadian musculoskeletal and pain clinics who underwent first-time SLBRFN after report of ≥80 % pain relief following dual diagnostic SLBBs. Patients were identified by electronic medical record query between 2016 and 2022. The primary outcome was the proportion of individuals with a ≥50 % reduction in the numeric pain rating scale (NPRS) score three months after SLBRFN. Secondary outcomes included the proportion of responders achieving the minimal clinically important difference (MCID) on the pain disability quality-of-life questionnaire (PDQQ), and the duration and mean percentage of pain relief among those with recurrent symptoms after a successful SLBRFN.

Results

Of the 70 participants included, 32 (45.7 %; 95 % CI = 34.6-57.3) reported a ≥50 % reduction in NPRS, and 35 (50.0 %; 95 % CI = 38.6-61.4) achieved the MCID on the PDQQ at 3-months. Among the 17 patients who reported a return of symptoms, the mean duration of relief was 8.0 ± 3.5 months, and the mean percentage of pain relief was 77.9 % ± 16.4 %. Logistic regression models revealed that the use of multi-tined RF probes and lower patient BMI were associated with treatment success.

Discussion/conclusion

SLBRFN reduced pain and disability in approximately 50 % of patients at 3 months when selected using relatively restrictive selection criteria. Treatment success was associated with multi-tined RF probe type and lower patient BMI. Larger prospective studies assessing long-term outcomes are needed to further evaluate the impact of different selection criteria and techniques on SLBRFN effectiveness.

Effectiveness of intra-articular analgesia in reducing postoperative pain after minimally invasive sacroiliac joint fusion: a double-blind randomized controlled trial

During the first postoperative days following minimally invasive sacroiliac joint fusion (MISJF), patients often report serious pain, which contributes to high utilization of painkillers and prevention of early mobilization. This prospective, double-blind randomized controlled trial investigates the effectiveness of intraoperative SIJ infiltration with bupivacaine 0.50% versus placebo (NaCl 0.9%) in 42 patients in reducing postoperative pain after MISJF. The primary outcome was difference in pain between bupivacaine and placebo groups, assessed as fixed factor in a linear mixed model. Secondary outcomes were opioid consumption, patient satisfaction, adverse events, and length of hospital stay. We found that SIJ infiltration with bupivacaine did not affect postoperative pain scores in comparison with placebo, neither as group-effect (p = 0.68), nor dependent on time (group*time: p = 0.87). None of the secondary outcome parameters were affected in the postoperative period in comparison with placebo, including opioid consumption (p = 0.81). To conclude, intra-articular infiltration of the SIJ with bupivacaine at the end of MISJF surgery is not effective in reducing postoperative pain. Hence, we do not recommend routine use of intraoperative SIJ infiltration with analgesia in MISJF.

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

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.

5. Sacroiliac joint pain

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.

Radiological Insights into Sacroiliitis: A Narrative Review

Sacroiliitis is the inflammation of the sacroiliac joint, the largest axial joint in the human body, contributing to 25% of lower back pain cases. It can be detected using various imaging techniques like radiography, MRI, and CT scans. Treatments range from conservative methods to invasive procedures. Recent advancements in artificial intelligence offer precise detection of this condition through imaging. Treatment options range from physical therapy and medications to invasive methods like joint injections and surgery. Future management looks promising with advanced imaging, regenerative medicine, and biologic therapies, especially for conditions like ankylosing spondylitis. We conducted a review on sacroiliitis using imaging data from sources like PubMed and Scopus. Only English studies focusing on sacroiliitis's radiological aspects were included. The findings were organized and presented narratively.

Comparative Efficacy of Clinical Interventions for Sacroiliac Joint Pain: Systematic Review and Network Meta-analysis With Preliminary Design of Treatment Algorithm

OBJECTIVE

We aimed to identify the most effective clinical treatment method for sacroiliac joint (SIJ)-related pain based on the systematic review and network meta-analysis (NMA) to evaluate the comparative efficacy of clinical interventions for sacroiliac joint pain by pooling the randomized controlled trials (RCTs).

METHODS

Our team conducted a systematic review and NMA of RCTs to determine the most effective clinical treatment for SIJ-related pain. We searched the PubMed (MEDLINE), Web of Science, Cochrane Library, and Scopus databases for RCTs until February 2023. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were followed. Pairwise and network meta-analyses were conducted using a random effects model.

RESULTS

Based on the search strategy and inclusion criteria, our systematic review and NMA included 9 randomized studies with 652 participants. Research has mainly focused on various radiofrequency sources, but their number is still low. In the network analysis, according to the NMA and mean ranking probabilities for the improvement of pain intensity (PI) and quality of life (QoL), sacroiliac joint fusion and cooled radiofrequency were associated with high treatment rank for improving PI and QoL in patients with sacroiliac joint pain.

CONCLUSION

This NMA suggest that SIJ fusion and cooled radiofrequency could be potential options for improving the QoL and relieving pain in patients with SIJ-related pain. Comparison studies of outcomes between these 2 procedures with solid methodology and a low risk of bias would be very beneficial to identify the optimal treatment option for this challenging disease.

Image-Guided Spine Interventions for Pain: Ongoing Controversies

An expanding array of image-guided spine interventions have the potential to provide immediate and effective pain relief. Innovations in spine intervention have proceeded rapidly, with clinical adoption of new techniques at times occurring before the development of bodies of evidence to establish efficacy. Although new spine interventions have been evaluated by clinical trials, acceptance of results has been hindered by controversies regarding trial methodology. This article explores controversial aspects of four categories of image-guided interventions for painful conditions: spine interventions for postdural puncture headache resulting from prior lumbar procedures, epidural steroid injections for cervical and lumbar radiculopathy, interventions for facet and sacroiliac joint pain, and vertebral augmentations for compression fractures. For each intervention, we summarize the available literature, with an emphasis on persistent controversies, and discuss how current areas of disagreement and challenge may shape future research and innovation. Despite the ongoing areas of debate regarding various aspects of these procedures, effective treatments continue to emerge and show promise for aiding relief of a range of debilitating conditions.

Effect of Fluoroscopic-Guided Corticosteroid Injection in Patients With Sacroiliac Joint Dysfunction

Background Sacroiliac joint dysfunction is a major cause of axial low back pain which can masquerade as pain from lumbar disc diseases. Treatment of axial back pain arising due to sacroiliac joint dysfunction remains a challenge. This study was conducted to evaluate the long and short-term effects of intra-articular corticosteroid injection in the relief of pain and disability caused by sacroiliac joint dysfunction. Methodology A total of 83 patients with sacroiliac joint dysfunction were included in this prospective randomized control study. Patients were randomized into two groups by a computer-generated randomization table. These two groups were treated with fluoroscopy-guided corticosteroid and local anesthetic injection (group A) and distilled water and local anesthetic injection (group B). Pre and post-intervention assessment of all patients was done based on the Numeric Pain Rating Scale (NPRS) for pain and Oswestry Disability Index (ODI) for disability. The outcome measures of the study were the NPRS and ODI assessed at the initial visit one (pre-injection), two weeks post-injection (visit 2), and four weeks post-injection (visit 3). Results Demographic data were comparable in both groups. There was no significant difference in pre-injection NPRS and ODI values in both groups. The changes in NPRS and ODI values were significant from pre-injection to two weeks to four weeks. Group A patients performed better in terms of a decrease in the perception of pain and a decrease in the perception of disability compared to group B patients in the second and fourth weeks of follow-up. Conclusions Fluoroscopy-guided corticosteroid injection is an effective measure for reducing pain and disability in patients with sacroiliac joint dysfunction.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Minimally invasive sacroiliac fusion, a case series, and a literature review

INTRODUCTION

Non-autoimmune sacroiliac joint pain contributes to nearly a quarter of low back pain patients. Non-surgical management fails to satisfy patients. A new minimally invasive technique for sacroiliac stabilization has been introduced, defying the traditional rules of fusion. The results outside explanatory trials and in day-to-day practice have not been reported.

MATERIALS AND METHODS

This case series includes 20 patients diagnosed with chronic sacroiliac pain resistant to conservative management for at least 6 months. The diagnosis was confirmed with a positive sacroiliac injection. Patients underwent stabilization using the iFuse^® implant. Patients were followed up for a minimum of one year. The primary outcome was the functional outcomes, assessed using VAS, ODI, and SF36. Secondary procedure rates, complication rates, and radiological assessments of fusion were collected as secondary outcomes.

RESULTS

At one year, the mean VAS score improved from 81.25 ± 10.7 SD preoperatively to 52.5 ± 26.8, p-value 0.0013. The mean ODI improved from 54.8 ± 11.21 SD preoperatively to 41.315 ± 15.34, P value = 0.0079. The mean PCS and MCS of SF36 improved by 17 and 20 points, respectively. Only 55% of patients achieved the MCID for the VAS score. 35% of the cohort had secondary procedures.

DISCUSSION

Minimally invasive sacroiliac fusion resulted in an improvement in mean functional scores with a wide dispersion. Patients not achieving MCID are patients with either a malpositioned implant, an associated lumbar pathology, or an inaccurate diagnosis. Our results are underwhelming compared to similar work but are still better than conservative cohorts in comparative studies.

CONCLUSION

Minimally invasive sacroiliac fusion can be used successfully in select patients. Attention to diagnosis and surgical technique can improve the reproducibility of results.

Ultrasound-guided platelet-rich-plasma injections for reducing sacroiliac joint pain: A paradigmatic case report and literature review

BACKGROUND

Sacro-iliac joint (SIJ) pain is an often-misdiagnosed cause (up to 30% cases) of atypical low back pain (LBP) that might be treated with a wide range of conservative interventions. However, Platelet-Rich-Plasma (PRP) ultrasound-guided injections at SIJ level in subjects with mitochondrial disorders have not yet been investigated.

CASE PRESENTATION

A 52-year-old Caucasian male with fluoroquinolone-related mitochondrial dysfunction referred to a Physical Medicine and Rehabilitation Outpatient, complaining of severe SIJ pain (Numeric Pain Related Scale, NPRS=8). We performed two bilateral PRP ultrasound-guided injections at the sacro-iliac level. PRP is a simple, efficient, and minimally invasive approach. After the first PRP injection, there was a considerable reduction of pain (NPRS=8 vs 5). The second PRP infiltration was performed after 2 weeks and in both cases no adverse events. At the 6-month follow-up evaluation, the patient showed good physical recovery, with the absence of pain (NPRS=0).

CONCLUSION

To the best of our knowledge, this is the first report in the literature assessing the safety and effectiveness of PRP ultrasound-guided injections for SIJ pain in a patient affected by mitochondrial disorders. Thus, this case report might have relevant clinical implications in the treatment of SIJ pain in patients affected by this rare pathological condition, albeit further observational studies are warranted to confirm these findings.

Sacroiliac joint pain in adolescents: Diagnostic and treatment challenges

The aim of this review was to assess diagnostic and treatment challenges of adolescents with SI joint pain. We diagnosed 13 of the patients who were referred to our chronic pain clinic because of low back pain (30%) with SI joint pain based on provocative tests response. We performed SI joint steroid infiltration. Six patients (46%) felt better immediately after the procedure and 1 (8%) patient had a one-side only pain relief after a bilateral block. Four of these patients (31%) did not experience any further episode of pain during the follow-up and three patients reported recurring pain on average 2 months after the initial procedure. The 2nd procedure was successful in two patients and the third one experienced pain again 12 months later, requiring a third successful infiltration. Six patients (46%) experienced pain again within a few hours or days after the infiltration and their pain score were unchanged compared with what they had reported prior to the procedure. We were unable to place the needle within the joint under fluoroscopy in 1 patient; however, we were successful repeating the procedure under CT guidance. One patient experienced a motor and sensory block in the distribution of the sciatic nerve immediately after the procedure, which resolved within 24 and 48 hours, respectively. SI joint pain is a distinctive pathology that can be present in children and adolescents and is often overlooked by practitioners. Its diagnosis and management are challenging in this population as it is in adults. SI joint steroids injections may play a role in the management of these patients.

Minimally Invasive and Conservative Interventions for the Treatment of Sacroiliac Joint Pain: A Review of Recent Literature

Sacroiliac joint (SIJ) pain is responsible for approximately 15-25% of reported back pain. Patients with SIJ pain report some of the lowest quality of life scores of any chronic disease. Understanding of the physiology and pathology of the SI joint has changed dramatically over the years, and SI joint pain and injury can now be thought of in two broad categories: traumatic and atraumatic. Both categories of SI joint injury are thought to be caused by inflammation or injury of the joint capsule, ligaments, or subchondral bone in the SI joint. Treatment of SI joint pain usually involves a multi-pronged approach, utilizing both, multi-modal medical pain control and interventional pain/surgical techniques such as steroid injections, radiofrequency nerve ablation, and minimally invasive sacroiliac arthrodesis. Though conservative management through multi-modal pain control and physical therapy have their role as first line therapies, an increasing body of evidence supports the use of minimally invasive procedures, both as adjuvant treatments to conservative management and as second line therapies for patient's that fail first line treatment.

First Spanish study on the effectiveness of ultrasound-guided sacroiliac joint injection in patients with spondylarthritis

Objective

To assess clinical improvement after ultrasound-guided injection of corticosteroids into the sacroiliac joint of patients with spondyloarthritis.

Methods

Observational, descriptive, retrospective study of patients with spondyloarthritis and sacroiliitis who received an ultrasound-guided injection into the sacroiliac joint between June 1, 2020 and May 31, 2021. Means were compared using the t test for the variables VAS, BASDAI, ASDAS, CRP, and ESR before and after the procedure. We evaluated the association between these variables and the clinical response using the odds ratio.

Results

We analyzed 32 patients with spondyloarthritis (age 42.69 ± 8.19 years; female sex, 56.25%) with a VAS score of 7.88 ± 0.79, BASDAI of 5.43 ± 1.48, and ASDAS of 3.27 ± 0.86 before the procedure. At 2–3 months, 75% of patients had improved: VAS 3.81 ± 2.33 (–4.07, p < 0.0001) and BASDAI 3.24 ± 1.6 (–2.19, p < 0.0001). At 5–6 months, 59.37% had improved: VAS 4.63 ± 2.31 (–3.25, p < 0.0001), BASDAI 3.57 ± 1.67 (–1.86, p < 0.0001), and ASDAS 2.27 ± 0.71 (–1.0, p < 0.0001). Bone marrow oedema resolved in 87.5% of cases compared with the previous magnetic resonance scan. No significant association was identified with the clinical response to the injection.

Conclusions

Ultrasound-guided injection of corticosteroids into the sacroiliac joint of patients with spondyloarthritis and active sacroiliitis leads to an improvement in symptoms that is maintained at 5–6 months. The procedure is effective, safe, inexpensive, and easy to apply.

Assessment of technical adequacy of sacral lateral branches cooled radiofrequency neurotomy

Objective

There were two primary objectives of the study: 1. assessment of the association between diagnostic sacral lateral branches (SLB) blocks and the ensuing numbness in the middle cluneal nerves (MCN) distribution, irrespective of whether the patients had positive or negative responses to blocks. 2. If the consistency of this causal relationship was established, we wanted to investigate a further correlation - hypoesthesia from local anesthetic blocks vs. hypoesthesia from radiofrequency neurotomy (RFN) vs. outcomes.

Design

This is a prospective observational study of sixty consecutive patients with sacroiliac (SI) joint complex pain and failure of previous intraarticular SI joint injection. The patients who had two positive diagnostic SLB blocks defined as ≥ 75% reduction in NRS scores were treated with cooled RFN of the L5 dorsal ramus and S1-S3 lateral branches. The patients were interviewed and evaluated at a one-month post-neurotomy follow-up appointment. Seven patients were also evaluated at a six-month follow-up visit after the procedure.

Methods

The primary outcomes of the study were absence/presence of post-procedural buttock hypoesthesia after diagnostic blocks and absence/presence of post-procedural buttock hypoesthesia at one month after a cooled RFN procedure. The secondary outcome measures related to the effectiveness of this procedure and included: pre- and post-procedure NRS scores; ODI scores initially, and at post RFN follow-up; analgesic consumption initially, and at one-month RFN follow-up; patient satisfaction with the cooled RFN treatment. A procedure was considered categorically successful if the patient gained ≥50% pain relief and was satisfied with its results.

Results

81/84 (96.4%; 95% CI [89.9%, 99.3%]) of the diagnostic SLB blocks lead to temporary sensory deficit to pinprick in the MCN distribution. If the block was positive, 58/58 (100.00%; 95% CI [93.8, 100.00%]) of the procedures led to hypoesthesia. For negative diagnostic blocks, 3/26 (11.5%; 95% CI [2.4%, 30.2%]) procedures lead to no hypoesthesia. The buttock hypoesthesia persisted in all patients with successful cooled RFN one month after this intervention. Among the patients with unsuccessful RFN, only 2/9 (22.2%, 95%CI [2.8%, 60.0]) still had hypoesthesia, but the rest of this group had no sensory deficit on pinprick examination. At 6-months follow-up buttock hypoesthesia had no association with the success of the procedure.The patients' average NRS scores decreased from baseline 7.1 (SD 1.7) to 4.3 (SD 3.3) at 1-month follow-up after RFN. Categorical success, based on ≥50% pain relief coupled with patients' satisfaction, was achieved in 12/21 (57.1%; 95% CI [34.0%, 78.2%]) of the subjects. Average ODI percentage score decreased from 41.7% (SD 15.1%) to 31.8% (SD 17.8%) at the primary endpoint of the study.

Conclusion

MCNs provide regular and clinically detectable innervation to the skin area overlaying posterior-medial aspects of the gluteus maximums muscle. Therefore, any technically accurate diagnostic block, irrespective of whether the patients have positive or negative responses, should result in the development of hypoesthesia in the area supplied by the MCNs. Immediately after the completion of the diagnostic procedure, the adequacy of the block should be tested. Absence of hypoesthesia suggests that the block may have been technically inadequate. Numbness in the buttock area innervated by the MCNs may serve as a marker of an adequately performed RFN procedure. If this procedure is unsuccessful in patients who do not develop post-neurotomy numbness in the area supplied by the MCNs, the failure of the intervention may stem from its inaccurate implementation rather than from its inherent ineffectiveness.

The effect of minimally invasive sacroiliac joint fusion compared with sham operation: study protocol of a prospective double-blinded multicenter randomized controlled trial

Background and purpose - The sacroiliac joint is increasingly recognized as a cause of pain in 15-30% of patients with low back pain. Nonoperative management is not always successful and surgical treatment with fusion of the joint is increasingly recommended. According to the literature, minimally invasive fusion reduces pain and improves function compared with nonoperative treatment. It is, however, unclear to what extent the placebo effect influences these results. Patients and methods - The trial is designed as a prospective multi-center, double-blind, randomized shamsurgery controlled trial with 2 parallel groups. 60 patients with a suspected diagnosis of sacroiliac joint pain confirmed with sacroiliac joint injection are included according to the trial inclusion criteria. Patients are randomized with a 1:1 allocation into 2 groups of 30 patients each. The primary end-point is group difference in sacroiliac joint pain intensity on the operated side at 6 months postoperatively, measured by the Numeric Rating Scale. The main objective is to examine whether there is a difference in pain reduction between patients treated with a minimally invasive fusion of the sacroiliac joint compared with patients undergoing a sham operation. Results - Unblinding occurs after the completed 6-month follow-up. The primary analysis will be performed when all patients have completed 6 months' follow-up. Follow-ups are continued to at least 2 years postoperatively. Data from the different groups will be compared based on the "intention to treat" principle.

Study protocol for a randomised controlled trial on the effect of local analgesia for pain relief after minimal invasive sacroiliac joint fusion: the ARTEMIS study

INTRODUCTION

Chronic lower back pain is a common report in the general population. A dysfunctional sacroiliac joint (SIJ) is estimated to be responsible for one in five patients with lower back pain. Minimally invasive sacroiliac joint fusion (MISJF) is a surgical procedure to treat SIJ dysfunction. During the procedure, the SIJ is stabilised by implants inserted percutaneously under fluoroscopy guidance. Postoperatively, patients often report a lot of pain, which contributes to patients taking high doses of painkillers (opioids for example,) and preventing early mobilisation. In several orthopaedic procedures, intraoperative infiltration of the wound bed results in decreased consumption of analgesics, earlier mobilisation and shorter hospitalisation time. The aim of this study is to investigate the effectiveness of intraoperative SIJ infiltration with analgesia in reducing postoperative pain after MISJF.

METHODS AND ANALYSIS

We will perform a two-centre, prospective, double-blind, randomised controlled trial to determine whether SIJ infiltration with 1.5-5 cc bupivacaine 0.50% is superior to 1.5-5 cc placebo (NaCl 0.9%) in reducing postoperative pain in patients after MISJF, and to determine whether bupivacaine significantly reduces opioid use in the direct postoperative period. Patients will be randomised with 1:1 allocation for either bupivacaine (intervention) or placebo SIJ infiltration. Postoperative pain will be measured by the Visual Analogue Scale pain score at entry and exit recovery, 2, 4, 6, 24 and 48 hours postoperatively.

ETHICS AND DISSEMINATION

This is the first trial that investigates the effectiveness of intraoperative SIJ infiltration with bupivacaine 0.50% in reducing postoperative pain after MISJF. If intraoperative SIJ infiltration with bupivacaine 0.50% proves to be effective, this might have important clinical implications, such as postoperative analgesics (opioids for example,) consumption, earlier mobilisation and potentially shorter hospitalisation time.

TRIAL REGISTRATION NUMBER

NL9151.

Multicenter study evaluating factors associated with treatment outcome for low back pain injections

BACKGROUND

There has been a worldwide surge in interventional procedures for low back pain (LBP), with studies yielding mixed results. These data support the need for identifying outcome predictors based on unique characteristics in a pragmatic setting.

METHODS

We prospectively evaluated the association between over two dozen demographic, clinical and technical factors on treatment outcomes for three procedures: epidural steroid injections (ESIs) for sciatica, and sacroiliac joint (SIJ) injections and facet interventions for axial LBP. The primary outcome was change in patient-reported average pain intensity on a numerical rating scale (average NRS-PI) using linear regression. For SIJ injections and facet radiofrequency ablation, this was average LBP score at 1 and 3 months postprocedure, respectively. For ESI, it was average leg pain 1- month postinjection. Secondary outcomes included a binary indicator of treatment response (success).

RESULTS

346 patients were enrolled at seven hospitals. All groups experienced a decrease in average NRS-PI (p<0.0001; mean 1.8±2.6). There were no differences in change in average NRS-PI among procedural groups (p=0.50). Lower baseline pain score (adjusted coefficient -0.32, 95% CI -0.48 to -0.16, p<0.0001), depressive symptomatology (adjusted coefficient 0.076, 95% CI 0.039 to 0.113, p<0.0001) and obesity (adjusted coefficient 0.62, 95% CI 0.038 to 1.21, p=0.037) were associated with smaller pain reductions. For procedural outcome, depression (adjusted OR 0.94, 95% CI 0.91, 0.97, p<0.0001) and poorer baseline function (adjusted OR 0.59, 95% CI 0.36, 0.96, p=0.034) were associated with failure. Smoking, sleep dysfunction and non-organic signs were associated with negative outcomes in univariate but not multivariate analyses.

CONCLUSIONS

Identifying treatment responders is a critical endeavor for the viability of procedures in LBP. Patients with greater disease burden, depression and obesity are more likely to fail interventions. Steps to address these should be considered before or concurrent with procedures as considerations dictate.

TRIAL REGISTRATION NUMBER

NCT02329951.

Successful Diagnosis of Sacroiliac Joint Dysfunction

Background

Sacroiliac joint (SIJ) pain is one of the most common causes of low back pain, accounting for 15 to 30% of all cases. Although SIJ dysfunction accounts for a large portion of chronic low back pain prevalence, it is often overlooked or under diagnosed and subsequently under treated. The purpose of this review was to establish a best practices model to effectively diagnose SIJ pain through detailed history, physical exam, review of imaging, and diagnostic block.

Methods

A literature search was performed on the diagnosis of sacroiliac joint pain and sacroiliac joint dysfunction. The authors proposed diagnostic recommendations based upon the available literature and a detailed understanding of diagnosing SIJ pain.

Results

The practitioner must focus on the history, location of pain, observed gait pattern, and perform key points of the physical exam including sacroiliac provocative maneuvers. If the patient exhibits at least three provocative maneuvers then the SIJ may be considered as a possible source of pain. Additionally, a thorough review of the imaging should be performed to rule out other etiologies of low back pain. In the absence of any pathognomonic tests or examination findings, diagnostic SIJ blocks have evolved as the diagnostic standard.

Conclusion

The diagnosis of SIJ pain is a multifaceted process that involves a careful assessment including differentiating other pain generators in the region. This involves careful history taking, appropriate physical examination including provocative maneuvers and diagnostic injections. Once the diagnosis is confirmed, long-term solutions may be considered, including recent advances in sacral lateral branch denervation and sacroiliac joint fusion.

Diagnostic Accuracy of Clusters of Pain Provocation Tests for Detecting Sacroiliac Joint Pain: Systematic Review With Meta-analysis

OBJECTIVE

To assess the diagnostic test accuracy of pain provocation tests for the sacroiliac joint.

DESIGN

Systematic review of diagnostic test accuracy.

LITERATURE SEARCH

Seven electronic databases and reference lists of included studies and previous reviews were searched.

STUDY SELECTION CRITERIA

Studies investigating the diagnostic accuracy of clusters of clinical tests for sacroiliac joint pain were included.

DATA SYNTHESIS

Bivariate random-effects meta-analysis was employed. Risk of bias and applicability concerns were assessed using the revised Quality Assessment of Diagnostic Accuracy Studies tool, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was used to judge credibility of evidence.

RESULTS

From 2195 records identified in the search, 5 studies were included that assessed clusters of pain provocation tests for the sacroiliac joint. The estimated positive likelihood ratio was 2.13 (95% confidence interval [CI]: 1.2, 3.9), the negative likelihood ratio was 0.33 (95% CI: 0.11, 0.72), and the diagnostic odds ratio was 9.01 (95% CI: 1.72, 28.4). The GRADE ratings for the outcomes were of very low certainty. Assuming a point prevalence of sacroiliac joint pain of 20%, we calculated a positive posterior probability of 35% (95% CI: 32%, 37%) and negative posterior probability of 8% (95% CI: 6%, 10%).

CONCLUSION

A positive result on a sacroiliac joint pain provocation test cluster gives the clinician 35% certainty of having correctly identified sacroiliac joint pain. Clusters of pain provocation tests for the sacroiliac joint do not provide sufficient diagnostic accuracy for ruling in the sacroiliac joint as the source of pain. Clinicians can rule out the sacroiliac joint as the source of pain with more confidence: the negative posttest probability indicates that the clinician can conclude with 92% certainty that a negative test result is correct. J Orthop Sports Phys Ther 2021;51(9):422-431. Epub 1 Jul 2021. doi:10.2519/jospt.2021.10469.

Image-guided spinal injection for pain management

Radiculopathy and spinal pain are debilitating conditions affecting millions of people worldwide each year. While most cases can be managed conservatively with physiotherapy and nonsteroidal anti-inflammatory medications, minimally invasive corticosteroid injections are the mainstay intervention for those not responsive to conservative treatment. Historically, spinal injections were performed in the absence of imaging guidance; however, imaging modalities, in particular fluoroscopy and computer tomography (CT), have become the standard of care in performing most of these procedures. Under imaging guidance, operators can accurately confirm needle placement and safely target localised pathologies.

Radiofrequency Ablation for Chronic Posterior Sacroiliac Joint Complex Pain: A Comprehensive Review

Radiofrequency ablation of the sacral lateral branches targets the innervation of the posterior sacroiliac ligaments and posterior portion of the sacroiliac joint. These structures are also collectively referred to as the posterior sacroiliac joint complex. This review will discuss current diagnostic block paradigms and selection criteria for sacral lateral branch radiofrequency ablation, varying techniques and technologies utilized for sacral lateral branch radiofrequency ablation, and updates on the clinical outcome literature. The current evidence suggests that sacral lateral branch radiofrequency ablation can provide relief for posterior sacroiliac joint complex pain, but the literature is limited by variability in selection criteria, the specific nerves targeted by radiofrequency ablation, and the types of radiofrequency ablation technology and techniques utilized in clinical outcome studies.

Minimally Invasive Sacroiliac Joint Fusion with Triangular Titanium Implants: Cost-Utility Analysis from NHS Perspective

OBJECTIVE

The aim was to identify the cost-effectiveness of minimally invasive sacroiliac joint fusion (MI SIJF) surgery with titanium triangular implants for patients with sacroiliac joint (SIJ) pain who have failed conservative management, compared to non-surgical management (NSM) from a National Health Service (NHS) England perspective.

METHODS

Over a time horizon of 5 years, a cohort state transition model compared the costs and outcomes of treating patients with MI SIJF to those of traditional NSM treatment pathways. The NSM arm included two treatments: grouped physical therapy and corticosteroid injections (PTSI) or radiofrequency ablation (RFA). Three different strategies were considered: (1) a stepped pathway, (2) patients split between PTSI and RFA, and (3) RFA only. The outcome measure was incremental cost-effectiveness ratio (ICER), reported in 2018 British pounds per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were used to test the robustness of the model results.

RESULTS

Patients undergoing MI SIJF accrued total procedure-related and pain-management costs of £8358, while NSM treatment strategy 1 had total costs of £6880. The MI SIJF cohort had 2.98 QALYs compared to strategy 1 with 2.30 QALYs. This resulted in an ICER for MI SIJF versus strategy 1 of £2164/QALY gained. Strategy 2 of the NSM arm had lower costs than strategy 1 (£6564) and 2.26 QALYs, and this resulted in an ICER of £2468/QALY gained for MI SIJF. Strategy 3 of the NSM arm had lower costs than strategy 1 (£6580), and this resulted in 2.28 QALYs and an ICER of £2518/QALY gained for MI SIJF. Probabilistic sensitivity analysis shows that at a threshold of £20,000/QALY gained, MI SIJF has a probability of being cost-effective versus NSM strategies of 96%, 97%, and 91% for strategies 1, 2, and 3, respectively.

CONCLUSION

MI SIJF appears to be cost-effective over a 5-year time horizon when compared to traditional NSM pathways in an NHS context.

Does Choice of Steroid Matter for Treatment of Chronic Low Back Pain with Sacroiliac Joint Injections: a Retrospective Study

PURPOSE OF REVIEW

Prevalence of chronic low back pain (cLBP) is increasing. Sacroiliac joint (SIJ) is a common source of cLBP, but data behind its diagnosis and treatment is controversial. There is moderate quality evidence for effectiveness of therapeutic SIJ injections. However, there are no studies comparing the two most common steroid preparations, methylprednisolone (MTP) and triamcinolone (TAC) in SIJ injections.

RECENT FINDINGS

After institutional IRB approval, a retrospective chart review was conducted to evaluate the effectiveness of SIJ injections in terms of pain relief at 1-month follow-up and compare MTP versus TAC. All injections were performed by a single pain physician with fluoroscopic guidance.

RESULTS

Sixty-five percent of patients in the MTP group and 57% patients in the TAC group had >50% pain relief at 1-month follow-up, with no statistical difference between the two groups. Patients in the TAC group had significantly greater BMI and consisted of higher proportion of smokers (72% patients in TAC group versus 39% patients in the MTP group, p-value 0.004). Other sources of pain such as facet joints were unmasked post-procedurally after SIJ injections, with this unmasking being significant for the TAC group. Opiate use decreased in the MTP group from 35% pre-procedurally to 20% post-procedurally, and this difference did not reach statistical significance. Both MTP and TAC are effective in providing pain relief for SIJ pain at 1-month follow-up, with no statistical difference between the two types of steroids. Although not statistically significant, there is a modest reduction in opiate use in the MTP group.

Interventional treatment options for women with pelvic pain

Purpose of review

I.To provide an overview of current interventional treatment options for women with chronic pelvic pain (CPP).

Recent findings

II.Accessibility of CT imaging, ultrasound, and fluoroscopy have assisted the development of novel interventional techniques. Similarly, neuromodulation techniques have improved with the development of novel stimulation patterns and device implants.

Summary

III.Numerous small-scale studies report high success rates with injection intervention therapies in CPP but there are limited well designed large-scale studies that demonstrate superiority of treatment. Female pelvic pain is difficult to diagnose due to the multifactorial etiology and the variable presentation causing delay in accurate diagnosis and lack of response to conventional medical and initial interventional therapies. Despite the shortfalls of current studies, collectively our understanding of chronic pain conditions and helpful injection interventions are improving. Undoubtedly the breadth of current research will provide a rich foundation for future large-scale well-designed studies involving multiple disciplines with more uniform methods and criteria to produce reliable and reproducible results.

Pain and functional outcomes of the sacroiliac joint after platelet-rich plasma injection: a descriptive review

The purpose of this manuscript is to highlight and review the status of literature regarding efficacy of platelet-rich plasma (PRP) in the treatment of sacroiliac joint (SIJ) dysfunction. A review of the literature on PRP interventions on the SIJ or ligaments was performed. Seven studies had improvements in their respective primary end point and demonstrated a strong safety profile without any serious adverse events. Only five articles demonstrated clinical efficacy of >50% in their primary outcome measures. There appears to be inconsistent and insufficient evidence for a conclusive recommendation for or against SIJ PRP. There is a need for adequately powered well-designed, standardized, double-blinded randomized clinical trials to determine the effectiveness of PRP in SIJ-mediated pain.

Intra-Articular Sacroiliac Joint Injection: Technical Guide

Sacroiliac (SI) joint pathology has been an increasingly discussed pathology as a potential etiology for significant low back and lower extremity pain. While patient history and examination maneuvers can assist with identifying the SI joint as a potential cause of pain, an intra-articular SI joint injection is critical to properly diagnose the SI joint as a clinically relevant pain generator. In addition to the diagnostic information from the injection, SI joint intra-articular injections can be performed for therapeutic benefit as part of a multi-modal, conservative treatment approach for SI joint pathology. We discuss our technique for safe and effective SI joint intra-articular injections as a both diagnostic and therapeutic aid for SI joint pathology.

Validity of Physical Exam Maneuvers in the Diagnosis of Sacroiliac Joint Pathology

BACKGROUND

A combination of physical examination maneuvers is currently considered necessary to help predict who will respond to injections in the sacroiliac joint. However, the literature on this topic currently consists of conflicting studies, with one showing the value of a combination of exam maneuvers and the other showing no real value.

OBJECTIVE

To determine the diagnostic validity of sacroiliac joint (SIJ) physical exam maneuvers using anesthetic intra-articular injection as a reference standard.

DESIGN

A single institution prospective study.

PARTICIPANTS

Patients with the clinical diagnosis of SIJ pain and referred for SIJ injection were enrolled.

MAIN OUTCOME MEASURE

Numeric rating scale (NRS) to assess pain intensity.

RESULTS

Participants underwent fluoroscopically guided SIJ intra-articular injection with 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg. Patients' pain was assessed via 0-10 NRS pre-injection and immediately postinjection to determine positive anesthetic response to the injection. Six physical exam maneuvers (thigh thrust, Geanslen's test, FABER test, distraction test, compression test, and sacral thrust) were performed pre-injection and 15 minutes postinjection. The results of these SIJ physical exam maneuvers were evaluated singly and in combinations for diagnostic power in relation to a positive anesthetic response (>80% relief) to the injection. No association was found between a single SIJ physical exam maneuver or combination of maneuvers and anesthetic response to the injection.

CONCLUSIONS

In this cohort, patient physical exam maneuvers to identify intra-articular SIJ pain did not demonstrate diagnostic value when compared with the reference standard of an intra-articular anesthetic block.

Ultrasound-guided interventions during pregnancy for lumbosacral pain unresponsive to conservative treatment: A retrospective review

PURPOSE

Current conventional therapeutic strategies for lumbosacral pain during pregnancy are usually inadequate and data regarding interventional analgesic procedures feasible in pregnant women is scarce. We decided to retrospectively review our experience of ultrasound-guided pain management procedures in pregnant women with lumbosacral pain unresponsive to conservative treatment.

METHODS

Twenty women in the second trimester of pregnancy with lumbosacral pain developed during pregnancy unresponsive to conservative treatments who underwent the following ultrasound-guided pain interventions were included: sacroiliac joint, caudal epidural, interlaminar epidural, and trigger point injections. All patients were followed up until early postnatal period using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores.

RESULTS

All but one patient achieved satisfactory pain control throughout the pregnancy with a single injection. Significant declines in ODI and VAS scores was attained within the first 2 weeks and first week of intervention, respectively, which was maintained thereafter until early postnatal period.

CONCLUSIONS

Injections used for effective interventional pain management in nonpregnant populations seem to represent an effective and safe method also for pregnant women when performed under ultrasound guidance, with rapid onset and enduring duration of action until the time of delivery.

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

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.

Does the presence of cranial contrast spread during a sacroiliac joint injection predict short-term outcome?

BACKGROUND

The innervation of the sacroiliac joint (SIJ) is complex, with a dual innervation originating from the lumbosacral plexus anteriorly as well as the sacral lateral branches posteriorly. Nociceptors are found in intra-articular structures as well as periarticular structures. In patients with SIJ pain, a fluoroscopy-guided SIJ injection is usually performed posteriorly into the bottom one-third of the joint with local anesthetic and corticosteroids, but this does not always reach all intra-articular structures. The correlation between a cranial contrast spread and clinical success is undetermined in patients with SIJ pain.

METHODS

In a tertiary referral pain center, electronic medical records of patients who underwent an SIJ injection were retrospectively analyzed. Only patients with at least three positive provocation maneuvers for SIJ pain were selected. Contrast images of the SIJ were classified as with or without cranial spread on fluoroscopy as a marker of intra-articular injection. Clinical success was defined as ≥50% improvement in the patient's global perceived effect after 3-4 weeks. The primary outcome was defined as the correlation between cranial contrast spread and clinical success after an SIJ injection.

RESULTS

128 patients in total were included. In 68 patients (53.1%) fluoroscopy showed cranial contrast spread. Clinical success was higher in patients with cranial spread of contrast (55 of 68, 81%) versus those without (35 of 60, 58%) (p=0.0067). In a multivariable analysis with age, gender, presence of rheumatoid arthritis, side, and number of positive provocation maneuvers, the cranial spread of contrast remained the only independent factor of clinical success (p=0.006; OR 3.2, 95% CI 1.4 to 7.7).

CONCLUSION

In patients with SIJ pain, identified by positive pain provocation maneuvers, cranial contrast spread as a marker of intra-articular injection, with subsequent injection of 3 mL of local anesthetic and methylprednisolone 40 mg, was significantly correlated with clinical success up to 4 weeks. Therefore, attempts should be made to reach this final needle position before injecting local anesthetic and corticosteroids. This result needs to be confirmed in a high-quality prospective trial.

A Review and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain

INTRODUCTION

The sacroiliac joint (SIJ) has been estimated to contribute to pain in as much as 38% of cases of lower back pain. There are no clear diagnostic or treatment pathways. This article seeks to establish a clearer pathway and algorithm for treating patients.

METHODS

The literature was reviewed in order to review the biomechanics, as well as establish the various diagnostic and treatment options. Diagnostic factors addressed include etiology, history, physical exam, and imaging studies. Treatment options reviewed include conservative measures, as well as interventional and surgical options.

RESULTS

Proposed criteria for diagnosis of sacroiliac joint dysfunction can include pain in the area of the sacroiliac joint, reproducible pain with provocative maneuvers, and pain relief with a local anesthetic injection into the SIJ. Conventional non-surgical therapies such as medications, physical therapy, radiofrequency denervation, and direct SI joint injections may have some limited durability in therapeutic benefit. Surgical fixation can be by a lateral or posterior/posterior oblique approach with the literature supporting minimally invasive options for improving pain and function and maintaining a low adverse event profile.

CONCLUSION

SIJ pain is felt to be an underdiagnosed and undertreated element of LBP. There is an emerging disconnect between the growing incidence of diagnosed SI pathology and underwhelming treatment efficacy of medical treatment. This has led to an increase in SI joint fixation. We have created a clearer diagnostic and treatment pathway to establish an algorithm for patients that can include conservative measures and interventional techniques once the diagnosis is identified.

Dry needling strategies for musculoskeletal conditions: Do the number of needles and needle retention time matter? A narrative literature review

Acupuncture and dry needling are both minimally invasive procedures that use thin, filiform needles without injectate for the management of a variety of neuromusculoskeletal pain conditions. While the theoretical constructs underlying the use of acupuncture and dry needling are unique, both appear to have the ability to elicit biochemical, biomechanical, endocrinological and neurovascular changes associated with reductions in pain and disability. However, optimal treatment dosage has yet to be determined, and there is a lack of consistency in the literature on the number of needles that should be inserted and the needle retention time. Therefore, the purpose of this narrative review is to further explore the importance of these two variables. While trigger point dry needling advocates single needle insertions via repetitive, quick in-and-out pistoning, most acupuncture and dry needling clinical trials have incorporated multiple needles for five to 40 min. Notably and to date, using a single needle to repeatedly prick trigger points one at a time with fast-in and fast-out pistoning maneuvers has not yet been shown to produce significant and clinically meaningful long term improvements in pain and disability in a wide array of musculoskeletal conditions. Insertion of multiple needles for typically 20-30 min durations has been shown to produce larger treatment effect sizes and longer-lasting outcomes than brief, single-needle strategies. Moreover, the number of needles and needle retention time are two variables associated with treatment dosage and must be carefully matched with specific musculoskeletal conditions and the patient's goals.

A painful unknown: sacroiliac joint diagnosis and treatment

The sacroiliac joint (SIJ) is a complex anatomical structure located near the centre of gravity of the body.

Micro-traumatic SIJ disorders are very difficult to diagnose and require a complete clinical and radiological examination.

To diagnose micro-trauma SIJ pain it is recommended to have at least three positive provocative specific manoeuvres and then a radiologically controlled infiltration test.

Conservative treatment combining physiotherapy and steroid injections is the most common therapy but has a low level of efficiency. SIJ thermolysis is the most efficient non-invasive therapy.

SIJ fusion using a percutaneous technique is a solution that has yet to be confirmed on a large cohort of patients resistant to other therapies.

Cite this article: EFORT Open Rev 2020;5:691-698. DOI: 10.1302/2058-5241.5.190081

Minimally Invasive Sacroiliac Joint Fusion: A Lateral Approach Using Triangular Titanium Implants and Navigation

Background:

Minimally invasive sacroiliac (SI) joint fusion is indicated for low back pain from the SI joint that is due to degenerative sacroiliitis and/or sacroiliac joint disruption. This technique is safe and effective in relieving pain uncontrolled by nonoperative management^1-4. There is some controversy, but there continues to be increasing evidence of effectiveness.

Description:

This procedure is performed, with the patient under general anesthesia and in the prone position, using fluoroscopy or 3-dimensional (3D) navigation such as cone-beam computed tomographic (CT) imaging. After navigation setup, a navigated probe is used to approximate the desired location of each implant and trajectory. These positions are marked on the skin, and the skin is incised. A 3 to 5-cm lateral incision is made. The gluteal fascia is bluntly dissected to the outer table of the ilium. A guide pin is passed across the SI joint and into the center of the sacrum lateral to the neural foramina, which is confirmed with imaging. This is then drilled and broached. Triangular titanium rods are placed. Typically, 3 implants are placed, 2 in S1 and 1 in S2. Multiplanar postplacement imaging of the pelvis is obtained. The wound is irrigated and closed in layers.

Alternatives:

Nonsurgical alternatives have been reported to include pharmacological therapies, such as nonsteroidal anti-inflammatory drugs, therapeutic SI joint blocks⁵, and physical therapy, such as core stabilization, orthotics (SI belts), and radiofrequency ablation^1,2,6-8. The surgical alternative is an open anterior or posterior approach with SI joint arthrodesis. The anterior approach differs by the resection of the SI joint cartilage, the use of a plate or screws across the joint for stabilization, and the packing of bone graft to facilitate fusion⁹. These are more morbid and have a much longer recovery.

Rationale:

Conservative management for SI joint pain is inadequate for all patients. Having 3 of 5 positive physical examination maneuvers⁷, having confirmatory diagnostic block(s)¹⁰, and ruling out the hip or spine as the pain generator provide a success rate of >80%. These patients have early and sustained clinically important and significantly improved outcomes across varying measures compared with conservative treatment^1-4,11,12.

Expected Outcomes:

Patients can expect to experience decreased pain, reduced disability, increased daily function, and improved quality of life soon after the procedure is performed. These patients typically have an improvement of ≥50% in the Oswestry Disability Index score and a clinically significant decrease in visual analog pain scores¹³. The procedure appears durable through at least 5 years¹⁴. Complete pain relief is rare, but clinically important improvement is typical.

Important Tips:

Proper setup of the navigation system or fluoroscopy is needed to ensure accurate starting points.

For 3D navigation, use a reference pin in the contralateral posterior superior iliac spine.

Although navigation is used, radiographic images are made periodically to confirm proper placement of guide pins and implants. Images provide the greatest benefit when establishing navigation, after guide-pin placement when an outlet view allows for evaluation of pin depth, and after implant placement to confirm proper placement.

Blood loss is generally low, but care should be taken to avoid vascular injury. Although rare, improper placement has led to injury of the superior gluteal artery¹⁵ and iliac artery¹⁶. This can be avoided by staying in bone.

Proper placement of the implant is imperative in this procedure. There is the potential for nerve injury with improper placement of the implant: an L5 nerve injury if the implant is too ventral or an S1 or S2 nerve injury if the implant is too deep and into the foramen. Revision surgery is commonly due to nerve root impingement and/or malpositioning.

Preoperative 3D imaging is indicated when it is necessary to rule out differential diagnoses that mimic SI joint pain. This enables the surgeon to rule out intrapelvic pathology, assess sacral bone density¹⁷, and identify dysmorphic sacra or transitional vertebrae.

The Effectiveness of Platelet-Rich Plasma Injection for the Treatment of Suspected Sacroiliac Joint Complex Pain; a Systematic Review

Objective

To determine the effectiveness of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) for the treatment of suspected sacroiliac joint complex (SIJC) pain.

Design

Systematic review.

Subjects

Persons aged ≥18 with suspected SIJC pain.

Comparison

Sham, placebo procedure, or active standard of care treatment.

Outcomes

The primary outcome was ≥50% pain improvement, and the secondary outcome was functional improvement of ≥30% at three or more months after the treatment intervention.

Methods

Publications in PubMed, MEDLINE, Embase, Scopus, and Cochrane Databases were reviewed up to April 3, 2019. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Grades of Recommendation, Assessment, Development, and Evaluation system and the joint consensus American Academy of Orthopedic Surgery/National Institutes of Health recommendations were used for quality assessment and reporting standards.

Results

Query identified 151 publications; three were appropriate for inclusion. There were no studies of BMAC that met inclusion criteria. There were three eligible PRP studies: one randomized comparative trial (RCT) and two case series. In the single RCT comparing ultrasound-guided PRP with corticosteroid injection for suspected SIJC pain, the PRP group had a significantly increased likelihood of achieving ≥50% improvement of pain at three months (adjusted odds ratio = 37, 95% confidence interval [CI] = 4.65–298.69). Pooled pain outcomes from two studies showed that 28/30, 93% (95% CI = 93–100%), experienced ≥50% pain improvement at three months.

Conclusions

The literature supporting the effectiveness of PRP for SIJC pain is very low-quality according to the GRADE system. Well-designed RCTs and large cohort studies with consistent selection protocols and reporting characteristics are needed to determine the effectiveness of PRP and BMAC for the treatment of SIJC pain.

Image guided sacroiliac joint corticosteroid injections in children: an 18-year single-center retrospective study

BACKGROUND

Sacroiliitis is commonly seen in enthesitis-related arthritis (ERA), a subtype of juvenile idiopathic arthritis (JIA). Sacroiliitis is characterized by the inflammation of the sacroiliac (SI) joints (+/- adjacent tissues). The treatment options include systemic therapy with or without corticosteroid SI joint injections. Image guided SI joint injections are frequently requested in pediatric patients with sacroiliitis. The purpose of this study was to evaluate the feasibility and efficacy of SI joint injections in children with sacroiliitis.

METHODS

A retrospective study of patients referred to Interventional Radiology (IR) for SI joint corticosteroid injections (2000-2018). Clinical information was collected from Electronic Patient Charts and procedural details from PACS. Efficacy was determined clinically, by MRI, or both when available.

RESULTS

50 patients (13.8 years; M:F = 35:15) underwent image-guided SI joint corticosteroid injections. Most common indications were JIA (84%) and inflammatory bowel disease (14%). 80% had bilateral injections. 80% were performed under general anesthesia and 20% under sedation. The corticosteroid of choice was triamcinolone hexacetonide in 98% of patients. Needle guidance and confirmation was performed using CT and fluoroscopy (54%), Cone Beam CT (CBCT, 46%), with initial ultrasound assistance in 34%. All procedures were technically successful without any complications. 32/50 patients had long-term follow-up (2 years); 21/32 (66%) had clinical improvement within 3-months. Of 15 patients who had both pre- and post-procedure MRIs, 93% showed short-term improvement. At 2 years, 6% of patients were in remission, 44% continued the same treatment and 47% escalated treatment.

CONCLUSION

Image-guided SI joint injections are safe and technically feasible in children. Imaging modalities for guidance have evolved, with CBCT being the current first choice. Most patients showed short-term clinical and imaging improvement, requiring long-term maintenance or escalation of medical treatment.

Nonoperative Treatment Options for Patients With Sacroiliac Joint Pain

Sacroiliac joint (SIJ) pain is thought to be a component of low back pain in 20% of people who suffer with it chronically. There is no consistent objective diagnostic testing that includes SIJ pain as the diagnosis and thereby it can become a diagnosis of exclusion. Treatment of SIJ pain is variable, and no set method or protocol of treatment has been found to be efficacious or reliable. Thus, the healthcare provider is often left to create an individual treatment plan based on their own experiences and expertise. The purpose of this narrative review is to describe and discuss nonoperative treatment options for patients with SIJ pain. Further, coordination of treatment options and progression of treatment will be offered.

Use of Diagnostic Injections to Evaluate Sacroiliac Joint Pain

The sacroiliac joint is a complex, variable, and irregular structure, thought to be the source of 15% to 30% of low back, pelvic, and radicular pain. Several predisposing factors, including prior spinal surgery and particularly lumbar fusion, can contribute to joint inflammation and acceleration of joint degeneration. Evaluation of the sacroiliac joint as a pain generator using history and physical alone can prove difficult, because a number of other pathologies can have a similar presentation. Whereas a number of tests are used to examine the joint, no single test alone has proven validity. Imaging alone has also not been proven efficacious, particularly in nonspondyloarthropathy-mediated pain. Although no "gold standard" exists, diagnostic sacroiliac joint block has been shown to be a useful confirmatory tool in assessing sacroiliac (SI) joint-mediated pain. Sacroiliac joint injection with local anesthetic and steroids can be used as a possible therapeutic endeavor to manage pain and inflammation.