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