Diagnosis and Treatment of Sacroiliac Joint Pain

Diagnosis and treatment of sacroiliac joint pain

Jonathan N. Sembrano M.D., Mark A. Reiley M.D., David W. Polly Jr., M.D. and Steven R. Garfin, M.D., Current Orthopaedic Practice 2011; Volume 22, No. 4:344–350

Low back pain is the most common type of adult pain and is a leading cause of disability. While this complaint may be ubiquitous, there are many possible causes. Studies have shown that the sacroiliac joint is the cause in approximately 15% of patients with low back pain. The exact pattern is complex. Provocative physical examination maneuvers may help provide a presumptive sacroiliac joint pain diagnosis. Confirmatory diagnosis is achieved with diagnostic injection. For disabling pain that fails to respond to nonoperative treatment, surgical fusion may be necessary; different fusion approaches have been described and are presented.

SI Joint Key Points:

Since many treatment modalities, and especially surgical treatment, are disease-specific or site-specific, it is likely that a significant cause of failed low back pain treatment is failure todiagnose the correct pain generator.
The SI joint is a significant component of low back pain (LBP), and most spine care providers are “reluctant or unaware” of SI joint as a cause of LBP.
Differential diagnosis of LBP including the SI joint is important to get to effective treatment.

Diagnosis of SI joint pain: Traumatic injury, pregnancy, leg-length inequality, scoliosis, poliomyelitis, poor quality footwear, previous spinal fusions, and hip osteoarthritis are all considered predisposing factors for SI joint dysfunction. Pain drawing of patients who had a positive injection response invariably localized their pain at or below the level of L5 is seen as an important diagnostic tool.

Physical Examination: Apresumptive diagnosis of SI joint pain is best obtained by reproduction of the patient’s typical or usual pain by stressing the SI joint. Multi-test regimens have been found to have better interobserver reliability than individual tests. Therefore, to increase clinical diagnostic accuracy, it is important to perform several if not all of these maneuvers.

Imaging Studies: Imaging studies for the evaluation for sacroiliac pathology represents a source of controversy among clinicians. It is unclear whether normal and abnormal radiographic studies can help differentiate symptomatic from asymptomatic patients, unless clear evidence of seronegative spondyloarthropathy, infection, arthritis or tumor is present.

SI Joint Injection: Pain relief obtained with SI joint injection currently is considered the gold standard for diagnosis of SI joint pain, and validity studies looking at various clinical findings and tests for SI joint pain have used injection as the reference standard.

Conclusion: The SI joint is an important potential low back pain generation, one that is challenging but not impossible to diagnose. Surgery is best reserved for SI joint pain refractory to non-operative care and with disabling symptoms.