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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 32  |  Issue : 1  |  Page : 4-15

Sacroiliac joint: A review


Department of Pain Management, Pain Clinic of India, Mumbai, Maharashtra, India

Date of Web Publication30-Apr-2018

Correspondence Address:
Dr. Khushali Tilvawala
23/Arbuda Society, Opposite LG Hospital, Maninagar, Ahmedabad, Gujarat 380008
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_18_18

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  Abstract 

Sacroiliac joint (SIJ) pain is one of the common but underdiagnosed source of mechanical low back pain. The incidence is estimated to be in the range of 15%–30% in patients with nonradicular low back pain. The signs and symptoms of SIJ pain mimic pain arising from other causes of low back pain. There is no single symptom or physical examination finding that can firmly diagnose SIJ as a source of patient's pain. There is good evidence suggesting that a combination of three or more positive provocative tests strongly suggests SIJ dysfunction. Intra-articular injection with local anesthetic is considered the gold standard for diagnosis of SIJ pain. Many treatment modalities are available for SIJ pain, ranging from conservative management to surgical interventions. This review article covers all the aspects of SIJ pain, with treatment section mainly covering evidence-based interventional procedures.

Keywords: Radio-frequency ablation, sacroiliac biomechanics, sacroiliac joint, sacroiliitis management


How to cite this article:
Tilvawala K, Kothari K, Patel R. Sacroiliac joint: A review. Indian J Pain 2018;32:4-15

How to cite this URL:
Tilvawala K, Kothari K, Patel R. Sacroiliac joint: A review. Indian J Pain [serial online] 2018 [cited 2018 Nov 19];32:4-15. Available from: http://www.indianjpain.org/text.asp?2018/32/1/4/231502


  Introduction Top


The sacroiliac joint (SIJ) is one of the common pain generators resulting in chronic pain. There is lot of evidence on computed tomography (CT), magnetic resonance imaging (MRI), and scientography that SIJ can be affected by various degenerative, inflammatory, and destructive pathologies.[1],[2],[3],[4],[5],[6],[7] This article reviews SIJ anatomy, biokinetics, clinical presentation, diagnosis, and management.


  Anatomy Top


Bones and cartilages of SIJ: The SIJ or sacroiliac (SI) joint is formed by the articular surfaces between the sacral and the iliac bones. The SIJ is the largest axial joint in the body with an average length of 17.5 cm.[2],[8] It is a synovial (diarthrodial) joint containing synovial fluid. It is more mobile in youth than later in life. Upper two-thirds of the joint becomes fibrotic in adults.

Capsule of SIJ: The superior portion of the capsule is a caudal extension of the iliolumbar ligament. The anterior portion is dense connective tissue and caudally blends with sacrospinous ligament. The posterior surface is made up of multiple interwoven bands (interosseous ligaments). The posterior capsule is disrupted and discontinued caudally. This leads to communication between SIJ and nearby neural structures.[9]

The other unique feature is that SIJ movements are associated with movements and stability of the anterior articulation of iliac bone, that is, pubic symphysis.

SIJ surface: A unique aspect of the SIJ, which separates it from other joints, is that the sacral surface is covered by a thick hyaline cartilage, whereas the iliac surface contains fibrocartilage.[10] The sacral articular surface is auricular and is concave in shape, whereas the iliac surface is convex in shape. The articular surfaces have many ridges and depressions that minimize movement and enhance stability.

Muscles and ligaments: The stability of SIJ is primarily maintained by the expansive ligamentous and muscle network across the joint.[11] Major muscles attached to the SIJ include the following [Figure 1]A:
Figure 1: (A) Muscles supporting SIJ (B) Ligaments of SIJ

Click here to view


  • Gluteus maximus is a hip extensor. It directly compresses SIJ due to its fiber orientation. These fibers bled with sacrotuberous ligament and thoracolumbar fascia.
  • Biceps femoris long head crosses over the ischial tuberosity and blends into the sacrotuberous ligament. Its contraction increases tension on the sacrotuberous ligament.
  • Piriformis muscle externally rotates femur; it crosses SIJ in perpendicular direction and compresses the joint.
  • Latissimus dorsi via thoracolumbar fascia deep fibers start from lower thoracic spinous processes and insert on iliac crest. Superficial and oblique caudal fibers blend with thoracolumbar fascia and then with the contralateral gluteus muscles.


Other muscles involved are the following:

  • Multifidus: Its tendon passes above interosseous ligament and inserts into sacrum, iliac crest, and sacrotuberous ligaments. Its contraction facilitates nutation.
  • Erector spinae: It extends spine and pelvis. Its contraction creates sacral nutation (locking) and thus ligaments are tightened and SIJ gets locked.
  • Transverse abdominal muscle is for core stabilization of the spine and pelvis.


The forces created by these muscles on SIJ, to provide stability, are called force closure.

Ligaments holding SIJ have the main function to limit its mobility [Figure 1]B. They include the following:

  • Iliolumbar ligament: It limits axial rotation and anterior glide of the L5 over the sacrum.
  • Anterior SI ligament: It opposes axial translation of sacrum and separation of the SIJ.
  • Dorsal SI ligament: It tightens during counternutation movement.
  • The sacrospinous ligament divides sciatic notch into greater sciatic foramen and lesser sciatic foramen above and below it, respectively. It prevents rotation movement of ilium over sacrum.
  • Sacrotuberous ligament resists sacral movement into nutation by tightening. It is also connected to the long head of the bicep femoris.
  • Interosseus ligaments: It fills up the irregular spaces posteriorly and superiorly. It resists the joint separation.



  Functions of SIJ Top


The musculoligamentous network ensures the limited range of motion but very high load-bearing strength. Main function of SIJ is to support the upper body and dampen the impact of ambulation, and these ligaments act together to maintain the self-bracing mechanism when weight is transferred from the torso to lower extremities.[12]

The SIJ functions as a self-compensating mechanism, which accommodates, mitigates, balances, stores, and redirects forces affecting the pelvis and spine. Different forces such as gravity, bearing, inertia, rotation, acceleration/deceleration, and ground-reactive are acting.

Any slight changes in the mobility or stability due to any cause may result in SIJ dysfunction.


  Biomechanics and Kinetics Top


The SIJ is considered as a stress-relieving joint, which acts as a buffer between lumbar spine and hip joint.[13]

  • Sacrum is wedge shaped.
  • Ridges and depressions provide stability to SIJ. These are formed in response to the stress during individual's life.
  • Female SIJ ligaments are more lax than males due to hormonal influences, especially during pregnancy and childbirth.
  • SIJ axial compression failure is 20 times and 2 times more susceptible to axial torsion overloading than lumbar motion segments. Repetitive injuries such as in athletes and other professions involved in similar activities expose them to SIJ injuries.
  • SIJ is not immobile as against the popular belief.
  • In vivo and in vitro studies show that there are different types of minor movements shown in SIJ, such as tilting, rotation, gliding, translation, and nodding.[14–16]
  • There are two movements: Nutation [Figure 2]A, which denotes movement of the base of sacrum anterior and inferior in relation to the ileum; and counternutation, which denotes movement of the base of sacrum posterior to superior. There is huge debate on the extent of movement and other axis of movement in SIJ [13] [Figure 2]B.
Figure 2: (A) Nutation movement of SIJ. (B) Counternutation movement of SIJ

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  Innervation Top
[Figure 3]

  • SIJ has very complex nerve supply, which is controversial and a topic of debate.
  • Posterior joint is supplied mainly by the dorsal rami of L4–S3 nerve roots.[17]
  • Others believe that L3 and S4 also contribute to the same.[8]
  • The consensus on supply of ventral SIJ is more debatable. Most studies do agree that the supply comes from ventral rami of L5–S2 and possibly L4. This is because in many individuals sacralization of L5 may lead to SIJ dysfunction.
  • Few older data also state that there might be some contributions from the superior gluteal and obturator nerves.[18]
  • Figure 3: Nerve supply of SIJ

    Click here to view



  Prevalence Top


Prevalence of SIJ pain is being studied in patients with mechanical low back pain (LBP), with research groups using different selection criteria, different block methods, and different criteria to define positive response. This led to varied prevalence rates. It affects up to 30% of the patients with nonradicular chronic low back pain (CLBP).[19]

Schwarzer et al.[20] in a prevalence study treated 43 consecutive patients with CLBP (below L5–S1) with fluoroscopically guided SIJ injections. He excluded 57 patients who had pain above L5–S1. The diagnostic criteria were pain relief following local anesthetic injection, abnormality seen on postarthrography CT scan, and concordant pain response during injection. He concluded that using pain relief following Local anesthetic (LA) injection as criteria, prevalence was found to be 30%. When added other criteria as seen on CT (posterior capsular tear), the prevalence reduced to 21%. When considered all three criteria for diagnosis, the prevalence was found to be only 16% (seven patients). Maigne et al.[21] performed series of SIJ blocks using different LA blocks in 54 patients as per guidelines issued by international spinal injection society. Nineteen patients had >75% relief following lidocaine, and of these, 10 patients had >2 h of relief following bupivacaine block. These patients were considered as true SIJ pain (95% CI, 9%–29%). This article suggests that by performing series of joint blocks using different local anesthetics, we can reduce the false-positive rates.

Comparative controlled studies using nonspecific nonradicular CLBP as inclusion criteria described SIJ prevalence to be 27% and 26%,[22],[23] whereas those using pain below L5 showed higher prevalence rates (40%–45%).[24],[25] Uncontrolled SIJ diagnostic blocks are associated with higher false-positive rates [19]


  Mechanisms of Injury Top


  1. Direct fall on buttocks [9]
  2. Rear-end motor vehicular accident (foot on the brake during accident)[9]
  3. Motor vehicular accident from the side, causing injury to side of the pelvis [9]
  4. Sudden fall into the hole [9]
  5. Misjudged height leading to sudden jerk while climbing down [9]
  6. Lumbar surgery in past leading to mechanical disturbances in musculoligamentous support system [9]
  7. Gravida/para patients[9]



  Cause of SIJ Dysfunction Top


  • True and apparent leg length discrepancy
  • Older age
  • Inflammatory arthritis
  • Previous spine surgery
  • Pregnancy
  • Trauma
  • Osteoarthritis
  • Ankylosing spondylitis (AS) (almost universal in these patients, symmetric or alternating)[26]
  • Reiter's syndrome (20%–30% of the patients, mostly asymmetric)[26]
  • Psoriatic arthritis (20%–30% of the patients, mostly asymmetric)[26]
  • Inflammatory arthritis
  • Enteropathic arthritis (15%–25% of the patients, mostly asymmetric)[26]



  Symptoms Top


  • SIJ pain can be presented as localized and/or referred pain [Figure 4].
  • Area of pain as drawn on pain diagram is usually in the area of 3 × 10 cm inferior to the posterior superior iliac spine (PSIS).[27–29]
  • Most common presentations include pain in the lower back, buttocks, leg, groin, and hip.[30],[31],[32]
  • Most common areas of referred pain are the buttocks (94%), lower lumbar region (72%), lower extremity (50%), and groin (14%).[27]
  • Some studies have found that when the worst pain within 10 cm of PSIS, SIJ as a pain generator is more likely.[31],[33]
  • Quality of the pain can range from dull and achy to sharp and stabbing.[20]
  • Most common discomfort is described as aching or hypersensitivity along the joint line to the ipsilateral hip and greater trochanter.
  • Aggravating factors include all types of physical activity, unspecified sustained positions, bending, climbing, rising, and sexual intercourse.[34]
  • Most studies agree that pain above the L5 spinous process is less likely to be originating from the SIJ.[30],[35],[36]
  • Because of extensive innervation of the joint, SIJ pain can have varied presentations. It can be presented as spasm of the muscle groups attached to the joint.[30],[35],[36],[37]
  • Pain may be in radicular pattern due to leakage of inflammatory mediators to nearby neural structures through the defect in the SIJ capsule.[9]
Figure 4: Clinical presentation of SIJ pain

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  Diagnosis Top


Diagnosis of SIJ dysfunction is challenging.

  • Asymmetry, erythema, or protrusion can rarely be seen on inspection.
  • Many pain provocative tests are available to predict SIJ dysfunction [Table 1]. Various studies have shown that when three provocative tests are used in combination, it increases the positive predictive value.[24],[35],[36],[37],[38]
  • SIJ block with LA is the gold standard for diagnosis of SIJ pain.
  • Because false-positive responses to single diagnostic blocks into synovial joints are common, comparative or placebo-controlled blocks are now considered essential before a diagnosis of SIJ mediated pain is confirmed.[39]
Table 1: Clinical tests for the diagnosis of SIJ pain

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  Investigations Top


Laboratory tests[40]

  • Complete blood count: gives information about infective, inflammatory pathologies
  • Erythrocyte sedimentation rate
  • C-reactive protein: gives information about infection and inflammatory pathology
  • Antinuclear antibody profile
  • Human leukocyte antigen-B27 status: one of the early indicators in patients with AS
  • Rheumatoid factor: positive in cases of rheumatoid arthritis
  • Prostate-specific antigen: high levels indicate probability of metastatic deposits
  • Plasma protein electrophoresis and other tests for malignancy


Imaging studies

  • X-ray [lumbosacral spine plain (AP and lateral views), pelvis (AP view)]: low sensitivity, high specificity [19]
  • CT scan: good for bone changes, 58% sensitive, 69% specific; cannot detect inflammation [19]
  • MRI: investigation of choice; highly sensitive for active sacroiliitis [19]
  • Bone scan: low sensitivity, high specificity (>90%)[19]
  • Ultrasound: useful in pregnancy, to detect posterior ligamentous pathology [19]


Diagnostic blocks

  • Intra-articular (IA) injection of SIJ: under fluoroscopy, CT guided, or ultrasonography guided.
  • Alternative approach is to perform L4 medial branch, L5 dorsal ramus, and S1–3 lateral branch of dorsal ramus nerve blocks.



  Differential Diagnosis Top


  • Discogenic pain
  • Facet joint pain
  • Myofascial pain syndrome
  • Piriformis pain syndrome



  Management Top


Treatments of Underlying Condition Medical Management

  • Inflammatory arthritis
  • Rheumatoid disease
  • Inflammatory bowel diseases
  • Ankylosing spondylitis
  • Reiter's syndrome


Activity modification

SIJ pain can be divided into following two phases [41]:

  1. Acute phase (1–7 days)
  2. Recovery phase (2–8 weeks)


Relative rest and avoidance of aggravating factors are advised in acute phase. Aggravating factors can be different for each patient, so it is mandatory to identify the activities that trigger and increase the SIJ pain.

In recovery phase, patient should be advised to maximize strength through physical therapy. This includes increasing mobility, stretching, strengthening, and correcting of any asymmetries and hyperactivity of muscle groups.[41],[42]

Physical therapy

This modality mainly includes stretching, strengthening, and stabilizing pelvic floor muscles; correcting gait abnormalities; and addressing postural and dynamic muscle imbalance.[41]

Manipulations

Various studies have shown effectiveness of SIJ and lumbar spine manipulations in improving visual analog scale and Oswestry Disability Index. Manipulations studied include high-velocity low-amplitude and Mulligan mobilization with movement.[42],[43]

Modalities

Some modalities that may be used during treatment include ultrasound with or without phonophoresis diathermy, moist heat or cold, and transcutaneous electrical nerve stimulation.[43]

Role of Nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered the first-line treatment for SIJ pain, especially of inflammatory origin such as AS and undifferentiated spondyloarthritis. A significant proportion of patients with AS showed significant clinical improvement with NSAID treatment.[44] The anti-inflammatory effects of NSAIDs are the reason for improvement of pain in patients with AS.[45],[46]


  Interventions for SIJ Pain Top


Intra-articular injection

IA injection of various agents such as corticosteroids, hyaluronic acid, and dextrose water is being studied to treat SIJ pain. Most use single-needle technique, but there is a good technique mentioning about use of two needles in the joint for better success rate.

Procedure details:

  • Patient in prone position.
  • Fluoroscopy guidance is essential.
  • L5–S1 disc space is squared using cephalad movement of fluoroscope.
  • Then the fluoroscope is moved in contralateral oblique angle.
  • SIJ is a broad joint and shows multiple medial and lateral joint lines. The medial joint lines denote posterior joint and lateral joint lines denote anterior joint lines.
  • End point of the oblique view is overlapping of two (medial and lateral) joint lines, till the very crisp lower one-third of the joint space is seen.
  • Spinal needle (25/23 G), with a gentle curve the tip to help navigation, is used to enter the joint space.
  • Once the needle is seen in the joint, nonionic contrast is injected to see the dye spread in the joint.
  • In one case series, Gupta [47] reported that if the needle is not in the joint space and dye is leaked, it is impossible to redirect the needle due to dye over the target area. So if there is any doubt that first needle is not in the joint space, he suggested placing two needles before injecting the dye. This will improve the success rate. He has also suggested using a dynamic continuous live fluoroscopy from right oblique to left oblique view.
  • If the needle is in the joint space, it will be seen to be in the joint space from each angle from ipsilateral to contralateral oblique views. Anytime if the needle is seen out of joint on the bone, it should be repositioned.
  • Final needle position is confirmed in lateral view, where it should be seen in the anterior one-third of the joint.[48]
  • Nonionic contrast medium is injected to obtain arthrogram. Check AP and lateral views [Figure 5]A and [Figure 5]B.
  • Dye is seen spreading in inferior recess, between the joint line in entire joint (inferior–superior direction) and in cases where the posterior capsule is torn, the dye is seen leaking toward sacrum and its foramina.[4],[48]
  • Relocate needle if there is vascular spread [Figure 5]C.
  • Volume injected in the joint is of equal importance. The capacity of the joint is only 1.08 mL (standard deviation is 0.29 mL).[5],[48] The contrast dye should be used in minimal quantity, so there is enough space for the therapeutic drug injection.
Figure 5: (A) IA contrast spread—AP view (double-needle technique). Note small black arrows showing contrast spread along the joint. Big arrow showing second needle tip in the joint space. (B) IA contrast spread lateral view. (C) Intravascular spread of contrast—black arrow

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Intra-articular steroid injection (IA injection): Various observational studies show beneficial effects for IA steroid in 79%–93% of the patients with average duration of effect lasting 9.9 months.[1],[49],[50],[51] A few controlled studies have also shown beneficial effects of steroids over saline.[52],[53]

Hansen et al.[19] in his systematic review concluded that the evidence for IA injection of steroids is poor for short- as well as long-term relief. This could be because of literature deficiency with well-controlled randomized studies.

Evidence: There is limited evidence for the effectiveness of IA steroid injections.[19]

Extra-articular/periarticular injections

Various studies combining periarticular local anesthetic and steroid injections show superior short-term relief but limited long-term effects.[54],[55],[56],[57] Murakami et al.[58] treated patients with SIJ pain with IA injections. In patients who did not respond to the IA injections, he gave extra-articular (EA)/periarticular injections. He observed that the improvement in pain was significantly higher (96%) in patients with EA injection compared to those with IA injection (62%). This may be due to pain generators present outside the SIJ, which were blocked by EA injections. This may include interosseous membranes and ligaments. Other reason may be additional dose of steroid in second injection. The patients might have been misdiagnosed as SIJ pain and actually they might be having dysfunction of other soft-tissue structures around the joint, which responded well to the EA injections. In 2016, Nacey et al.[59] treated 99 patients and performed 113 SIJ injections. He concluded that there is no significant difference in pain relief between IA and EA injections.

Evidence: On the basis of limited results, there is limited (or poor) evidence for periarticular injections of local anesthetic and steroid.[19]

Radio-frequency denervation

The radio-frequency ablation (RFA) is one of the best treatment options for these patients if the relief with IA injection is short term. It gives long-lasting relief. Various RFA techniques are used for the SIJ. These can be IA or RFA of the nerves supplying SIJ. We are discussing each one with their effectiveness and evidences.

Conventional RFA

Technique: The patient is in prone position. L4 medial branches and L5 dorsal rami are ablated. In sacral area, S1–S3 foramina are identified under fluoroscope. At 1, 4, and 7 O'clock positions of foramen, the needle tips are placed (should be less than 6 mm apart for bipolar lesion and more than 6 mm for unipolar lesion),[60] and ablation is performed after satisfactory sensory and motor stimulation. The temperature used is 70° C–90° C for 1–2 min at each target point. The procedure is then repeated at other levels [Figure 6].
Figure 6: CRF lesioning—sites for needle placement

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A few studies are available showing effects of IA RFA. In one study, author has used IA denervation,[61] and few studies have used a combination of IA and standard denervation techniques explained previously. The standard technique is superior to the IA denervation. Cohen [27] in his review article concluded that denervation of nerve supply yields better results than IA RFA.

Limitations: Lateral branches supplying SIJ vary from patient to patient, side to side, and level to level. As the lesion size in conventional radio-frequency (CRF) is small (approximately 4 mm in horizontal diameter), it can miss the nociceptive impulses transmitting from SIJ. So, multiple lesions are required to block these impulses, which is more time-consuming and increases radiation exposure. Some authors have described fluid irrigation methods to increase the lesion size.[62],[63]

The main limitation of percutaneous radio-frequency (RF) procedure for SIJ is that the pain emerging from the ventral SIJ cannot be treated.[62]

Evidence: The level of evidence for CRF is limited,[61],[64],[65] which is mainly because of the limitation in positioning of the needle.

Pulsed RFA

Technique: Method and needle placement is similar to conventional RFA. RF parameters are 120 s at 45 V. Once one lesion is created, needle is rotated 180° and another lesion is created. Many mechanisms are hypothesized in various studies. The most convincible explanation is that pulsed RF (PRF) creates an electrical field that inhibits transmission of A-delta and C fibers, and possibly enhances descending modulatory systems. This is in contrast to CRF or cooled RF where nerve damage occurs resulting in  Wallerian degeneration More Details and inhibition of pain transmission.[66],[67] Few authors have placed the needle tip intra-articularly and performed PRF lesioning.[61],[68],[69] Main mechanism for IA PRF is that electric field generated by RF probe affects immune cells, which in turn modulates production of anti-inflammatory mediators.

Evidence: Only few studies are available on PRF of SIJ. They concluded that PRF denervation of the medial branch of L4, the posterior primary rami of L5, and the lateral branches S1 and S2 is an effective treatment for selected patients with SIJ dysfunction unresponsive to other forms of therapy.[70] Because of paucity of the research and studies, no recommendation can be given for this technique. Further studies in a controlled, blinded trial are required.

Bipolar RFA

In bipolar RFA, a second electrode is placed close (<6 mm)[71] to the first so that the current flows between the two electrodes to create a continuous lesion. The conceptual appeal of bipolar RF denervation lies in its ability to maximize lesion size by use of an enclosed electrical circuit, so that the placement of electrodes close to the foramen where the lateral branches converge can theoretically interrupt all nociceptive input.

Cooled RFA

The main feature of cooled RFA is internally cooled, large-bore electrodes [Figure 7]. It uses irrigation so that the surrounding tissue reaches neuroablative temperature slowly whereas the adjacent tissue temperature is maintained at lower level, which prevents charring. This allows greater lesion expansion (a twofold increase in diameter, >3 cm distal to the active tip depth, and an eightfold increase in area), which in turn increases the likelihood of successful neurotomy of all the nociceptive inputs. Needle placement is same as in conventional RFA. As RF lesion extends distal to the tip, electrodes need to be placed at a greater distance (>7 mm) from the foramina to prevent increase in the temperature of sacral foramina [19] [Figure 7].
Figure 7: Cooled RF lesioning, positioning of the electrode tip around the dorsal sacral foramen. (A) – Position of RF electrode for cooled RF lesioning at S1 dorsal foramen. (B) - Position of RF electrode for cooled RF lesioning at L5 dorsal ramus, S1-S3 dorsal foramen

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Disadvantages of cooled RFA include the greater expense, longer lesioning time, and larger electrode size, which enhance the risk of bleeding and procedure-related pain. The larger lesions are more likely to capture superficial branches; there is also a higher incidence of cutaneous paresthesias.[22]

Evidence: Cohen et al.[72] treated 77 patients with SIJ IA injection and confirmed SIJ as a pain generator. In this study, he noted the results with cooled RFA were better.[72] In contrast, Cheng et al.[65] in his study performed RFA in 88 patients. He found no significant advantage of cooled RFA over conventional RFA procedure.[65] Hansen et al.[19] found evidences for cooled RFA to be fair. Stelzer et al.[73] recently found that cooled RFA procedure showed promising, long-lasting improvements in pain, quality of life, and medication usage in a large European study population, with benefits persisting in some subjects at 20 months after treatment.

Strip Lesion RFA

The main objective is to create a continuous strip lesion from L5 to S4 dorsal rami.

Two techniques are mentioned in the literature, which are as follows:

  1. Guide block: Cheng et al.[74] suggested a guide block containing nine through holes along a straight line in the long axis with an equal distance of 10 mm between two adjacent RF probes. RF probes can be passed through these holes and multiple parallel lesions can be created depending on the height of the patient [Figure 6]. He concluded that new RFA technique reduced operating time by more than 50%, decreased X-ray exposure by more than 80%, cut the cost by more than $1000 per case, and was significantly associated with improved clinical outcomes despite of the limitations of the study design [Figure 8].
  2. Simplicity probe: Another probe, which can be used to create a strip lesion, is Simplicity III (NeuroTherm®, Wilmington, MA). It was introduced to ablate the lateral branches that innervate the SIJ with a single percutaneous entry point. The Simplicity probe is a solid RF electrode with three active areas that create three monopolar lesions and two bipolar lesions in a sequential manner across the lateral branches of S1–S4[75] [Figure 9], [Figure 10], [Figure 11]. The main advantages of this probe include a single percutaneous insertion site, no need for introducers, and the creation of a continuous “strip” lesion that ensures capture of most lateral branches. Not many studies are available for this technique. In recent studies, authors concluded that Simplicity RF neurotomy of lateral branches of S1–S3 by creating a “strip lesion” along with CRF denervation of the L5 dorsal ramus can be effective in improving pain scores for up to 12 months.[76],[77]
Figure 8: Guide block used for strip lesion of lateral branches to the SIJ

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Figure 9: Simplicity probe for SIJ lateral branches lesioning

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Figure 10: Simplicity probe–electrode placement

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Figure 11: Placement of simplicity probe for strip lesioning of lateral branches

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Evidence: A very limited number of studies are available to recommend this technique. The evidence is limited.

Regenerative therapies

Prolotherapy (proliferative therapy) involves injecting irritant solution to intra/periarticular area, which induces mild degree of inflammation and promotes healing. Final result of prolotherapy is strengthening of ligament and muscles surrounding the joint, which increases stability and in turn decreases pain. Various concentrations of dextrose water have been used for SIJ prolotherapy.

IA prolotherapy: Kim et al.[78] compared IA prolotherapy to IA steroid injection. He injected 25% dextrose in patients with diagnosed SIJ dysfunction. The author concluded that there was no significant difference between both the groups at 3 months follow-up, but on a long-term follow-up, prolotherapy was more effective. Kim et al.[78] used 5% dextrose water and found similar results. Mitchell et al.[79] injected 50% dextrose in deep interosseous ligaments and concluded that at 12 months posttreatment, prolotherapy can be an effective treatment for increasing stability and strength and decreasing pain in patients with SIJ pain.

Disadvantages: It involves multiple injections, postinjection pain, and limited research material availability.

Cryoanalgesia

Mechanism includes inducing ice crystal formation that damages the vasa nervorum, leading to severe endoneurial edema and disruption of neural transmission.

Main advantage of cryotherapy is larger lesion size compared to RFA and it leaves the myelin sheath and endoneurium intact.

Disadvantage is its relative shorter duration of relief and higher risk of bleeding and unwanted nearby nerve injury.[22]

Currently, there are no published studies evaluating cryoanalgesia for SIJ pain.

Surgical Management

Surgical options for SIJ dysfunction include open surgery and minimally invasive surgery. Open surgical access for SIJ arthrodesis can be performed anteriorly or posteriorly. Anterior approach has advantages such as visualizing ventral and cranial synovial portion of the sacroiliac complex without sacrificing any of the primary soft tissue (ligamentous) stabilizers.[80] Minimally invasive surgery technique enables arthrodesis by inserting bone material in the cage-type screw and may avoid wound-related complications.[80]


  Conclusion Top


SIJ is a complex joint. The movements and kinetics are also very complex. A number of causes can lead to SIJ dysfunction. Diagnosis of SIJ pain is difficult, and we cannot rely on clinical examination, laboratory tests, and radiological tests. Diagnostic SIJ block using different local anesthetics is the gold standard for confirming SIJ as a source of pain. The treatment involves various interventions and rehabilitation therapies. SIJ steroid injections, RFA of S1–S3 lateral branches, L4 medial branch with L5 dorsal ramus (using various techniques such as CRF, cooled RF, bipolar, strip lesions), and regenerative therapies such as dextrose prolotherapy and platelet-rich plasma are few commonly performed interventions. The evidence is limited for most interventions and is mainly due to lack of good studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Abstract
Introduction
Anatomy
Functions of SIJ
Biomechanics and...
Prevalence
Mechanisms of Injury
Symptoms
Diagnosis
Investigations
Differential Dia...
Management
Interventions fo...
Conclusion
Innervation (Fig...
Innervation
Cause of SIJ Dys...
References
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