Sacroiliac JointSacroiliac JointJ. Scott Bainbridge, MDJ. Scott Bainbridge, MD

www.DenverBackPainSpecialiwww.DenverBackPainSpecialists.comsts.com

SIJ BackgroundSIJ Background Proposed as potential source of pain Proposed as potential source of pain

by Goldthwaite in 1905by Goldthwaite in 1905 Incidence of SIJ pain in LBP Incidence of SIJ pain in LBP

population: 18-40% (Schwarzer, population: 18-40% (Schwarzer, Maigne, DePalma, Liliang, Maigne, DePalma, Liliang, Schofferman)Schofferman)

SIJ AnatomySIJ Anatomy

SIJ AnatomySIJ Anatomy Diarthrodial jointDiarthrodial joint Hyalin cartilage, fibrocartilage also on ilial sideHyalin cartilage, fibrocartilage also on ilial side Interlocking contoursInterlocking contours Ligaments: anterior and posterior SIL, Ligaments: anterior and posterior SIL,

interosseous SIL, sacrospinous and interosseous SIL, sacrospinous and sacrotuberoussacrotuberous

Muscles: paraspinous, gluteal, psoas, iliacus, Muscles: paraspinous, gluteal, psoas, iliacus, abdominal, sartorius, rectus femoris, hamstrings, abdominal, sartorius, rectus femoris, hamstrings, latissimus dorsi (lumbodorsal fascia) latissimus dorsi (lumbodorsal fascia)

NutationNutation

SIJ InnervationSIJ Innervation

SIJ InnervationSIJ Innervation Early: Cunningham’s…, Bernard and Early: Cunningham’s…, Bernard and

Cassidy, Ikeda, Nagakawa, etc. included Cassidy, Ikeda, Nagakawa, etc. included anterior innervation (ventral rami)anterior innervation (ventral rami)

Fortin et al, Grob et al: macroscopic and Fortin et al, Grob et al: macroscopic and fetal microscopic fetal studies: fetal microscopic fetal studies: innervation entirely dorsal rami (S1-3[4])innervation entirely dorsal rami (S1-3[4])

Yin, Willard, Carreiro, Dreyfuss: defined Yin, Willard, Carreiro, Dreyfuss: defined (fluoro) course of sacral dorsal rami; (fluoro) course of sacral dorsal rami; reported SIJRF pilot technique and reported SIJRF pilot technique and resultsresults

S-1 Dorsal RamiS-1 Dorsal Rami

Yin, et al. Spine 2003

S-2 Dorsal RamiS-2 Dorsal Rami

S-3 Dorsal RamiS-3 Dorsal Rami

DiagnosisDiagnosis X-ray, MRI, CT, bone scan generally not helpful X-ray, MRI, CT, bone scan generally not helpful

except to rule in/out fracture, stress response, except to rule in/out fracture, stress response, infection, tumor, sacroiliitisinfection, tumor, sacroiliitis

Arthrogram may show capsular disruptionArthrogram may show capsular disruption Need double intraarticular SIJ blocks to diagnose, Need double intraarticular SIJ blocks to diagnose,

although single IA, posterior ligament, or dorsal rami although single IA, posterior ligament, or dorsal rami blocks have been used by various blocks have been used by various authors/practitionersauthors/practitioners

Blockade of the L5 Dorsal Rami and Sacral 1-3 lateral Blockade of the L5 Dorsal Rami and Sacral 1-3 lateral branches, using the multi-site, multi-depth technique branches, using the multi-site, multi-depth technique of Dreyfuss, et al. (Pain Medicine 2009) is necessary of Dreyfuss, et al. (Pain Medicine 2009) is necessary for radiofrequency neurotomy (RFN) screeningfor radiofrequency neurotomy (RFN) screening..

Diagnosis - HistoryDiagnosis - History Unilateral pain at or below PSIS, Unilateral pain at or below PSIS,

PSIS pointing (Fortin, Maigne)PSIS pointing (Fortin, Maigne) , no pain above L5, pain over SIJ and , no pain above L5, pain over SIJ and

Buttock (Dreyfuss, et al)Buttock (Dreyfuss, et al)

Diagnosis – Physical Diagnosis – Physical ExamExam

Maigne: Patrick’s – trend – p=0.9Maigne: Patrick’s – trend – p=0.9 Broadhurst and Bond: double blind, Broadhurst and Bond: double blind,

lido v salinelido v saline FABER (Flexion, ABduction, External FABER (Flexion, ABduction, External

Rotation)Rotation) POSH (POsterior SHear)POSH (POsterior SHear) REAB (REsisted ABduction)REAB (REsisted ABduction) 100% specificity, 77-80% specificity @ 100% specificity, 77-80% specificity @

70% < pain70% < pain

Diagnosis – Physical Diagnosis – Physical ExamExam

Dreyfuss, et al (multidisciplinary Dreyfuss, et al (multidisciplinary expert panel)expert panel) 12 key pain, Hx, and PE parameters12 key pain, Hx, and PE parameters Single block, 90% reliefSingle block, 90% relief PSIS pointing, no pain above L5, sacral PSIS pointing, no pain above L5, sacral

sulcus tenderness, pain over SIJ/buttocksulcus tenderness, pain over SIJ/buttock Gillet’s test best of provocative Gillet’s test best of provocative

maneuversmaneuvers

Diagnosis – Physical Diagnosis – Physical ExamExam

Van der Wurff, et al, 2006Van der Wurff, et al, 2006 Double blocks, >50% reliefDouble blocks, >50% relief 3 of 5 positive tests (distraction, 3 of 5 positive tests (distraction,

compression, thigh thrust, Patrick, compression, thigh thrust, Patrick, Gaenslen)Gaenslen)

Sensitivity .85, specificity .79Sensitivity .85, specificity .79 PPV .77, NPV .87PPV .77, NPV .87

Discogenic: Centralization w McKenzie Discogenic: Centralization w McKenzie methodmethod Pain w rising from sittingPain w rising from sitting

Sacroiliac: Unilateral pain; No lumbar Sacroiliac: Unilateral pain; No lumbar painpain Pain rising from sittingPain rising from sitting 3/5 provocation tests: distraction, 3/5 provocation tests: distraction,

compression, sacral thrust, thigh thrust, compression, sacral thrust, thigh thrust, Gaenslen’sGaenslen’s

LZJ: no pain rising from sittingLZJ: no pain rising from sitting

SIJ - TreatmentSIJ - Treatment Manual therapyManual therapy Exercise (m. balance, stabilization)Exercise (m. balance, stabilization) MedicationMedication IA injection (corticosteroids)IA injection (corticosteroids) ProlotherapyProlotherapy PRP – Platelet Rich PlasmaPRP – Platelet Rich Plasma NeuromodulationNeuromodulation Dennervation (RF neurotomy)Dennervation (RF neurotomy)