Ultrasound-Guided Versus Fluoroscopy-Guided Sacroiliac Joint Intra-articular Injections in the Noninflammatory Sacroiliac Joint Dysfunction: A Prospective,Randomized, Single-Blinded Study

Objective

To compare the short-term effects and safety of ultrasound (US)-guided sacroiliac joint (SIJ) injections with fluoroscopy (FL)-guided SIJ injections in patients with noninflammatory SIJ dysfunction.

Design

Prospective, randomized controlled trial.

Setting

University hospital.

Participants

Patients (N=120) with noninflammatory sacroiliac arthritis were enrolled.

Intervention

All procedures were performed using an FL or US apparatus. Subjects were randomly assigned to either the FL or US group. Immediately after the SIJ injections, fluoroscopy was applied to verify the correct placement of the injected medication and intravascular injections.

Main Outcome Measures

Treatment effects and functional improvement were compared at 2 and 12 weeks after the procedures.

Results

The verbal numeric pain scale and Oswestry Disability Index improved at 2 and 12 weeks after the injections without statistical significances between groups. Of 55 US-guided injections, 48 (87.3%) were successful and 7 (12.7%) were missed. The FL-guided SIJ approach exhibited a greater accuracy (98.2%) than the US-guided approach. Vascularization around the SIJ was seen in 34 of 55 patients. Among the 34 patients, 7 had vascularization inside the joint, 23 had vascularization around the joint, and 4 had vascularization both inside and around the joint. Three cases of intravascular injections occurred in the FL group.

Conclusions

The US-guided approach may facilitate the identification and avoidance of the critical vessels around or within the SIJ. Function and pain relief significantly improved in both groups without significant differences between groups. The US-guided approach was shown to be as effective as the FL-guided approach in treatment effects. However, diagnostic application in the SIJ may be limited because of the significantly lower accuracy rate (87.3%).     

Sacroiliac joint fusion and the implications for manual therapy diagnosis and treatment

The present paper examines gender differences and changes in prevalence of ankylosed sacroiliac joint (SIJ) with age. SIJs of 287 patients (159 males and 128 females), aged 22-93 years, were examined for fusion, using 3-D CT images. Presence, side and location of the fusion along the joint borders were recorded. Fusion of the SIJ was found to be gender and age dependent; present in 27.7% of all males in contrast to only 3.0% in females (p<0.001). The phenomenon increased with age in the male population from 5.8% in the 20-39 age cohorts to 46.7% in the 80+ cohort. As mobilization and/or manipulation of a dysfunctional SIJ are common procedures used by manual therapists, the effect that aging has on SIJ mobility requires therapists to alter or change their method with advancing age.     

SAPHO综合征患者骶髂关节病变的MRI表现

目的回顾性分析13例SAPHO综合征患者的骶髂关节MRI图像,旨在提高临床医师对此病的认识,提高诊断的准确性。材料与方法纳入2014年11月至2015年8月于北京协和医院就诊的13例伴骶髂关节受累的SAPHO综合征患者,其中女9例,男4例,平均年龄(45.9±8.9)岁,总结其骶髂关节病变的影像学特征。结果 13例患者中双侧骶髂关节受累者有11例,单侧者2例,因此,共24个骶髂关节受累。16个关节以骶骨侧病变为主,20个关节病变同时累及滑膜部和韧带部。一些骶髂关节邻近骨质出现异常MRI信号,包括骨髓水肿信号(16/24)、脂肪沉积信号(24/24)、骨质破坏(18/24)、骨质硬化(19/24)。关节间隙增宽者占8.3%(2/24),关节间隙狭窄者占16.7%(4/24),关节强直者占20.8%(5/24)。25%(6/24)的病变关节出现关节腔积液,8.3%(2/24)的病变关节出现周边软组织水肿。结论 SAPHO综合征患者的骶髂关节病变多为双侧受累、骶骨侧病变为主,且具有新老病灶并存的特点,较少引起关节强直。上述特征可从影像学上提示SAPHO综合征,结合患者的皮肤病变,综合评估做出诊断。     

Age, body mass index, and gender differences in sacroiliac joint pathology

OBJECTIVE: To evaluate the correlation between age, gender, and body mass index as they relate to sacroiliac joint pathology diagnosed by dual comparative local anesthetic blocks. DESIGN: This was a retrospective review of patients at a university spine center from August 2001 until August 2004. RESULTS: One hundred fifty-eight patients underwent sacroiliac joint (SIJ) injections with average symptom duration of 34.0 mos. Of those patients, 26.6% were found to have SIJ pain by dual injections. The average age of this group was 53.3 yrs old; for those who had negative injections, it was 46.8 yrs old (P = 0.0025). The body mass indexes for the positive and negative SIJ pain groups were 30.2 and 29.3 kg/m2 (P = 0.40), respectively. The gender makeup of the positive and negative groups showed 64.3% female and 62.1% female (P = 0.85), respectively. Smoking tobacco status was not statistically significant between the two groups, with 29.6% of smokers having a positive block and 26.1% having a negative block (P = 0.35). CONCLUSIONS: Our results suggest an age difference for those patients who have SIJ pain. These patients tend to be older than those without. Gender, age, and smoking status were not found to correlate with SIJ pathology.     

Disorders of the Sacroiliac Joint

Abstract: Controversies have surrounded the sacroiliac joint. The sacroiliac joint (SIJ) is a considerably complex and strong joint with limited mobility, mechanically serving as a force transducer and a shock absorber. Anatomical changes are seen in the SIJ throughout an individual's lifetime. The ligamentous system associated with the SIJ serves to enhance stability and offer proprioceptive feedback in context with the rich plexus of articular receptors. Stability in the SIJ is related to form and force closure. Movement in the SIJ is 3‐D about an axis outside of the joint. The functional examination of the SIJ is related to a clinical triad.     

强直性脊柱炎患者血清和骶髂关节结缔组织生长因子的表达——附30例检测分析

目的：了解AS患者血清和骶髂关节中结缔组织生长因子（CTGF）的表达情况。方法：选择30例AS患者和20名健康志愿者,分为AS组和健康对照组。采用ELISA法检测两组的血清CTGF水平,AS组患者行CT引导下骶髂关节细针穿刺活组织检查术,组织标本应用免疫组织化学染色检测CTGF的表达情况。结果：AS组骶髂关节组织的CTGF在血管翳炎症细胞及骨髓细胞的胞浆中高度表达,其阳性细胞数为（57．9±42．4）／HP,明显多于正常骶髂关节组织（2．7±2．5）／HP（P〈0．05）,AS组血清CTGF水平略低于健康对照组,但比较差异无统计学意义（P〉0．05）。结论：AS骶髂关节中存在CTGF的高表达,提示CTGF可能在AS关节软骨纤维化、关节强直中起重要的作用。     

Intertester reliability for selected clinical tests of the sacroiliac joint

The purpose of this study was to examine the intertester reliability of 13 tests for sacroiliac joint (SIJ) dysfunction. Eight therapists examined 17 patients in two clinical settings. In each case, two therapists independently examined the patients and obtained results on all 13 of the SIJ tests. Patients with lumbosacral pain and unilateral lower extremity symptoms of a duration less than one year were examined. All the therapists had specialized in orthopedic physical therapy and had been trained in SIJ examination. Reliability was poor; 11 of the 13 tests resulted in less than 70% agreement. The two tests that relied solely on subjective patient response and imparted no information on SIJ position or mobility were within a range of 70% to 90% agreement. Our findings suggest the necessity of reviewing examination methods for the SIJ and improving reliability of clinical testing of this joint.     

Schmerzen und Funktionsstörungen des Iliosakralgelenks bei Bandscheibenvorfällen der unteren Lendenwirbelsäule

Back and leg pain in patients with lumbar disc herniation can be caused by various mechanisms. In addition to nerve root compression, functional alterations in the sacroiliac joint, facet joint or the iliolumbar and sacrotuberal ligaments can produce "pseudoradicular" lower back syndrome. The following study attempts to show whether or not pain and functional alterations in the sacroiliac joint (SIJ) correlate with herniations revealed by computed tomography (CT). The study also attempts to determine the correlation between pain and functional changes of the SIJ and the size and level of the disc herniation. Fifty patients with monosegmental disc herniations revealed by CT who showed no signs of bone or soft tissue alterations were included in this study. The average duration of the patients' complaints of leg or back pain was 5.7 years. Ninety-six percent of these patients had received conservative treatment before admission to our hospital. All patients were compared to a control group consisting of 16 healthy subjects of comparable age. All patients underwent a comprehensive functional, neurologic and radiologic examination. The CTs were analyzed by a standardized three-dimensional method. All of the 50 patients had sciatica complaints and a disc herniation revealed by CT. In two cases hemiation of the L3-4 disc was demonstrated, in 14 cases L4-5 disc herniation and in 34 cases a L5-S1 disc herniation. In contrast to the control group of 15 healthy subjects, the patients showed a significant number of functional disorders upon examination. In 84% of all patients, movement of the SIJ was restricted. Painful palpation of the symphysis was demonstrated in 46% of all cases. Thirty-five percent of patients with herniation of L4-5 disc demonstrated SIJ tenderness as opposed to 65% of the patients with herniation of the L5-S1 disc. This SIJ tenderness did not correlate with motion of the SIJ. In addition, SIJ motion and frequency of sensory dysfunction showed no correlation with the size of the disc herniation. Paralysis and loss of reflexes showed a positive correlation with the increasing size of the disc herniation. SIJ tenderness decreased as the size of the herniation increased. Dysfunction of the ipsilateral SIJ is explained by increased muscular tone caused by irritation of the n. sinuvertebralis and its lumbar coupling. Frequency of SIJ tenderness is significantly higher in patients with herniations between L5 and S1. Since the SIJ is innervated by the r. dorsalis of the sacral roots, the increased tenderness can be explained by the change in neurovegetative innervation of the SIJ. Due to the high correlation between lumbar disc herniation and SIJ dysfunction, disc herniation should be considered as a possible cause of sacroiliac-joint syndrome.     

Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome

OBJECTIVE: To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic sacroiliac joint injections in patients with sacroiliac joint syndrome. DESIGN: A retrospective study design with independent clinical review was utilized. Thirty-one patients were included; each patient met specific physical examination criteria and failed to improve clinically after at least 4 wk of physical therapy. Each patient demonstrated a positive response to a fluoroscopically guided diagnostic sacroiliac joint injection. Therapeutic sacroiliac joint injections were administered in conjunction with physical therapy. Outcome measures included Oswestry scores, Visual Analog Scale pain scores, work status, and medication usage. RESULTS: Patients' symptom duration before diagnostic injection averaged 20.6 mo. An average of 2.1 therapeutic injections was administered. Follow-up data collection was obtained at an average of 94.4 wk. A significant reduction (P = 0.0014) in Oswestry disability score was observed at the time of follow-up. Visual Analog Scale pain scores were reduced (P < 0.0001) at the time of discharge and at follow-up. Work status was also significantly improved at the time of discharge (P = 0.0313) and at follow-up (P = 0.0010). A trend (P = 0.0645) toward less drug usage was observed. CONCLUSIONS: These initial findings suggest that fluoroscopically guided therapeutic sacroiliac joint injections are a clinically effective intervention in the treatment of patients with sacroiliac joint syndrome. Controlled, prospective studies are necessary to further clarify the role of therapeutic injections in this patient population.     

超声与CT融合成像在定位强直性脊柱炎骶髂关节炎性血流信号中的价值

目的应用超声与CT融合成像对强直性脊柱炎(AS)患者骶髂关节区探及异常低阻血流信号的位置进行判断,探讨其临床应用价值。方法对84例AS患者实施经骶髂关节3对骶骨后孔层面(level)的超声与CT图像融合,并对图像融合成功者行多普勒超声检查。对两具骨盆标本实施骶髂关节系统解剖及断层解剖,根据其解剖学特点,对AS患者3个level层面处探及的低阻血流信号的位置进行分类,以此判断其组织来源。结果成功实施图像融合的AS患者中,level 1~3层面探及低阻血流信号的关节数分别为128个、105个和61个。3个level层面间炎性血流信号位置按关节内及周围定位的分布情况比较,差异有统计学意义(χ^2=9.101,P=0.011)。结合融合图像及解剖学研究结果,level 1和level 2层面探及低阻血流信号多定位于关节韧带部(128/128、98/105);而level 3层面血流信号多定为于滑膜部(39/61);仅少数位于level 2(2个)及level 3(10个)层面处于滑膜部及韧带部交界处的血流信号在融合图像下无法精确定位。3个level层面间炎性血流信号根据解剖学类型定位情况比较,差异有统计学意义(χ^2=174.607,P<0.01)。结论大多骶髂关节后部超声测得的异常血流信号可通过超声与CT融合成像准确地定位于关节韧带部或滑膜部,提示为不同的炎症类型;该低阻血流信号可作为评价AS的可靠指标之一。     

Anterior dysfunction of the sacroiliac joint as a major factor in the etiology of idiopathic low back pain syndrome

The purpose of this article is to describe the author's theories as to how anterior dysfunction of the sacroiliac joints (SIJs) is a major factor in the etiology of idiopathic low back pain syndrome (ILBPS). Most research and treatment have been directed toward the intervertebral disk; however, it is unlikely that disk dysfunction is always the primary etiology. A review of the literature is used to outline and describe the characteristics of ILBPS and to make a case that these characteristics are consistent with those of a specific dysfunction of the SIJs. Functions of the intervertebral disks and the SIJs are described and related to SIJ dysfunction and to some of its common consequences. Treatment is discussed as it relates to the pathomechanics and their correction.     

Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study

BACKGROUND AND PURPOSE: The authors examined the intertester reliability of assessments made based on a composite of 4 tests of pelvic symmetry or sacroiliac joint (SIJ) movement that are advocated in the literature for identifying people with SIJ region dysfunction. "Sacroiliac joint region dysfunction" is a term used to describe pain in or around the region of the joint that is presumed to be due to malalignment or abnormal movement of the SIJs. SUBJECTS: Sixty-five patients with low back pain and unilateral buttock pain were seen in 1 of 11 outpatient clinics. METHODS: Thirty-four therapists, randomly paired for each subject, served as examiners. Kappa coefficients and observed proportions of positive (Ppos) and negative (Pneg) agreement were calculated to estimate reliability. RESULTS: For the composite test results, percentages of agreement ranged from 60% to 69%, kappa coefficients varied from.11 to.23, and Ppos was lower than 50%. DISCUSSION AND CONCLUSION: Reliability of measurements obtained with the 4 tests appears to be too low for clinical use. Given the measurement error found in this study, the authors suspect it is likely that either the proper treatment technique will not be chosen based on the test results or the intervention will be applied to the wrong side. The 4 tests probably should not be used to examine patients suspected of having SIJ region dysfunction, although the role of therapist training in use of the procedures is unclear.     

Percutaneous Sacroplasty and Sacroiliac Joint Cementation under Fluoroscopic Guidance for Lower Back Pain Related to Sacral Metastatic Tumors with Sacroiliac Joint Invasion

Abstract: Cancer patients with bone metastases are at risk of a variety of skeletal events, including vertebral compression and pathologic fractures. Approximately 30% to 40% of patients with advanced lung cancer will develop bone metastases in the course of their disease, resulting in a significant negative impact on both morbidity and survival. Skeletal complications of bone metastases include pain, pathologic fractures, spinal cord compression, and hypercalcemia. The spine is the most frequent site of skeletal metastases. We present a 48‐year‐old female with intractable and incapacitating low back pain because of metastatic bone tumor in the left lateral side of S1 and S2 with left sacroiliac invasion. Imaging identified a metastatic invasion of the sacrum. Percutaneous sacroplasty, a safe and effective procedure for sacral‐insufficient fractures, was performed under fluoroscopy guidance. However, the expected pain relief was not achieved. At 1 month, the patient remained invalided by severe back pain, which was localized to the left sacroiliac joint. In a second procedure, the sacroiliac joint was cemented. Pain relief was complete, immediate, and sustained until the patient's death related to the underlying oncologic disease. No complications were observed. Few reports exist about the treatment of sacral metastatic tumors with percutaneous sacroplasty. Further, no previous reports about sacroiliac joint cementation for joint stabilization have been found. In the present case, sacroiliac joint cementation successfully resolved residual pain that remained despite percutaneous sacroplasty treatment of the pathologic sacral fracture.     

Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests

Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference standards. The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference standard. In a blinded concurrent criterion-related validity design study, 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection procedures were examined using a specific clinical examination and received diagnostic intraarticular sacroiliac joint injections. The centralisation and peripheralisation phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process. Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection. Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain. In the primary subset analysis of 34 patients, sensitivity, specificity and positive likelihood ratio (95% confidence intervals) of the clinical evaluation were 91% (62 to 98), 83% (68 to 96) and 6.97(2.70 to 20.27) respectively. The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac joints     

Sacroiliac joint injections performed with sonographic guidance.

OBJECTIVE: To investigate the feasibility and effectiveness of sonographic guidance for therapeutic intra-articular sacroiliac joint injections in patients with sacroiliitis. METHODS: Thirty-four consecutive patients with sacroiliitis were enrolled in this study. The synovial portions of 60 sacroiliac joints received injections under sonographic guidance. For treatment, a mixture of a corticosteroid and a local anesthetic was injected intra-articularly. Fluoroscopic spot images were obtained to assess the accuracy of the sonographically guided technique. RESULTS: Of the 60 sonographically guided injections, 46 (76.7%) were successful (i.e., intra-articular), and 14 (23.3%) were missed. The successful intra-articular injection rate was 60% in the first 30 injections, and it gradually improved, reaching 93.5% in the last 30 injections. The mean procedure time was 9 minutes. CONCLUSIONS: Our initial experience suggests that sonographically guided therapeutic injections to sacroiliac joints could be valuable alternatives to other guidance modalities in patients with sacroiliitis. In the hands of experienced radiologists, this technique is safe, rapid, and reproducible.     

Cooled Radiofrequency System for the Treatment of Chronic Pain from Sacroiliitis: The First Case‐Series

? Abstract: Sacroiliitis and sacroiliac (SI) joint dysfunction are frequent causes of the chronic lower back pain. Therapeutic solutions include intra‐atricular injections with short‐term pain relief and surgical fusion, which appears ineffective. Radiofrequency (RF) of the joint capsule or lateral branches has been previously reported with variable successes. Cooling tissue adjacent to the electrode (cooled RF) increases the radius of lesion. We present here the first retrospective data on pain relief and changes in function after such RF denervation. We reviewed electronic records of 27 patients with chronic low back pain (median 5 years) who underwent cooled RF of S1, S2, and S3 lateral branches and of dorsal ramus (DR) L5 following two diagnostic SI joint blocks (>50% of pain relief). Patient sample consisted of 20 women and 7 men, 38 to 92 years old. Pain disability index (PDI), visual analog scale (VAS) pain scores, global patient satisfaction (GPE) and opioid use before and 3–4 months after the procedure were analyzed. One patient had an incomplete chart. Observed were improvements in function (PDI) from 32.7 ± 9.9 to 20.3 ± 12.1 (P < 0.001) and VAS pain scores 7.1 ± 1.6 to 4.2 ± 2.5 (P < 0.001) at 3–4 months after the procedure. Opioid use decreased from median 30 to 20 mg morphine equivalent. Eighteen patients rated their improvement in pain scores using GPE as improved or much improved, while eight claimed minimal or no improvement. The majority of patients with chronic SI joint pain experienced a clinically relevant degree of pain relief and improved function following cooled RF of sacral lateral branches and DR of L5 at 3–4 months follow‐up. ?     

A case report of sacroiliac joint dysfunction with urinary symptoms

Patients with sacroiliac joint (SIJ) dysfunction have various presenting symptoms. An unusual case of SIJ dysfunction presenting primarily with urinary urgency is described. The symptoms were relieved completely after the successful manipulation of the SIJ.     

Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests

Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard. In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and specificity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842. In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP.     

Computerized tomographic localization of clinically-guided sacroiliac joint injections

OBJECTIVE: The goal of this study was to use computed tomographic (CT) scanning to localize clinically guided sacroiliac (SI) joint injections and identify other structures affected by this procedure. DESIGN: A prospective, double-blind, correlational outcome study design was used. Injection of 39 SI joints with a mixture of bupivacaine (0.25%), methylprednisolone (40 mg), and iohexol (Omnipaque; 180 mg/dl) using a clinically guided technique, (i.e., no image guidance) was performed. Patients had CT scans obtained both immediately after needle placement and after contrast injection. Neither the patients nor their clinicians were aware of the CT findings at the time of injection. SETTING: Academic multidisciplinary pain center. PATIENTS: Patients with SI disease by clinical criteria. RESULTS: Intra-articular injection was accomplished in 8 of 37 (22%) patients. Injected material was identified within 1 cm of the joint 68% of the time. Epidural (spinal canal) injected material was seen 24% of the time. CONCLUSIONS: The low rate of intra-articular injection seen with this clinically-guided technique suggests restraint in its use for injection therapy. Some image guidance (e.g., fluoroscopy, CT) is probably necessary to reliably inject the SI joint. Perhaps in clinical settings, where image guidance is not readily available, a clinically-guided technique could initially be tried in patients at low risk for complications from such injections. This study also provides an anatomic explanation for the occasional weakness observed after SI joint injection.     

Physical therapeutic options for residual sacrotuberous ligament pain after treatment of sacroiliac joint dysfunction

[Purpose] To evaluate the incidence of pain originating from the sacrotuberous ligament after sacroiliac joint treatment, and to determine effective physical therapeutic options for sacrotuberous ligament pain. [Participants and Methods] Among 303 patients with sacroiliac joint dysfunction, 57 patients (20 males, 37 females) with persistent lower-buttock pain after sacroiliac joint injections were included in the study. The incidence of sacrotuberous ligament pain and the physical findings from the first evaluation were investigated by physical therapists. [Results] Diagnostic sacrotuberous ligament injections identified lower-buttock pain originating from the sacrotuberous ligament in 57.9% of the patients (33 out of 57 patients) after treatment of sacroiliac joint dysfunction. Of these, 11 patients experienced relief after sacrotuberous ligament injection alone; the others required physical therapy. Sacrotuberous ligament relaxation alone was effective in eight patients; biceps femoris relaxation was required in eight patients; and gluteus maximus contraction exercise was required in six patients. [Conclusion] After sacroiliac joint treatment, the incidence of residual sacrotuberous ligament pain in the persisting lower-buttock pain was 57.9%. In addition to sacrotuberous ligament relaxation, biceps femoris relaxation was effective in patients who showed both higher differences in the straight leg raising test and biceps femoris tenderness, while gluteus maximus contraction exercises were effective in patients with gluteus maximus weakness.