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Sacroiliac Joint Pain, A Review

Sacroiliac Joint Pain, A Review. Ahmad Al-khayer SpR Rehabilitation Medicine. Controversies. Anatomy SIJ movements Do clinical tests have a role? Is imaging conclusive? Is SIJ intraarticular injection conclusive? Treatment??. Controversies. Anatomy SIJ movements

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Sacroiliac Joint Pain, A Review

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  1. Sacroiliac Joint Pain, A Review Ahmad Al-khayer SpR Rehabilitation Medicine

  2. Controversies • Anatomy • SIJ movements • Do clinical tests have a role? • Is imaging conclusive? • Is SIJ intraarticular injection conclusive? • Treatment??

  3. Controversies • Anatomy • SIJ movements • Do clinical tests have a role? • Is imaging conclusive? • Is SIJ intraarticular injection conclusive? • Treatment?? • The diagnosis of SIJ pain is in itself controversial!!!

  4. Aims • History • Anatomy, Biomechanics, Movements • Pathophysiology • Diagnosis (Pain Distributions, Clinical & Radiological Tests, Intraarticular injection) • Treatment (Conservative, Minimally Invasive, Surgical)

  5. History • Hippocrates observed that a woman’s pelvis separated during labour and remained so after birth. Lynch 1920 (Surg Gynecol Obstet 575-580)

  6. History • Hippocrates observed that a woman’s pelvis separated during labour and remained so after birth. Lynch 1920 (Surg Gynecol Obstet 575-580) • Albee 1909 (JAMA 53;1273-67), Smith-Paterson 1926 (JBJS 8;118-136), Campbell 1927(Surg Gynecol Obstet 45;218-9)

  7. History • Hippocrates observed that a woman’s pelvis separated during labour and remained so after birth. Lynch 1920 (Surg Gynecol Obstet 575-580) • Albee 1909 (JAMA 53;1273-67), Smith-Paterson 1926 (JBJS 8;118-136), Campbell 1927(Surg Gynecol Obstet 45;218-9) • Development of discectomy surgery by Mixter and Barr 1934 (New Engl J Med 211;210-15)

  8. History • Hippocrates observed that a woman’s pelvis separated during labour and remained so after birth. Lynch 1920 (Surg Gynecol Obstet 575-580) • Albee 1909 (JAMA 53;1273-67), Smith-Paterson 1926 (JBJS 8;118-136), Campbell 1927(Surg Gynecol Obstet 45;218-9) • Development of discectomy surgery by Mixter and Barr 1934 (New Engl J Med 211;210-15) • Schwarzer 1995 (Spine 20;31-7), Maigne 1996 (Spine 21:1889-92), Katz 2003 (J Spinal Disord Tech 16;96-9). The cause of chronic low back pain in 13-30% of patients.

  9. C or Ear shaped by adulthood. Fibrous capsule; thin anteriorly, absent posteriorly Synovial (75% of its superior part is not) Anatomy

  10. C or Ear shaped Fibrous capsule; thin anteriorly, absent posteriorly Synovial (75% of its superior part is not) True diarthrodial joint: The concave sacral surface is covered with thick hyaline cartilage, the convex iliac surface is covered with fibrocartilage Anatomy

  11. Ant Post Anatomy

  12. The morphology of the SIJ changes with age; Flat until puberty By 30 bony ridges on the ilium side By fourth decade ridges on both sides Anatomy

  13. The morphology of the SIJ changes with age; Flat until puberty By 30 bony ridges on the ilium side By fourth decade ridges on both sides Anatomy • It varies greatly in size, shape, contour from side to side and between individuals

  14. The morphology of the SIJ changes with age; Flat until puberty By 30 bony ridges on the ilium side By fourth decade ridges on both sides Anatomy • It varies greatly in size, shape, contour from side to side and between individuals • The synovial cleft narrows with age; 1-2mm in individuals aged 50 to 70 0-1mm in over 70

  15. Anatomy

  16. Anatomy

  17. The old bridge of Stirling, built about 1550 • Both Highland troops and the British army tried to cross during the 1745 Jacobite rebellion

  18. Biomechanics • “Keystone in an arch”effect; the greater the force the greater the resistance

  19. Biomechanics • “Keystone in an arch”effect; the greater the force the greater the resistance • Triplanar shock absorber, base of spine • Transmits and dissipates upper trunk loads

  20. Movements • Powerful ligament (interosseous) • Different and variable shape • Keystone

  21. Movements • Powerful ligament (interosseous) • Different and variable shape • Keystone Does it actually move?

  22. Movements • Many type of movements have been described by Weisl 1955, Mitchell 1979, Beal 1982, Woerman 1982, Aitken 1986, Bernard 1987, Lee 1989, Shaw 1992, Oldrieve 1996)

  23. Movements • Many type of movements have been described by Weisl 1955, Mitchell 1979, Beal 1982, Woerman 1982, Aitken 1986, Bernard 1987, Lee 1989, Shaw 1992, Oldrieve 1996) • Movement of ilium on the sacrum (upslip, downslip, outflare, inflare, anterior torsion, posterior torsion) • Movement of sacrum on the ilium (nutation, counter-nutation, sacral side bending, rotation)

  24. Movements • “Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis”. Sturessone et al 1989, (Spine 14(2): 162-5) • 25 patients (21F: 4M). Physiological and extreme physiological positions. Mean rotations around axial axis 2.5 degrees (0.8 degree-3.9 degrees). Mean translation was 0.7 mm (0.1-1.6 mm).

  25. Movements • The two most common types of motion are nutation (backward rotation of the ilium on the sacrum) and counternutation (forward rotation) • SIJ motion progressivelydecreases in men aged between 40 and 50 and in women aged over 50. Dreyfuss 1995 (Spine 6;785-813)

  26. Pathophysiology • Multiple theories: • Ligamentous or Capsular tension • Bony arthritis • Synovial inflammation • Extraneous compression or shear forces • Hypo or hypermobility • Abnormal mechanics • Myofascial

  27. Pathophysiology • SIJ dysfunction (postpartum, limb length discrepancy, repetitive minor trauma) • Infection (haematogenous) • Spondyloarthropathies (Ank spond, Reiter’s) • Degenerative arthritis • Post traumatic arthritis (insufficiency factures, major trauma) • Previous spinal surgery (lumbar stabilisation....)

  28. Pathophysiology (less frequent) • Metabolic and endocrine disorders (crystal induced joint disorders, hyperparathyroidism) • Primary tumors (chondrosarcoma, giant cell tumors...) • Mets to pelvis • Idiopathic • Rare causes (iatrogenic, psychogenic).

  29. Pathophysiology • Dreyfuss 1995 (Clin N Am 6;785-813) • Intraarticular sources: Spondyloarthropathies, OA, infection, metabolic • Extraarticular sources: ligamentous sprain, SIJ fractures, insufficiency fractures, ligamentous, tendious, fascial attachment • Tumors • Iatrogenic

  30. Pathophysiology • Dreyfuss 1995 (Clin N Am 6;785-813) • Intraarticular sources: Spondyloarthropathies, OA, infection, metabolic • Extraarticular sources: ligamentous sprain, SIJ fractures, insufficiency fractures, ligamentous, tedious, fascial attachment • Tumors • Iatrogenic • Could the above be relevant for treatment?

  31. Diagnosis Pain distribution Clinical Tests Radiological Investigations Intraarticular Injection

  32. Pain Distributions • Fortin et al 1994 (Spine;19:1475-82). 10 asymptomatic volunteers, SIJ injection with contrast material followed by Xylocaine. Buttock hypoesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This corresponded to the area of maximal pain noted upon injection. SIJ pain referral map was generated.

  33. Pain Distributions • Fortin et al 1994 (Spine;19:1483-9). 54 patients completed pain diagrams. Two blinded clinicians selected 16 patients whose diagrams most represented the SIJ referral diagrams from study 1. 100% of these 16 had pain provocation with SIJ injection.

  34. Pain Distributions • Fortin et al 1994 (Spine;19:1483-9). 54 patients completed pain diagrams. Two blinded clinicians selected 16 patients whose diagrams most represented the SIJ referral diagrams from study 1. 100% of these 16 had pain provocation with SIJ injection. How many of the remaining could have had SIJ pain too?

  35. Pain Distributions • Slipman et al 2000 (Arch Phys Med Rehabil 81;334-8) 50 (18M:32F) patients. All demonstrated a positive diagnostic response to a fluoroscopically guided SIJ injection. Each patient's preinjection pain description was used to determine areas of pain referral.

  36. Pain Distributions • Slipman et al 2000 (Arch Phys Med Rehabil 81;334-8) 50 (18M:32F) patients. All demonstrated a positive diagnostic response to a fluoroscopically guided SIJ injection. Each patient's preinjection pain description was used to determine areas of pain referral. 47 buttock pain, 36 lower lumbar pain. 7 groin pain. 25 lower-extremity pain. 14 leg pain distal to the knee, and 6 patients reported foot pain.

  37. Pain Distributions • Slipman et al 2000 (Arch Phys Med Rehabil 81;334-8) 50 (18M:32F) patients. All demonstrated a positive diagnostic response to a fluoroscopically guided SIJ injection. Each patient's preinjection pain description was used to determine areas of pain referral. 47 buttock pain, 36 lower lumbar pain. 7 groin pain. 25 lower-extremity pain. 14 leg pain distal to the knee, and 6 patients reported foot pain. 18 potential pain-referral zones were established.

  38. Pain Distributions

  39. Pain Distributions Only 4% of patients mark any pain above L5 on self reported Pain drawings. Dreyfuss 1996 (Spine, 21:2594-2602)

  40. Pain Distributions Many diseases mimic SIJ pain: Spinal disorders Non- spinal disorders: Gastrointestinal Genitourinary Pubic symphysis motion Myofascial imbalances Aberrant gait Hip joint disorders

  41. Clinical Tests • Pain provocative tests • Palpation tests • Motion demands tests

  42. Clinical Tests • Pain provocative tests • Patrick’s test 77% sensitivity, 100 % specificity*. (FABER) • Thigh thrust test 80% sensitivity, 100% specificity*. (Post shearing stress applied to SIJ through Femur) • * (Broadhurst 1998, J Spinal Disord 11;341-345) • Palpation tests • Motion demands tests

  43. Clinical Tests • Pain provocative tests • Palpation tests • The midline sacral thrust test 89% sensitivity, 14% specificity (patient prone, post ant force) • (Dreyfuss 1996 Spine 21:2594-2602) • Motion demands tests

  44. Clinical Tests • Pain provocative tests • Palpation tests • Motion demands tests Sitting tolerance 78% sensitivity, 58% specificity (Stark et al) Standing, Flexion

  45. Clinical Tests Partick’s test Yeaoman’s test Lewin Ganslen’ test Pelvic rock’ test Stretch test

  46. Clinical Tests • Clinical examination cannot definitely confirm that the SIJ is the source of patient’s pain *Dreyfuss P et al; Spine 1996; 21(22): 2594–602. Van der Wurff P et al ; Man Ther, 2000; 5(1): 30-6. Van der Wurff P et al ; Man Ther, 2000; 5(2): 89-96*

  47. Radiological Investigations • X-rays, CT, MRI, and bone scan do not provide consistent findings that can be used for the diagnosis *Prather H; Clin J Sport Med, 2003; 13(4): 252-5, Dreyfuss P et al; Am Acad Orthop Surg. 2004; 12(4):255-65, Rothschild BM et al; Clin Exp Rheumatol, 1994; 12(3): 267-74*

  48. Intraarticular Injection • LA • Gold standard for diagnosis of intraarticular SIJ pain • 70-80% relief of pain is diagnostic *Dreyfuss P et al; Am Acad Orthop Surg. 2004; 12(4):255-65, Maldjian C et al; Radiol Clin North Am, 1998; 36(3): 497-508. Maigne JY et al; Spine, 1996; 21(16): 1889-92. Luukkainen RK et al; Clin Exp Rheumatol. 2002; 20(1):52-4*

  49. Intraarticular InjectionThe Technique • Dussault et al 2000(Radiology, 214:273-7) Patients prone. C-arm fluoroscope angled 20 to 25 in a caudal direction. Straight needle is advanced perpendicular to the table aiming to post inf part of SIJ. 97% success rate reported.

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