The Sacroiliac Joint as a Cause of Pain – Review of the Sacroiliac Joint Morphology and Models for Pain Genesis

2021 ◽  
Author(s):  
Anna Völker ◽  
Hanno Steinke ◽  
Christoph-Eckhard Heyde
Keyword(s):  
Back Pain ◽  
Sacroiliac Joint ◽  
Radicular Pain ◽  
Leg Pain ◽  
Joint Stability ◽  
Anatomical Structures ◽  
Dorsal Rami ◽  
Lateral Branches ◽  
Complex Joint ◽  
Pain Generator

Abstract Introduction In recent years, the sacroiliac joint has become increasingly important as a generator of low back pain with and without pseudo-radicular pain in the legs. Up to 27% of reported back pain is generated by disorders in the sacroiliac joint. Method This review is based on a selective literature search of the sacroiliac joint (SIJ) as a possible pain generator. It also considers the anatomical structures and innervation of the sacroiliac joint. Results The SIJ is a complex joint in the region of the posterior pelvis and is formed by the sacrum and the ilium bones. The SIJ is very limited in movement in all three planes. Joint stability is ensured by the shape and especially by strong interosseous and extraosseous ligaments. Different anatomical variants of the sacroiliac joint, such as additional extra-articular secondary joints or ossification centres, can be regularly observed in CT scans. There is still controversy in the literature regarding innervation. However, there is agreement on dorsal innervation of the sacroiliac joint from lateral branches of the dorsal rami of the spinal nerves S I–S III with proportions of L III and L IV as well S IV. Nerve fibres and mechanoreceptors can also be detected in the surrounding ligaments. Conclusion A closer look at the anatomy and innervation of the SIJ shows that the SIJ is more than a simple joint. The complex interaction of the SIJ with its surrounding structures opens the possibility that pain arises from this area. The SIJ and its surrounding structures should be included in the diagnosis and treatment of back and leg pain. Published literature include a number of plausible models for the sacroiliac joint as pain generator. The knowledge of the special anatomy, the complex innervation as well as the special and sometimes very individual functionality of this joint, enhance our understanding of associated pathologies and complaints.

scholarly journals The Anatomy of the Lateral Branches of the Sacral Dorsal Rami: Implications for Radiofrequency Ablation

2014 ◽  
Vol 5;17 (5;9) ◽  
pp. 459-464
Author(s):  
Joseph Fortin
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Radiofrequency Ablation ◽  
Sacroiliac Joint ◽  
Low Back ◽  
Sacral Foramina ◽  
Dorsal Rami ◽  
Lateral Branches ◽  
The Right ◽  
Segmental Innervation

Background: The sacroiliac joint (SIJ) is a major source of pain in patients with chronic low back pain. Radiofrequency ablation (RFA) of the lateral branches of the dorsal sacral rami that supply the joint is a treatment option gaining considerable attention. However, the position of the lateral branches (commonly targeted with RFA) is variable and the segmental innervation to the SIJ is not well understood. Objectives: Our objective was to clarify the lateral branches’ innervation of the SIJ and their specific locations in relation to the dorsal sacral foramina, which are the standard RFA landmark. Methods: Dissections and photography of the L5 to S4 sacral dorsal rami were performed on 12 hemipelves from 9 donated cadaveric specimens. Results: There was a broad range of exit points from the dorsal sacral foramina: ranging from 12:00 – 6:00 position on the right side and 6:00 – 12:00 on the left positions. Nine of 12 of the hemipelves showed anastomosing branches from L5 dorsal rami to the S1 lateral plexus. Limitations: The limitations of this study include the use of a posterior approach to the pelvic dissection only, thus discounting any possible nerve contribution to the anterior aspect of the SIJ, as well as the possible destruction of some L5 or sacral dorsal rami branches with the removal of the ligaments and muscles of the low back. Conclusion: Widespread variability of lateral branch exit points from the dorsal sacral foramen and possible contributions from L5 dorsal rami and superior gluteal nerve were disclosed by the current study. Hence, SIJ RFA treatment approaches need to incorporate techniques which address the diverse SIJ innervation. Key words: Sacroiliac joint pain, radiofrequency ablation, dorsal sacral rami, low back pain

Robotic Sacroiliac Fixation Technique for Triangular Titanium Implant in Adult Degenerative Scoliosis Surgery: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Connor Berlin ◽  
Parantap Patel ◽  
Isador Lieberman ◽  
Mark Shaffrey ◽  
Avery Buchholz
Keyword(s):  
Back Pain ◽  
Sacroiliac Joint ◽  
Titanium Implants ◽  
Leg Pain ◽  
Definitive Treatment ◽  
Scoliosis Surgery ◽  
Corrective Surgery ◽  
Degenerative Scoliosis ◽  
Adult Degenerative Scoliosis ◽  
K Wires

Abstract Corrective surgery remains a definitive treatment for adult spinal deformity, improving pain and disability. With these cases, instrumentation to the pelvis with iliac fixation is recommended. Whether iliac or S2-Alar-Iliac (S2AI) trajectories are used, sacroiliac joint pain and long-term sacroilitis can be common after long-fusion constructs.1-3 Sacroiliac fusion with triangular titanium implants during fusion can reduce back pain associated with sacroiliac joint degeneration,3 provides reduction in sacroiliac joint motion and stress when added to S2AI screws, and potentially enhances mechanical stability of fusion constructs.4 Here, we present a technique for placing triangular titanium sacroiliac implants (iFuse BedrockTM; SI-BONE Inc, Santa Clara, California) alongside S2AI screws using a robotic platform (Mazor X; Medtronic Sofamor Danek, Medtronic Inc, Dublin, Ireland). Navigated robotics allows reduction in human error with implant placement, and potentially decreased operative time/fluoroscopy.5-7 Key surgical steps include placement of K wires for S2AI and bilateral SI-implants, tapping, replacing SI-implant K wires with guide pins, placing S2AI screws, and finally placing the SI-implant. Final placement is verified with intraoperative fluoroscopy. The patient described is a 61-yr-old woman with worsening adult degenerative scoliosis, lower back pain, left leg radicular pain, and mild right leg pain who failed conservative treatment. Examination revealed diminished strength in both legs. Imaging was significant for moderate sigmoid scoliosis, discogenic disease, and osteoarthritis at all levels. She consented to undergo corrective surgery. Postoperatively, the patient experienced resolution of her leg weakness and pain. Imaging demonstrated appropriate positioning of hardware. Prospective studies on the efficacy of the SI-implant are underway.

Anatomical study of the innervation of different parts of the posterior ligamentous region of the sacroiliac joint

2021 ◽  
pp. rapm-2020-102366
Author(s):  
Weijia Zhu ◽  
Qinghao Zhao ◽  
Runxun Ma ◽  
Zezheng Liu ◽  
Jianjun Zhao ◽  
...  
Keyword(s):  
Sacroiliac Joint ◽  
Anatomical Study ◽  
Transverse Diameter ◽  
Orientation Relation ◽  
Terminal Nerve ◽  
Dorsal Rami ◽  
Sacral Nerves ◽  
Lateral Branches ◽  
Clinical Verification ◽  
Different Parts

Background and objectivesThe periarticular sacroiliac joint (SIJ) technique has become an important area of focus, and the quartering of the SIJ posterior ligamentous region has been proposed as a way to refine this technique. However, detailed nerve distribution combined with the division of the SIJ posterior ligamentous region is lacking. We aimed to explore the innervation of the SIJ posteriorly based on the quartering of the SIJ posterior ligamentous region.MethodsSixteen SIJs from eight embalmed cadavers were studied. Each SIJ posterior ligamentous region was equally divided into areas 0–3 from top to bottom. The origin, distribution, quantity, transverse diameter, spatial orientation, relation with bony structures, and the number of identifiable terminal nerve branches in each area were examined.ResultsAreas 0–1 were innervated by the lateral branches of the dorsal rami of L4−L5 directly in all specimens. Areas 2–3 were innervated by that of both lumbar and sacral nerves via the posterior sacral network (PSN), with L5 contributing to the PSN in all specimens and L4 in 68.75%. The number of identifiable terminal nerve branches were significantly higher in areas 2–3 than in areas 0–1.ConclusionsThe inferior part of the SIJ posterior ligamentous region seems to be the main source of SIJ-related pain and is innervated by lumbar and sacral nerves via the PSN. However, the superior part directly innervated by lumbar nerves should not be neglected, and further clinical verification is needed.

Efficacy of Duloxetine in Chronic Low Back Pain with a Neuropathic Component

2016 ◽  
Vol 124 (1) ◽  
pp. 150-158 ◽  
Author(s):  
Regina P. Schukro ◽  
Matthias J. Oehmke ◽  
Angelika Geroldinger ◽  
Georg Heinze ◽  
Hans-Georg Kress ◽  
...  
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Chronic Low Back Pain ◽  
Pain Treatment ◽  
Treatment Phase ◽  
Radicular Pain ◽  
Leg Pain ◽  
Low Back ◽  
Double Blind ◽  
Vas Score

Abstract Background Among patients with chronic low back pain (CLBP), approximately 37% show signs of a neuropathic pain component (radicular pain). Treatment of this condition remains challenging. Therefore, the current study aimed to investigate the efficacy of duloxetine in the treatment of CLBP patients with neuropathic leg pain. Methods The study was conducted as a prospective, randomized, placebo-controlled, double-blind crossover trial. CLBP with a visual analog scale (VAS) score greater than 5 and a neuropathic component that was assessed clinically and by the painDETECT questionnaire (score > 12) were required for inclusion. Patients were randomly assigned to either duloxetine or placebo for 4 weeks followed by a 2-week washout period before they crossed over to the alternate phase that lasted another 4 weeks. Duloxetine was titrated up to 120 mg/day. The primary outcome parameter was mean VAS score during the last week of treatment in each phase (VASweek4). Results Of 41 patients, 21 patients completed both treatment phases. In the intention-to-treat analysis (n = 25), VASweek4 was significantly lower in the duloxetine phase compared with placebo (4.1 ± 2.9 vs. 6.0 ± 2.7; P = 0.001), corresponding to an average pain reduction of 32%. The painDETECT score at the end of each treatment phase was significantly lower in the duloxetine phase compared with placebo (17.7 ± 5.7 vs. 21.3 ± 3.6 points; P = 0.0023). Adverse events were distributed equally between the duloxetine (65%) and placebo phases (62%) (P = 0.5). Conclusion In this crossover study, duloxetine proved to be superior to placebo for the treatment of CLBP with a neuropathic leg pain.

scholarly journals An Unusual Case of Radicular Pain Caused by Bilateral Lumbar Synovial Cyst: A Case Report and Review of the Literature

2020 ◽  
Vol 2020 ◽  
pp. 1-6
Author(s):  
David Ruiz-Picazo ◽  
José Ramírez-Villaescusa ◽  
Ana Verdejo-González
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Treatment Options ◽  
Synovial Cyst ◽  
Radicular Pain ◽  
Magnetic Resonance Images ◽  
Leg Pain ◽  
Low Back ◽  
Disc Disease ◽  
Management Options

Introduction. Spinal synovial cysts (SSCs) constitute an uncommon degenerative lesion of the spine. They are usually asymptomatic but they may also cause symptoms of variable severity. SSCs are benign growths adjoining the facet joints that may induce low back pain, lumbar radiculopathy, and neurological deficit. There are different treatment options that range from conservative management to interventions like image-guided epidural steroid injection or direct cyst puncture and finally to open or endoscopic spinal canal decompression and spinal bone fusion with/without instrumentation. A discussion of current management options for this unusual disease is presented. Material and Methods. A 52-year-old female patient presented with low back pain and left leg pain. Plain radiography demonstrated instability at the L4-L5 level. Magnetic resonance images (MRIs) revealed a bilateral cystic lesion at the L4-L5 level with associated instability and degenerative disc disease at the level L5-S1. Initially, conservative treatment was performed by aspiration of the left cyst and infiltration with corticosteroids with improvement of the pain for 1 year. After this period, the radicular and the low back pain reoccurred. Results. Following leg pain recurrence, a hybrid L4-S1 fusion was performed. After surgery, there was clinical improvement and six months later, the patient returned to daily activities. The radiological study after five-year follow-up shows adequate implant position, without signs of loosening, compatible with solid fusion. Conclusion. After reviewing the literature, the optimal management for patients with symptomatic lumbar synovial cyst must be very individualized, which is essential to achieve a favorable outcome.

scholarly journals Functional outcome of microscopic lumbar discectomy for the treatment of lumbar disc prolapse

2018 ◽  
Vol 4 (3) ◽  
pp. 389
Author(s):  
Ansari Ishtyaque Abdul Aziz ◽  
Ansari Muqtadeer Abdul Aziz
Keyword(s):  
Back Pain ◽  
Lumbar Disc ◽  
Japanese Orthopaedic Association ◽  
Significant Proportion ◽  
Scientific Basis ◽  
Radicular Pain ◽  
Lumbar Discectomy ◽  
Leg Pain ◽  
Disc Prolapse ◽  
Lumbar Disc Prolapse

<p class="abstract"><strong>Background:</strong> Back pain constitutes significant proportion of orthopaedic practitioner OPD. Lumbar disc prolapse constitutes important cause of back pain with radiculopathic leg pain. Different techniques have evolved to treat this disorder non-operatively and operatively. Operative techniques vary a lot in the field of spine surgery depending on the surgeon, institute, infrastructure and cost. We present simple, cost effective, cosmetic, operative technique with scientific basis which gives better visualization for decompression of nerve root in this paper called microscopic lumbar discectomy (MLD).</p><p class="abstract"><strong>Methods:</strong> On the basis of inclusion and exclusion criteria 26 patients were operated by microscopic lumbar discectomy (MLD) technique. All the patients were followed up at the interval of 1 month, 3 months and 6 months and assessment was done of subjective and objective findings with Japanese orthopaedic association (JOA) score and rate of improvement (RI) was calculated. Out of 26 patients 18 were men and 8 were women. Age ranges from 28 years to 72 years. Mean age being 47.8 years.<strong></strong></p><p class="abstract"><strong>Results:</strong> Out of 26 patients at the time of discharge, 20 patients (87.5%) could walk independently without any aid and without any radicular pain. In most of the patients 19 (73.07%) sciatica improved immediately. The pre-operative mean±SD (SE) JOA score was 8.346±0.85 (0.169) which improved to 11.807±0.694 (0.136) after 1 month and 13.19±0.895 (0.175) after 6 months.</p><p class="abstract"><strong>Conclusions:</strong> Excellent to good results and improvement can be achieved surgically, economically and cosmetically by microscopic lumbar discectomy technique in the spine lumbar disc prolapse patients at many spine centre with cosmesis, good results and rehabilitation of the patient.</p><p class="abstract"> </p>

scholarly journals Comparison of Efficacy of Lateral Branch Pulsed Radiofrequency Denervation and Intraarticular Depot Methylprednisolone Injection for Sacroiliac Joint Pain

2018 ◽  
Vol 1 (21;1) ◽  
pp. 489-496
Author(s):  
Samarjit Dey
Keyword(s):  
Sacroiliac Joint ◽  
Joint Pain ◽  
Pulsed Radiofrequency ◽  
Sacroiliac Joint Pain ◽  
Post Procedure ◽  
Radiofrequency Denervation ◽  
Group A ◽  
Dorsal Rami ◽  
Group B ◽  
Lateral Branches

Background: Sacroiliac joint dysfunctional pain has always been an enigma to the pain physician, whether it be the diagnosis or the treatment. Diagnostic blocks are the gold standard way to diagnose this condition. Radiofrequency neurotomy of the nerves supplying the sacroiliac joint has shown equivocal results due to anatomical variation. Intraarticular depo-steroid injection is a traditional approach to treating sacroiliac joint pain. For long-term pain relief, however, lesioning the sacral lateral branches may be a better approach. Objective: This study compared the efficacy of intraarticular depo-methylprednisolone injection to that of pulsed radiofrequency ablation for sacroiliac joint pain. Study Design: This study used a randomized, prospective design. Setting: Thirty patients with diagnostic block-confirmed sacroiliac joint dysfunctional pain were randomly assigned to 2 groups. One group received intraarticular methylprednisolone and another group underwent pulsed radiofrequency of the L4 medial branch, the L5 dorsal rami, and the lateral sacral branches. Results: Reduction in Numeric Rating Scale (NRS) for pain at 1 month post-procedure remained similar in Group A, while in Group B few patients reported a further decrease in the NRS score (3.333 ± 0.4880 and 2.933 ± 0.5936, respectively). At 3 months post-procedure, the NRS score began to rise in most patients in group A, while in Group B, the NRS score remained the same since the last visit (4.400 ± 0.9856 and 3.067 ± 0.8837, respectively). At 6 months post-procedure, the NRS score began to rise further in most patients in group A. In Group B, the NRS score remained the same in most of the patients since the last visit (5.400 ± 1.549 and 3.200 ± 1.207). There was a marked difference between the 2 groups in Oswestry Disability Index (ODI) scores at 3 months post-procedure (Group A, 12.133 ± 4.486 vs Group B, 9.133 ± 3.523) and at 6 months post-procedure there was a significant (P = 0.0017) difference in ODI scores between Group A and Group B (13.067 ± 4.284 and 8.000 ± 3.703, respectively). Global Perceived Effect (GPE) was assessed in both groups at 3 months post-procedure Only 33.3% (Confidence Interval (CI) of 11.8- 61.6 ) of patients in Group A had positive GPE responses whereas in Group B, 86.67% (CI of 59.5- 98.3 ) of patients had positive GPE responses. At 6 months post-procedure, the proportion of patients with positive GPE declined further in Group A, while in Group B, positive GPE responses remained the same (20% with a CI of 4.30- 48.10 and 86.67% with a CI of 59.5- 98.3, respectively ). Limitations: Small sample size. Conclusion: This comparative study shows that pulsed radiofrequency denervation of the L4 and L5 primary dorsal rami and S1-3 lateral branches provide significant pain relief and functional improvement in patients with sacroiliac joint pain. Key words: Low back pain, sacroiliac joint dysfunctional pain, radiofrequency, intraarticular injection

scholarly journals Outcomes of decompression without fusion in patients with lumbar spinal stenosis and substantial back pain

2021 ◽  
pp. 1-4
Author(s):  
Rachid Bech-Azeddine ◽  
Søren Fruensgaard ◽  
Mikkel Andersen ◽  
Leah Y. Carreon
Keyword(s):  
Back Pain ◽  
Spinal Stenosis ◽  
Lumbar Spinal Stenosis ◽  
Structural Instability ◽  
Radicular Pain ◽  
Leg Pain ◽  
Neurogenic Claudication ◽  
Vas Score ◽  
The Mean ◽  
Lumbar Spinal

OBJECTIVEThe predominant symptom of lumbar spinal stenosis (LSS) is neurogenic claudication or radicular pain. Some surgeons believe that the presence of substantial back pain is an indication for fusion, and that decompression alone may lead to worsening of back pain from destabilization associated with facet resection. The purpose of this study was to determine if patients with LSS and clinically significant back pain could obtain substantial improvements in back pain after a decompression alone without fusion.METHODSThe DaneSpine database was used to identify 2737 patients with LSS without segmental instability and a baseline back pain visual analog scale (VAS) score ≥ 50 who underwent a decompression procedure alone without fusion. Standard demographic and surgical variables and patient outcomes, including back and leg pain VAS score (0–100), Oswestry Disability Index (ODI), and EQ-5D at baseline and at 12 months postoperatively, were collected.RESULTSA total of 1891 patients (69%) had 12-month follow-up data available for analysis; the mean age was 66.4 years, 860 (46%) were male, the mean BMI was 27.8 kg/m2, and 508 (27%) were current smokers. At 12 months postoperatively, there were statistically significant improvements (p < 0.001) from baseline for back pain (72.1 to 42.1), leg pain (71.2 to 41.3), EQ-5D (0.35 to 0.61), and ODI (44.1 to 27.8).CONCLUSIONSPatients with LSS, clinically substantial back pain, and no structural instability obtain improvement in back pain after decompression-only surgery and do not need a concomitant fusion.

scholarly journals Multivariable Analysis of the Relationship Between Pain Referral Patterns and the Source of Chronic Low Back Pain

2012 ◽  
Vol 2;15 (2;3) ◽  
pp. 171-178
Author(s):  
Michael J. DePalma
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Chronic Low Back Pain ◽  
Sacroiliac Joint ◽  
Joint Pain ◽  
Facet Joint ◽  
Thigh Pain ◽  
Leg Pain ◽  
Low Back ◽  
Referral Patterns

Background: Discogenic, facet joint, and sacroiliac joint mediated axial low back pain may be associated with overlapping pain referral patterns into the lower limb. Differences between pain referral patterns for these three structures have not been systematically investigated. Objective: To examine the individual and combined relationship of age, hip/girdle pain, leg pain, and thigh pain and the source of internal disc disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP) in consecutive chronic low back pain (CLBP) patients. Design: Retrospective chart review. Setting: Community based interventional spine practice. Patients: 378 cases from 358 consecutive patients were reviewed and 157 independent cases from 153 patients who underwent definitive diagnostic injections were analyzed. Methods: Charts of consecutive low back pain patients who underwent definitive diagnostic spinal procedures were retrospectively reviewed. Patients underwent provocation lumbar discography, dual diagnostic medial branch blocks, or intra-articular diagnostic sacroiliac joint injections based on clinical presentation. Some subjects underwent multiple diagnostic injections until the source of their chronic low back pain (CLBP) was identified. Main Outcome Measurements: Based on the results of diagnostic injections, subjects were classified as having IDD, FJP, SIJP, or other. The mean age/standard deviation and the count/percentage of patients reporting hip girdle pain, leg pain, or thigh pain were estimated for each diagnostic group and compared statistically among the IDD, FJP, SIJP, and other source groups. Next, the 4 predictor variables were simultaneously modeled with a single multinomial logistic regression model to explore the adjusted relationship between the predictors and the source of CLBP. Results: The mean age was significantly different among the source groups. IDD cases were significantly younger than FJP, SIJP, and other source groups and FJP cases were significantly younger than other sources. The age by thigh pain interaction effect was statistically significant (P = 0.021), indicating that the effect of age on the source of CLBP depends on thigh pain, and similarly, that the effect of thigh pain on the source of CLBP depends on age. Limitations: Retrospective study design. Conclusions: The presence or absence of thigh pain possesses a significant correlation on the source of CLBP for varying ages, whereas the presence of hip/girdle pain or leg pain did not significantly discriminate among IDD, FJP, or SIJP as the etiology of CLBP. Younger age was predictive of IDD regardless of the presence or absence of thigh pain. Key words: low back pain, intervertebral disc, zygapophyseal joint, sacroiliac joint, pain referral patterns

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