Evaluation of Sacroiliac Joint Interventions: A
Systematic Appraisal of the Literature

Background: The sacroiliac joint has been implicated as a source of low back and lower extremity pain. There are no definite historical, physical, or radiological features that can definitively establish a diagnosis of sacroiliac joint pain. Based on the present knowledge, an accurate diagnosis is made only by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected patients with chronic low back pain utilizing controlled comparative local anesthetic blocks. Study Design: A systematic review of diagnostic and therapeutic sacroiliac joint interventions. Objective: To evaluate the accuracy of diagnostic sacroiliac joint interventions and the utility of therapeutic sacroiliac joint interventions. Methods: The literature search was carried out by searching the databases of PubMed, EMBASE, and Cochrane reviews. Methodologic quality assessment of included studies was performed using the Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria for diagnostic accuracy and observational studies, whereas randomized trials were evaluated utilizing the Cochrane review criteria. Only studies with scores of 50 or higher were included for assessment. Level of evidence was based on the U.S. Preventive Services Task Force (USPSTF) criteria. Outcome Measures: For diagnostic interventions, the outcome criteria included at least 50% pain relief coupled with a patient’s ability to perform previously painful maneuvers with sustained relief using placebo-controlled or comparative local anesthetic blocks. For therapeutic purposes, outcomes included significant pain relief and improvement in function and other parameters. Short-term relief for therapeutic interventions was defined as 6 months or less, whereas long-term effectiveness was defined as greater than 6 months. Results: The indicated level of evidence is II-2 for the diagnosis of sacroiliac joint pain utilizing comparative, controlled local anesthetic blocks. The prevalence of sacroiliac joint pain is estimated to range between 10% and 38% using a double block paradigm in the study population. The false-positive rate of single, uncontrolled, sacroiliac joint injections is 20% to 54%. The evidence for provocative testing to diagnose sacroiliac joint pain is Level II-3 or limited. For radiofrequency neurotomy the indicated evidence is limited (Level II-3) for short- and longterm relief. Limitations: The limitations of this systematic review include the paucity of literature evaluating the role of both diagnostic and therapeutic interventions and widespread methodological flaws. Conclusions: The indicated evidence for the validity of diagnostic sacroiliac joint injections is Level II-2. The evidence for the accuracy of provocative maneuvers in the diagnosing of sacroiliac joint pain is limited (Level II-3). The evidence for radiofrequency neurotomy is also limited (Level II-3). Key words: Chronic low back pain, sacroiliac joint pain, sacroiliitis, sacroiliac joint injection, sacroiliac joint dysfunction, thermal radiofrequency, pulsed radiofrequency

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Sacroiliac Joint Interventions: A Systematic Review

January 2018 - Pain Physician ◽

10.36076/ppj.2007/10/165 ◽

2007 ◽

Vol 1;10 (1;1) ◽

pp. 165-184

Author(s):

Hans C. Hansen

Keyword(s):

Systematic Review ◽

Low Back Pain ◽

Back Pain ◽

Local Anesthetic ◽

Sacroiliac Joint ◽

Joint Pain ◽

Low Back ◽

Sacroiliac Joint Pain ◽

Radiofrequency Neurotomy ◽

Joint Injections

Background: The sacroiliac joint is a diarthrodial synovial joint with abundant innervation and capability of being a source of low back pain and referred pain in the lower extremity. There are no definite historical, physical, or radiological features to provide definite diagnosis of sacroiliac joint pain, although many authors have advocated provocational maneuvers to suggest sacroiliac joint as a pain generator. An accurate diagnosis is made by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected cases with chronic low back pain utilizing controlled comparative local anesthetic blocks. Intraarticular injections, and radiofrequency neurotomy have been described as therapeutic measures. This systematic review was performed to assess diagnostic testing (non-invasive versus interventional diagnostic techniques) and to evaluate the clinical usefulness of interventional techniques in the management of chronic sacroiliac joint pain. Objective: To evaluate and update the available evidence regarding diagnostic and therapeutic sacroiliac joint interventions in the management of sacroiliac joint pain. Study Design: A systematic review using the criteria as outlined by the Agency for Healthcare Research and Quality (AHRQ), Cochrane Review Group Criteria for therapeutic interventions and AHRQ, and Quality Assessment for Diagnostic Accuracy Studies (QUADAS) for diagnostic studies. Methods: The databases of EMBASE and MEDLINE (1966 to December 2006), and Cochrane Reviews were searched. The searches included systematic reviews, narrative reviews, prospective and retrospective studies, and cross-references from articles reviewed. The search strategy included sacroiliac joint pain and dysfunction, sacroiliac joint injections, interventions, and radiofrequency. Results: The results of this systematic evaluation revealed that for diagnostic purposes, there is moderate evidence showing the accuracy of comparative, controlled local anesthetic blocks. Prevalence of sacroiliac joint pain is estimated to range between 10% and 27% using a double block paradigm. The false-positive rate of single, uncontrolled, sacroiliac joint injections is around 20%. The evidence for provocative testing to diagnose sacroiliac joint pain is limited. For therapeutic purposes, intraarticular sacroiliac joint injections with steroid and radiofrequency neurotomy were evaluated. Based on this review, there is limited evidence for short-term and longterm relief with intraarticular sacroiliac joint injections and radiofrequency thermoneurolysis. Conclusions: The evidence for the specificity and validity of diagnostic sacroiliac joint injections is moderate. The evidence for accuracy of provocative maneuvers in diagnosis of sacroiliac joint pain is limited. The evidence for therapeutic intraarticular sacroiliac joint injections is limited. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain is limited. Keywords: Low back pain, sacroiliac joint pain, axial pain, spinal pain, diagnostic block, sacroiliac joint injection, thermal radiofrequency, and pulsed radiofrequency

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A Systematic Evaluation of Prevalence and Diagnostic Accuracy of Sacroiliac Joint Interventions

January 2018 - Pain Physician ◽

10.36076/ppj.2012/15/e305 ◽

2012 ◽

Vol 3;15 (3;5) ◽

pp. E305-E344 ◽

Cited By ~ 8

Author(s):

Thomas T. Simopoulos

Keyword(s):

Systematic Review ◽

Low Back Pain ◽

Back Pain ◽

Diagnostic Accuracy ◽

Local Anesthetic ◽

Sacroiliac Joint ◽

Joint Pain ◽

The United States ◽

Low Back ◽

Sacroiliac Joint Pain

Background: The contributions of the sacroiliac joint to low back and lower extremity pain have been a subject of considerable debate and research. It is generally accepted that 10% to 25% of patients with persistent mechanical low back pain below L5 have pain secondary to sacroiliac joint pathology. However, no single historical, physical exam, or radiological feature can definitively establish a diagnosis of sacroiliac joint pain. Based on present knowledge, a proper diagnosis can only be made using controlled diagnostic blocks. The diagnosis and treatment of sacroiliac joint pain continue to be characterized by wide variability and a paucity of the literature. Objective: To evaluate the accuracy of diagnostic sacroiliac joint interventions. Study Design: A systematic review of diagnostic sacroiliac joint interventions. Methods: Methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less than 50% are presented descriptively and analyzed critically. The level of evidence was classified as good, fair, or limited (or poor) based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: In this evaluation we utilized controlled local anesthetic blocks using at least 50% pain relief as the reference standard. Results: The evidence is good for the diagnosis of sacroiliac joint pain utilizing controlled comparative local anesthetic blocks. The prevalence of sacroiliac joint pain is estimated to range between 10% and 62% based on the setting; however, the majority of analyzed studies suggest a point prevalence of around 25%, with a false-positive rate for uncontrolled blocks of approximately 20%. The evidence for provocative testing to diagnose sacroiliac joint pain was fair. The evidence for the diagnostic accuracy of imaging is limited. Limitations: The limitations of this systematic review include a paucity of literature, variations in technique, and variable criterion standards for the diagnosis of sacroiliac joint pain. Conclusions: Based on this systematic review, the evidence for the diagnostic accuracy of sacroiliac joint injections is good, the evidence for provocation maneuvers is fair, and evidence for imaging is limited. Key words: Chronic low back pain, sacroiliac joint pain, sacroiliitis, sacroiliac joint injection, sacroiliac joint dysfunction, provocation manuevers, controlled diagnostic blocks, intraarticular injection, extraarticular injection.

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A Systematic Evaluation of the Therapeutic Effectiveness of Sacroiliac Joint Interventions

January 2018 - Pain Physician ◽

10.36076/ppj.2012/15/e247 ◽

2012 ◽

Vol 3;15 (3;5) ◽

pp. E247-E278 ◽

Cited By ~ 1

Author(s):

Hans Hansen

Keyword(s):

Systematic Review ◽

Sacroiliac Joint ◽

Joint Pain ◽

Randomized Trials ◽

Low Back ◽

Pulsed Radiofrequency ◽

Short Term ◽

Sacroiliac Joint Pain ◽

Radiofrequency Neurotomy

Background: The contribution of the sacroiliac joint to low back and lower extremity pain has been a subject of debate with extensive research. It is generally accepted that approximately 10% to 25% of patients with persistent low back pain may have pain arising from the sacroiliac joints. In spite of this, there are currently no definite conservative, interventional, or surgical management options for managing sacroiliac joint pain. In addition, there continue to be significant variations in the application of various techniques as well as a paucity of literature. Study Design: A systematic review of therapeutic sacroiliac joint interventions. Objective: To evaluate the accuracy of therapeutic sacroiliac joint interventions. Methods: The available literature on therapeutic sacroiliac joint interventions in managing chronic low back and lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria for randomized trials of interventional techniques and the criteria developed by the Newcastle-Ottawa Scale for observational studies. The level of evidence was classified as good, fair, or limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature published from 1966 through December 2011 that was identified through searches of PubMed and EMBASE, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: For this systematic review, 56 studies were considered for inclusion. Of these, 45 studies were excluded and a total of 11 studies met inclusion criteria for methodological quality assessment with 6 randomized trials and 5 non-randomized studies. The evidence for cooled radiofrequency neurotomy in managing sacroiliac joint pain is fair. The evidence for effectiveness of intraarticular steroid injections is limited (or poor). The evidence for periarticular injections of local anesthetic and steroid or botulinum toxin is limited (or poor). The evidence for effectiveness of conventional radiofrequency neurotomy is limited (or poor). The evidence for pulsed radiofrequency is limited (or poor). Limitations: The limitations of this systematic review include a paucity of literature on therapeutic interventions, variations in technique, and variable diagnostic standards for sacroiliac joint pain. Conclusions: The evidence was fair in favor of cooled radiofrequency neurotomy and limited (or poor) for short-term and long-term relief from intraarticular steroid injections, periarticular injections with steroids or botulin toxin, pulsed radiofrequency, and conventional radiofrequency neurotomy. Key words: Chronic low back pain, sacroiliac joint pain, sacroiliitis, sacroiliac joint injection, sacroiliac joint dysfunction, thermal radiofrequency, pulsed radiofrequency

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Characteristics of the spinopelvic parameters of patients with sacroiliac joint pain

Scientific Reports ◽

10.1038/s41598-021-84737-1 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Juichi Tonosu ◽

Hiroyuki Oka ◽

Kenichi Watanabe ◽

Hiroaki Abe ◽

Akiro Higashikawa ◽

...

Keyword(s):

Sacroiliac Joint ◽

Joint Pain ◽

Pelvic Incidence ◽

Demographic Characteristics ◽

Sacral Slope ◽

Low Back ◽

Spinopelvic Parameters ◽

Sacroiliac Joint Pain ◽

Physical Findings ◽

Univariate Analyses

AbstractTo evaluate the characteristics of the spinopelvic parameters on radiography in patients with sacroiliac joint pain (SIJP). Two hundred fifty patients were included and divided into the SIJP group (those diagnosed with SIJP based on physical findings and response to analgesic periarticular injections; n = 53) and the non-SIJP group (those with low back pain [LBP] because of other reasons; n = 197). We compared their demographic characteristics and spinopelvic parameters using radiography. All differences found in the patients’ demographic characteristics and spinopelvic parameters were analyzed. More female participants experienced SIJP than male participants (P = 0.0179). Univariate analyses revealed significant differences in pelvic incidence (PI) (P = 0.0122), sacral slope (SS) (P = 0.0034), and lumbar lordosis (LL) (P = 0.0078) between the groups. The detection powers for PI, SS, and LL were 0.71, 0.84, and 0.66, respectively. Logistic regression analyses, after adjustment for age and sex, revealed significant differences in PI (P = 0.0308) and SS (P = 0.0153) between the groups, with odds ratios of 1.03 and 1.05, respectively. More female participants experienced SIJP than male participants. Higher PI and SS values were related to SIJP among LBP patients.

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Systematic Review of Diagnostic Utility and Therapeutic Effectiveness of Thoracic Facet Joint Interventions

January 2018 - Pain Physician ◽

10.36076/ppj.2008/11/611 ◽

2008 ◽

Vol 5;11 (10;5) ◽

pp. 611-629

Author(s):

Sairam Atluri

Keyword(s):

Back Pain ◽

Local Anesthetic ◽

Joint Pain ◽

Facet Joint ◽

Therapeutic Interventions ◽

Medial Branch ◽

Radiofrequency Neurotomy ◽

Level I ◽

Facet Joint Pain ◽

Facet Joint Interventions

Background: Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of the patients based on the responses to controlled diagnostic blocks. Systematic reviews have established moderate evidence for controlled comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and upper back pain, moderate evidence for therapeutic thoracic medial branch blocks, and limited evidence for radiofrequency neurotomy of therapeutic facet joint nerves. Objectives: To determine the clinical utility of diagnostic and therapeutic thoracic facet joint interventions in diagnosing and managing chronic upper back and mid back pain. Study Design: Systematic review of diagnostic and therapeutic thoracic facet joint interventions. Methods: Review of the literature for utility of facet joint interventions in diagnosing and managing facet joint pain was performed according to the Agency for Healthcare Research and Quality (AHRQ) criteria for diagnostic studies and observational studies and the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by United States Preventive Services Task Force (USPSTF) for therapeutic interventions. Recommendations were based on the criteria developed by Guyatt et al. Data sources included relevant literature of the English language identified through searches of Medline and EMBASE from 1966 to July 2008 and manual searches of bibliographies of known primary and review articles. Results of the analysis were performed for diagnostic and therapeutic interventions separately. Outcome Measures: For diagnostic interventions, studies must have been performed utilizing controlled local anesthetic blocks. For therapeutic interventions, the primary outcome measure was pain relief (short-term relief = up to 6 months and long-term relief > 6 months) with secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: Based on the controlled comparative local anesthetic blocks, the evidence for the diagnosis of thoracic facet joint pain is Level I or II-1. The evidence for therapeutic thoracic medial branch blocks is Level I or II-1. The recommendation is IA or 1B/strong for diagnostic and therapeutic medial branch blocks. Conclusion: The evidence for the diagnosis of thoracic facet joint pain with controlled comparative local anesthetic blocks is Level I or II-1. The evidence for therapeutic facet joint interventions is Level I or II-1 for medial branch blocks. Recommendation is 1A or 1B/strong for diagnostic and therapeutic medial branch blocks. Key words: Chronic thoracic pain, mid back or upper back pain, thoracic facet or zygapophysial joint pain, facet joint nerve blocks, medial branch blocks, controlled comparative local anesthetic blocks, therapeutic thoracic medial branch blocks, thoracic radiofrequency neurotomy, thoracic intraarticular facet joint injections

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Lateral branch blocks

10.1093/med/9780197607947.003.0007 ◽

2021 ◽

pp. 75-82

Author(s):

Benjamin K. Homra ◽

Yashar Eshraghi ◽

Maged Guirguis

Keyword(s):

Radiofrequency Ablation ◽

Local Anesthetic ◽

Sacroiliac Joint ◽

Joint Pain ◽

Lateral Branch ◽

Ultrasound Technique ◽

Posterior Aspect ◽

Sacroiliac Joint Pain ◽

Lateral Branches

The posterior sacral network is a complex meshwork of lateral branches of the dorsal sacral rami that innervate the posterior aspect of the sacroiliac joint. Pain arising from this joint can be diagnostically targeted using either a fluoroscopic or ultrasound technique to determine if the patient would benefit from radiofrequency ablation of the lateral branches. Injecting local anesthetic near the dorsal foramina using these techniques will temporarily block the transmission of pain by the lateral branches from the sacroiliac joint. This chapter covers the anatomy of the posterior sacral network, discusses the details of the two techniques for lateral branch blocks and evidence for their utility, provides information about the risks and contraindications associated with the techniques, and concludes by discussing the implications of the procedure.

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120 Efficacy of Radiofrequency Neurotomy for Lumbar Facet Syndrome and Sacroiliac Joint Pain

Neurosurgery ◽

10.1227/01.neu.0000467082.85849.62 ◽

2015 ◽

Vol 62 ◽

pp. 203-204 ◽

Cited By ~ 1

Author(s):

Ana Isabel Lopes Luis ◽

Miguel Vasconcelos Casimiro ◽

Carla Reizinho

Keyword(s):

Sacroiliac Joint ◽

Joint Pain ◽

Sacroiliac Joint Pain ◽

Radiofrequency Neurotomy ◽

Facet Syndrome ◽

Lumbar Facet

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Low back pain: Sacroiliac joint pain may be myth

BMJ ◽

10.1136/bmj.329.7459.232 ◽

2004 ◽

Vol 329 (7459) ◽

pp. 232.1 ◽

Cited By ~ 2

Author(s):

Andrew N Bamji

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Sacroiliac Joint ◽

Joint Pain ◽

Low Back ◽

Sacroiliac Joint Pain

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Randomized Placebo-controlled Study Evaluating Lateral Branch Radiofrequency Denervation for Sacroiliac Joint Pain

Anesthesiology ◽

10.1097/aln.0b013e31817f4c7c ◽

2008 ◽

Vol 109 (2) ◽

pp. 279-288 ◽

Cited By ~ 169

Author(s):

Steven P. Cohen ◽

Robert W. Hurley ◽

Chester C. Buckenmaier ◽

Connie Kurihara ◽

Benny Morlando ◽

...

Keyword(s):

Pain Relief ◽

Local Anesthetic ◽

Sacroiliac Joint ◽

Joint Pain ◽

Lateral Branch ◽

Controlled Study ◽

Sacroiliac Joint Pain ◽

Long Term Treatment ◽

Radiofrequency Denervation ◽

Dorsal Rami

Background Sacroiliac joint pain is a challenging condition accounting for approximately 20% of cases of chronic low back pain. Currently, there are no effective long-term treatment options for sacroiliac joint pain. Methods A randomized placebo-controlled study was conducted in 28 patients with injection-diagnosed sacroiliac joint pain. Fourteen patients received L4-L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation using cooling-probe technology after a local anesthetic block, and 14 patients received the local anesthetic block followed by placebo denervation. Patients who did not respond to placebo injections crossed over and were treated with radiofrequency denervation using conventional technology. Results One, 3, and 6 months after the procedure, 11 (79%), 9 (64%), and 8 (57%) radiofrequency-treated patients experienced pain relief of 50% or greater and significant functional improvement. In contrast, only 2 patients (14%) in the placebo group experienced significant improvement at their 1-month follow-up, and none experienced benefit 3 months after the procedure. In the crossover group (n = 11), 7 (64%), 6 (55%), and 4 (36%) experienced improvement 1, 3, and 6 months after the procedure. One year after treatment, only 2 patients (14%) in the treatment group continued to demonstrate persistent pain relief. Conclusions These results provide preliminary evidence that L4 and L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation may provide intermediate-term pain relief and functional benefit in selected patients with suspected sacroiliac joint pain. Larger studies are needed to confirm these results and to determine the optimal candidates and treatment parameters for this poorly understood disorder.

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The Effects of Radiofrequency Neurotomy Using a Strip-Lesioning Device on Patients with Sacroiliac Joint Pain: Results from a Single-Center, Randomized, Sham-Controlled Trial

January 2018 - Pain Physician ◽

10.36076/ppj.2018.6.607 ◽

2018 ◽

Vol 1 (21;1) ◽

pp. 607-618 ◽

Cited By ~ 3

Author(s):

Vivek Mehta

Keyword(s):

Back Pain ◽

Sacroiliac Joint ◽

Joint Pain ◽

Controlled Trial ◽

Active Group ◽

Sham Treatment ◽

Randomized Controlled ◽

Sacroiliac Joint Pain ◽

Radiofrequency Neurotomy

Background: Radiofrequency neurotomy (RFN) is a therapy aimed at providing lasting back pain relief for sacroiliac joint (SIJ) pain. A recent advancement in RFN is a strip lesioning technique that involves placement of a single curved electrode and a 3-pole design that facilitates the creation of 5 overlapping lesions. These lesions form one long strip lesion accessible through a single entry point, without the need for multiple punctures. Although the early case series data looks promising, there is lack of long-term, randomized, controlled study evaluating the strip-lesioning system for SIJ pain. Objectives: The purpose of this study was to examine the safety and effectiveness of RFN using a strip lesioning device for reduction of SIJ pain. Study Design: Prospective, double-blind, randomized, sham-controlled trial with 6-month follow-up Setting: A tertiary care interventional pain management center in the UK Methods: Patients with SIJ pain with positive diagnostic local anesthetic blocks were randomly assigned (2:1) to either the sham (no RF lesions performed) or the active group (RF lesions performed). The primary endpoint was improvement of pain using the Numeric Rating Scale (NRS-11) at 3 months. Results were analyzed using nonparametric tests. Safety, secondary, and long-term outcome data were also collected. Results: Seventeen of 30 enrolled patients were randomly assigned to active treatment (n = 11) or sham treatment (n = 6). At 3 months, the mean NRS-11 score for the active group had decreased significantly, from 8.1 (± 0.8) at baseline to 3.4 (± 2.0) (P < 0.001). The sham group did not experience a statistically or clinically meaningful decrease in mean NRS-11 score from baseline (7.3 ± 0.8) to 3 months (7.0 ± 1.7). On average, patients in the active group moved from borderline anxiety at baseline (9.4 ± 5.9) to no anxiety (6.6 ± 6.3) at 3 months. Results were similar at 6 months. Limitations: Recruitment was stopped at 30 enrolled patients, only 17 of whom were randomly assigned to active or sham treatment, after the interim analysis indicated a statistically significant (P < 0.001) difference in the pain outcome between the treatment and the sham groups. Conclusions: This study demonstrated that radiofrequency neurotomy using a strip lesioning device is an appropriate therapy to treat SIJ pain. Key words: Radiofrequency, sacroiliac joint pain, low back pain, neurotomy, randomized controlled trial, simplicity

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