Transcript Document

Sacroiliac Joint Pain, A Review
Ahmad Al-khayer
SpR Rehabilitation Medicine
Controversies
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Anatomy
SIJ movements
Do clinical tests have a role?
Is imaging conclusive?
Is SIJ intraarticular injection conclusive?
Treatment??
Controversies
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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!!!
Aims
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History
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Anatomy, Biomechanics, Movements
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Pathophysiology
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Diagnosis (Pain Distributions, Clinical & Radiological
Tests, Intraarticular injection)
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Treatment (Conservative, Minimally Invasive,
Surgical)
History
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Hippocrates observed that a woman’s pelvis
separated during labour and remained so after birth.
Lynch 1920 (Surg Gynecol Obstet 575-580)
History
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Hippocrates observed that a woman’s pelvis
separated during labour and remained so after birth.
Lynch 1920 (Surg Gynecol Obstet 575-580)
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Albee 1909 (JAMA 53;1273-67), Smith-Paterson 1926
(JBJS 8;118-136), Campbell 1927(Surg Gynecol Obstet 45;218-9)
History
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Hippocrates observed that a woman’s pelvis
separated during labour and remained so after birth.
Lynch 1920 (Surg Gynecol Obstet 575-580)
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Albee 1909 (JAMA 53;1273-67), Smith-Paterson 1926
(JBJS 8;118-136), Campbell 1927(Surg Gynecol Obstet 45;218-9)
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Development of discectomy surgery by Mixter and
Barr 1934 (New Engl J Med 211;210-15)
History
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Hippocrates observed that a woman’s pelvis
separated during labour and remained so after birth.
Lynch 1920 (Surg Gynecol Obstet 575-580)
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Albee 1909 (JAMA 53;1273-67), Smith-Paterson 1926
(JBJS 8;118-136), Campbell 1927(Surg Gynecol Obstet 45;218-9)
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Development of discectomy surgery by Mixter and
Barr 1934 (New Engl J Med 211;210-15)
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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.
Anatomy
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C or Ear shaped by adulthood.
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Fibrous capsule; thin anteriorly, absent posteriorly
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Synovial (75% of its superior part is not)
Anatomy
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C or Ear shaped
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Fibrous capsule; thin anteriorly, absent posteriorly
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Synovial (75% of its superior part is not)
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True diarthrodial joint: The concave sacral surface is
covered with thick hyaline cartilage, the convex iliac
surface is covered with fibrocartilage
Anatomy
Ant
Post
Anatomy
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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
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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
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It varies greatly in size, shape, contour from side to
side and between individuals
Anatomy
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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
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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
Anatomy
Anatomy
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The old bridge of Stirling, built about 1550
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Both Highland troops and the British army tried to
cross during the 1745 Jacobite rebellion
Biomechanics
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“Keystone in an arch”effect; the
greater the force the greater the
resistance
Qui ckTi me™ and a
TIFF (Uncompressed) decompressor
are needed to see this pictur e.
Biomechanics
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“Keystone in an arch”effect; the
greater the force the greater the
resistance
Triplanar shock absorber, base of spine
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Transmits and dissipates upper trunk loads
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Qui ckTi me™ and a
TIFF (Uncompressed) decompressor
are needed to see this pictur e.
Movements
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Powerful ligament (interosseous)
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Different and variable shape
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Keystone
Movements
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Powerful ligament (interosseous)
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Different and variable shape
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Keystone
Does it actually move?
Movements
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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)
Movements
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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)
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Movement of ilium on the sacrum (upslip, downslip,
outflare, inflare, anterior torsion, posterior torsion)
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Movement of sacrum on the ilium (nutation, counternutation, sacral side bending, rotation)
Movements
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“Movements of the sacroiliac joints. A roentgen
stereophotogrammetric analysis”. Sturessone et al
1989, (Spine 14(2): 162-5)
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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).
Movements
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The two most common types of motion are nutation
(backward rotation of the ilium on the sacrum) and
counternutation (forward rotation)
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SIJ motion progressively decreases in men aged
between 40 and 50 and in women aged over 50.
Dreyfuss 1995 (Spine 6;785-813)
Pathophysiology
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Multiple theories:
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Ligamentous or Capsular tension
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Bony arthritis
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Synovial inflammation
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Extraneous compression or shear forces
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Hypo or hypermobility
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Abnormal mechanics
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Myofascial
Pathophysiology
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SIJ dysfunction (postpartum, limb length discrepancy,
repetitive minor trauma)
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Infection (haematogenous)
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Spondyloarthropathies (Ank spond, Reiter’s)
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Degenerative arthritis
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Post traumatic arthritis (insufficiency factures, major
trauma)
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Previous spinal surgery (lumbar stabilisation....)
Pathophysiology
(less frequent)
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Metabolic and endocrine disorders (crystal induced
joint disorders, hyperparathyroidism)
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Primary tumors (chondrosarcoma, giant cell
tumors...)
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Mets to pelvis
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Idiopathic
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Rare causes (iatrogenic, psychogenic).
Pathophysiology
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Dreyfuss 1995 (Clin N Am 6;785-813)
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Intraarticular sources: Spondyloarthropathies, OA,
infection, metabolic
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Extraarticular sources: ligamentous sprain, SIJ
fractures, insufficiency fractures, ligamentous,
tendious, fascial attachment
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Tumors
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Iatrogenic
Pathophysiology
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Dreyfuss 1995 (Clin N Am 6;785-813)
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Intraarticular sources: Spondyloarthropathies, OA,
infection, metabolic
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Extraarticular sources: ligamentous sprain, SIJ
fractures, insufficiency fractures, ligamentous,
tedious, fascial attachment
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Tumors
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Iatrogenic
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Could the above be relevant for treatment?
Diagnosis
Pain distribution
Clinical Tests
Radiological Investigations
Intraarticular Injection
Pain Distributions
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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.
Pain Distributions
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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.
Pain Distributions
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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?
Pain Distributions
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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.
Pain Distributions
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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.
Pain Distributions
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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.
Pain Distributions
Pain Distributions
Only 4% of patients
mark any pain above L5 on
self reported Pain drawings.
Dreyfuss 1996
(Spine, 21:2594-2602)
Pain Distributions
Many diseases mimic SIJ pain:
Spinal disorders
Non- spinal disorders:
Gastrointestinal
Genitourinary
Pubic symphysis motion
Myofascial imbalances
Aberrant gait
Hip joint disorders
Clinical Tests
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Pain provocative tests
Palpation tests
Motion demands tests
Clinical Tests
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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)
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* (Broadhurst 1998, J Spinal Disord 11;341-345)
Palpation tests
Motion demands tests
Clinical Tests
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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)
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Motion demands tests
Clinical Tests
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Pain provocative tests
Palpation tests
Motion demands tests
Sitting tolerance 78% sensitivity, 58%
specificity (Stark et al)
Standing, Flexion
Clinical Tests
Partick’s test
Lewin Ganslen’ test
Pelvic rock’ test
Stretch test
Yeaoman’s test
Clinical Tests
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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*
Radiological Investigations
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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*
Intraarticular Injection
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LA
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Gold standard for diagnosis of intraarticular SIJ pain
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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*
Intraarticular Injection
The Technique
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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.
Intraarticular Injection
The Technique
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Buchowski et al 2005 (The Spine Journal, 520-528)
Patients prone.
C-arm fluoroscope angled 20 to 25 in a caudal
direction and away from the side to be injected.
Spinal needle is advanced in the direction of the
beam aiming for the post inf aspect of the joint.
Intraarticular Injection
The Technique
Treatment
Conservative
Minimally invasive
Surgical
Conservative Treatment
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Medications (NSAID, opiate,
antidepressants)
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Physical therapy (aerobic
conditioning, activity
modification, posture education,
early mobilisation..)
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Orthotics and shoe modification
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Others (rest, heat, manipulation,
chiropractic)
Minimally Invasive Treatment
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Intraarticular Injections: LA and corticosteroid
-Braun 1996. 30 SPA, CT guided Intra SIJ. Statistically
significant improvement 5 m. (J Rheumatol 23;659-64)
-Hanly 2000. 13 SPA & 6 non SPA. CT guided intra SIJ
injection. Transient improvement at 1-3 m. No significant
improvement at 6 m. (J Rheumtol 27;719-22)
-Slipman 2001. Retrospectively 31 non SPA. Fluoroscopic
guided Intra SIJ. Average 2.1 injectio. Average follow up
94.4 w. Significant reduction in Oswestry & VAS. Work
status & medication consumption improved. (Am J Phys Med
Rehabil, 80(6): 425-32)
Minimally Invasive Treatment
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Periarticular Injections: LA and corticosteroid.
- Luukkainen 2002. 24 non SPA patients. Double blind
controlled. 13 with MP & LA and 11 of NACL & LA.
Significant improvement of MP over NACL at one month.
(Clin Exp Rheumtol 20;52-54)
Minimally Invasive Treatment
- Murakami 2007.
Pain provocation test identified pain in SIJ area.
Intraarticular injection for the first 25 patients and
extraarticular for the second 25.
LA. Restriction of activities of daily life scale.
Improvement in 9 out of 25 intra and 25 out of 25
extra.
The 16 intra were then injected extra and showed
improvement.
Extra is easier and should be tried first. (J Orthop Sci, 12(3):
274-80)
Minimally Invasive Treatment
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Prolotherapy: Phenol, glycerine, dextrose, glucose
into surrounding ligaments produce extra collagen.
Strengthen SIJ. (Keating 1999, Movement, Stability and Low Back
Pain 573-586)
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Neuroaugmentation: Electrical stimulation to spinal
cord or deep brain. (Calvillo, 1998, Spine 23;1069-1072)
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Viscosupplementation: Hyaluronic acid into SIJ.
Lubricant. (Calvillo1998, Spine 23;1069-1072)
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Radiofrequency neurotomy: Heat to S1, S3. (Yin 2003,
Spine 28;2419-2425)
Surgical treatment
21 surgical technique were identified in 2007
Arthrodesis or stabilisation
Open procedures
& bone graft
Metal work
No metal work
Percutaneous
No bone graft
Surgical treatment
1. All the identified papers were case reports, case
series, or technique papers.
2. Only four papers collected the data prospectively
3. Sample size ranged from 1 to 172
4. Follow up period ranged from 6 weeks to 9 years
5. Minimal statistical analysis.
6. Lack of information on functional outcome.
7. SIJ arthrodesis was only considered when
conservative treatment failed
(Al-khayer 2007, J Back Musculoskeletal Rehab, 20;135-141)
Summary
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SIJ is an important cause of low back pain
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Referral zones are wide
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Clinical tests can be used as screening tool
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The gold standard test for diagnosis of intraarticular
SIJ pain is is Intraarticular injection of LA
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Treatment is multidisciplinary, and it is affected by the
source of pain
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Research
Questions