7 SIJ InnervationEarly: Cunningham’s…, Bernard and Cassidy, Ikeda, Nagakawa, etc. included anterior innervation (ventral rami)Fortin et al, Grob et al: macroscopic and fetal microscopic fetal studies: innervation entirely dorsal rami (S1-3)Yin, Willard, Carreiro, Dreyfuss: defined (fluoro) course of sacral dorsal rami; reported SIJRF pilot technique and results
11 DiagnosisX-ray, MRI, CT, bone scan generally not helpful except to rule in/out fracture, stress response, infection, tumor, sacroiliitisArthrogram may show capsular disruptionNeed double intraarticular SIJ blocks to diagnose, although single IA, posterior ligament, or dorsal rami blocks have been used by various authors/practitionersBlockade of the L5 Dorsal Rami and Sacral 1-3 lateral branches, using the multi-site, multi-depth technique of Dreyfuss, et al. (Pain Medicine 2009) is necessary for radiofrequency neurotomy (RFN) screening.
12 Diagnosis - HistoryUnilateral pain at or below PSIS, PSIS pointing (Fortin, Maigne), no pain above L5, pain over SIJ and Buttock (Dreyfuss, et al)
14 Diagnosis – Physical Exam Dreyfuss, et al (multidisciplinary expert panel)12 key pain, Hx, and PE parametersSingle block, 90% reliefPSIS pointing, no pain above L5, sacral sulcus tenderness, pain over SIJ/buttockGillet’s test best of provocative maneuvers
15 Diagnosis – Physical Exam Van der Wurff, et al, 2006Double blocks, >50% relief3 of 5 positive tests (distraction, compression, thigh thrust, Patrick, Gaenslen)Sensitivity .85, specificity .79PPV .77, NPV .87
16 Discogenic: Centralization w McKenzie method Pain w rising from sittingSacroiliac: Unilateral pain; No lumbar painPain rising from sitting3/5 provocation tests: distraction, compression, sacral thrust, thigh thrust, Gaenslen’sLZJ: no pain rising from sitting