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Sacroiliac Joint J. Scott Bainbridge, MD www.DenverBackPainSpecialists.com.

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Presentation on theme: "Sacroiliac Joint J. Scott Bainbridge, MD www.DenverBackPainSpecialists.com."— Presentation transcript:

1 Sacroiliac Joint J. Scott Bainbridge, MD

2 SIJ Background Proposed as potential source of pain by Goldthwaite in 1905 Proposed as potential source of pain by Goldthwaite in 1905 Incidence of SIJ pain in LBP population: % (Schwarzer, Maigne, DePalma, Liliang, Schofferman) Incidence of SIJ pain in LBP population: % (Schwarzer, Maigne, DePalma, Liliang, Schofferman)

3 SIJ Anatomy

4 Diarthrodial joint Diarthrodial joint Hyalin cartilage, fibrocartilage also on ilial side Hyalin cartilage, fibrocartilage also on ilial side Interlocking contours Interlocking contours Ligaments: anterior and posterior SIL, interosseous SIL, sacrospinous and sacrotuberous Ligaments: anterior and posterior SIL, interosseous SIL, sacrospinous and sacrotuberous Muscles: paraspinous, gluteal, psoas, iliacus, abdominal, sartorius, rectus femoris, hamstrings, latissimus dorsi (lumbodorsal fascia) Muscles: paraspinous, gluteal, psoas, iliacus, abdominal, sartorius, rectus femoris, hamstrings, latissimus dorsi (lumbodorsal fascia) Nutation Nutation

5

6 SIJ Innervation

7 Early: Cunninghams…, Bernard and Cassidy, Ikeda, Nagakawa, etc. included anterior innervation (ventral rami) Early: Cunninghams…, 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[4]) Fortin et al, Grob et al: macroscopic and fetal microscopic fetal studies: innervation entirely dorsal rami (S1-3[4]) Yin, Willard, Carreiro, Dreyfuss: defined (fluoro) course of sacral dorsal rami; reported SIJRF pilot technique and results Yin, Willard, Carreiro, Dreyfuss: defined (fluoro) course of sacral dorsal rami; reported SIJRF pilot technique and results

8 S-1 Dorsal Rami Yin, et al. Spine 2003

9 S-2 Dorsal Rami

10 S-3 Dorsal Rami

11 Diagnosis X-ray, MRI, CT, bone scan generally not helpful except to rule in/out fracture, stress response, infection, tumor, sacroiliitis X-ray, MRI, CT, bone scan generally not helpful except to rule in/out fracture, stress response, infection, tumor, sacroiliitis Arthrogram may show capsular disruption Arthrogram may show capsular disruption Need double intraarticular SIJ blocks to diagnose, although single IA, posterior ligament, or dorsal rami blocks have been used by various authors/practitioners Need double intraarticular SIJ blocks to diagnose, although single IA, posterior ligament, or dorsal rami blocks have been used by various authors/practitioners Blockade 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. Blockade 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 - History Unilateral pain at or below PSIS, PSIS pointing (Fortin, Maigne) Unilateral pain at or below PSIS, PSIS pointing (Fortin, Maigne), no pain above L5, pain over SIJ and Buttock (Dreyfuss, et al), no pain above L5, pain over SIJ and Buttock (Dreyfuss, et al)

13 Diagnosis – Physical Exam Maigne: Patricks – trend – p=0.9 Maigne: Patricks – trend – p=0.9 Broadhurst and Bond: double blind, lido v saline Broadhurst and Bond: double blind, lido v saline FABER (Flexion, ABduction, External Rotation) FABER (Flexion, ABduction, External Rotation) POSH (POsterior SHear) POSH (POsterior SHear) REAB (REsisted ABduction) REAB (REsisted ABduction) 100% specificity, 77-80% 70% < pain 100% specificity, 77-80% 70% < pain

14 Diagnosis – Physical Exam Dreyfuss, et al (multidisciplinary expert panel) Dreyfuss, et al (multidisciplinary expert panel) 12 key pain, Hx, and PE parameters 12 key pain, Hx, and PE parameters Single block, 90% relief Single block, 90% relief PSIS pointing, no pain above L5, sacral sulcus tenderness, pain over SIJ/buttock PSIS pointing, no pain above L5, sacral sulcus tenderness, pain over SIJ/buttock Gillets test best of provocative maneuvers Gillets test best of provocative maneuvers

15 Diagnosis – Physical Exam Van der Wurff, et al, 2006 Van der Wurff, et al, 2006 Double blocks, >50% relief Double blocks, >50% relief 3 of 5 positive tests (distraction, compression, thigh thrust, Patrick, Gaenslen) 3 of 5 positive tests (distraction, compression, thigh thrust, Patrick, Gaenslen) Sensitivity.85, specificity.79 Sensitivity.85, specificity.79 PPV.77, NPV.87 PPV.77, NPV.87

16 Discogenic: Centralization w McKenzie method Discogenic: Centralization w McKenzie method Pain w rising from sitting Pain w rising from sitting Sacroiliac: Unilateral pain; No lumbar pain Sacroiliac: Unilateral pain; No lumbar pain Pain rising from sitting Pain rising from sitting 3/5 provocation tests: distraction, compression, sacral thrust, thigh thrust, Gaenslens 3/5 provocation tests: distraction, compression, sacral thrust, thigh thrust, Gaenslens LZJ: no pain rising from sitting LZJ: no pain rising from sitting

17 SIJ - Treatment Manual therapy Manual therapy Exercise (m. balance, stabilization) Exercise (m. balance, stabilization) Medication Medication IA injection (corticosteroids) IA injection (corticosteroids) Prolotherapy Prolotherapy PRP – Platelet Rich Plasma PRP – Platelet Rich Plasma Neuromodulation Neuromodulation Dennervation (RF neurotomy) Dennervation (RF neurotomy)


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