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

SIJ Background Proposed as potential source of pain by Goldthwaite in 1905 Incidence of SIJ pain in LBP population: 18-40% (Schwarzer, Maigne, DePalma, Liliang, Schofferman)

SIJ Anatomy

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

SIJ Innervation

SIJ Innervation Early: 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[4]) Yin, Willard, Carreiro, Dreyfuss: defined (fluoro) course of sacral dorsal rami; reported SIJRF pilot technique and results

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

S-2 Dorsal Rami

S-3 Dorsal Rami

Diagnosis 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 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.

Diagnosis - History Unilateral pain at or below PSIS, PSIS pointing (Fortin, Maigne) , no pain above L5, pain over SIJ and Buttock (Dreyfuss, et al)

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

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

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

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

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