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

2. 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)

3. SIJ Anatomy

4. 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

6. SIJ Innervation

7. 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

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
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.

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

13. 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% 70% < pain

14. 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

15. 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

16. 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

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