Back Pain – SI Joint Dysfunction

Sacroiliac joint pain pain sacroiliac (SI) has gained much attention in the last ten years as an underestimated cause of back pain with some studies indicate that it is responsible for 15% to 40% of back pain. The increased attention is due to increased knowledge of the SI joints intimate role in the stability of the pelvis. I hope more doctors believe the pain in SI joint differential after reading this article. Pathophysiology of SI joint dysfunction due to inflammation in the joint sacroilitis called himself. Pain in SI joint is common in rheumatoid patients and spondyloarthropathies. The other cause of SI joint dysfunction is derived from the SI joint instability. Many experts believe that the pain of the ISA is a component of a larger problem of instability of the pelvis (1). The pelvic instability has traditionally been underestimated as a cause of back pain, buttock pain, pain in the groin and leg pain. Physiotherapists and doctors of osteopathic medicine have been teaching these concepts for years but only recently has this diffusion of knowledge is a trend towards the dominant thinking among doctors. The complex of the ASI (the ASI and its associated ligaments) is the major support structure of the pelvic ring and the complex is strongest ligament in the body. The complex consists of interosseous sacroiliac ligaments, iliolumbar ligament, posterior sacroiliac ligaments, and sacrotuberous and sacrospinous ligaments. The SI joints are two of the three joints involved in the stability of the pelvic ring. The pelvic ring is the meeting place of the force vectors of the upper body and lower extremities. The joint third in the pelvic ring is the symphysis pubis. The instability of the pelvis causes rotation of the pelvis, which can also cause twisting of the symphysis pubis. Coupling this with its previous location seems to provide an explanation for why patients with SI joint instability may also experience pain in the groin before. Anecdotal evidence of this is seen when patients undergo a joint success in the SI-joint injection relieved of all his subsequent back, buttocks, and leg symptoms, but the patient still has pain in the groin. Groin pain is rarely eliminated by injections of the ISA, unless to correct pelvic symmetry. If the SI joints are unstable, which can cause significant pain and discomfort on the SI joints as well as numerous areas mentioned. If a person affected by the SI joint pain is only pain in his sacroiliac joint, he / she must be lucky. Most times the SI joint instability causes unnatural tension across the lower back and pelvic region which causes a sometimes confusing clinical picture. The pain referral patterns of pain of the ISA is often confused with L5 or S1 radiculopathy or radiculitis. Reference standards of the SI joint dysfunction (2) SI joint dysfunction often presents with a confusing clinical picture. 1. Pain in the buttocks 94% 2. Lower back pain in 74%, 3. Pain in the lower extremity 50%, with 28% of the pains of the lower extremities are distal to the knee 4. The pain goes all the way to the bottom 13%. Younger patients are more likely to refer pain distal to the knee. 5. Groin pain 14%. Most patients with SI joint instability may also experience pain in the gluteal region due to secondary muscle spasm of the gluteal muscles and pyramidal complex. Symptoms of the lower limbs is explained by the natural tendency to piriformis spasm or tightening in the sciatic nerve when the ASI is out of alignment. This spasm of the gluteal muscles and piriformis can cause a mechanical displacement or compression of the sciatic nerve as it exits just below the SI joint (see Figure 1. Note the intimate relationship between the piriformis, SI joint, and the sciatic nerve). Patients often complain of pain in the buttocks and radiating pain to the knees and even feet. Not all back pain and leg pain due to a pinched nerve of a herniated intervertebral disc. SI joint dysfunction closely mimics S1 or L5 radiculitis or radiculopathy due to irritation from the above or pinching the sciatic nerve. Pain in the groin and abdominal pain are common with SI joint instability. Many times in the groin pain is mistaken for a urologic problem, such as pudendal neuralgia, prostatitis, genitofemoral neuralgia, or epidydymitis sterile (1). It is likely that this is due to the natural tension of the nerves and ligaments of the symphysis pubis or actual compression of the pudendal nerve that lies between the ligament and the sacrospinous ligament sacrotuberous. The distance between these two ligaments is reduced sharply when the ilium and sacrum, are out of alignment i. e. The instability of the sacroiliac joint. The typical history of SI joint dysfunction is low back pain lateral or bilateral, usually below the rim of the pelvis. The pain may also extend to the hip, groin, pelvis, leg and foot. The most common location of pain in the buttocks with pain extending to the knee. Women are much more affected than men, although the relationship is unclear. The mechanism of injury is a continuum of events completely atraumatic to the obvious trauma, such as car accidents, childbirth, or falls. Just over one third of failed back surgery patients suffer from SI joint dysfunction. In my practice, I often see patients who lose a substantial amount of weight and then develop a SI joint dysfunction. The etiology of this is unclear. Women who have had multiple births also appear to have a higher incidence of SI joint dysfunction. Symptoms may be acute or injury may occur as distance or cumulative with chronic ups and downs of symptoms with a slow progression over time. Patients often experience some temporary relief with manipulation. Patients should change positions frequently to avoid pain. This is called "Theater Cocktail syndrome. The patient's legs may also feel that they will take, but by objective evidence of the strength of motor dysfunction is not. This syndrome is called "Slipping crutch." Patients often have difficulty sleeping and getting out of bed in the morning can be painful. Movement continued after awakening tends to relieve the pain. There are many provocative physical examination maneuvers used to help establish the diagnosis of SI joint dysfunction. Passing through each of these provocative maneuvers is beyond the scope of this article. Importantly, the predictive value of provocative SI joint maneuvers in the determination of the SI joint dysfunction is only 60% (4). The conclusion of a recent study Slipman et al (5) was that physical examination techniques at best into the SI joint dysfunction on the differential diagnosis of a patient's back pain. Of the alleged signs of sacroiliac joint pain, maximum pain below L5, along with pointing to the PSIS or local tenderness medial to the PSIS (sacral sulcus) has the highest positive predictive value (PPD) in 60% (4). Diagnosis The gold standard for diagnosis of SI joint dysfunction is SI fluoroscopy guided injection together. Fluoroscopy is needed to inject with accuracy and consistency of the sacroiliac joint. Only 12% of patients joint SI joint injections when fluoroscopy was not used (3). It is also important to anesthetize the entire SI joint complex. In my experience as a medical intervention of pain can not be done constantly by palpation alone, especially in obese patients. It's humiliating to see a change anatomy under fluoroscopic guidance. What is perceived on palpation is sometimes very different from the actual location of the structure that feel. Of equal importance is that these diagnostic injections are followed with a physical exam while the patient is in the recovery room. Sending a patient home, making the monitoring of several weeks, and then determine if this "diagnosis" of the injection was a success has always proven to be an error to establish a pathological diagnosis. Treatment There is no specific treatment for SI joint dysfunction that helps all patients. Treatment varies if the dysfunction is intra-articular (inflammatory), or is a lack of stability. Conservative treatment should be tried first, including manipulation by a physiotherapist or an osteopathic physician qualified to restore normal movement and balance, self-correction of the exercises at home, a walking program (to avoid large axial load exercises) and consolidate the basis of exercises (Pilates, Yoga, physical therapy or guided). Some patients also benefit from a quality SI joint support belt. If conservative therapy is not useful then I recommend an injection of diagnostic SI joint complex. The injection should include the SI joint (intra-articularly) and the ligaments that support with lasting pain relief for the duration of local anesthesia, and greater than 75% relief of pain. If there is any question about the positivity of this diagnostic test should be repeated. Radiofrequency denervation If the diagnosis is established by intra-articular injection and SI joint pain relief using conservative therapy does not provide pain relief in the long term, then the consideration of other treatments can be done. Radiofrequency denervation of a SI joint is about 65% success rate for patients who have failed other conservative treatments and only mild instability around the joint. The procedure involves neurotomy of lateral branch nerves, which stretched over the sacrum and supply the posterior SI joint. The advantage of the RF SI joint is that it is a very safe procedure with almost no morbidity documented. Prolotherapy Another treatment for the sacroiliac pain is Prolotherapy. Prolotherapy works by stimulating an inflammatory cascade that leads to fibroblast activity reinforcing the ligament and tendon entheses. Prolotherapy SI joint usually requires strong solutions prolotherapy. In my experience, hypertonic dextrose prolotherapy only 20 to 30% relief of pain in most patients. More aggressive Prolotherapy generally reduces pain by 50% or more in approximately 75% of patients. The biggest advantage of prolotherapy is that it provides a level of permanent relief. SI joint fusion if the patient does not prolotherapy radio and the last treatment option would be the consideration of a merger of the SI joint. The data results from the fusion of the SI joint is not very favorable. However, new minimally invasive SI joint fusions have been recently approved by the FDA that show promise. Patients with very diffuse pelvic pain and leg pain are not good candidates for fusion surgery.