Sacroiliac Joint Block and Neuroablation

Chapter 11 Sacroiliac Joint Block and Neuroablation



Kyung-Hoon Kim, MD, PhD, Sang-Wook Shin, MD, PhD


The sacroiliac joint (SIJ) is the largest axial joint in the body with an average surface area of 17.5 cm2 [1]. It is a large, auricular-shaped, diarthrodial synovial joint. However, only the anterior third of the interface between the sacrum and ilium is a true synovial joint; the rest of the junction is comprised of an intricate set of ligamentous connections. If the joints become painful, they may cause pain in the low back, buttocks, abdomen, groin or legs (Figs. 11-1 and 11-2).


image

Figure 11–1 Density of referral zones for sacroiliac joint pain. 0.5+ is the least common referral zone, 4+ the most common.


image

Figure 11–2 Common referral zones for sacroiliac joint pain. The sacroiliac joint can become inflamed from an acute injury or from chronic postural abnormalities. Undue stress on the joint following low back fusion surgery can also cause inflammation and pain here. Pain from sacroiliac joint abnormalities occurs in the low back, buttock/hip, abdomen, groin, or legs.


The primary function of the sacroiliac joint is to lend stability, which it accomplishes through the following mechanisms:


image The transmission and dissipation of truncal loads to the lower extremities

image Limiting of x-axis rotation

image Facilitation of parturition

The biomechanics of the SIJ withstand a medially directed force six times greater than the lumbar spine, but only half of the torsion and 1/20 of the axial compression load.



Sacroiliac joint dysfunction


Typically, SIJ dysfunction is initially symptomatic after a minor traumatic event, such as a fall onto the buttocks or a slip while pushing a heavy object. It is then aggravated by transitional activities, such as climbing stairs, getting up from a chair, and getting out of a car. Pain in the SIJ can also be provoked by activities requiring asymmetrical loading through the lower extremities or pelvis, such as skating, gymnastics, golfing, and step aerobics.


Dreyfuss and colleagues [2] have shown that the pain referral pattern in asymptomatic volunteers consists of the following areas:


image The buttock, the groin, and the entire lower limb, but not the back above the L5 level

image An area extending 10 cm caudally and 3 cm laterally from the posterior superior iliac spine

The diagnostic criteria for sacroiliac joint syndrome, as defined by the International Association for the Study of Pain (IASP), are as follows:


image Pain in the region of the SIJ with possible radiation to the groin, medial buttocks, and posterior thigh

image Reproduction of pain by physical examination techniques that stress the joint

image Elimination of pain with intra-articular injection of a local anesthetic

image An ostensibly morphologically normal joint without demonstrable pathognomonic radiographic abnormalities

One of the most consistent physical findings in patients with SIJ dysfunction is point-specific tenderness over the sacral sulcus as well as the posterior sacroiliac spine.


The prevalence of SIJ pain in carefully screened patients with low back pain (LBP) is in the range of 15% to 25%. 39% of patients with SIJ dysfunction were also diagnosed [3] with an associated spinal disorder. Of these spinal disorders complicated by SIJ dysfunction, the most common are as follows:


image Facet joint syndrome (41%)

image Spondylolisthesis (29%)

SIJ dysfunction can stem from both intra-articular and extra-articular sources, although extra-articular sources such as enthesopathy and fractures are more common. Nociception in the SIJ can also be caused by pathologic changes affecting many different SIJ structures, such as the following:


image Capsular or synovial disruption

image Capsular and ligamentous tension

image Hypomobility or hypermobility

image Extraneous compression or shearing forces

image Abnormal joint mechanics

image Microfractures or macrofractures

image Chondromalacia

image Soft tissue injury

image Inflammation

The following factors predispose an individual to SIJ dysfunction:


image Degenerative joint disease

image Joint (ligamentous) laxity and pregnancy

image A history of minor direct trauma, such as a fall onto the buttocks

The average mechanical threshold of the SIJ nociceptive unit is shown in Table 11.1.


Table 11.1 Average Mechanical Threshold of Sacroiliac Joint and Other Nociceptive Units















Nociceptive Unit Average Mechanical Threshold (g)
Sacroiliac joint 70
Lumbar facet joint 6
Anterior lumbar disc 241

SIJ treatment options are injections, nerve blocks, and denervation. A sacroiliac joint injection serves the following two purposes:


image Injecting anesthetic medication into the joint confirms whether or not pain comes from the joint.

image The local anesthetic and cortisone can help break a pain cycle, possibly facilitating a rehabilitative exercise program.

The evidence for the effectiveness of SIJ block and denervation as diagnostic and therapeutic methods for SIJ dysfunction is shown in Table 11.2.


Table 11.2 Level of Evidence for Intra-articular Injection and Neurotomy















Intra-articular injection:  
Diagnostic method Moderate evidence for diagnosis of pain from the sacroiliac joint (SIJ)
Therapeutic method Moderate evidence for short-term relief (<3 months)
Limited evidence for long-term relief
Radiofrequency neurotomy Indeterminate evidence for managing SIJ pain


Indications


The primary indication for treatment with SIJ block and neuroablation is intra-articular sacroiliac joint pain. The diagnostic criteria for identifying idiopathic intra-articular sacroiliac joint pain are as follows:


image Absence of neurologic deficits

image Absence of dural tension signs

image Absence of laboratory, imaging, or clinical evidence of medical causes of sacroiliac joint pain

image Maximal pain below L5

image No evidence of lumbar pain generators (if indicated, this can be confirmed through negative results of zygapophys-eal joint block and discography)

image At least 75% relief with controlled, dual, fluoroscopically guided, contrast-enhanced intra-articular SIJ injections

Several major diagnostic tests are used to confirm a diagnosis of intra-articular SIJ pain; they are described in Table 11.3 and Box 11.1, and shown in Figures 11-3 through 11-5.


Table 11.3 Sensitivity and Specificity of Major Diagnostic Tests Used to Identify Patients with Intra-articular Sacroiliac Joint Pain



























































Test Sensitivity Specificity
Sacroiliac joint pain ++++ +
Groin pain + +++
Buttock pain ++++ +
Indication of posterior superior iliac spine as pain source ++++ ++
Abnormal sitting posture + ++++
Pain lessens with:
Nonsteroidal anti-inflammatory drugs
Exercise
Manipulation
++
++
+++
++
++++
++++
Gillet test ++ +++
Patrick test +++ +
Gaenslen test +++ ++
Sacral sulcus tenderness ++++ +
Midline sacral thrust +++ ++
Bone scan ++ ++++
Computed tomography +++ +++

+, 0-25%; ++, 26%-50%; +++, 51%-75%; ++++, 76%-100%.



BOX 11.1 Common Tests Utilized in Evaluation of Sacroiliac Joint Dysfunction



Laguerre Test


To differentiate hip pain from sacroiliac pain, the patient is supine. The examiner passively flexes the patient’s hip and knee 90°. Then the hip is passively abducted and placed in extreme external rotation. This maneuver moves the femoral head into the anterior part of the joint capsule of the hip. Pain within the hip suggested degenerative disease, hip dysplasia, or contracture of the iliopsoas muscle. Pain felt posteriorly in the sacroiliac joint suggests a disease process at that site.

Related posts:

Lateral Interbody Fusion Using the XLIF System Minimally Invasive Percutaneous Lumbar Fusion Technique Paravertebral Block Anterior Endoscopic Cervical Microdecompression of Disc and Foramen Outcome Measurements for Minimally Invasive Percutaneous Spine Techniques Spinal Cord Stimulation

Stay updated, free articles. Join our Telegram channel
Tags:
Aug 5, 2016 | Posted by in NEUROSURGERY | Comments Off on Sacroiliac Joint Block and Neuroablation

Full access? Get Clinical Tree
Get Clinical Tree app for offline access