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1.  Gynecological Surgery and Low Back Pain in Older Women 
Objective: To determine sacroiliac joint compliance characteristics and pelvic floor movements in older women relative to gynecological surgery history and back pain complaints. Design: Single-visit laboratory measurement. Setting: University clinical research center. Participants: Twenty-five women aged 65 years or older. Outcome Measures: Sacroiliac joint compliance measured by Doppler imaging of vibrations and ultrasound measures of pelvic floor motion during the active straight leg raise test. Results: Doppler imaging of vibrations demonstrated test reliability ranging from 0.701 to 0.898 for detecting vibration on the ilium and sacrum sides of the sacroiliac joint. The presence of low-back pain or prior gynecological surgery was not significantly associated with a difference in the compliance or laxity symmetry of the sacroiliac joints. No significant difference in pelvic floor movement was found during the active straight leg raise test between subject groups. All P values were ≥.4159. Conclusions: Prior gynecological surgery and low-back pain were not significantly associated with side-to-side differences in the compliance of the sacroiliac joints or in significant changes in pelvic floor movement during a loading maneuver in a group of older women.
doi:10.1177/2151458510378006
PMCID: PMC3597293  PMID: 23569659
aging; back pain; gynecologic surgery; sacroiliac joint; pelvic floor; Doppler imaging of vibrations
2.  The predictive value of the sacral base pressure test in detecting specific types of sacroiliac dysfunction 
Abstract
Objective
This study aimed to evaluate the validity of the sacral base pressure test in diagnosing sacroiliac joint dysfunction. It also determined the predictive powers of the test in determining which type of sacroiliac joint dysfunction was present.
Methods
This was a double-blind experimental study with 62 participants. The results from the sacral base pressure test were compared against a cluster of previously validated tests of sacroiliac joint dysfunction to determine its validity and predictive powers. The external rotation of the feet, occurring during the sacral base pressure test, was measured using a digital inclinometer.
Results
There was no statistically significant difference in the results of the sacral base pressure test between the types of sacroiliac joint dysfunction. In terms of the results of validity, the sacral base pressure test was useful in identifying positive values of sacroiliac joint dysfunction. It was fairly helpful in correctly diagnosing patients with negative test results; however, it had only a “slight” agreement with the diagnosis for κ interpretation.
Conclusions
In this study, the sacral base pressure test was not a valid test for determining the presence of sacroiliac joint dysfunction or the type of dysfunction present. Further research comparing the agreement of the sacral base pressure test or other sacroiliac joint dysfunction tests with a criterion standard of diagnosis is necessary.
doi:10.1016/j.jcme.2007.04.003
PMCID: PMC2647083  PMID: 19674694
3.  Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint 
Sacroiliac joint (SIJ) pain refers to the pain arising from the SIJ joint structures. SIJ dysfunction generally refers to aberrant position or movement of SIJ structures that may or may not result in pain. This paper aims to clarify the difference between these clinical concepts and present current available evidence regarding diagnosis and treatment of SIJ disorders. Tests for SIJ dysfunction generally have poor inter-examiner reliability. A reference standard for SIJ dysfunction is not readily available, so validity of the tests for this disorder is unknown. Tests that stress the SIJ in order to provoke familiar pain have acceptable inter-examiner reliability and have clinically useful validity against an acceptable reference standard. It is unknown if provocation tests can reliably identify extra-articular SIJ sources of pain. Three or more positive pain provocation SIJ tests have sensitivity and specificity of 91% and 78%, respectively. Specificity of three or more positive tests increases to 87% in patients whose symptoms cannot be made to move towards the spinal midline, i.e., centralize. In chronic back pain populations, patients who have three or more positive provocation SIJ tests and whose symptoms cannot be made to centralize have a probability of having SIJ pain of 77%, and in pregnant populations with back pain, a probability of 89%. This combination of test findings could be used in research to evaluate the efficacy of specific treatments for SIJ pain. Treatments most likely to be effective are specific lumbopelvic stabilization training and injections of corticosteroid into the intra-articular space.
PMCID: PMC2582421  PMID: 19119403
Corticosteroid Injection; Diagnostic Accuracy; Intra-Articular Injection; Lumbopelvic Stabilization Training; Pregnancy-Related Pelvic Girdle Pain; Sacroiliac Joint Dysfunction; Sacroiliac Joint Pain
4.  VALIDITY AND RELIABILITY OF CLINICAL TESTS FOR THE SACROILIAC JOINT 
Background: The sacroiliac joint (SIJ) can be a source of low back pain. The complexity of the system involving the SIJ and the varied SIJ pain referral pattern makes it difficult to clinically assess SIJ dysfunction. Despite the emergence of detail of the SIJ complex, the basis of the clinical tests has not been thoroughly investigated.
Objective: To review the literature from the last decade dealing with the validity and reliability of clinical tests for SIJ dysfunction in order to determine which tests are reliable and valid.
Discussion: For clinical tests with multiple studies, there was agreement on reliability for Gaenslens, Thigh Thrust test, Finger Point test and SIJ Pain Mapping and agreement on validity for Thigh Thrust test. However, Gillets Test, Patrick’s FABER and Sacral Thrust/Compression were considered invalid and unreliable, although these results may have been influenced by methodological shortcomings. Examination of the entire SIJ complex may mean that a series of tests are required.
PMCID: PMC2051080  PMID: 17987177
Sacroiliac joint; reliability; validity; clinical tests
5.  Pain originating from the sacroiliac joint is a common non-traumatic musculoskeletal complaint in elite inline-speedskaters - an observational study 
Study design
Observational study
Objectives
To investigate common non-traumatic musculoskeletal complaints of the low back in elite inline-speedskaters of the German national team.
Summary of background data
Traumatic injuries associated with falls or collisions are well documented in speedskaters but so far no studies have investigated non-traumatic low back pain. Previously, the sacroiliac joint was suspected as a frequent origin of complaint, we aimed to investigate this assumption.
Methods
Two chiropractors examined elite inline-speedskaters of the German national team during three sports events between summer 2010 and 2011. A test cluster of five provocative tests for the sacroiliac joint was selected based on reliability and validity.
Results
A total of 37 examinations were conducted on 34 athletes with low back pain during the three sport events. The reported pain intensities ranged from mild to moderate pain (VAS 23.4 ± 13.4 to 35.1 ± 19.2). About 90% of cases showed involvement of the SI joint of which again 90% presented with left sided symptoms.
Conclusions
Non-traumatic complaints of the low back originating from the left sacroiliac joint frequently occur in competitive inline speedskaters.
doi:10.1186/2045-709X-20-5
PMCID: PMC3317439  PMID: 22404796
Speedskating; Non-traumatic; Sacro-iliac joint; Sport-specific; Pain
6.  Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature 
Objective
To determine which physical examination tests have the highest sensitivity, specificity, and predictive values for determining the presence of sacroiliac joint injuries and/or dysfunction when compared with the gold standard of a sacroiliac joint block.
Data sources
A systematic search of the literature was conducted for articles that evaluated clinical sacroiliac joint tests for sensitivity, specificity, and predictive value when compared to sacroiliac joint block. The search was conducted using several online databases: Medline, Embase, Cinahl, AMED, and the Index to Chiropractic Literature. Reference and journal searching and contact with several experts in the area was also employed.
Data extraction
Studies selected for inclusion were evaluated with a data extraction sheet and assessed for methodological quality using an assessment tool based on accepted principles of evaluation.
Data synthesis
Article results were compared, no attempt to formally combine the results into a meta-analysis was made.
Results
Seven papers were identified for inclusion in the review, two of which dealt with the same study, thus six studies were to be assessed although one paper could not be obtained. The most recently published article had the highest methodological quality. Study designs rarely incorporated randomized, placebo controlled, double blinded study designs or confirmatory sacroiliac joint blocks. There was considerable inconsistency between studies in design and outcome measurement, making comparison difficult. Five tests were found to have sensitivity and specificity over 60% each in at least one study with at least moderately high methodological quality. Using several tests and requiring a minimum number to be positive yielded adequate sensitivity and specificity for identifying sacroiliac joint injury when compared with sacroiliac joint block.
Conclusion
Practitioners may consider using the distraction test, compression test, thigh thrust/posterior shear, sacral thrust, and resisted hip abduction as these were the only tests to have specificity and sensitivity greater than 60% in at least one study. Further research using improved methodology is required to determine the optimal tests and combinations of tests to identify sacroiliac joint injuries.
PMCID: PMC1924656  PMID: 17657289
sacroiliac; joint; examination; sacro-iliaque; articulation; examen
7.  Agreement between diagnoses reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain 
Background
The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70% of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine single tests in relation to single reference standards, yet in clinical practice, clinicians use multiple tests and select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards.
Methods
We compared blinded clinical diagnoses with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiotherapists examined consecutive patients with chronic lumbopelvic pain and/or referred LES scheduled to receive the reference standard examinations. When diagnoses were in complete agreement regardless of complexity, "exact" agreement was recorded. When the clinical diagnosis was included within the reference standard diagnoses, "clinical agreement" was recorded. The proportional chance criterion (PCC) statistic was used to estimate agreement on multiple diagnostic possibilities because it accounts for the prevalence of individual categories in the sample. The kappa statistic was used to estimate agreement on six pathoanatomic diagnoses.
Results
In a sample of chronic LBP patients (n = 216) with high levels of disability and distress, 67% received a patho-anatomic diagnosis based on available reference standards, and 10% had more than one tissue origin of pain identified. For 27 diagnostic categories and combinations, chance clinical agreement (PCC) was estimated at 13%. "Exact" agreement between clinical and reference standard diagnoses was 32% and "clinical agreement" 51%. For six pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33% with actual agreement 56%. There was no overlap of 95% confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatomic categories produced a kappa of 0.31.
Conclusion
Clinical diagnoses agree with reference standards diagnoses more often than chance. Using available reference standards, most patients can have a tissue source of pain identified.
doi:10.1186/1471-2474-6-28
PMCID: PMC1184083  PMID: 15943873
8.  Comparative effectiveness of open versus minimally invasive sacroiliac joint fusion 
Background
The mainstay of sacroiliac joint disruption/degenerative sacroiliitis therapy has been nonoperative management. This nonoperative management often includes a regimen of physical therapy, chiropractic treatment, therapeutic injections, and possibly radiofrequency ablation at the discretion of the treating physician. When these clinical treatments fail, sacroiliac joint fusion has been recommended as the standard treatment. Open and minimally invasive (MIS) surgical techniques are typical procedures. This study aims to compare the perioperative measures and Oswestry Disability Index (ODI) outcomes associated with each of these techniques.
Methods
A comparative retrospective chart review of patients with sacroiliac joint fusion and a minimum of 1 year of follow-up was performed. Perioperative measures and ODI scores were compared using the Fisher’s exact test and two nonparametric tests, ie, the Mann–Whitney U test and the Wilcoxon signed-rank test. The results are presented as percent or median with range, as appropriate.
Results
Forty-nine patients from two institutions underwent sacroiliac joint fusion between 2006 and 2012. Ten patients were excluded because of incomplete data, leaving 39 evaluable patients, of whom 22 underwent open and 17 underwent MIS sacroiliac joint fusion. The MIS group was significantly older (median age 66 [39–82] years) than the open group (median age 51 [34–74] years). Surgical time and hospital stay were significantly shorter in the MIS group than in the open group. Preoperative ODI was significantly greater in the open group (median 64 [44–78]) than in the MIS group (median 53 [14–84]). Postoperative improvement in ODI was statistically significant within and between groups, with MIS resulting in greater improvement.
Conclusion
The open and MIS sacroiliac joint fusion techniques resulted in statistically and clinically significant improvement for patients with degenerative sacroiliitis refractory to nonoperative management. However, the number of patients reaching the minimal clinically important difference and those showing overall improvement were greater in the MIS group.
doi:10.2147/MDER.S60370
PMCID: PMC4051734  PMID: 24940087
sacroiliac joint; arthrodesis; sacroiliac joint disruption; degenerative sacroiliitis
9.  Role of computed tomography in the evaluation of suspected sacroiliac joint disease. 
Computed tomography (CT) was compared with plain radiography in 41 examinations of selected patients with a clinical history suggestive of sacroiliac joint disease. The obliquity of the sacroiliac joints renders radiographic interpretation difficult. In the 41 cases who were examined with standard anteroposterior and posteroanterior radiographs of the sacroiliac joints, four were normal, eight abnormal and 29 were equivocal. Equivocal findings included indistinct and possibly irregular articular margins to the joints and subarticular sclerosis. Of the 29 equivocal studies, nine were normal on CT and 20 were abnormal. CT demonstrated definite changes of sacroiliac joint disease in 29 of the 41 examinations, 16 of which were sacroiliitis and 13 osteoarthritis. With plain radiography four of the eight abnormal studies were consistent with sacroiliitis, and four with osteoarthritis. It is concluded that CT is more sensitive than plain radiography in the evaluation of sacroiliac joint disease, and is especially valuable when there are equivocal plain radiographs.
Images
PMCID: PMC1292730  PMID: 2395146
10.  Low level laser therapy (LLLT) for patients with sacroiliac joint pain 
Laser Therapy  2011;20(2):117-121.
Background and Aims: Sacroiliac joint pain not associated with a major etiological factor is a common problem seen in the orthopedic clinical setting, but diagnosis is difficult because of the anatomical area and thus it is sometimes difficult to effect a complete cure. Low level laser therapy (LLLT) has been well-reported as having efficacy in difficult pain types, so the following preliminary study was designed to assess the efficacy of LLLT for sacroiliac pain.
Materials and Methods: Nine patients participated, 4 males and 5 females, average age of 50.4 yrs, who attended the outpatient department with sacroiliac pain. The usual major disorders were ruled out. Pain was assessed subjectively pre-and post-LLLT on a visual analog scale, and trunk range of motion was examined with the flexion test to obtain the pre- and post-treatment finger to floor distance (FFD). The LLLT system used was an 830 nm CW diode laser, 1000 mW, 30 sec/point (20 J/cm2) applied on the bilateral tender points twice/week for 5 weeks. Baseline and final assessment values (after the final treatment session) were compared with the Wilcoxon signed rank test (nonparametric score).
Results: All patients completed the study. Eight of the 9 patients showed significant pain improvement and 6 demonstrated significantly increased trunk mobility (P <0.05 for both).
Conclusions: LLLT was effective for sacroiliac pain, and this may be due to improvement of the blood circulation of the strong ligaments which support the sacroiliac joint, activation of the descending inhibitory pathway, and the additional removal of irregularities of the sacroiliac joint articular surfaces. Further larger-scale studies are warranted.
doi:10.5978/islsm.20.117
PMCID: PMC3799023  PMID: 24155520
Sacroiliac joint; Low Level Laser Therapy; Sacroiliac joint pain
11.  Imaging in ankylosing spondylitis 
Imaging is an integral part of the management of patients with ankylosing spondylitis and axial spondyloarthritis. Characteristic radiographic and/or magnetic resonance imaging (MRI) findings are key in the diagnosis. Radiography and MRI are also useful in monitoring the disease. Radiography is the conventional, albeit quite insensitive, gold standard method for assessment of structural damage in spine and sacroiliac joints, whereas MRI has gained a decisive role in monitoring disease activity in clinical trials and practice. MRI may also, if ongoing research demonstrates a sufficient reliability and sensitivity to change, become a new standard method for assessment of structural damage. Ultrasonography allows visualization of peripheral arthritis and enthesitis, but has no role in the assessment of axial manifestations. Computed tomography is a sensitive method for assessment of structural changes in the spine and sacroiliac joints, but its clinical utility is limited due to its use of ionizing radiation and lack of ability to assess the soft tissues. It is exciting that with continued dedicated research and the rapid technical development it is likely that even larger improvements in the use of imaging may occur in the decade to come, for the benefit of our patients.
doi:10.1177/1759720X11436240
PMCID: PMC3403247  PMID: 22859929
ankylosing spondylitis; computed tomography; imaging; magnetic resonance imaging; radiography; spondyloarthritis; ultrasonography; ultrasound
12.  Distraction test of the posterior superior iliac spine (PSIS) in the diagnosis of sacroiliac joint arthropathy 
BMC Surgery  2013;13:52.
Background
The sacroiliac joint (SIJ) is a frequently underestimated cause of lower back (LBP). A simple clinical test of sufficient validity would be desirable. The aim of this study was to evaluate the diagnostic value of a new PSIS distraction test for the clinical detection of SIJ arthropathy and to compare it to several commonly used clinical tests.
Methods
Consecutive patients, where a SIJ pathology had been confirmed by an SIJ infiltration were enrolled (case group, 61 SIJs in 46 patients). Before infiltration, patients were tested for pain with PSIS distraction by a punctual force on the PSIS in medial-to-lateral direction (PSIS distraction test), pain with pelvic compression, pelvic distraction, Gaenslen test, Thigh Thrust, and Faber (or Patrick’s) test. In addition, these clinical tests were applied to both SIJs of a population of individuals without history of LBP (control group, 64 SIJs in 32 patients).
Results
Within the investigated cohort, the PSIS distraction test showed a sensitivity of 100% and a specificity of 89% for SIJ pathology. The accuracy of the test was 94%, the positive predictive value (PPV) was 90% and the negative predictive value (NPV) was 100%. Pelvic compression, pelvic distraction, Gaenslen test, Thigh Thrust, and Faber test were associated with a good specificity (> 90%) but a poor sensitivity (< 35%).
Conclusions
Within our population of patients with confirmed SIJ arthropathy the PSIS distraction test was found to be of high sensitivity, specificity and accuracy. In contrast, common clinical tests showed a poor sensitivity. The PSIS distraction test seems to be an easy-to-perform and clinically valuable test for SIJ arthropathy.
doi:10.1186/1471-2482-13-52
PMCID: PMC3827936  PMID: 24175954
Sacroiliac joint pain; Provocation test; Joint infiltration; Diagnostic value
13.  Clinical Incidence of Sacroiliac Joint Arthritis and Pain after Sacropelvic Fixation for Spinal Deformity 
Yonsei Medical Journal  2012;53(2):416-421.
Purpose
Sacroiliac fixation using iliac screws for highly unstable lumbar spine has been reported with an improved fusion rate and clinical results. On the other hand, there is a potential for clinical problems related to iliac fixation, including late sacroiliac joint arthritis and pain.
Materials and Methods
Twenty patients were evaluated. Degenerative scoliosis was diagnosed in 7 patients, failed back syndrome in 6 patients, destructive spondyloarthropathy in 4 patients, and Charcot spine in 3 patients. All patients underwent posterolateral fusion surgery incorporating lumbar, S1 and iliac screws. We evaluated the pain scores, bone union, and degeneration of sacroiliac joints by X-ray imaging and computed tomography before and 3 years after surgery. For evaluation of low back and buttock pain from sacroiliac joints 3 years after surgery, lidocaine was administered in order to examine pain relief thereafter.
Results
Pain scores significantly improved after surgery. All patients showed bone union at final follow-up. Degeneration of sacroiliac joints was not seen in the 20 patients 3 years after surgery. Patients showed slight low back and buttock pain 3 years after surgery. However, not all patients showed relief of the low back and buttock pain after injection of lidocaine into the sacroiliac joint, indicating that their pain did not originate from sacroiliac joints.
Conclusion
The fusion rate and clinical results were excellent. Also, degeneration and pain from sacroiliac joints were not seen within 3 years after surgery. We recommend sacroiliac fixation using iliac screws for highly unstable lumbar spine.
doi:10.3349/ymj.2012.53.2.416
PMCID: PMC3282959  PMID: 22318832
Sacroiliac; fixation; iliac screws; degeneration; pain
14.  RHEUMATOID (MARIE-STRUMPELL) SPONDYLITIS, Technique of Examination and Importance of the Costal Joints 
California Medicine  1949;70(4):257-261.
Rheumatoid spondylitis in the early prodromal stage may present a complex and obscure clinical picture making diagnosis difficult. It is in this early stage that roentgen examination of the small joints of the spine will often aid in or lead to the correct diagnosis of the disease in which the classical clinical symptoms and roentenographic findings in the sacroiliac fissure have not appeared and may never appear. The changes in these small joints, particularly in the costovertebral and costotransverse joints, are less obvious and require experienced and careful interpretation, but it is to these that the roentgenologist must direct his attention if he is to be of assistance in early diagnosis. A technical procedure for this examination is presented, along with a discussion of the clinical importance of changes at this site.
Demonstration of involvement of the sacroiliac joints is of diagnostic importance, but this finding is no more necessary to the diagnosis of rheumatoid spondylitis than is involvement of any other single joint of the spine. Insistence on sacroiliac involvement will often result in missed diagnosis, and has led in part to erroneous conclusions as to sex incidence of the disease.
Images
PMCID: PMC1643771  PMID: 18116229
15.  An annotated bibliography of spinal motion palpation reliability studies 
Background
Several literature reviews have addressed the reliability of spinal and sacroiliac (SI) motion palpation (MP), finding that, in general, interexaminer reliability is slight and intraexaminer reliability is moderate.
Methods
We performed a literature search of four biomedical databases to locate articles that dealt with MP of the spine or SI joints. The abstracts of the retrieved citations were independently screened for inclusion by two of the authors. The full-text of potentially includable articles was examined by the same two authors to assess whether they met all of the inclusion criteria. The validity of the included studies was evaluated using a 6-point scale.
Results
The initial searches netted 415 citations; another 30 were harvested from the secondary search. Fifty-nine articles were removed as duplicates and 305 failed to meet the inclusion criteria. Another 33 were excluded because they did not adequately describe the method of analysis, used a combination of tests, were not actually MP studies, or were not reliability studies.
Annotated bibliography
Summaries of 48 articles that dealt with the reliability of spinal and SI MP are presented. Where appropriate, we have commented on some of the methodological deficiencies that were discovered.
PMCID: PMC2652630  PMID: 19421352
motion palpation; spine; sacroiliac; reliability
16.  Pyomyositis of the iliacus muscle and pyogenic sacroiliitis after sacroiliac joint block -A case report- 
Korean Journal of Anesthesiology  2013;64(5):464-468.
Sacroiliac joint block can be performed for the diagnosis and treatment of sacroiliac joint dysfunction. Although sacroiliac joint block is a common procedure, complications have not been reported in detail. We report a case of iliacus pyomyositis and sacroiliac joint infection following a sacroiliac joint block. A 70-year-old female patient received sacroiliac joint blocks to relieve pelvic pain. The patient was admitted to the emergency room two days after the final sacroiliac joint block (SIJB) with the chief complaints of left pelvic pain corresponding to a visual analogue scale (VAS) score of 9 and fever. A pelvic MRI indicated a diagnosis of myositis. After 1 month of continuous antibiotic therapy, the patient's erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level remained elevated. A 67Ga SPECT/CT was done. Abnormal uptake was seen at the left sacroiliac joint (SIJ), and septic sacroiliitis was suspected. The CRP normalized to 0.29 mg/dl and the ESR decreased to 60 mm/hr, and the patient had no fever after 57 days of antibiotic therapy. She was directed for follow up at an outpatient clinic.
doi:10.4097/kjae.2013.64.5.464
PMCID: PMC3668112  PMID: 23741573
Iliacus; Infection; Pyomyositis; Sacroiliac
17.  Sacroiliac joint pain due to bacterial infection: a report of two cases 
Isolated infection of the sacroiliac joint is a rare cause of low back pain. Delayed diagnosis can result in significant morbidity. The diagnosis may be missed initially if physicians do not consider the possibility of infection. The clinical index of suspicion should increase in the presence of certain historical and examination findings. These include intravenous drug use, immunosuppression, recent infection elsewhere, fever and warmth or swelling over the sacroiliac joint. Two cases of sacroiliac joint pain due to Staphylococcus aureus infection are presented, with an overview of the etiology, diagnosis and management of the disorder.
Images
PMCID: PMC2485062
sacroiliac joint; pyogenic infection; diagnosis; chiropractic; manipulation
18.  Early axial spondyloarthritis 
Current opinion in rheumatology  2010;22(5):603-607.
Purpose of review
To summarize recent advances in the classification of preradiographic axial spondyloarthritis (SpA).
Recent findings
Inflammation in the sacroiliac joints precedes radiographic damage that is necessary to establish a diagnosis of ankylosing spondylitis (AS). Preradiographic axial SpA refers to patients with SpA who exhibit signs and symptoms of axial involvement, but lack criteria for AS. Patients with axial SpA can have remarkably similar clinical features and disease activity as those with early AS. MRI is a sensitive method for detecting sacroiliac joint inflammation, which is useful in predicting the development of AS. Whole-body MRI has emerged as a means to visualize additional areas of involvement. However, it may be less sensitive than conventional MRI, and thus its added value will need to be further assessed. The incorporation of MRI evaluation of the sacroiliac joints and HLA-B27 testing into criteria for identifying individuals with preradiographic axial disease has led to the development of criteria for classifying axial SpA.
Summary
The development of classification criteria for axial SpA will aid in the identification of patients suitable for clinical trials testing whether early intervention will slow the development and/or progression of structural changes in that lead to AS.
doi:10.1097/BOR.0b013e32833c7255
PMCID: PMC3023975  PMID: 20592602
19.  An atypical case of nephrolithiasis with transient remission of symptoms following spinal manipulation 
Objective
Nephrolithiasis is a common condition with symptoms similar to common mechanical lesions of the lumbar spine and pelvis. The purpose of this report is to outline a case of nephrolithiasis that closely mimicked sacroiliac joint syndrome in subjective report, objective findings, and reduction of symptoms with spinal manipulation.
Clinical Features
A 41-year-old obese male patient with mild pain over the left posterior sacroiliac joint, penile paresthesia, and the penile sensation of urinary urgency presented for chiropractic care. Subjective history and objective evaluation suggested sacroiliac joint syndrome.
Intervention and Outcome
A trial of conservative management including spinal manipulation was initiated. Following each treatment, the patient reported temporary relief of all symptoms (4 hours to 2 days). After unsuccessful permanent resolution of symptoms, a urinalysis was performed; and a follow-up computerized tomography scan revealed a large renal calculus obstructing the left ureter. Laser lithotripsy produced obliteration of the stone and complete resolution of symptoms.
Conclusions
This report outlines the potential overlap of symptoms of visceral and somatic lesions in both presentation and response to care. In this case, a favorable response to spinal manipulation masked the most likely underlying symptom generator. This encounter demonstrates the potential need for further clinical examination in the instance of the unresponsive mechanical lesion. This report also supports the need for future research into spinal manipulation as a possible adjunct for visceral pain management.
doi:10.1016/j.jcm.2010.02.005
PMCID: PMC2943659  PMID: 21629552
Spinal manipulation; Renal calculi; Nephrolithiasis; Chiropractic
20.  Anterior Pelvic Plating and Sacroiliac Joint Fixation in Unstable Pelvic Ring Injuries 
Yonsei Medical Journal  2012;53(2):422-426.
Purpose
To analyze the effectiveness of anterior pelvic plating and subsequent percutaneous sacroiliac joint screw fixation in patients with unstable pelvic ring injuries.
Materials and Methods
Thirty-two patients were included with twenty-one males and eleven females. The mean age was 41 years (range, 19-76). The mean follow-up period was 51 months (range, 36-73). According to AO-OTA classification, there were 11 cases of B2 injuries, 8 cases of B3 injuries, 9 cases of C1 injuries, 2 cases of C2 injuries and 2 cases of C3 injuries. In the posterior lesions, there were 20 cases of sacral fractures and 12 cases of sacroiliac joint disruptions or dislocations. Anterior pelvic plating and subsequent percutaneous sacroiliac joint fixation were performed.
Results
The clinical results were 16 cases of excellent, 10 cases of good, 4 cases of moderate and 2 cases of poor functional results. The 2 cases out of 7 moderate reductions had poor functional results with residual neurologic symptoms. The radiological results were 16 cases of anatomic, 9 cases of nearly anatomic and 7 cases of moderate reduction. All patients were healed except 3 cases of nonunion at the pubic ramus. The complications encountered were 3 cases of screw loosening, 2 cases of anterior plate breakage and 1 case of postoperative infection.
Conclusion
In patients with unstable pelvic ring injuries, anterior pelvic plating and subsequent percutaneous sacroiliac joint screw fixation may be a useful surgical option. The radiological results and residual neurologic symptoms had effects on its functional results.
doi:10.3349/ymj.2012.53.2.422
PMCID: PMC3282962  PMID: 22318833
Pelvic ring injuries; anterior pelvic plating; sacroiliac joint fixation
21.  Management of a low back pain patient with a prosthesis and a foot drop orthotic 
INTRODUCTION
The effect of altered gait on body mechanics presents a stress on patient’s sacroiliac joints (SIJ). The gait of the patient is this case report is altered because of a transtibial amputation with prosthesis; he also has a foot drop orthotic.
CLINICAL FEATURES
A 40-year-old man had left sacroiliac pain. The pain began 3 days before visiting the clinic and has been constant since its onset. It is alleviated by resting on his side. He reported that he had been painting his mother’s house for 3 days before the pain started. Past history is significant for a spinal cord injury with resultant right leg foot drop; in addition, he has a left leg prosthesis.
INTERVENTION AND OUTCOME
Adjustments to the sacroiliac joint were performed on a Zenith-Thompson Terminal Point adjusting table, utilizing only motion palpation to assess for subluxation. The adjustments consisted of contacting the left posterior superior iliac spine (PSIS) and applying 3 successive high-velocity, low-amplitude thrusts to it. Initial visit schedules were bi-weekly and progresses to bi-monthly as needed.
CONCLUSION
Patient with prosthesis can benefit greatly from chiropractic care, to assist them in maintaining proper joint motion and gait patterns that allow them to walk more freely.
PMCID: PMC1840023  PMID: 17549210
low back pain; amputation; prosthesis
22.  Buttock pain: a missed diagnosis 
BMJ Case Reports  2012;2012:bcr1120115258.
A 13-year-old school boy presented with right-sided buttock pain, features of sepsis and Staphylococcus aureus positive blood cultures. On examination, he was febrile and in severe pain, with limited hip rotation and positive sacroiliac stress tests. Initial imaging with pelvic x-ray, hip ultrasound and MRI were normal. Despite this, a diagnosis of septic arthritis of the hip was presumed, and the patient underwent a washout of the right hip. When the imaging was reviewed in more detail, it was noted that a section of the sacroiliac joint was abnormal. Subsequent pelvic MRI confirmed that this was, in fact, septic sacroiliitis. The patient made a good recovery following washout of the right sacroiliac joint and 6 weeks of antibiotics.
doi:10.1136/bcr.11.2011.5258
PMCID: PMC3387474  PMID: 22707699
23.  Usefulness of Pain Distribution Pattern Assessment in Decision-Making for the Patients with Lumbar Zygapophyseal and Sacroiliac Joint Arthropathy 
Journal of Korean Medical Science  2007;22(6):1048-1054.
There are currently no initial guides for the diagnosis of somatic referred pain of lumbar zygapophyseal joint (LZJ) or sacroiliac joint (SIJ). We developed a classification system of LZJ and SIJ pain, the "pain distribution pattern template (PDPT)" depending on the pain distribution patterns from a pool of 200 patients whose spinal pain source was confirmed. We prospectively applied the PDPT to determine its contribution to clinical decision-making for 419 patients whose pain was presumed to arise from the LZJs (259 patients) or SIJs (160 patients). Forty-nine percent (128/259) of LZJ and 46% (74/160) of SIJ arthopathies diagnosed by PDPT were confirmed by nerve blocks. Diagnostic reliabilities were significantly higher in Type A and C patterns in LZJ and Type C in SIJ arthropathies, 64%, 80%, and 68.4%, respectively. For both LZJ and SIJ arthropathies, favorable outcome after radiofrequency (RF) neurotomies was similar to the rate of positive responses to diagnostic blocks in Type A to Type D, whereas the outcome was unpredictable in those with undetermined type (Type E). Considering the paucity of currently available diagnostic methods for LZJ and SIJ arthropathies, PDPT is useful in clinical decision-making as well as in predicting the treatment outcome.
doi:10.3346/jkms.2007.22.6.1048
PMCID: PMC2694630  PMID: 18162721
Low Back Pain; Zygapophyseal Joint; Sacroiliac Joint; Diagnosis; Radiofrequency Neurotomy
24.  Cooled radiofrequency denervation for treatment of sacroiliac joint pain: two-year results from 20 cases 
Journal of Pain Research  2013;6:505-511.
Background
Sacroiliac joint pain is a common cause of chronic low back pain. Different techniques for radiofrequency denervation of the sacroiliac joint have been used to treat this condition. However, results have been inconsistent because the variable sensory supply to the sacroiliac joint is difficult to disrupt completely using conventional radiofrequency. Cooled radiofrequency is a novel technique that uses internally cooled radiofrequency probes to enlarge lesion size, thereby increasing the chance of completely denervating the sacroiliac joint. The objective of this study was to evaluate the efficacy of cooled radiofrequency denervation using the SInergy™ cooled radiofrequency system for sacroiliac joint pain.
Methods
The charts of 20 patients with chronic sacroiliac joint pain who had undergone denervation using the SInergy™ cooled radiofrequency system were reviewed at two years following the procedure. Outcome measures included the Numeric Rating Scale for pain intensity, Patient Global Impression of Change, and Global Perceived Effect for patient satisfaction.
Results
Fifteen of 20 patients showed a significant reduction in pain (a decrease of at least three points on the Numeric Rating Scale). Mean Numeric Rating Scale for pain decreased from 7.4 ± 1.4 to 3.1 ± 2.5, mean Patient Global Impression of Change was “improved” (1.4 ± 1.5), and Global Perceived Effect was reported to be positive in 16 patients at two years following the procedure.
Conclusion
Cooled radiofrequency denervation showed long-term efficacy for up to two years in the treatment of sacroiliac joint pain.
doi:10.2147/JPR.S46827
PMCID: PMC3706381  PMID: 23869175
ablation; chronic low back pain; intervention; neurotomy; sacroiliitis
25.  Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain 
European Spine Journal  2007;16(10):1539-1550.
Clinical practice guidelines state that the tissue source of low back pain cannot be specified in the majority of patients. However, there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain. The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint or sacroiliac joint (SIJ) as the source of low back pain. MEDLINE, EMBASE and CINAHL were searched up to February 2006 with citation tracking of eligible studies. Eligible studies compared index tests with an appropriate reference test (discography, facet joint or SIJ blocks or medial branch blocks) in patients with low back pain. Positive likelihood ratios (+LR) > 2 or negative likelihood ratios (-LR) < 0.5 were considered informative. Forty-one studies of moderate quality were included; 28 investigated the disc, 8 the facet joint and 7 the SIJ. Various features observed on MRI (high intensity zone, endplate changes and disc degeneration) produced informative +LR (> 2) in the majority of studies increasing the probability of the disc being the low back pain source. However, heterogeneity of the data prevented pooling. +LR ranged from 1.5 to 5.9, 1.6 to 4.0, and 0.6 to 5.9 for high intensity zone, disc degeneration and endplate changes, respectively. Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain: +LR = 2.8 (95%CI 1.4–5.3). Absence of degeneration on MRI was the only test found to reduce the likelihood of the disc as the source of pain: −LR = 0.21 (95%CI 0.12–0.35). While single manual tests of the SIJ were uninformative, their use in combination was informative with +LR of 3.2 (95%CI 2.3–4.4) and −LR of 0.29 (95%CI 0.12–0.35). None of the tests for facet joint pain were found to be informative. The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. However, the changes in probability are usually small and at best moderate. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear.
Electronic supplementary material
The online version of this article (doi:10.1007/s00586-007-0391-1) contains supplementary material, which is available to authorized users.
doi:10.1007/s00586-007-0391-1
PMCID: PMC2078309  PMID: 17566796
Systematic review; Low back pain; Diagnosis

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