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1.  Distraction test of the posterior superior iliac spine (PSIS) in the diagnosis of sacroiliac joint arthropathy 
BMC Surgery  2013;13:52.
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.
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).
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%).
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.
PMCID: PMC3827936  PMID: 24175954
Sacroiliac joint pain; Provocation test; Joint infiltration; Diagnostic value
2.  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
3.  Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge 
European Spine Journal  2012;21(9):1788-1796.
Recently, the sacroiliac joint (SIJ) has gained increased attention as a source of persistent or new pain after lumbar/lumbosacral fusion. The underlying pathophysiology of SIJ pain may be increased mechanical load, iliac crest bone grafting, or a misdiagnosis of SIJ syndrome. Imaging studies show more frequent degeneration of the SIJ in patients with lumbar/lumbosacral fusion than in patients without such fusion. Using injection tests, it has been shown that SIJ pain is the cause of persistent symptoms in a considerable number of patients after fusion surgery. Recent articles reporting on surgical outcomes of SIJ fusion include a high percentage of patients who had lumbar/lumbosacral fusion or surgery before, although well-controlled clinical studies are necessary to assess the efficacy of surgical treatment. Taking these findings into consideration, the possibility that the SIJ is the source of pain should be considered in patients with failed back surgery syndrome after lumbar/lumbosacral fusion.
PMCID: PMC3459112  PMID: 22581257
Sacroiliac joint pain; Lumbosacral fusion; Lumbar fusion; Pathophysiology
4.  Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces 
Annals of Biomedical Engineering  2008;36(3):415-424.
Effective stabilization of the sacroiliac joints (SIJ) is essential, since spinal loading is transferred via the SIJ to the coxal bones, and further to the legs. We performed a biomechanical analysis of SIJ stability in terms of reduced SIJ shear force in standing posture using a validated static 3-D simulation model. This model contained 100 muscle elements, 8 ligaments, and 8 joints in trunk, pelvis, and upper legs. Initially, the model was set up to minimize the maximum muscle stress. In this situation, the trunk load was mainly balanced between the coxal bones by vertical SIJ shear force. An imposed reduction of the vertical SIJ shear by 20% resulted in 70% increase of SIJ compression force due to activation of hip flexors and counteracting hip extensors. Another 20% reduction of the vertical SIJ shear force resulted in further increase of SIJ compression force by 400%, due to activation of the transversely oriented M. transversus abdominis and pelvic floor muscles. The M. transversus abdominis crosses the SIJ and clamps the sacrum between the coxal bones. Moreover, the pelvic floor muscles oppose lateral movement of the coxal bones, which stabilizes the position of the sacrum between the coxal bones (the pelvic arc). Our results suggest that training of the M. transversus abdominis and the pelvic floor muscles could help to relieve SI-joint related pelvic pain.
PMCID: PMC2239251  PMID: 18204902
Static forces; Sacroiliac joints; Pelvis; Pelvic floor muscles; Human posture
5.  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.
PMCID: PMC2694630  PMID: 18162721
Low Back Pain; Zygapophyseal Joint; Sacroiliac Joint; Diagnosis; Radiofrequency Neurotomy
6.  Sciatica-like symptoms and the sacroiliac joint: clinical features and differential diagnosis 
European Spine Journal  2013;22(7):1657-1664.
To compare the clinical features of patients with sacroiliac joint (SIJ)-related sciatica-like symptoms to those with sciatica from nerve root compression and to investigate the necessity to perform radiological imaging in patients with sciatica-like symptoms derived from the SIJ.
Patients with pain radiating below the buttocks with a duration of 4 weeks to 1 year were included. After physical and radiological examinations, a diagnosis of SI joint-related pain, pain due to disk herniation, or a combination of these two causes was made.
Patients with SIJ-related leg pain (n = 77/186) were significantly more often female, had shorter statue, a shorter duration of symptoms, and had more often pain radiating to the groin and a history of a fall on the buttocks. Muscle weakness, corkscrew phenomenon, finger-floor distance ≥25 cm, lumbar scoliosis, positive Bragard or Kemp sign, and positive leg raising test were more often present when radiologic nerve root compression was present. Although these investigations may help, MRI of the spine is necessary to discriminate between the groups.
Sciatica-like symptoms derived from the SIJ can clinically mimic a radiculopathy. We suggest to perform a thorough physical examination of the spine, SI joints, and hips with additional radiological tests to exclude other causes.
PMCID: PMC3698344  PMID: 23455949
Sacroiliac joint; Leg pain; Sciatica; Lumbar disk; Differential diagnosis
7.  Sacroiliac joint pain: burden of disease 
The sacroiliac joint (SIJ) is an important and significant cause of low back pain. We sought to quantify the burden of disease attributable to the SIJ.
The authors compared EuroQol 5D (EQ-5D) and Short Form (SF)-36-based health state utility values derived from the preoperative evaluation of patients with chronic SIJ pain participating in two prospective clinical trials of minimally invasive SIJ fusion versus patients participating in a nationally representative USA cross-sectional survey (National Health Measurement Study [NHMS]). Comparative analyses controlled for age, sex, and oversampling in NHMS. A utility percentile for each SIJ subject was calculated using NHMS as a reference cohort. Finally, SIJ health state utilities were compared with utilities for common medical conditions that were published in a national utility registry.
SIJ patients (number [n]=198) had mean SF-6D and EQ-5D utility scores of 0.51 and 0.44, respectively. Values were significantly depressed (0.28 points for the SF-6D utility score and 0.43 points for EQ-5D; both P<0.0001) compared to NHMS controls. SIJ patients were in the lowest deciles for utility compared to the NHMS controls. The SIJ utility values were worse than those of many common, major medical conditions, and similar to those of other common preoperative orthopedic conditions.
Patients with SIJ pain presenting for minimally invasive surgical care have marked impairment in quality of life that is worse than in many chronic health conditions, and this is similar to other orthopedic conditions that are commonly treated surgically. SIJ utility values are in the lowest two deciles when compared to control populations.
PMCID: PMC3990391  PMID: 24748825
sacroiliac joint fusion; chronic lower back pain; quality of life; utility assessment; comparative assessments
8.  Outcome of distraction interference arthrodesis of the sacroiliac joint for sacroiliac arthritis 
Indian Journal of Orthopaedics  2013;47(5):437-442.
After lumbar or lumbosacral fusion for various spine disorders, adjacent segment disease has been reported. Most of the studies have focused on proximal segment disease. The author has reported sacroiliac joint degeneration in these patients. Based on our own experiences with an increasing number of patients with sacroiliac joint (SIJ) arthralgia after multi-level lumbar or lumbosacral fusion procedures, we evaluated a surgical procedure called distraction arthrodesis of the SIJ for patients with refractory severe pain of the SIJ.
Materials and Methods:
Nineteen (19) consecutive patients were recruited and evaluated prospectively after undergoing distraction arthrodesis of the SIJ. The inclusion criteria for the surgical procedure were degeneration of the SIJ and failed conservative treatment. Magnetic resonance imaging (MRI) scans and CT scans were performed in all cases. The clinical outcome was assessed using the Visual Analog Scale and the Oswestry Disability Index (ODI). CT scans were performed postoperatively and again at the final followup to evaluate assess fusion. The data was analyzed using the SPSS software (version 10.0; SPSS, Chicago, IL) and statistical analysis was performed. The P values were based on the Student t-test.
The mean followup was 13.2 months. All patients had an instrumented lumbar or lumbosacral fusion. The overall fusion rate of SIJ was 78.9% (15/19 joints). All patients demonstrated significant improvement in VAS and ODI scores compared to preoperative values. The mean VAS score was 8.5 before surgery and was 6 at final followup, demonstrating 30% improvement. The mean ODI scores were 64.1 before surgery and 56.97 at the final followup, demonstrating 12% improvement.
Refractory sacroiliac pain as a result of multi-level fusion surgery can be successfully treated with minimally invasive arthrodesis. It offers a safe and effective treatment for severe SIJ pain. Careful patient selection is important.
PMCID: PMC3796914  PMID: 24133301
Arthrodesis; distraction; interference; recesses; sacroiliac joint
9.  Sacroiliac joint dysfunction in patients with imaging-proven lumbar disc herniation 
European Spine Journal  1998;7(6):450-453.
A dysfunction of a joint is defined as a reversible functional restriction of motion presenting with hypomobility according to manual medicine terminology. The aim of our study was to evaluate the frequency and significance of sacroiliac joint (SIJ) dysfunction in patients with low back pain and sciatica and imaging-proven disc herniation. We examined the SIJs of 150 patients with low back pain and sciatica; all of these patients had herniated lumbar disks, but none of them had sensory or motor losses. Forty-six patients, hereinafter referred to as group A, were diagnosed with dysfunction of the SIJ. The remaining 104 patients, hereinafter referred to as group B, had no SIJ dysfunction. Dysfunctions were resolved with mobilizing and manipulative techniques of manual medicine. Regardless of SIJ findings, all patients received intensive physiotherapy throughout a 3-week hospitalisation. At the 3 weeks follow-up, 34 patients of group A (73.9%) reported an improvement of lumbar and ischiadic pain, 5 patients were pain free. Improvement was recorded in 57 of the group B patients (54.8%); however, nobody in group B was free of symptoms. We conclude that in the presence of lumbar and ischiadic symptoms our presented data suggest consideration of SIJ dysfunction, requiring manual medicine examination and, in the presence of SIJ dysfunction, appropriate therapy, regardless of intervertebral disc pathomorphology. This could avoid wrong indications for nucleotomy.
PMCID: PMC3611293  PMID: 9883953
Key words Lumbar disc herniation; Sacroiliac joint dysfunction; Manual therapy
10.  Three-Dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility 
The high frequency of static and dynamic palpation methods used during evaluation of SIJ problems in clinical practice demands an understanding of the factual quantity of movement at the SIJ. The objective of this systematic literature review was to synthesize three-dimensional (3-D) motion of the sacroiliac joint (SIJ) during various functional static postures and movements and to determine the clinical utility of movement during examination. A computer-based search was performed by means of OVID, which included Medline (February 1966 to April 2007) and CINAHL (February 1982 to April 2007) using the key words Pelvis, Kinematics, Imaging, Three-dimensional, and Stereophotogrammetric. Articles included in-vivo or in-vitro studies that investigated human SIJs with 3-D analysis. Three-dimensional analyses conducted using mathematical modeling, computerized modeling, and/or skin markers were not included because of concerns of transferability and validity. Studies that failed to report standard error of measurement (SEM) or defined tabulated values for translations or rotations using the Cartesian coordinate system were not considered for this study. Studies included for review were analyzed by the SBC biomechanical checklist to measure the quality of procedural design. Seven manuscripts were eligible for inclusion in this study. Rotation ranged between −1.1 to 2.2 degrees along the X-axis, −0.8 to 4.0 degrees along the Y-axis, and −0.5 to 8.0 degrees along the Z-axis. Translation ranged between −0.3 to 8.0 millimeters (mm) along the X-axis, −0.2 to 7.0 mm along the Y-axis, −0.3 to 6.0 mm along the Z-axis. Motion of the SIJ is limited to minute amounts of rotation and of translation suggesting that clinical methods utilizing palpation for diagnosing SIJ pathology may have limited clinical utility.
PMCID: PMC2565072  PMID: 19119382
Sacroiliac Joint; Cartesian Coordinate System; Roentgen Stereophotogrammetric Analysis; Pelvic Kinematics; Systematic Review
11.  Can erosions on MRI of the sacroiliac joints be reliably detected in patients with ankylosing spondylitis? - A cross-sectional study 
Arthritis Research & Therapy  2012;14(3):R124.
Erosions of the sacroiliac joints (SIJ) on pelvic radiographs of patients with ankylosing spondylitis (AS) are an important feature of the modified New York classification criteria. However, radiographic SIJ erosions are often difficult to identify. Recent studies have shown that erosions can be detected also on magnetic resonance imaging (MRI) of the SIJ early in the disease course before they can be seen on radiography. The goals of this study were to assess the reproducibility of erosion and related features, namely, extended erosion (EE) and backfill (BF) of excavated erosion, in the SIJ using a standardized MRI methodology.
Four readers independently assessed T1-weighted and short tau inversion recovery sequence (STIR) images of the SIJ from 30 AS patients and 30 controls (15 patients with non-specific back pain and 15 healthy volunteers) ≤45 years old. Erosions, EE, and BF were recorded according to standardized definitions. Reproducibility was assessed by percentage concordance among six possible reader pairs, kappa statistics (erosion as binary variable) and intraclass correlation coefficient (ICC) (erosion as sum score) for all readers jointly.
SIJ erosions were detected in all AS patients and six controls by ≥2 readers. The median number of SIJ quadrants affected by erosion recorded by four readers in 30 AS patients was 8.6 in the iliac and 2.1 in the sacral joint portion (P < 0.0001). For all 60 subjects and for all four readers, the kappa value for erosion was 0.72, 0.73 for EE, and 0.63 for BF. ICC for erosion was 0.79, 0.72 for EE, and 0.55 for BF, respectively. For comparison, the kappa and ICC values for bone marrow edema were 0.61 and 0.93, respectively.
Erosions can be detected on MRI to a comparable degree of reliability as bone marrow edema despite the significant heterogeneity of their appearance on MRI.
PMCID: PMC3446505  PMID: 22626458
12.  The relationship between hamstring length and gluteal muscle strength in individuals with sacroiliac joint dysfunction 
It has been suggested that tight hamstring muscle, due to its anatomical connections, could be a compensatory mechanism for providing sacroiliac (SI) joint stability in patients with gluteal muscle weakness and SIJ dysfunction. The purpose of this study was to determine the relationship between hamstring muscle length and gluteal muscle strength in subjects with sacroiliac joint dysfunction. A total of 159 subjects with and without low back pain (LBP) between the ages of 20 and 65 years participate in the study. Subjects were categorized into three groups: LBP without SIJ involvement (n = 53); back pain with SIJ dysfunction (n = 53); and no low back pain (n = 53). Hamstring muscle length and gluteal muscle strength were measured in all subjects. The number of individuals with gluteal weakness was significantly (P = 0.02) higher in subjects with SI joint dysfunction (66%) compared to those with LBP without SI joint dysfunctions (34%). In pooled data, there was no significant difference (P = 0.31) in hamstring muscle length between subjects with SI joint dysfunction and those with back pain without SI involvement. In subjects with SI joint dysfunction, however, those with gluteal muscle weakness had significantly (P = 0.02) shorter hamstring muscle length (mean = 158±11°) compared to individuals without gluteal weakness (mean = 165±10°). There was no statistically significant difference (P>0.05) in hamstring muscle length between individuals with and without gluteal muscle weakness in other groups. In conclusion, hamstring tightness in subjects with SI joint dysfunction could be related to gluteal muscle weakness. The slight difference in hamstring muscle length found in this study, although statistically significant, was not sufficient for making any definite conclusions. Further studies are needed to establish the role of hamstring muscle in SI joint stability.
PMCID: PMC3172951  PMID: 22294848
Low back pain; Sacroiliac joint; Hamstring muscle length; Gluteal muscle weakness; Pelvic dysfunction; Muscle imbalance
13.  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.
PMCID: PMC2078309  PMID: 17566796
Systematic review; Low back pain; Diagnosis
14.  Tumor necrosis factor inhibitor therapy but not standard therapy is associated with resolution of erosion in the sacroiliac joints of patients with axial spondyloarthritis 
Arthritis Research & Therapy  2014;16(2):R100.
Radiography is an unreliable and insensitive tool for the assessment of structural lesions in the sacroiliac joints (SIJ). Magnetic resonance imaging (MRI) detects a wider spectrum of structural lesions but has undergone minimal validation in prospective studies. The Spondyloarthritis Research Consortium of Canada (SPARCC) MRI Sacroiliac Joint (SIJ) Structural Score (SSS) assesses a spectrum of structural lesions (erosion, fat metaplasia, backfill, ankylosis) and its potential to discriminate between therapies requires evaluation.
The SSS score assesses five consecutive coronal slices through the cartilaginous portion of the joint on T1-weighted sequences starting from the transitional slice between cartilaginous and ligamentous portions of the joint. Lesions are scored dichotomously (present/absent) in SIJ quadrants (fat metaplasia, erosion) or halves (backfill, ankylosis). Two readers independently scored 147 pairs (baseline, 2 years) of scans from a prospective cohort of patients with SpA who received either standard (n = 69) or tumor necrosis factor alpha (TNFα) inhibitor (n = 78) therapy. Smallest detectable change (SDC) was calculated using analysis of variance (ANOVA), discrimination was assessed using Guyatt’s effect size, and treatment group differences were assessed using t-tests and the Mann–Whitney test. We identified baseline demographic and structural damage variables associated with change in SSS score by univariate analysis and analyzed the effect of treatment by multivariate stepwise regression adjusted for severity of baseline structural damage and demographic variables.
A significant increase in mean SSS score for fat metaplasia (P = 0.017) and decrease in mean SSS score for erosion (P = 0.017) was noted in anti-TNFα treated patients compared to those on standard therapy. Effect size for this change in SSS fat metaplasia and erosion score was moderate (0.5 and 0.6, respectively). Treatment and baseline SSS score for erosion were independently associated with change in SSS erosion score (β = 1.75, P = 0.003 and β = 0.40, P < 0.0001, respectively). Change in ASDAS (β = −0.46, P = 0.006), SPARCC MRI SIJ inflammation (β = −0.077, P = 0.019), and baseline SSS score for fat metaplasia (β = 0.085, P = 0.034) were independently associated with new fat metaplasia.
The SPARCC SSS method for assessment of structural lesions has discriminative capacity in demonstrating significantly greater reduction in erosion and new fat metaplasia in patients receiving anti-TNFα therapy.
PMCID: PMC4060567  PMID: 24755322
15.  Metabolic disturbances identified by SPECT-CT in patients with a clinical diagnosis of sacroiliac joint incompetence 
European Spine Journal  2013;22(7):1674-1682.
To establish the sensitivity and specificity of cross-sectional scintigraphy [single photon emission computed tomography (SPECT)] combined with computed X-ray tomography (CT) in the detection of sacroiliac joint (SIJ) mechanical dysfunction and evaluate reproducibility of reporting.
Patients with pelvic girdle pain either on the basis of peri-partum SIJ dysfunction or trauma were included. These patients were imaged with bone scintigraphy with hybrid imaging with SPECT/CT.
The study group comprised 100 patients (72 females, 28 males). Trauma accounted for 52 % and the remainder were patients with peri-partum pain. Average age was 43 years and average length of history was >2 years. The major finding was increased uptake in the upper SIJ and posterior soft-tissues/ligaments. Hybrid imaging had a sensitivity of 95 % and specificity of 99 %. Positive predictive value was 99 % and negative predictive value 94 %. Power of the test was 1.0. Reproducibility of the test was good with kappa values of 0.85.
Hybrid imaging with SPECT/CT reproducibly demonstrates metabolic alterations around the SIJ in patients with SIJ dysfunction, which we have termed SIJ incompetence. The condition is more common than previously recognised and frequently occurs after trauma, which has not been reported previously.
PMCID: PMC3698330  PMID: 23455953
Sacroiliac joint; SPECT/CT; Sacroiliac joint incompetence; Pain provocation tests; Pain palpation tests
16.  Dual fibular allograft dowel technique for sacroiliac joint arthrodesis 
Study design: Retrospective case series.
Objective: To assess fusion rates in patients with sacroiliac joint (SIJ) pain following a minimally invasive technique using fibular dowel allograft.
Methods: Thirty-seven consecutive patients (mean age: 42.5 years [range, 23–63 years]) with SIJ pain treated with 38 minimally invasive elective SIJ arthrodeses were retrospectively reviewed using chart and x-ray data. The fusion procedure consisted of minimal muscle stripping over the posterior SIJ and insertion of a cranial and caudal fibular dowel graft across the joint following placement of Steinmann pins. Fusion was deemed to be present when bone bridging trabeculae could be seen crossing the SIJ on either oblique x-rays or by computed tomographic scan. Patients were followed-up for a mean of 52 months (range, 24–62 months). Visual Analog Scale (VAS) was used to monitor clinical pain improvement.
Results: Thirty-four patients with SIJ arthrodeses (89.5%) healed and led to substantial improvement in VAS pain scores (preoperative 9.1, postoperative 3.4) (P < .001). This improvement in VAS occurred over a 6-month period and was sustained through subsequent follow-up. Nonunion occurred in four patients with SIJ (10.5%). Each SIJ nonunion was successfully treated by secondary autogenous bone grafting and compression screw fixation.
Conclusions: In patients with primary low back pain attributable to the SIJ, a minimally invasive, dual fibular dowel graft provided high rates of fusion and improved pain scores.
PMCID: PMC3592760  PMID: 23532182
17.  Pelvic joint fusions in patients with chronic pelvic girdle pain: a 23-year follow-up 
European Spine Journal  2012;22(4):871-877.
Fusion of the sacroiliac joints (SIJ) has been a treatment option for patients with severe pelvic girdle pain (PGP). The primary aims were to evaluate the long-term outcomes in patients who underwent SIJ fusion and to compare 1-year outcomes with long-term outcomes. The secondary aim was to compare patients who underwent SIJ fusion with a comparable group who did not.
This study includes fifty patients that underwent SIJ fusion between 1977 and 1998. Function (the Oswestry disability index; ODI), pain intensity (visual analogue scale; VAS) and health-related quality of life (SF-36) were determined according to a patient-reported questionnaire. The questionnaire scores were compared with previously recorded 1-year outcomes and with questionnaire scores from a group of 28 patients who did not undergo SIJ fusion.
The patients who underwent SIJ fusion reported a mean ODI of 33 (95 % CI 24–42) and a mean VAS score of 54 (95 % CI 46–63) 23 years (range 19–34) after surgery. Regarding quality of life, the patients reported reduced physical function, but mental health was not affected in the same manner. The patients with successful 1-year outcomes (48 %) retained significantly improved function and reduced pain levels compared with the subgroup of patients with unsuccessful 1-year outcomes (28 %). The patients who underwent surgery did not differ from the non-surgery group in any outcome at the long-term follow-up.
Patients treated with SIJ fusion had moderate disability and pain 23 years after surgery, and the 1-year outcomes were sustained 23 years after surgery. Although many fused patients reported good outcome, this group did not differ from the comparable non-surgical group.
PMCID: PMC3631030  PMID: 23001416
Sacroiliac joint; Pelvic girdle pain; Long-term follow-up; Fusion; Arthrodesis
18.  Stabilization of the sacroiliac joint in vivo: verification of muscular contribution to force closure of the pelvis 
European Spine Journal  2004;13(3):199-205.
A model of sacroiliac joint (SIJ) function postulates that SIJ shear is prevented by friction, dynamically influenced by muscle force and ligament tension. Thus, SIJ stability can be accommodated to specific loading situations. The purpose of this study was to examine, in vivo, whether muscles contribute to force closure of the SIJ. SIJ stiffness was measured using a verified method combining color Doppler imaging with induced oscillation of the ilium relative to the sacrum in six healthy women. SIJ stiffness was measured both in a relaxed situation and during isometric voluntary contractions (electromyographically recorded). The biceps femoris, gluteus maximus, erector spinae, and contralateral latissimus dorsi were included in this study. Results were statistically analyzed. The study showed that SIJ stiffness significantly increased when the individual muscles were activated. This held especially true for activation of the erector spinae, the biceps femoris and the gluteus maximus muscles. During some tests significant co-contraction of other muscles occurred. The finding that SIJ stiffness increased even with slight muscle activity supports the notion that effectiveness of load transfer from spine to legs is improved when muscle forces actively compress the SIJ, preventing shear. When joints are manually tested, the influence of muscle activation patterns must be considered, since both inter- and intra-tester reliability of the test can be affected by muscle activity. In this respect, the relation between emotional states, muscle activity and joint stiffness deserves further exploration.
PMCID: PMC3468133  PMID: 14986072
Sacroiliac joint; Stabilization; Emotions; Doppler; Electromyography
Background and Purpose:
Sacroiliac joint dysfunction (SIJD) is a condition affecting 15–30% of patients with low back pain seen in outpatient clinics. Currently there is no well‐defined standard of care. The purpose of this case report is to discuss the multidisciplinary management between an athletic trainer and an optometrist for an athlete with bilateral SIJ dysfunction and a visual midline shift syndrome.
Case Description:
A 21‐year‐old collegiate baseball player reported to the athletic training room, presenting with low back pain of three day duration, with tenderness over both posterior superior iliac spines (PSIS) (left > right). His pain at its worse was a 7/10 on the Numeric Pain Scale (NPS). The pain increased to the point that it limited his activities of daily living (ADLs) including getting dressed, putting on his shoes, sleeping, and getting in and out of a car.
The athlete was initially treated using traditional muscle energy techniques (MET) based intervention to correct SIJD, and lumbar stabilization exercises directed by a licensed athletic trainer, as well as manipulation by a chiropractor. Three weeks of treatment did not prove to be beneficial with only a minimal (1 point on the NPRS) decrease in pain. The athlete was then referred to the head athletic trainer for consultation who prescribed orthotics, for bilateral rear‐foot valgus, and Postural Restoration (PR) therapeutic exercises. After two weeks of orthotic use and PR exercises the athlete’s pain decreased one additional point on the NPRS. Due to lack of progress, an optometrist was then consulted. The neuro‐optometrist prescribed 2 diopter base‐down prisms to be worn two hours a day, for four weeks. After four weeks of prisms and new exercises, the athlete was asymptomatic and returned to full pain‐free baseball participation without further complications.
The Oswestry Disability Index Questionnaire (ODI) was 48% at initial (severe disability), 40% at five weeks and 0% at discharge. The Numeric Pain Scale (NPS) score went from 7/10 to 0/10.
The athlete demonstrated only minimal relief of symptoms following MET, therapeutic exercises, and chiropractic manipulation. Intervention using prism glasses and PR exercises, designed to optimize posture and correct his visual midline shift syndrome, led to complete resolution of his symptoms.
Evidence Level:
PMCID: PMC3811731  PMID: 24175150
neuro‐optometry,; postural restoration,; prisms,; sacroiliac joint dysfunction
20.  Spondyloarthritis-related and degenerative MRI changes in the axial skeleton - an inter- and intra-observer agreement study 
The Back Pain Cohort of Southern Denmark (BaPa Cohort) was initiated with the aim of evaluating the clinical relevance of magnetic resonance imaging (MRI) in the diagnosis of early spondyloarthritis (SpA). In order to facilitate the collection of MRI data for this study, an electronic evaluation form was developed including both SpA-related and degenerative axial changes. The objective of the current study was to assess the intra- and inter-observer agreement of the MRI changes assessed.
Three radiologists evaluated 48 MRI scans of the whole spine and the sacroiliac joints from a subsample of the BaPa Cohort, consisting of patients with non-specific low back pain and patients with different stages of SpA features. The spine was evaluated for SpA-related and degenerative MRI changes and the SIJ for SpA-related changes. Inter- and intra-observer agreements were calculated with kappa statistics. In the interpretation of the kappa coefficient, the standards for strength of agreement reported by Landis and Koch were followed.
A total of 48 patients, 40% men and mean age of 31 years (range 18 – 40 years), were evaluated once by all three readers and re-evaluated by two of the readers after 4-12 weeks. For MRI changes in the spine, substantial to almost perfect observer agreement was found for the location and the size of vertebral signal changes and for disc degeneration and disc contour. For the sacroiliac joints, substantial or almost perfect observer agreement was found for the grading of bone marrow oedema and fatty marrow deposition, the depth of bone marrow oedema and for subchondral sclerosis. Global assessment of the SpA diagnosis had substantial to almost perfect observer agreements.
The acceptable agreement for key MRI changes in the spine and sacroiliac joints makes it possible to use these MRI changes in the BaPa Cohort study and other studies investigating MRI changes in patients with non-specific low back pain and suspected SpA.
PMCID: PMC3848902  PMID: 24060355
Agreement; Ankylosing spondylitis; Arthritis; Diagnosis; Kappa; Low back pain; Magnetic resonance imaging; Sacroiliac joint; Sacroiliitis; Spine; Spondyloarthropathy; Spondylarthritis
21.  Sagittal Sacropelvic Morphology and Balance in Patients with Sacroiliac Joint Pain Following Lumbar Fusion Surgery 
To investigate the sagittal sacropelvic morphology and balance of the patients with SIJ pain following lumbar fusion.
Among 452 patients who underwent posterior lumbar interbody fusion between June 2009 and January 2013, patients with postoperative SIJ pain, being responded to SIJ block were enrolled. For a control group, patients matched for sex, age group, the number of fused level and fusion to sacrum were randomly selected. Patients were assessed radiologic parameters including lumbar lordosis, pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS). To evaluate the sagittal sacropelvic morphology and balance, the ratio of PT/PI, SS/PI and PT/SS were analyzed.
A total of 28 patients with SIJ pain and 56 patients without SIJ pain were assessed. Postoperatively, SIJ pain group showed significantly greater PT (p=0.02) than non-SIJ pain group. Postoperatively, PT/PI and SS/PI in SIJ pain group was significantly greater and smaller than those in non-SIJ pain group respectively (p=0.03, 0.02, respectively) except for PT/SS (p=0.05). SIJ pain group did not show significant postoperative changes of PT/PI and SS/PI (p=0.09 and 0.08, respectively) while non-SIJ pain group showed significantly decrease of PT/PI (p=0.00) and increase of SS/PI (p=0.00).
This study presents different sagittal sacropelvic morphology and balance between the patients with/without SIJ pain following lumbar fusion surgery. The patients with SIJ pain showed retroversed pelvis and vertical sacrum while the patients without SIJ pain have similar morphologic features with asymptomatic populations in the literature.
PMCID: PMC3836926  PMID: 24278648
Sacroiliac joint pain; Lumbar fusion surgery; Sacropelvic morphology; Lumbopelvic parameters
22.  Management of a low back pain patient with a prosthesis and a foot drop orthotic 
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.
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.
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.
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
23.  Sacroiliac joint pain as an important element of psoriatic arthritis diagnosis 
Psoriatic arthritis (PsA) is a chronic inflammatory disease characterized by the coexistence of arthritis with psoriasis of the skin and nails. The sacroiliac joints were observed in 34-78% of patients with psoriatic arthritis. Due to such a high prevalence of SIJ dysfunction, understanding pathophysiology of pain and the associated pain pattern becomes a very important aspect of PsA diagnosis. As far as the etiology of SI joint dysfunction is concerned, it has not been disambiguated yet. Among the main causative factors, injuries and strains of the structures surrounding the joint are noted. Joint pathology usually manifests itself by pain occurring within the area of the joint. The causes of pain may be divided into two categories: intra-articular and extra-articular. Pain caused by the SI joint may be nociceptive or neural in nature, whereas the pain pattern characteristic of the joint correlates with its innervation and is consistent with S2 dorsal rami.
PMCID: PMC3834688  PMID: 24278057
sacroiliac joint; pain pattern; pathomechanism; psoriatic arthritis
24.  Pelvic joint fusion in patients with severe pelvic girdle pain – a prospective single-subject research design study 
The fusion of the pelvic joints in patients with severe pelvic girdle pain (PGP) is a controversial and insufficiently studied procedure. The aims of this study were to evaluate physical function and pain after sacroiliac joint (SIJ) fusion.
A single-subject research design study with repeated measurements was conducted; pre-operatively and at 3, 6 and 12 months post-operatively. The outcome measures considered were the Oswestry disability index (ODI), visual analogue scale (VAS), and SF-36. Eight patients with severe PGP received open-accessed unilateral anterior SIJ fusion and fusion of the pubic symphysis.
Seven patients reported positive results from the surgery. At 1 year post-operation, significant (p < 0.001) reductions in ODI (54 to 37) and VAS (82 to 57) were reported. The physical functioning, bodily pain, and social functioning scores in the SF-36 were also improved.
Positive and significant changes in disability and pain at 1 year after SIJ fusion were observed. Despite these positive results, open accessed anterior fusion of the SIJ was associated with adverse events and complications such as infection and nerve damage.
PMCID: PMC3995535  PMID: 24629145
Sacroiliac joint; Fusion; Pain; Arthrodesis; Surgery; Pelvic girdle pain
25.  Utilization of Minimally Invasive Surgical Approach for Sacroiliac Joint Fusion in Surgeon Population of ISASS and SMISS Membership 
The sacroiliac joint (SIJ) may be a source of chronic low back pain in 15 -22% of patients. Over the past four years MIS is an emerging standard of care for SI joint fusion. The International Society for the Advancement of Spine Surgery (ISASS) and Society for Minimally Invasive Spine Surgery (SMISS) conducted a survey of their members to examine current preferences in surgeon practice of MIS SI fusion.
To qualify for survey participation, the surgeon had to perform at least one open or MIS SIJ fusion procedure between 2009 and 2012. All surgeons were instructed to review their records. This included the number of surgical procedures performed annually from 2009-2012, site of service where each procedure was commonly performed, and average length of stay for each approach.
Twenty four percent (121/500) of the eligible members participated in this survey. This survey revealed that the percentage of MIS procedures increased from 39% in 2009 to over 87% in 2012. The survey showed a significant increase in average number of MIS surgeries and a significant difference between open and MIS surgeries in 2012 (p<0.0001). In addition, 80% of the survey respondents indicated a lack of preference toward open approach if that was the only available option.
According to performed survey, MIS SIJ fusion is preferred over open technique. Incorporation of the MIS technique into the spine surgeon's specter of skills would allow an increased number of surgical options as well as possible increase in outcome quality.
PMCID: PMC3924210  PMID: 24551025
Sacroiliac joint; Minimally invasive fusion; Sacroiliitis; Sacroiliac disruption.

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