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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.
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
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.  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.
doi:10.1007/s10439-007-9385-8
PMCID: PMC2239251  PMID: 18204902
Static forces; Sacroiliac joints; Pelvis; Pelvic floor muscles; Human posture
4.  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.
doi:10.1007/s00586-003-0575-2
PMCID: PMC3468133  PMID: 14986072
Sacroiliac joint; Stabilization; Emotions; Doppler; Electromyography
5.  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.
doi:10.1055/s-0032-1327806
PMCID: PMC3592760  PMID: 23532182
6.  Sciatica-like symptoms and the sacroiliac joint: clinical features and differential diagnosis 
European Spine Journal  2013;22(7):1657-1664.
Purpose
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1007/s00586-013-2660-5
PMCID: PMC3698344  PMID: 23455949
Sacroiliac joint; Leg pain; Sciatica; Lumbar disk; Differential diagnosis
7.  Outcome of distraction interference arthrodesis of the sacroiliac joint for sacroiliac arthritis 
Indian Journal of Orthopaedics  2013;47(5):437-442.
Background:
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.
Results:
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.
Conclusions:
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.
doi:10.4103/0019-5413.118197
PMCID: PMC3796914  PMID: 24133301
Arthrodesis; distraction; interference; recesses; sacroiliac joint
8.  Sacroiliac joint pain: burden of disease 
Objectives
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.2147/MDER.S59437
PMCID: PMC3990391  PMID: 24748825
sacroiliac joint fusion; chronic lower back pain; quality of life; utility assessment; comparative assessments
9.  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
10.  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.
Introduction
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/ar3854
PMCID: PMC3446505  PMID: 22626458
11.  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.
doi:10.1007/s00586-012-2350-8
PMCID: PMC3459112  PMID: 22581257
Sacroiliac joint pain; Lumbosacral fusion; Lumbar fusion; Pathophysiology
12.  Metabolic disturbances identified by SPECT-CT in patients with a clinical diagnosis of sacroiliac joint incompetence 
European Spine Journal  2013;22(7):1674-1682.
Purpose
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1007/s00586-013-2725-5
PMCID: PMC3698330  PMID: 23455953
Sacroiliac joint; SPECT/CT; Sacroiliac joint incompetence; Pain provocation tests; Pain palpation tests
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.
doi:10.1007/s00586-007-0391-1
PMCID: PMC2078309  PMID: 17566796
Systematic review; Low back pain; Diagnosis
14.  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.
doi:10.1007/s005860050107
PMCID: PMC3611293  PMID: 9883953
Key words Lumbar disc herniation; Sacroiliac joint dysfunction; Manual therapy
15.  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.
Introduction
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/ar4548
PMCID: PMC4060567  PMID: 24755322
16.  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
17.  Sagittal Sacropelvic Morphology and Balance in Patients with Sacroiliac Joint Pain Following Lumbar Fusion Surgery 
Objective
To investigate the sagittal sacropelvic morphology and balance of the patients with SIJ pain following lumbar fusion.
Methods
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.
Results
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).
Conclusion
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.
doi:10.3340/jkns.2013.54.3.201
PMCID: PMC3836926  PMID: 24278648
Sacroiliac joint pain; Lumbar fusion surgery; Sacropelvic morphology; Lumbopelvic parameters
18.  Pelvic joint fusions in patients with chronic pelvic girdle pain: a 23-year follow-up 
European Spine Journal  2012;22(4):871-877.
Purpose
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1007/s00586-012-2512-8
PMCID: PMC3631030  PMID: 23001416
Sacroiliac joint; Pelvic girdle pain; Long-term follow-up; Fusion; Arthrodesis
19.  What is the source of low back pain? 
Aims:
Determining the source of low back pain (LBP) is still controversial. This study was designed to determine the source of LBP and its relations with age and gender.
Settings and Design:
A retrospective chart review at Isfahan University of Medical Sciences, Isfahan, Iran.
Materials and Methods:
A total of 1,125 patients were evaluated to determine the sources of their LBP with physical examinations, imaging, injections, and other laboratory examinations, if needed. The patients were divided into five groups based on their ages. Frequencies of the sources of pain were assessed in the five age groups, and the assessments were done separately by gender.
Statistical Analysis Used:
Independent t-test, analysis of variance (ANOVA), chi-square test.
Results:
The patients enrolled in this study consisted of 527 males (46.8%) and 598 females (53.2%). The frequencies of the sources of pain were, in descending order, spine (689, 61.2%), no cause found (163, 14.5%), spine with sacroiliac joint (SIJ) (72, 6.4%), spine with hip (65, 5.8%), SIJ (60, 5.3%), hip (44, 3.9%), spine along with hip and SIJ (20, 1.8%), hip with SIJ (8, 0.7%), and other diseases (4, 0.4%). There were significant statistical differences between the genders and mean ages for different sources (P = 0.03 and 0.000, respectively).
Conclusions:
This study showed that the spine was the main source of LBP in all age groups. Physicians should always be alert for other sources in middle-aged and older patients. Future studies with long-term follow-up for determining the benefits of treatments are warranted.
doi:10.4103/0974-8237.121620
PMCID: PMC3872656  PMID: 24381452
Etiology; low back pain; source; spine
20.  High bone turnover assessed by 18F-fluoride PET/CT in the spine and sacroiliac joints of patients with ankylosing spondylitis: comparison with inflammatory lesions detected by whole body MRI 
EJNMMI Research  2012;2:38.
Background
This study compares the frequency and distribution of increased activity on 18 F-fluoride PET/CT with the presence of bone marrow edema on whole-body MR imaging in the spine and sacroiliac joints (SIJ) of patients with active ankylosing spondylitis (AS).
Methods
Ten patients (6 men and 4 women), between 30 and 58 years old (median 44) with active AS, were prospectively examined with both whole-body MRI and 18 F-fluoride PET/CT. Patients fulfilled modified NY criteria and had a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of at least 4. Increased radiotracer uptake in PET/CT and bone marrow edema in whole-body MRI of spine and SIJ was evaluated independently by two blinded observers for each modality. Kappa statistics were used to compare interobserver agreement as well as scores of consensus reading of the two imaging modalities.
Results
Analysis of interobserver agreement for PET/CT yielded a kappa value of 0.68 for spinal lesions and of 0.88 for SIJ lesions. The corresponding kappa values for the MRI modality were 0.64 and 0.93, respectively. More spinal lesions were detected by MRI in comparison to PET/CT (68 vs. 38), whereas a similar number of SIJ quadrants scored positive in both modalities (19 vs. 17). Analysis of agreement of lesion detection between both imaging modalities yielded a kappa value of only 0.25 for spinal lesions and of 0.64 for SIJ lesions.
Conclusion
Increased 18 F-fluoride uptake in PET/CT is only modestly associated with bone marrow edema on MRI in the spine and SIJ of patients with AS, suggesting different aspects of bone involvement in AS.
doi:10.1186/2191-219X-2-38
PMCID: PMC3472173  PMID: 22788874
18F-fluoride PET/CT; Whole-body MRI; Ankylosing spondylitis; Syndesmophytes; Inflammation
21.  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.
doi:10.1179/106698110X12804993426848
PMCID: PMC3172951  PMID: 22294848
Low back pain; Sacroiliac joint; Hamstring muscle length; Gluteal muscle weakness; Pelvic dysfunction; Muscle imbalance
22.  A manual therapy and exercise approach to meralgia paresthetica in pregnancy: a case report 
Abstract
Objective
To present a case of a pregnant patient with meralgia paresthetica who improved using manual therapy and exercise procedures.
Clinical Features
A 22-year-old patient in the sixteenth week of pregnancy had low back pain, bilateral anterolateral thigh paresthesia and groin pain for a duration of 1 month. She had no motor deficits in either lower extremity and her reflexes were intact. As a standard clinic procedure, a battery of functional tests were performed including: active straight leg raise, long dorsal ligament test, and the pelvic pain provocation procedure. Based on her clinical history and physical responses to the aforementioned functional tests, the diagnosis of meralgia paresthetica was deduced.
Intervention and Outcome
Treatment was provided at 6 visits over a 6-week period where the patient underwent evaluation, manual intervention, and exercise prescription. Active Release Technique (ART) was performed to the restricted right sacroiliac (SIJ) complex and quadratus lumborum muscles. ART and post-isometric relaxation were applied to the illiopsoas muscles. The home exercise program consisted of pelvic/low back mobility, stabilization and relaxation exercises. After 6 treatments, the patient reported complete resolution of low back pain and left lower extremity symptoms and a 90% improvement in the right thigh symptoms. At her one-year follow-up, the patient reported no further complications and the absence of pain.
Conclusions
Manual therapy and exercises may serve as an effective treatment protocol for pregnant patients experiencing low back pain complicated by paresthesia. Because these conservative procedures offer a low-risk intervention, additional clinical studies are warranted to further study this treatment.
doi:10.1016/S0899-3467(07)60140-2
PMCID: PMC2647064  PMID: 19674679
Pregnancy; Pelvic Pain; Meralgia Paresthetica
23.  Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial 
European Spine Journal  2013;22(10):2310-2317.
Purpose
The sacroiliac joint (SIJ) may be a cause of sciatica. The aim of this study was to assess which treatment is successful for SIJ-related back and leg pain.
Methods
Using a single-blinded randomised trial, we assessed the short-term therapeutic efficacy of physiotherapy, manual therapy, and intra-articular injection with local corticosteroids in the SIJ in 51 patients with SIJ-related leg pain. The effect of the treatment was evaluated after 6 and 12 weeks.
Results
Of the 51 patients, 25 (56 %) were successfully treated. Physiotherapy was successful in 3 out of 15 patients (20 %), manual therapy in 13 of the 18 (72 %), and intra-articular injection in 9 of 18 (50 %) patients (p = 0.01). Manual therapy had a significantly better success rate than physiotherapy (p = 0.003).
Conclusion
In this small single-blinded prospective study, manual therapy appeared to be the choice of treatment for patients with SIJ-related leg pain. A second choice of treatment to be considered is an intra-articular injection.
Electronic supplementary material
The online version of this article (doi:10.1007/s00586-013-2833-2) contains supplementary material, which is available to authorized users.
doi:10.1007/s00586-013-2833-2
PMCID: PMC3804708  PMID: 23720124
Sacroiliac joint;  Treatment;  Manual therapy;  Physiotherapy;  Injection
24.  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
25.  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

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