Sacroiliac joint Pain and Osteoarthritis - An Update

       Sacroiliac joint Pain and Osteoarthritis - An Update

                                        Dr KS Dhillon

Introduction

The sacroiliac (SI) joint is the largest axial joint in the body. The anterior third is a diarthrodial synovial joint and rest of it is a syndesmosis, hence it is often referred to as a  diarthroamphiathrodial joint. There are multiple causes of SI joint pain but the cause of pain in most patient remains unknown. In 15% to 25% of patients with axial low back pain the SI joint is believed to be the cause of the pain. Osteoarthritis is probably the least common cause of SI joint pain. History, physical examination and radiological imaging are usually insufficient to diagnose SI joint pain. Small volume local anesthetic blocks are usually used to confirm that SI joint is the cause of pain but the validity of this test remains unproven. Though there are several invasive and non-invasive methods of treating SI joint pain, there is limited evidence of long term effectiveness of any of them. This review will outline the anatomy of the SI joint, the causes and prevalence of SI joint pain, as well as provide updates on the diagnosis and treatment of SI joint pain.

Anatomy of the sacroiliac (SI) joint

The sacroiliac joint is formed by the first three segment of the sacrum and the iliac bone. It is one of the largest axial joint in the body, with an average surface area of 17.5 cm2 [1]. It is an auricular-shaped (C-shaped), diarthrodial synovial joint where the sacral articular cartilage is hyaline and the iliac cartilage is fibrous [2]. The hyaline cartilage is replaced by fibrocartilage later in life. In reality only the anterior third of the joint is a synovial joint and the rest of the SI joint consists of ligamentous structures (interosseous sacroiliac ligament) which convert it into a syndesmosis. Hence some authors call it an amphiarthrodial or diarthroamphiathrodial joint [3]. The main part of the joint which connects the sacrum to the ilium is the posterior ligamentous structures which stabilise the joint and prevents movements in all planes. In women these ligaments are weaker which allows the mobility that is necessary for parturition [4].

Stability to the joint is conferred by the irregular articular surfaces and the the ligaments around the joint. These include the anterior, posterior and interosseous sacroiliac ligaments; iliolumbar, sacrotuberous and sacrospinous ligaments [5].

Besides the configuration of the joint and the ligaments, the latissimus dorsi via the thoracolumbar fascia, the gluteus maximus, and the piriformis also influence the movements and stability of the SI joint [6,7].

The nerve supply of the SI joint is a contentious issue. The information is sparse and variable. The Gray’s anatomy text makes no mention of it.
Solonen’s collection of data from past studies showed that the innervation is by branches from the lumbosacral plexus, superior gluteal nerve, dorsal rami of S1 and S2, and obturator nerve [3]. Cunningham’s Textbook of Anatomy on the other hand states that, “The sacroiliac joint is supplied: (1) by twigs directly from the sacral plexus and the dorsal ramus of the first two sacral nerves; and (2) by branches from the superior gluteal and obturator nerves” [2].

Nagakawa [8] reported that the SI joint innervation is by nerve filaments which are derived from the the ventral rami of L4 and L5, the superior gluteal nerve, and also from the dorsal rami of L5, S1, and S2.

Grob et al [9] found that the innervation of the SI joint is almost exclusively derived from the sacral dorsal rami.
There is a widely held belief that there are no movements at the SI joints but studies, however, show that there is  screw-axis motion of simultaneous sagittal plane rotation and translation at the joints [10,11]. The joint apparently fuses after the age 50 years [5,12].

A loss of SI joint synovial cavity and adhesion formation has been reported in both sexes. Sashin [13] concluded that the SI joints remain diarthrodial until the mid-adult years, and then motion progressively decreases. His conclusions were based on 257 postmortem examinations. He found that there was sacroiliac osteophyte formation in 85 percent of the males and 50 percent of the females, in individuals aged between 40 to 49 years. One hundred percent of the males aged between 50 to 59 years had osteophyte formation and in 60 percent of the individuals there was sacroiliac joint ankylosis.

Degenerative Sacroiliac Joint disease

The prevalence of abnormalities of the sacroiliac (SI) joint in the population remains unresolved [14]. O'Shea et al [14] studied the radiographic prevalence of SI joint abnormalities in patients with low back pain. Their cohort included 315 (173 men, 142 women) patients with age ranging from 18 – 60 years. Of the 315 patients, 100 (31.7%) had radiographic abnormalities of the SI joint. Possible degenerative changes were seen in 17 (male 8, female 9) patients (5.4%) and definite degenerative changes were seen in 56 (male 15, female 41) patients (17.7%). Twenty five (7.9%) had radiographic evidence of inflammatory disease of the SI joint. Two women had radiographic evidence of Osteitis condensans ilii. Degenerative changes were predominantly seen in women (68%) and inflammatory were predominantly seen in men (63%). In women, the authors found no correlation between degenerative SI joint abnormalities and degenerative changes in the lumbar spine. They also found a poor correlation between radiographic changes and symptoms.

Hodge and Bessette [15] retrospectively review 64 lower lumbar spine CT scans performed in patients with low back pain. The scans were of 29 women and 35 men, with a mean age 52 years. They evaluated the SI joint for osteoarthritic changes and they found that 16 SI joints (25%) were normal. In 48 cases (75%), there was evidence of osteoarthritis. In 8 cases (16%) there was some disagreement between the two readers but a consensus diagnosis of osteoarthritis was made.

Degenerative changes in the sacroiliac joint has been demonstrated pathologically in cadavers less than 30 years of age [16,17,18]. Pathologic abnormalities, however, become prominent in middle aged and elderly patients and usually involve the ilium. These changes include fibrillation of the cartilage and erosion with sloughing and denudation of cartilaginous surfaces. Subchondral eburnation and osteophytes become obvious. A   partial or complete fibrous ankylosis of the joint cavity occurs [16,17].

On radiographs of the SI joint the joint space in young adults is between 2-5 mm. A reduction of joint space between sacrum and ilium is common in patients over the age of 40 years and thereafter it increases in frequency [18]. Subchondral sclerosis and osteophytes are often present. The osteophytes may completely or partially bridge the joint. In the elderly, the incidence of complete bony ankylosis, which occurs by fusion of the osteophytes, varies between 20% to greater than 80% [16,17,18]. Focal calcification and ossification of the ligaments may occasionally be seen [19].

Prevalence of sacroiliac Joint Pain

Dysfunctional SI joints are known to cause low back pain. The prevalence of back pain due to SI joint dysfunction has not been well studied. The earlier studies used means that are not so reliable to make a diagnosis of SI joint pain. They used physical examination findings and/or radiological imaging to make the diagnosis of SI joint pain. One such large study was conducted by Bernard and Kirkaldy-Willis [20]. They found a prevalence rate of 22.5% in 1293 adult patients who presented with LBP. Their diagnoses was  predominantly based on physical examination.

Schwarzer et al [21] used fluoroscopically guided local anesthetic SI joint injections to diagnose SI joint pain.They found a 30% prevalence rate using the local anesthetic injections.
Maigne et al [22] conducted a prevalence study in 54 patients with unilateral LBP using a local anesthetic injections into the SI joint. They found a prevalence rate of 18.5%.

Etiologies of SI joint pain

The cause of SI joint pain can be intraarticular or extraarticular. Extraarticular sources are more common and include enthesopathy, fractures, ligamentous injury, and myofascial pain. Intraarticular sources of pain include arthritis and infection.

There are numerous predisposing risk factors for SI joint pain and these include, true and apparent leg length discrepancy, gait abnormalities, prolonged vigorous exercise, scoliosis, and spinal fusion to the sacrum [4].

These factors increase the risk by increasing the stress across the SI joint.
Arthritis including spondyloarthropathies and osteoarthritis can be one of the sources of the pain in the low back.

Diagnosis of SI joint pain

Physical examination

Diagnosis of SI joint pain is difficult and complex. There are dozens of physical examination tests available to diagnose such pain but none of them are of much value. The two most widely used tests tests are the Patrick’s  and Gaenslen’s  distraction tests. Clinical studies show that neither a medical history nor physical findings are consistently able to identify the SI joint as the source of pain [21,23,24]. In fact Dreyfuss et al. [25] found a 20% incidence of asymptomatic adults having positive findings on 3 commonly performed SI joint provocation tests.

Radiological examination

Studies examining radiologic findings in patients with SI joint pain have not lived up to expectation either. Maigne et al [26] and Slipman et al [27],
found sensitivities of 46% and 13% respectively for the diagnosis of SI joint pain with the use of radionuclide bone scanning. The low sensitivities indicate that bone scanning is a poor screening test for SI joint pain.The  correlation between diagnostic injections and symptoms with CT and radiographic stereophotogrammetry has also been found to be poor [28,29]. Elgafy et al [29] in a retrospective analysis found that CT imaging had a 57.5% sensitivity and 69% specificity in diagnosing SI joint pain.

Diagnostic Blocks

Pain relief after properly performed local anesthetic block of the SI joint is usually referred to as the most reliable test for diagnosing SI joint pain.

The validity of this assumption has, however, never been proven. Several factors affect the sensitivity and specificity of this test. These include ‘ the placebo effect, convergence and referred pain, neuroplasticity and central sensitization, expectation bias, unintentional sympathetic blockade, systemic absorption of LA, and psychosocial issues’ [4]. Furthermore obtaining a satisfactory SI joint block is very challenging. Extravasation of the local anesthetic (LA) into the surrounding pain generating structures can give false-positive blocks and failure to get adequate spread of the LA in the SI joint can produce false negative blocks.

North et al [30] did a randomized prospective study of 33 patients with sciatica due to lumbosacral spine disease. They found that the specificity of all blocks wa exceedingly low. For sciatic nerve blocks, the specificity was only between 24% and 36%. They however did not study blocks for the SI joint.

SI joints injections are difficult and can be associated with significant complications. Fortin et al [31] found extravasation of contrast in 9 out 10 volunteers who had SI joint injections for SI joint referral patterns mapping. Forty percent of the subjects had lower extremity numbness after LA injections which indicates inadvertent anesthetization of the lumbosacral nerve roots.
In a study by Maigne et al [22] 3 out 67 patients who had SI joint injections developed sciatic palsy and in 7 other patients penetration of the joint was not possible. Other investigators have reported a less than 5% failure rates with fluoroscopically guided SI joint injections [21,24,32]. There apparently is ‘no infallible, universally accepted method for diagnosing pain originating in the SI joint(s)’ [4].

Treatment of SI joint pain.

Sacroiliac joint is an uncommon source of low back pain [22] and OA of the SI joint is an uncommon cause of SI joint pain. Just as it is difficult to diagnose SI joint pain, similarly it is difficult to treat SI joint pain. The treatment can either be symptomatic or involve treating the underlying cause. There are a wide variety of treatments available for treating SI joint pain but there is a lack controlled outcome studies to guide treatment.

Psychosocial Issues

More and more evidence is becoming available to show that psychogenic syndromes play an important role not only in the genesis of low back pain but also in its treatment.
Polatin et al [33] studied 200 patients with chronic low back pain and they found that 77% of the patients met the lifetime diagnostic criteria for psychiatric illness. Fifty nine percent of the patients showed current symptoms for least one psychiatric diagnosis, with the most common being depression, substance abuse, and anxiety disorders. In more than 50% of the patients with depression and in more than 90% of the patients with anxiety disorder (95%) and substance abuse (94%) had psychopathological symptoms before the onset of back pain. Most of the studies, though not all, have reported that untreated psychopathology has a negative effect on the outcome of treatment of low back pain [34].

Besides psychiatric illness, social factors also have a role to play in the prognosis of low back pain. These include ‘return-to-work decisions, medication use issues, ….. negative environmental factors, codependency issues, secondary gains and their impact, presence of pain games, negatively acting financial considerations,.... presence of poor role models, impact of pain on general functioning, and the patient's future plans’ [35].

A multidisciplinary approach which identifies and treats concomitant psychosocial issues will have a better outcome in treatment of patients with SI joint pain.

Conservative management

There is a dearth of literature on the conservative management of SI joint pain. The principles of treatment of low back pain would apply to SI joint pain. The role of NSAIDs in the treatment of acute low back pain has been well established [36]. The use of NSAIDs and relative rest during the acute phase, along with application of cold compresses or hot packs can help relieve the pain.

Once the acute phase is over function can improve with therapeutic exercises and physical therapy [37]. The aim of the therapy would include  increasing mobility, stretching, strengthening, and correcting of asymmetries and correction hyperactivity of muscle groups.

High-velocity low-amplitude (HVLA) manipulation of the SIJ and spine has been used for the treatment of SI joint with some success [38]. Other modalities that have used in the treatment of SI joint pain include, ultrasound, diathermy, moist heat or cold, and TENS (transcutaneous electrical nerve stimulation) [39]. Stabilization of the SI joint with a compression belt has been used by some to treat pain in patient with SIJ dysfunction [40].

Injection therapy

Whenever a decision to undertake interventional treatment is taken, it is important to have sufficient clinical evidence to support the diagnosis and sufficient evidence to support the type of treatment to be undertaken. The source of pain whether intra or extra articular must be known. In patients with pain due to arthritis the source of pain would likely be intraarticular. SI joint injections have been shown to have some efficacy in treatment of SI joint pain, though the evidence is not overwhelming.
Most of the studies which support the use intraarticular steroid injections are observational studies [41-44].

There is a randomized controlled study, with a small patient population and short follow up, which studied the use intraarticular steroids. Maugers et al [45] performed a double-blind study in 10 patients (13 articulations) who had painful sacroiliitis. At 1 month follow up they found that 5 of the 6 joints injected with corticosteroids showed a pain relief of more than 70% and there was no pain relief in the placebo group. There was relapse of pain in one patient who had an injection of steroid. Six SI joints in the placebo group and two patients with failure and relapse of the corticosteroid group were reinjected with corticosteroid. At 3 and 6 months, success rates declined to 62 and 58%, respectively.

Systematic review of evidence for the effectiveness of intra-articular injections for SI joint pain shows that there is limited evidence of long term effectiveness [47,48].

Radiofrequency denervation

Radiofrequency denervation procedures have been used for pain relief from SIJ dysfunction.The innervation and target nerves for radiofrequency denervation (RFD) of the SIJ remain unclear. Radiofrequency denervation involves the use of radiofrequency (RF) to ablate the lateral branch nerves that innervate the SI joint. The lateral branch RF denervation is usually effective in alleviating extraarticular SIJ pain rather than intraarticular pain. Hence it is effective in younger patients who are more likely to have extra articular pathology in the ligaments which are innervated by the lateral branches [49].

There are controlled and uncontrolled studies that have demonstrated benefits of RF denervation, but none have compared RF denervation to more conservative therapy. Patient who have obtained effective but short term relief with SI joint block are the best candidates for SIJ denervation.
Vallejo et al [50] carried out a prospective case series in 22 patients with refractory sacroiliac pain who received pulsed radiofrequency denervation of the medial branch of L4, posterior primary rami of L5, and lateral branches S1 and S2. Sixteen patients (72.7%) experienced good to excellent pain relief following PRFD. The duration of pain relief was 6-9 weeks in four patients, 10-16 weeks in five patients, and 17-32 weeks in seven patients. Six patients (26.1%) did not respond to PRFD and had less than 50% reduction in VAS and were considered failures.

Ferrante et al. [51] carried out a prospective study where intra-articular RF ablation was carried out in 50 SI joint in 33 patients. The outcome was measured using visual analog scale (VAS), physical examination findings, pain diagrams, and opioid usage. A successful RF ablation was defined as a 50 % reduction in SIJ pain for more than 6 months, and only 36.4 % of subjects met the criteria. A positive response was found to be associated with an atraumatic inciting event.
Burnham and Yasui [52] carried out an uncontrolled, prospective, cohort study of 9 patients with SI joint pain who had RF ablation of the SI joint.

The subjects were asked to answer questionnaires which evaluated pain intensity and frequency, analgesic intake, disability, satisfaction with current pain level and the RF procedure. They found that 8 of the 9 subjects were satisfied with the procedure.

Cohen et al [53] carried out a randomized placebo-controlled study in 28 patients with injection-diagnosed sacroiliac joint pain. Fourteen patients received L4-L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation using cooling-probe technology and 14 patients had placebo denervation. At one month follow up 79% in the denervation group and 14% in the placebo group had significant pain relief (i.e relief of 50% and more). At 8 months only 57% of the denervation group had significant pain relief and at 1 year only 2 patients (14%) in the treatment group continued to demonstrate persistent pain relief.

Hansen et al [54] carried out a systematic review of the literature in 2007 of the therapeutic sacroiliac joint interventions in the management of sacroiliac joint pain. They found that ‘there is limited evidence for short-term and long-term relief with intraarticular sacroiliac joint injections and radiofrequency thermoneurolysis’.

Rupert et al [55] in 2009 did a systematic appraisal of literature which evaluated SI joint interventions. They found that the indicated evidence for radiofrequency neurotomy of the SI joint is limited at Level II-3 for short-term (less than 6 months) and long-term relief (more than 6 months).
RF ablation can be associated with complications.  RF ablation can be associated with postprocedure numbness and tingling in about 20% of the patient  due to severing of cutaneous sensory branches. Bleeding and infection can occur after the procedure. Accidental ablation of the sacral spinal nerves can lead to incontinence, worsening pain or lower extremity weakness.

McKenzie-Brown et al [47] carried a systematic review of the effectiveness sacroiliac joint interventions in the treatment of SIJ pain. They found 4 relevant reports, one was prospective and three were retrospective. They found that the evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain was limited.

Hansen et al [48] in systematic review of the literature also found that the evidence for the use of RF ablation in the treatment of SIJ pain is limited.

Surgical intervention for SIJ pain

Buchowski et al [56] reported the functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint. Twenty patients had SI joint arthrodesis for sacroiliac symptoms which were due to sacroiliac joint dysfunction (13 patients), osteoarthritis (5 patients), and spondyloarthropathy and sacroiliac joint instability (1 each). There was solid fusion in seventeen patients (85%). Only fifteen patients (75%) completed preoperative and postoperative SF-36 forms. Significant  improvement occurred in the physical functioning, bodily pain, vitality, social functioning, and in the neurogenic and pain indices.

Schütz and Grob [57] carried out a retrospective study in 17 patients with chronic SI joint syndrome who had a bilateral SI joint fusion. All the patients had positive response to local anesthetic block.The indication for SI joint fusion was chronic SI joint syndrome due to posttraumatic (5 patients) or idiopathic (12 patients) SI joint degeneration. Eighty two percent of the patients were dissatisfied with the procedure and 65% of the patients required reoperation.

Waisbrod et al [58] retrospectively reviewed 22 SI joint arthrodesis in patients with OA of the SI joint. The review was at between 12 and 55 months follow up. The outcome was defined as satisfactory, if there was at least 50% reduction of pain,no need for analgesics, and the patient continued with the same occupation as before the surgery. They found the the outcome was satisfactory in only 50% of the patients. After excluding patients with psychosomatic pain, the authors said that there was a 70% success rate.

Wise and Dall [59] reported the outcome of minimally invasive sacroiliac arthrodesis in 13 patient. Six of the patients had a bilateral fusion (total 19 joints). The follow up was between between 24 months to 35 months (mean 29.5 months). They had an overall fusion rate of 89% (17/19 joints).
On the average there was an improvement of 4.9 in the visual analog scale. The leg pain improved an average of 2.4 points and dyspareunia improved an average of 2.6 points on the visual analog scale.
Zaidi et al [60] did a systematic review of the literature to access the surgical and clinical efficacy of sacroiliac joint fusion. They reviewed a total of 16 peer-reviewed journal articles. There were 5 consecutive case series, 8 retrospective studies, and 3 prospective cohort studies with a total of 430 patients. One hundred and thirty one underwent open surgery and 299 underwent minimally invasive surgery (MIS) for SIJ fusion. The mean follow-up for open surgery was 60 months and for MIS it was 21 months. The underlying pathology in these patients was:

• SIJ degeneration/arthrosis  in 257 patients [59.8%]
• SIJ dysfunction 79 patients [18.4%]
• Postpartum instability 31 patients [7.2%]
• Posttraumatic 28 patients [6.5%]
• Idiopathic 25 patients [5.8%]
• Pathological fractures 6 [1.4%]
• HLA-B27+/rheumatoid arthritis 4 patients [0.9%]

The radiographically confirmed fusion rates for open surgery were between  20%-90% and for MIS between 13%-100%. Rates of excellent satisfaction, as determined by pain reduction, function, and quality of life, in patient with open surgery ranged from 18% to 100% with a mean of 54%. For patients who had MIS, an excellent outcome as judged by patients' stated satisfaction with the surgery, ranged from 56% to 100% with a mean of mean 84%. The reoperation rate after open surgery ranged from 0% to 65% with a mean of 15% whereas with MIS the reoperation rates varied from 0% to 17% with a mean of 6%. Major complication rates were high and ranged from 5% to 20%. A study which addressed safety reported a 56% adverse event rate.

The authors concluded that surgical intervention for SIJ pain may be beneficial in a subset of patients but keeping in mind the difficulty in making an accurate diagnosis and the fact that the evidence for the efficacy of SIJ fusion is lacking, serious consideration should be given to alternative treatments before considering a fusion of the SI joint.

Conclusions

The SI joint is a complex diarthroamphiathrodial joint. SI joint is believed to be the source of pain in 15% to 25% of patients with axial low back pain. Clinical presentation is usually nonspecific and physical examination maneuvers have little or no diagnostic value. Radiological investigations have low diagnostic sensitivity and specificity. Pain relief after properly performed local anesthetic block of the SI joint is usually referred to as the most reliable test (gold standard) for diagnosing SI joint pain. The validity of this assumption has, however, never been proven. Of the many treatment options such as activity modification, physical therapy modalities, orthosis, manipulation, injections, radiofrequency procedures, and surgery, none have stood the test of time. Treatment has to be tailored to the individual patient and treating patients with SIJ pain will continue to remain a challenge.

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