A systematic review of sacroiliac joint interventions

Pain Physician. Physician. 2005;8:115-125, ISSN 1533-3159 A Systematic Review A Systematic Review of Sacroiliac Joint Interventions Anne Marie McKenzie-Brown, MD, Rinoo V. Shah, MD, Nalini Sehgal, MD, and Clifford R. Everett, MD Background: The sacroiliac joint is an accepted source of low back pain with or without associated lower extremity symptoms. The diagnosis and management of sacroiliac joint pain and the role of interventional techniques have been controversial. Objective: To evaluate the clinical usefulness of sacroiliac joint interventions in the diagnosis and management of sacroiliac joint pain. Study Design: A systematic review using the criteria as outlined by the Agency for Healthcare Research and Quality (AHRQ), Cochrane Review Group Criteria, and QUADAS criteria for diagnostic studies. Methods: The databases of EMBASE and MEDLINE (1966 to November 2004), and Cochrane Review were searched. The search- es included systematic reviews, narrative reviews, prospective and retrospective studies, and cross-references from articles reviewed. The search strategy included sacroiliac joint pain and dysfunction, sacroiliac joint injections, interventions, and radiofrequency. Results: The results of this systematic evaluation showed that for diagnostic purposes, there is moderate evidence showing the accuracy of comparative, controlled local anesthetic blocks. Prevalence of sacroiliac joint pain was demonstrated to be 10% to 19% by a double block paradigm. The falsepositive rate of single, uncontrolled, sacroiliac joint injections was reported as 20%. For therapeutic purposes intraarticular sacroiliac joint injections with steroid and radiofrequency neurotomy were evaluat- ed. Based on this review, there was moderate evidence for short-term and limited evidence for long-term relief with intraarticular sacroiliac joint injections. Evidence for radiofrequency neurotomy in managing sacroiliac joint pain was limited or inconclusive. Conclusions: The evidence for the speciicity and validity of diagnostic sacroiliac joint injections was moderate. The evidence for therapeutic intraarticular sacroiliac joint injections was limited to moderate. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain was limited. Keywords: Low back pain, sacroiliac joint pain, axial pain, spinal pain, diagnostic block, and sacroiliac joint injection Descriptions฀of฀the฀sacroiliac฀joint฀as฀ a฀source฀of฀low฀back฀pain฀date฀back฀to฀the฀ early฀ 1900’s.฀ ฀ It฀ was฀ not฀ until฀ after฀ 1934,฀ when฀Mixter฀and฀Barr฀(1)฀described฀disc฀ herniation฀ as฀ another฀ source฀ of฀ pain฀ in฀ the฀lumbar฀spine,฀that฀it’s฀prominence฀as฀ a฀major฀source฀of฀back฀pain฀declined฀(24).฀ Until฀ recently,฀ the฀ evidence฀ for฀ the฀ sacroiliac฀ joint฀ as฀ a฀ pain฀ generator฀ had฀ been฀ only฀ empirical,฀ derived฀ from฀ successful฀ treatment฀ of฀ patients฀ with฀ sacroiliac฀joint฀pain฀with฀certain฀clinical฀symptoms฀and฀physical฀findings฀(5).฀฀The฀sacroiliac฀joint฀is฀unable฀to฀function฀in฀isolation;฀anatomically฀and฀biomechanically฀it฀ shares฀all฀of฀its฀muscles฀with฀the฀hip฀joint.฀฀ Ligamentous฀ structures฀ and฀ the฀ muscles฀ they฀ support฀ affect฀ much฀ of฀ the฀ stability฀ of฀the฀sacroiliac฀joint.฀฀These฀include฀the฀ very฀strong฀interosseous฀ligaments฀as฀well฀ as฀ the฀ iliolumbar,฀ sacrotuberous฀ and฀ sacrospinous฀ ligaments.฀ ฀ The฀ result฀ is฀ very฀ limited฀motion฀of฀the฀sacroiliac฀joint฀under฀normal฀circumstances.฀฀The฀sacroiliac฀ joint฀is฀also฀closely฀associated฀with฀the฀piriformis,฀gluteus,฀erector฀spinae,฀and฀quadratus฀lumborum฀muscles฀(4,฀6).฀฀Sacroiliac฀ joint฀ pain฀ may฀ be฀ the฀ result฀ of฀ direct฀ trauma,฀ unidirectional฀ pelvic฀ shear,฀ repetitive฀ and฀ torsional฀ forces.฀ ฀ Chou฀ et฀ al฀ (7),฀ after฀ looking฀ retrospectively฀ at฀ 54฀ patients฀ with฀ sacroiliac฀ joint฀ pain,฀ found฀ that฀trauma฀(44%)฀and฀cumulative฀or฀repetitive฀injury฀(21%)฀were฀inciting฀events฀ for฀ the฀ development฀ of฀ sacroiliac฀ joint฀ pain฀ and฀ that฀ 35%฀ of฀ patients฀ had฀ idiopathic฀or฀spontaneous฀onset฀of฀their฀pain.฀ Of฀those฀with฀idiopathic฀or฀spontaneous฀ etiologies฀ for฀ their฀ sacroiliac฀ joint฀ pain,฀ greater฀ than฀ 50%฀ of฀ patients฀ had฀ prior฀ lumbar฀surgery.฀ The฀sacroiliac฀joint฀is฀a฀diarthrodial฀ joint.฀฀The฀sacroiliac฀joint฀receives฀innervation฀ from฀ the฀ lumbosacral฀ nerve฀ roots฀ (8-13).฀฀Fortin฀et฀al฀(9),฀based฀on฀an฀anatomic฀study฀on฀adult฀cadavers,฀concluded฀ that฀the฀sacroiliac฀joint฀is฀predominantly,฀ if฀not฀entirely,฀innervated฀by฀sacral฀dorsal฀ rami.฀฀Murata฀et฀al฀(8)฀illustrated฀that฀the฀ sensory฀nerve฀fibers฀to฀the฀dorsal฀side฀of฀ the฀sacroiliac฀joint฀were฀derived฀from฀the฀ DRGs฀of฀the฀lower฀lumbar฀and฀sacral฀levels฀(from฀L4฀to฀S2),฀and฀those฀to฀the฀ventral฀side฀from฀the฀DRGs฀of฀the฀upper฀lumbar,฀lower฀lumbar,฀and฀sacral฀levels฀(from฀ L1฀to฀S2).฀฀Vilensky฀et฀al฀(12)฀showed฀the฀ presence฀of฀nerve฀fibers฀and฀mechanoreceptors฀in฀the฀sacroiliac฀ligament. Referral฀ patterns฀ of฀ sacroiliac฀ joint฀ provocation฀or฀irritation฀have฀been฀published.฀ Fortin฀ et฀ al฀ (14)฀ successfully฀ generated฀a฀pain฀referral฀map฀using฀provocative฀injections฀first฀of฀dye,฀then฀local฀anesthetic฀into฀the฀sacroiliac฀joint฀in฀10฀asymptomatic฀volunteers.฀฀Fortin฀et฀al฀(15)฀ also฀ evaluated฀ the฀ applicability฀ of฀ a฀ pain฀ referral฀ map฀ as฀ a฀ screening฀ tool฀ for฀ sacroiliac฀joint฀dysfunction.฀฀In฀a฀retrospective฀study,฀Slipman฀et฀al฀(16)฀demonstrated฀ sacroiliac฀ joint฀ pain฀ referral฀ zones.฀฀ Schwarzer฀et฀al฀(17)฀found฀the฀only฀distinguishing฀ pattern฀ of฀ the฀ patients฀ who฀ responded฀to฀sacroiliac฀joint฀injections฀to฀be฀ From Emory Department of Anesthesiology, Emory Center for Pain Medicine, Atlanta, GA , Texas Tech University, Lubbock, TX, University of Wisconsin Hospital & Clinics, Madison, WI, and University of Rochester Medical Center, Rochester, NY. Address Correspondence: Ann Marie McKenzieBrown, MD, Emory Center for Pain Medicine, 550 Peachtree Street, NE, Atlanta GA 30308 Disclaimer: Nothing of monetary value was received in the preparation of this manuscript. Conlict of Interest: None Acknowledgement: Manuscript received on 12/21/2004 Revision submitted on 01/07/2005 Accepted for publication on 01/09/2005 Pain Physician Vol. 8, No. 1, 2005 McKenzie-Brown et al • Systematic Review of Sacroiliac Joint Interventions 116 Table 1. Domains and elements for diagnostic studies developed by the Agency for Healthcare Research and Quality (AHRQ) Domain# Study฀Population Adequate฀Description฀of฀Test Appropriate฀Reference฀Standard Blinded฀Comparison฀of฀Test฀and฀Reference฀ Avoidance฀of฀Verii฀cation฀Bias Elements* •฀฀Subjects฀similar฀to฀populations฀in฀which฀the฀test฀would฀be฀used฀and฀with฀a฀similar฀spectrum฀ of฀disease •฀฀Details฀of฀test฀and฀its฀administration฀sufi฀cient฀to฀allow฀for฀replication฀of฀study฀ •฀฀Appropriate฀reference฀standard฀(“gold฀standard”)฀used฀for฀comparison •฀฀Independent,฀blind฀interpretation฀of฀test฀and฀reference •฀฀Decision฀to฀perform฀reference฀standard฀not฀dependent฀on฀results฀of฀test฀under฀study Key฀domains฀are฀in฀italics฀฀฀฀*Elements฀appearing฀in฀italics฀are฀those฀with฀an฀empirical฀basis.฀฀Elements฀appearing฀in฀bold฀are฀those฀considered฀ essential฀to฀give฀a฀system฀a฀Yes฀rating฀for฀the฀domain.฀฀Adapted฀from฀ref฀39 #฀ 1. Was฀the฀spectrum฀of฀patients฀representative฀of฀the฀patients฀who฀will฀receive฀the฀test฀ in฀practice? 2. 3. Were฀selection฀criteria฀clearly฀described? Is฀the฀reference฀standard฀likely฀to฀correctly฀classify฀the฀target฀condition? 4. Is฀the฀time฀period฀between฀reference฀standard฀and฀index฀test฀short฀enough฀to฀be฀ reasonably฀sure฀that฀the฀target฀condition฀did฀not฀change฀between฀the฀two฀tests? Did฀the฀whole฀sample฀or฀a฀random฀selection฀of฀the฀sample,฀receive฀verii฀cation฀using฀ a฀reference฀standard฀of฀diagnosis? Did฀patients฀receive฀the฀same฀reference฀standard฀regardless฀of฀the฀index฀test฀result? Was฀the฀reference฀standard฀independent฀of฀the฀index฀test(i.e.฀the฀index฀test฀did฀not฀ form฀part฀of฀the฀reference฀standard)? Was฀the฀execution฀of฀the฀index฀test฀described฀in฀sufi฀cient฀detail฀to฀permit฀ replication฀of฀the฀test? Was฀the฀execution฀of฀the฀reference฀standard฀described฀in฀sufi฀cient฀detail฀to฀permit฀ its฀replication? computed฀ tomography฀ (30),฀ bone฀ scans฀ (31,฀ 32),฀ nuclear฀ imaging฀ (33-36),฀ and฀ magnetic฀ resonance฀ imaging฀ (37)฀ in฀ delineating฀radiographic฀sacroiliac฀joint฀abnormalities,฀ there฀ are฀ no฀ definitive฀ corroborative฀ radiologic฀ findings฀ identified฀ thus฀ far฀ in฀ patients฀ with฀ sacroiliac฀ joint฀ syndrome฀(5,฀27).฀฀Associations฀have฀been฀ made฀ between฀ a฀ history฀ of฀ prior฀ spinal฀ surgery฀and฀sacroiliac฀joint฀pain.฀฀Katz฀et฀ al฀(38)฀retrospectively฀evaluated฀low฀back฀ pain฀ patients฀ who฀ had฀ prior฀ lumbosacral฀fusion฀and฀found฀that฀32%฀to฀61%฀of฀ those฀patients฀possibly฀had฀sacroiliac฀joint฀ pain.฀ ฀ Diagnostic฀ blocks฀ of฀ a฀ sacroiliac฀ joint฀can฀be฀performed฀in฀order฀to฀determine฀that฀the฀sacroiliac฀joint฀is฀the฀source฀ of฀the฀patient’s฀pain.฀฀The฀sacroiliac฀joint฀ can฀be฀anesthetized฀with฀intraarticular฀injection฀of฀local฀anesthetic฀performed฀under฀fluoroscopy฀with฀confirmation฀of฀dye฀ spread฀ throughout฀ the฀ joint฀ space.฀ ฀ Similarly,฀ intraarticular฀ injections฀ with฀ steroid฀and฀radiofrequency฀neurotomy฀have฀ been฀employed฀to฀manage฀chronic฀sacroiliac฀joint฀pain฀as฀therapeutic฀interventional฀ techniques.฀ ฀ However,฀ there฀ has฀ been฀ no฀ systematic฀ evaluation฀ of฀ the฀ evidence฀ of฀ diagnostic฀ sacroiliac฀ joint฀ injections฀ or฀ therapeutic฀ sacroiliac฀ joint฀ injections.฀฀ Hence฀ this฀ systematic฀ review฀ was฀ undertaken฀to฀assess฀the฀level฀of฀evidence฀for฀diagnostic฀ sacroiliac฀ joint฀ blocks฀ and฀ therapeutic฀ sacroiliac฀ joint฀ interventions฀ involving฀ intraarticular฀ injections฀ and฀ radiofrequency฀neurotomy. Were฀the฀index฀test฀results฀interpreted฀without฀knowledge฀of฀the฀results฀of฀the฀ reference฀standard? Were฀the฀reference฀standard฀results฀interpreted฀without฀knowledge฀of฀the฀results฀of฀ the฀index฀test? Were฀the฀same฀clinical฀data฀available฀when฀test฀results฀were฀interpreted฀as฀would฀be฀ available฀when฀the฀test฀is฀used฀in฀practice? Were฀uninterpretable/intermediate฀test฀results฀reported? Were฀withdrawals฀from฀the฀study฀explained? Search Strategy The฀ databases฀ of฀ EMBASE฀ (1966฀ –฀ November฀ 2004),฀ PubMed/MEDLINE฀ (1966฀to฀November฀2004),฀and฀MD฀Consult฀were฀searched.฀฀A฀Cochrane฀Database฀ search฀ was฀ performed.฀ ฀ The฀ searches฀ included฀ systematic฀ reviews,฀ narrative฀ re- groin฀pain฀(p฀<฀0.004). The฀rationale฀for฀the฀use฀of฀sacroiliac฀joint฀blocks฀as฀the฀tool฀for฀the฀diagnosis฀ of฀sacroiliac฀joint฀pain฀is฀based฀upon฀the฀ fact฀that฀sacroiliac฀joints฀are฀richly฀innervated฀and฀have฀been฀shown฀to฀be฀capable฀ of฀being฀a฀source฀of฀low฀back฀pain฀and฀referred฀pain฀in฀the฀lower฀extremity฀(8-17).฀฀ There฀are฀no฀absolute฀historical,฀physical,฀ or฀radiological฀features฀to฀provide฀definitive฀diagnosis฀of฀sacroiliac฀joint฀pain฀(1625).฀ ฀ Nevertheless,฀ Broadhurst฀ and฀ Bond฀ (25)฀reported฀77%฀to฀87%฀sensitivity฀with฀ three฀positive฀provocative฀sacroiliac฀joint฀ maneuvers.฀ ฀ Laslett฀ et฀ al฀ (18)฀ found฀ that฀ when฀patients฀had฀three฀or฀more฀positive฀ provocative฀ sacroiliac฀ tests,฀ they฀ were฀ 28฀ times฀more฀likely฀to฀have฀significant฀pain฀ relief฀ following฀ a฀ diagnostic฀ sacroiliac฀ joint฀injection.฀฀Patients฀with฀pain฀above฀ the฀ L5฀ spinous฀ process฀ are฀ less฀ likely฀ to฀ have฀ pain฀ originating฀ from฀ the฀ sacroiliac฀ joint฀ (18,฀ 19,฀ 25).฀ Thus,฀ a฀ corroborative฀ history฀and฀physical฀examination฀can฀enter฀into฀the฀differential฀diagnosis฀of฀sacroiliac฀joint฀pain฀but฀cannot฀make฀a฀definitive฀diagnosis฀of฀sacroiliac฀joint฀syndrome฀ (26,฀27).฀In฀spite฀of฀reports฀of฀the฀efficacy฀ of฀ plain฀ films฀ (21,฀ 28,฀ 29),฀ computed฀ tomography฀ (22),฀ single฀ photon฀ emission฀ Table 2. Items utilized for assessment of quality of individual articles of diagnostic studies by QUADAS tool Item 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Adapted฀from฀ref฀40 Pain Physician Vol. 8, No. 1, 2005 McKenzie-Brown et al • Systematic Review of Sacroiliac Joint Interventions 117 Table 3. AHRQ’s key domains and elements for systems to rate quality of randomized controlled trials Domain* Study฀Question Study฀Population Elements# •฀฀Clearly฀focused฀and฀appropriate฀question •฀฀Description฀of฀study฀population •฀฀Specii฀c฀inclusion฀and฀exclusion฀criteria •฀฀Sample฀size฀justii฀cation฀ Randomization •฀฀Adequate฀approach฀to฀sequence฀generation฀ •฀฀Adequate฀concealment฀method฀used •฀฀Similarity฀of฀groups฀at฀baseline Blinding Interventions •฀฀Double-blinding฀(e.g.,฀of฀investigators,฀caregivers,฀subjects,฀assessors,฀and฀other฀key฀study฀personnel฀as฀ appropriate)฀to฀treatment฀allocation •฀฀Intervention(s)฀clearly฀detailed฀for฀all฀study฀groups฀(e.g.,฀dose,฀route,฀timing฀for฀drugs,฀and฀details฀sufi฀cient฀for฀ assessment฀and฀reproducibility฀for฀other฀types฀of฀interventions) •฀฀Compliance฀with฀intervention •฀฀Equal฀treatment฀of฀groups฀except฀for฀intervention Outcomes Statistical฀Analysis฀ •฀฀Primary฀and฀secondary฀outcome฀measures฀specii฀ed •฀฀Assessment฀method฀standard,฀valid,฀and฀reliable •฀฀Appropriate฀analytic฀techniques฀that฀address฀study฀withdrawals,฀loss฀to฀follow-up,฀missing฀data,฀and฀intention฀ to฀treat •฀฀Power฀calculation •฀฀Assessment฀of฀confounding •฀฀Assessment฀of฀heterogeneity,฀if฀applicable Results •฀฀Measure฀of฀effect฀for฀outcomes฀and฀appropriate฀measure฀of฀precision Discussion •฀฀Conclusions฀supported฀by฀results฀with฀possible฀biases฀and฀limitations฀taken฀into฀consideration Funding฀or฀Sponsorship •฀฀Proportion฀of฀eligible฀subjects฀recruited฀into฀study฀and฀followed฀up฀at฀each฀assessment •฀฀Type฀and฀sources฀of฀support฀for฀study *Key฀domains฀are฀in฀italics #Elements฀appearing฀in฀italics฀are฀those฀with฀an฀empirical฀basis.฀฀Elements฀appearing฀in฀bold฀are฀those฀ considered฀essential฀to฀give฀a฀system฀a฀Yes฀rating฀for฀the฀domain.฀ Adapted฀from฀ref฀39 views,฀prospective฀and฀retrospective฀studies฀ and฀ cross-references฀ from฀ articles฀ reviewed,฀ the฀ search฀ strategy฀ included฀ sacroiliac฀joint฀pain฀and฀dysfunction,฀sacroiliac฀ joint฀ injections,฀ and฀ sacroiliac฀ joint฀ radiofrequency.฀ ฀ One฀ reviewer฀ assessed฀ the฀ quality฀ of฀ the฀ articles฀ for฀ inclusion.฀฀ Three฀ reviewers฀ evaluated฀ the฀ studies.฀ A฀ list฀ was฀ generated฀ of฀ the฀ abstracts฀ reviewed.฀ ฀ If฀ there฀ were฀ no฀ clear฀ exclusion฀ criteria฀ within฀ the฀ abstract฀ then฀ the฀ full฀ article฀was฀reviewed.฀฀Those฀articles฀were฀ then฀outlined฀for฀their฀study฀population,฀ outcome฀and฀quality. without฀ leg฀ pain฀ for฀ at฀ least฀ 3฀ months;฀ participants฀ had฀ tried฀ and฀ failed฀ conservative฀ management;฀ pain฀ sufficient฀ to฀ be฀ referred฀ to฀ a฀ pain฀ specialist/spinal฀ injectionist฀for฀the฀diagnostic฀injection.฀฀Prior฀ radiographic฀ imaging฀ excluding฀ an฀ anatomic฀cause฀for฀the฀patient’s฀symptoms. Types฀of฀interventions Local฀ anesthetic฀ injections;฀ placebo฀ controlled฀ injections;฀ double฀ injections฀ with฀a฀screening฀lidocaine฀sacroiliac฀joint฀ injection฀followed฀by฀a฀bupivacaine฀confirmatory฀injection;฀sacroiliac฀joint฀injections฀ with฀ local฀ anesthetic฀ and฀ steroid;฀ and฀radiofrequency฀neurotomy. Exclusion criteria Types฀of฀studies฀ Case฀reports;฀descriptive฀reports Types฀of฀participants฀฀ Participants฀ with฀ pain฀ symptoms฀ for฀<฀3฀months;฀sacroiliac฀joint฀injections฀ performed฀on฀animals. Types฀of฀interventions฀ Single฀ injections;฀ non-fluoroscopic฀ /non-radiographically฀ guided฀ injections,฀ surgical฀interventions฀(fusions,฀fixations) Methodological Quality Methodological฀ quality฀ of฀ articles฀ Inclusion Criteria was฀assessed฀by฀the฀criteria฀established฀by฀ Types฀of฀Outcome฀measures AHRQ฀ (39),฀ criteria฀ described฀ for฀ QUATypes฀of฀studies฀ Pain฀ relief฀ was฀ the฀ main฀ outcome฀ DAS฀ (40),฀ and฀ Cochrane฀ Review฀ Group฀ Study฀ designs฀ that฀ used฀ controlled฀ measured.฀ ฀ The฀ pain฀ relief฀ had฀ to฀ be฀ at฀ for฀randomized฀trials฀(41).฀฀The฀details฀of฀ and฀ uncontrolled฀ studies฀ of฀ sacroiliac฀ least฀50%. application฀ of฀ these฀ criteria฀ are฀ illustratjoint฀injections฀were฀included. ed฀in฀Tables฀1฀to฀5.฀฀Inclusion฀and฀excluTypes฀of฀participants฀฀ sion฀ criteria฀ were฀ used฀ as฀ described฀ elseSubjects฀with฀low฀back฀pain฀with฀or฀ where฀(42-44). Pain Physician Vol. 8, No. 1, 2005 McKenzie-Brown et al • Systematic Review of Sacroiliac Joint Interventions 118 Table 4. Methodologic quality criteria list (key items of internal validity) of Cochrane Musculoskeletal Review Group Patient฀selection 1.฀Treatment฀allocation ฀฀฀฀฀฀฀Was฀the฀method฀of฀randomization฀described฀and฀adequate?฀ ฀฀฀฀฀฀฀Was฀the฀treatment฀allocation฀concealed?฀฀ ฀ ฀ ฀ 2.฀Were฀the฀groups฀similar฀at฀baseline฀regarding฀the฀most฀important฀prognostic฀indicators?฀ Intervention 3.฀Was฀the฀care฀provider฀blinded?฀฀ ฀ ฀ ฀ 4.฀Was฀controlled฀for฀co-interventions฀which฀could฀explain฀the฀results? 5.฀Was฀the฀compliance฀rate฀(in฀each฀group)฀unlikely฀to฀cause฀bias? 6.฀Was฀the฀patient฀blinded? ฀ ฀ ฀ ฀ ฀ Outcome฀measurement 7.฀Was฀the฀outcome฀assessor฀blinded?฀฀ ฀ ฀ ฀ 8.฀Was฀at฀least฀one฀of฀the฀primary฀outcome฀measures฀applied?฀฀ ฀ 9.฀Was฀the฀withdrawal/drop-out฀rate฀unlikely฀to฀cause฀bias?฀฀ ฀ Statistics 10.฀Did฀the฀analysis฀include฀an฀intention-to-treat฀analysis?฀฀ ฀ ฀ ฀ ฀ Adapted฀from฀ref฀41 Table 5. AHRQ’s key domains and elements for systems to rate quality of observational studies Domain* Elements# Study฀Question •฀฀Clearly฀focused฀and฀appropriate฀question Study฀Population Comparability฀of฀Subjects† Exposure฀or฀Intervention •฀฀Description฀of฀study฀populations •฀฀Use฀of฀concurrent฀controls •฀฀Clear฀dei฀nition฀of฀exposure฀ •฀฀Measurement฀method฀standard,฀valid฀and฀reliable •฀฀Exposure฀measured฀equally฀in฀all฀study฀groups Outcome฀Measurement Statistical฀Analysis฀ Results Discussion Funding฀or฀Sponsorship •฀฀Primary/secondary฀outcomes฀clearly฀dei฀ned •฀฀Assessment฀of฀confounding฀factors฀ •฀฀Measure฀of฀effect฀for฀outcomes฀and฀appropriate฀measure฀ of฀precision •฀฀Conclusions฀supported฀by฀results฀with฀possible฀biases฀ and฀limitations฀taken฀into฀consideration •฀฀Type฀and฀sources฀of฀support฀for฀study * Key฀domains฀are฀in฀italics #Elements฀appearing฀in฀italics฀are฀those฀with฀an฀empirical฀basis.฀฀Elements฀appearing฀in฀bold฀ are฀those฀considered฀essential฀to฀give฀a฀system฀a฀Yes฀rating฀for฀the฀domain.฀For฀purposes฀of฀ this฀systematic฀review,฀the฀bold฀elements฀were฀considered,฀and฀to฀be฀included฀studies฀needed฀ to฀have฀at฀least฀5฀of฀the฀8฀essential฀elements. †Domain฀for฀which฀a฀Yes฀rating฀required฀that฀a฀majority฀of฀elements฀be฀considered. Adapted฀from฀ref฀39 Analysis of Evidence Qualitative฀ analysis฀ was฀ conducted฀using฀five฀levels฀of฀evidence฀as฀shown฀ in฀Table฀6.฀฀ For฀ therapeutic฀ intraarticular฀ injections฀ the฀ primary฀ outcome฀ measure฀ was฀ pain฀relief.฀฀Other฀outcome฀measures฀utilized฀ were฀ functional฀ improvement,฀ psychological฀ improvement฀ and฀ return฀ to฀ Pain Physician Vol. 8, No. 1, 2005 work.฀฀For฀therapeutic฀interventions฀with฀ intraarticular฀ injections฀ short-term฀ relief฀ was฀defined฀as฀less฀than฀6฀weeks,฀and฀longterm฀relief฀was฀defined฀as฀6฀weeks฀or฀longer.฀฀In฀contrast,฀for฀radiofrequency฀neurotomy,฀ short-term฀ relief฀ was฀ defined฀ as฀ less฀ than฀ 3฀ months฀ and฀ long-term฀ relief฀ was฀defined฀as฀3฀months฀or฀longer.฀฀ For฀diagnostic฀interventions฀placebo฀ controlled฀or฀comparative,฀controlled฀local฀ anesthetic฀ blocks฀ were฀ considered฀ as฀ satisfactory฀criteria.฀฀The฀criterion฀of฀pain฀ relief฀was฀considered฀as฀appropriate฀as฀described฀by฀individual฀authors. A฀study฀was฀judged฀to฀be฀positive฀if฀ the฀authors฀concluded฀that฀it฀was฀positive.฀฀ If฀the฀authors฀concluded฀a฀study฀as฀negative,฀and฀there฀was฀a฀preponderance฀of฀evidence฀showing฀the฀positive฀nature฀of฀the฀ study฀ the฀ conclusion฀ was฀ altered฀ for฀ the฀ purposes฀of฀analysis฀of฀evidence. RESULTS Diagnostic Sacroiliac Joint Injections The฀ database฀ search฀ produced฀ 104฀ article฀ abstracts฀ for฀ review฀ for฀ diagnostic฀interventions.฀฀Of฀these,฀5฀articles฀were฀ reviewed฀ (17,฀ 18,฀ 28,฀ 45,฀ 46).฀ ฀ However,฀ 2฀ were฀ excluded฀ because฀ they฀ were฀ only฀ single฀injection฀studies฀(17,฀45).฀฀The฀remaining฀3฀were฀chosen฀for฀the฀study.฀฀All฀ 3฀ studies฀ were฀ performed฀ under฀ fluoroscopic฀ guidance฀ and฀ employed฀ a฀ comparative,฀controlled฀local฀anesthetic฀technique.฀฀All฀3฀used฀a฀screening฀lidocaine฀injection฀followed฀by฀a฀confirmatory฀bupivacaine฀injection฀of฀those฀who฀had฀a฀positive฀response.฀฀Laslett฀et฀al฀(18),฀however,฀ used฀steroid฀after฀the฀lidocaine฀injection.฀฀ The฀ study฀ was฀ included฀ for฀ review฀ as฀ it฀ was฀ followed฀ by฀ a฀ bupivacaine฀ injection฀ and฀ those฀ patients฀ who฀ had฀ prolonged฀ pain฀relief฀following฀the฀steroid฀were฀excluded฀from฀the฀study.฀฀The฀only฀randomized฀study฀was฀the฀one฀by฀Manchikanti฀et฀ al฀(46).฀฀All฀patients฀who฀were฀selected฀for฀ the฀ double฀ block฀ had฀ low฀ back฀ pain฀ and฀ all฀had฀positive฀provocative฀maneuvers฀to฀ the฀sacroiliac฀joint.฀฀In฀none฀of฀these฀studies฀was฀a฀single฀provocative฀maneuver฀diagnostic฀for฀sacroiliac฀joint฀pain.฀฀In฀these฀ studies,฀ sacroiliac฀ joint฀ pain฀ was฀ seen฀ in฀ 2%฀to฀18%฀of฀the฀patients฀evaluated฀(18,฀ 28,฀ 46).฀ ฀ Description฀ of฀ included฀ studies฀ along฀ with฀ methodologic฀ quality฀ criteria฀ are฀illustrated฀in฀Table฀7. Maigne฀et฀al฀(28)฀studied฀67฀patients฀ who฀ had฀ chronic฀ (>฀ 50฀ days)฀ unilateral฀ low฀back฀pain฀(VAS฀>4)฀with฀or฀without฀ radiation฀to฀the฀posterior฀thigh฀with฀associated฀ pain฀ and฀ tenderness฀ over฀ the฀ posterior฀sacroiliac฀joint.฀฀The฀block฀was฀successful฀ in฀ 54฀ patients.฀ ฀ Double฀ injections฀ were฀performed฀with฀a฀screening฀diagnostic฀ lidocaine฀ injection฀ (2฀ ml)฀ performed฀ first.฀฀Relief฀of฀>฀75%฀relief฀was฀considered฀ a฀positive฀result.฀฀Nineteen฀of฀54฀patients฀ had฀>฀75%฀relief฀from฀the฀screening฀block฀ McKenzie-Brown et al • Systematic Review of Sacroiliac Joint Interventions 119 Table 6. Designation of levels of evidence Level฀I฀ Conclusive:฀Research-based฀evidence฀with฀multiple฀relevant฀and฀high-quality฀scientii฀c฀studies฀or฀consistent฀reviews฀of฀metaanalyses฀ Level฀II฀ Strong:฀Research-based฀evidence฀from฀at฀least฀one฀properly฀designed฀randomized,฀controlled฀trial;฀or฀research-based฀evidence฀ from฀multiple฀properly฀designed฀studies฀of฀smaller฀size;฀or฀multiple฀low฀quality฀trials.฀ Moderate:฀a)฀Evidence฀obtained฀from฀well-designed฀pseudorandomized฀controlled฀trials฀(alternate฀allocation฀or฀some฀other฀ method);฀b)฀evidence฀obtained฀from฀comparative฀studies฀with฀concurrent฀controls฀and฀allocation฀not฀randomized฀(cohort฀ studies,฀case-controlled฀studies,฀or฀interrupted฀time฀series฀with฀a฀control฀group);฀c)฀evidence฀obtained฀from฀comparative฀ studies฀with฀historical฀control,฀two฀or฀more฀single-arm฀studies,฀or฀interrupted฀time฀series฀without฀a฀parallel฀control฀group.฀ Level฀III฀ Level฀IV฀ Limited:฀Evidence฀from฀well-designed฀nonexperimental฀studies฀from฀more฀than฀one฀center฀or฀research฀group;฀or฀conl฀icting฀ evidence฀with฀inconsistent฀i฀ndings฀in฀multiple฀trials฀ Level฀V฀ Indeterminate:฀Opinions฀of฀respected฀authorities,฀based฀on฀clinical฀evidence,฀descriptive฀studies,฀or฀reports฀of฀expert฀ committees.฀ Adapted฀from฀ref฀43,฀44 and฀10฀of฀19฀participants฀had฀>฀75%฀improvement฀ from฀ the฀ confirmatory฀ block.฀฀ Of฀ the฀ 54,฀ 10฀ or฀ 18.5%฀ were฀ considered฀ to฀have฀sacroiliac฀joint฀pain.฀฀As฀only฀patients฀with฀a฀high฀likelihood฀of฀sacroiliac฀ joint฀pain฀were฀included฀in฀the฀study,฀no฀ determination฀of฀the฀prevalence฀of฀sacroiliac฀joint฀pain฀can฀be฀made. Manchikanti฀et฀al฀(46)฀evaluated฀120฀ patients฀ that฀ presented฀ to฀ the฀ pain฀ clinic฀ with฀low฀back฀pain฀for฀>฀6฀months.฀฀All฀of฀ the฀ participants฀ initially฀ had฀ facet฀ blocks฀ and฀were฀negative฀for฀facet฀joint฀pain.฀฀Patients฀ without฀ facet฀ joint฀ pain,฀ but฀ with฀ suspected฀ sacroiliac฀ joint฀ involvement฀ (pain฀in฀the฀sacral฀region,฀sacroiliac฀joint฀ tenderness฀ and฀ positive฀ provocative฀ maneuvers)฀ had฀ a฀ sacroiliac฀ joint฀ injection.฀฀ They฀ had฀ screening฀ sacroiliac฀ joint฀ injections฀ with฀ 2%฀ lidocaine฀ followed฀ in฀ 3฀ to฀ 4฀ weeks฀ by฀ confirmatory฀ bupivacaine฀ blocks.฀ ฀ Twenty฀ of฀ 120฀ patients฀ had฀ sacroiliac฀joint฀injections฀and฀6฀of฀20฀patients฀ had฀ a฀ positive฀ response฀ to฀ the฀ screening฀ Table 7. Characteristics of reported prospective diagnostic studies Study Maigne฀et฀al฀(28) AHRQ฀Score 3/5 QUADAS฀Score 10/14 Manchikanti฀et฀ al฀฀(46) AHRQ฀Score 4/5 QUADAS฀Score 11/14 Laslett฀et฀al฀(18) AHRQ฀Score 5/5 QUADAS฀Score 12/14 Participants Objective(s) Intervention(s) Result(s) 77฀patients฀aged฀18-75฀ attending฀a฀public฀hospital฀ with฀chronic฀unilateral฀LBP฀ with฀or฀without฀radiation฀to฀ the฀posterior฀thigh฀for฀>฀50฀ days฀(median฀4.2฀months).฀฀ Patients฀had฀failed฀epidural฀ or฀lumbar฀facet฀injections. Determine฀the฀ prevalence฀of฀ sacroiliac฀joint฀pain฀in฀ a฀selected฀population฀ of฀patients฀with฀ low฀back฀pain฀and฀ assess฀certain฀pain฀ provocation฀tests. Successful฀blockade฀of฀ the฀sacroiliac฀joint฀in฀ 54฀patients.฀฀A฀screening฀block฀was฀done฀ with฀2%฀lidocaine฀and฀ a฀coni฀rmatory฀block฀ was฀performed฀with฀ bupivacaine฀0.5%฀> 75%฀relief฀was฀considered฀a฀positive฀block.฀฀ 19/54฀patients฀had฀>฀75%฀ relief฀with฀lidocaine.฀฀10/19฀ patients฀had฀relief฀with฀ coni฀rmatory฀bupivacaine฀and฀ were฀considered฀to฀have฀SIJ฀ pain.฀฀There฀was฀no฀statistically฀ signii฀cant฀association฀between฀ response฀to฀blocks฀and฀any฀ single฀clinical฀parameter.฀฀No฀ pain฀provocation฀test฀predicted฀ SIJ฀pain. 120฀patients฀(age฀18-90)฀ presenting฀to฀the฀clinic฀with฀ >฀6฀months฀of฀low฀back฀pain฀ and฀no฀structural฀basis฀for฀฀ the฀pain฀by฀radiographic฀ imaging.฀฀Patients฀who฀ failed฀facet฀blocks,฀had฀SIJ฀ tenderness,฀and฀positive฀ provocative฀maneuvers฀had฀ an฀SIJ฀injection.฀ Determine฀the฀ frequency฀of฀various฀ structures฀responsible฀ for฀low฀back฀pain. All฀patients฀had฀facet฀ blocks.฀฀Nonresponders฀ who฀i฀t฀criteria฀had฀ double฀injection฀SIJ฀ blocks.฀฀The฀screening฀ block฀was฀done฀with฀ 2%฀lidocaine฀and฀the฀ coni฀rmatory฀block฀was฀ performed฀using฀0.5%฀ bupivacaine. 20฀patients฀had฀clinical฀diagnosis฀ of฀SIJ฀pain.฀฀6/20฀had฀>฀75%฀ relief฀from฀the฀lidocaine฀blocks.฀฀ 2/6฀had฀>฀75%฀relief฀from฀ the฀bupivacaine฀blocks.฀฀The฀ incidence฀of฀SIJ฀pain฀was฀2%฀of฀ the฀overall฀sample฀and฀10%฀of฀ those฀suspected฀to฀have฀SIJ฀pain.฀฀ The฀false฀positive฀rate฀was฀22%. 62฀patients฀with฀buttock฀ pain฀with฀or฀w/o฀LE฀ involvement฀referred฀for฀ diagnostic฀injections.฀฀ Patients฀failed฀prior฀ interventions฀and฀had฀prior฀ imaging฀studies. Comparison฀of฀SIJ฀ provocative฀tests฀and฀ reasoning฀process฀ using฀McKenzie฀ evaluation฀with฀SIJ฀ double฀injections. 48฀patients฀had฀SIJ฀ diagnostic฀injection฀ with฀Lidocaine.฀฀After฀ symptom฀reproduction฀ steroid฀was฀added.฀16฀ patients฀had฀pain฀relief.฀฀ 5฀remained฀pain฀free฀ and฀11฀had฀coni฀rmatory฀blocks฀and฀all฀were฀ positive. There฀was฀a฀91%฀sensitivity฀and฀ 78%฀specii฀city฀when฀double฀SI฀ Joint฀injection฀was฀compared฀ to฀>3฀SI฀Joint฀pain฀provocation฀ tests฀and฀clinical฀reasoning. Pain Physician Vol. 8, No. 1, 2005 120 block.฀฀Of฀those฀6฀patients,฀2฀had฀a฀positive฀response฀to฀the฀confirmatory฀bupivacaine฀ block฀ resulting฀ in฀ a฀ 2%฀ prevalence฀ of฀sacroiliac฀joint฀pain.฀฀A฀definite฀or฀positive฀ response฀ was฀ defined฀ as฀ >฀ 80%฀ relief฀of฀pain.฀฀ Laslett฀et฀al฀(18)฀sought฀to฀validate฀a฀ specific฀clinical฀examination฀and฀reasoning฀ to฀ diagnose฀ sacroiliac฀ joint฀ pain฀ by฀ confirming฀the฀diagnosis฀by฀diagnostic฀injections.฀฀They฀evaluated฀62฀patients฀who฀ presented฀to฀the฀clinic฀with฀buttock฀pain฀ with฀or฀without฀lower฀extremity฀pain฀for฀ diagnostic฀ injections.฀ ฀ Patients฀ with฀ pain฀ above฀L5฀and฀those฀with฀midline฀or฀symmetric฀pain฀were฀excluded.฀฀The฀patients฀ had฀ a฀ clinical฀ examination฀ by฀ a฀ physical฀ therapist฀who฀was฀blinded฀to฀the฀imaging฀ studies.฀฀A฀radiologist฀who฀was฀blinded฀to฀ the฀results฀of฀the฀clinical฀examination฀performed฀double฀sacroiliac฀joint฀injections.฀฀ The฀ screening฀ sacroiliac฀ joint฀ injection฀ performed฀with฀lidocaine฀(<฀1.5฀mL)฀was฀ considered฀a฀positive฀injection฀if฀the฀injection฀ provoked฀ familiar฀ pain฀ and฀ resulted฀ in฀>฀80%฀pain฀relief.฀฀Once฀the฀injection฀ recreated฀ the฀ patient’s฀ familiar฀ pain,฀ steroid฀was฀then฀injected฀into฀the฀joint.฀฀Forty-eight฀ patients฀ had฀ the฀ screening฀ lidocaine฀injection.฀฀Sixteen฀of฀48฀had฀>฀80%฀ pain฀relief.฀฀Of฀those,฀5฀remained฀pain฀free฀ and฀were฀then฀excluded.฀฀Eleven฀patients฀ went฀on฀to฀have฀the฀confirmatory฀bupivacaine฀injections,฀all฀of฀them฀were฀positive.฀฀ Of฀ note,฀ 10฀ of฀ 11฀ sacroiliac฀ joint฀ injections฀ met฀ the฀ clinical฀ examination฀ criteria฀for฀having฀sacroiliac฀joint฀pain฀and฀the฀ diagnostic฀accuracy฀of฀the฀clinical฀examination฀and฀clinical฀reasoning฀process฀was฀ found฀to฀be฀superior฀to฀the฀sacroiliac฀joint฀ pain฀ provocation฀ tests฀ alone.฀ ฀ The฀ steroid฀added฀to฀the฀screening฀aspect฀of฀this฀ study฀makes฀it฀more฀difficult฀to฀interpret.฀฀ In฀addition,฀the฀patients฀studied฀were฀not฀ consecutive;฀consequently,฀this฀study฀was฀ subject฀ to฀ verification฀ bias.฀ ฀ Thus,฀ 10฀ of฀ 62฀ (16%)฀ patients฀ studied฀ had฀ sacroiliac฀ joint฀pain฀as฀defined฀by฀pain฀relief฀following฀a฀double฀local฀anesthetic฀injection. Accuracy Sacroiliac฀ joint฀ blocks฀ have฀ been฀ shown฀to฀have฀face฀validity.฀฀Low฀volumes฀ of฀local฀anesthetic฀selectively฀injected฀into฀ the฀target฀joint฀after฀dye฀verification฀of฀the฀ needle฀position฀may฀anesthetize฀the฀joint.฀฀ Appropriate฀ precautions฀ need฀ to฀ be฀ observed฀to฀ensure฀there฀is฀no฀extravasation฀ to฀adjacent฀structures฀(62).฀฀ Pain Physician Vol. 8, No. 1, 2005 McKenzie-Brown et al • Systematic Review of Sacroiliac Joint Interventions Sacroiliac฀joint฀blocks฀also฀have฀been฀ shown฀ to฀ have฀ construct฀ validity.฀ ฀ However,฀ to฀ have฀ construct฀ validity,฀ sacroiliac฀ joint฀ blocks฀ must฀ be฀ controlled.฀ ฀ Single฀diagnostic฀blocks฀carry฀a฀false-positive฀ rate฀of฀20%฀(28).฀฀Patients฀are฀liable฀to฀report฀ relief฀ of฀ pain฀ after฀ diagnostic฀ block฀ for฀reasons฀other฀than฀the฀pharmacological฀ action฀ of฀ drug฀ administration฀ (47).฀฀ Consequently,฀ it฀ is฀ imperative฀ to฀ know฀ in฀ every฀ individual฀ case฀ whether฀ the฀ response฀is฀a฀true฀positive.฀฀The฀validity฀of฀ controlled฀ comparative฀ local฀ anesthetic฀blocks฀for฀facet฀joint฀diagnostic฀blocks฀ was฀ confirmed฀ with฀ placebo฀ controlled฀ diagnostic฀blocks฀(47,฀48). False฀positive฀rate฀of฀diagnostic฀sacroiliac฀joint฀injection฀was฀evaluated฀in฀two฀ groups฀ of฀ patients,฀ with฀ a฀ false฀ positive฀ rate฀of฀20%฀(28)฀and฀22%฀(46).฀฀It฀is฀also฀ possible฀to฀have฀extravasation฀of฀the฀local฀ anesthetic฀if฀care฀is฀not฀taken฀to฀avoid฀spill฀ over฀into฀adjacent฀structures฀(62). Prevalence This฀ review฀ led฀ to฀ inclusion฀ of฀ two฀ studies฀ (28,฀ 46)฀ utilizing฀ controlled฀ local฀ anesthetic฀blocks. Schwarzer฀ et฀ al฀ (17)฀ utilized฀ a฀ single฀local฀anesthetic฀block.฀฀Thus,฀the฀value฀ of฀this฀evaluation฀is฀unknown.฀฀Pang฀et฀al฀ (45)฀also฀utilized฀single฀block฀with฀a฀prevalence฀report฀of฀10%฀of฀chronic฀low฀back฀ pain฀ patients.฀ Laslett฀ (18)฀ used฀ a฀ double฀ block฀paradigm฀but฀confused฀the฀data฀by฀ following฀the฀lidocaine฀injection฀with฀steroid,฀ which฀ made฀ the฀ blocks฀ more฀ therapeutic฀ in฀ nature.฀ ฀ Indeed฀ 5฀ patients฀ remained฀ pain฀ free฀ throughout฀ the฀ study฀ and฀ had฀ to฀ be฀ eliminated.฀ ฀ ฀ Maigne฀ et฀ al฀ (28),฀even฀though฀utilizing฀a฀double฀block฀ paradigm฀ that฀ validated฀ the฀ diagnostic฀ ability฀of฀the฀test฀with฀false-positive฀rates,฀ failed฀ to฀ provide฀ the฀ prevalence฀ rate฀ in฀ chronic฀spinal฀pain฀populations,฀as฀it฀was฀ performed฀ in฀ a฀ select฀ group฀ of฀ patients฀ with฀suspicion฀of฀sacroiliac฀joint฀pain.฀Finally,฀Manchikanti฀et฀al฀(46)฀showed฀a฀low฀ prevalence฀of฀sacroiliac฀joint฀pain฀with฀a฀ double฀ block฀ paradigm.฀ ฀ The฀ study฀ was฀ performed฀in฀patients฀suffering฀with฀low฀ back฀ pain฀ and฀ negative฀ for฀ other฀ sources฀of฀pain.฀฀ Even฀ though฀ short-term฀ relief฀ from฀ sacroiliac฀joint฀injection฀is฀considered฀as฀a฀ gold฀standard฀for฀the฀diagnosis฀of฀sacroiliac฀joint฀pain,฀there฀was฀no฀blinded฀comparison฀of฀the฀test฀or฀reference฀standard฀in฀ evaluation฀of฀these฀investigations฀. Level of Evidence Based฀ on฀ the฀ present฀ evaluation฀ of฀ three฀controlled฀trials฀(18,฀28,฀46),฀the฀evidence฀for฀sacroiliac฀joint฀diagnostic฀blocks฀ in฀diagnosing฀pain฀of฀sacroiliac฀joint฀originwas฀moderate. Therapeutic Sacroiliac Joint Interventions Sacroiliac฀ joint฀ pain฀ may฀ be฀ managed฀ by฀ intraarticular฀ injections,฀ or฀ neurolysis฀of฀sacroiliac฀joint฀innervation. Intraarticular Blocks Our฀search฀criteria฀yielded฀28฀reports฀ describing฀the฀effectiveness฀of฀these฀interventions.฀ ฀ From฀ these,฀ 6฀ relevant฀ evaluations฀ were฀ selected฀ for฀ review฀ and฀ evidence฀ synthesis฀ (49-54).฀ ฀ Of฀ these,฀ two฀ studies฀were฀randomized฀(49,฀50),฀3฀were฀ prospective฀ evaluations฀ (51-53),฀ and฀ one฀ was฀a฀retrospective฀evaluation฀(54). Methodological Quality Of฀the฀two฀randomized฀trials฀selected฀for฀review,฀one฀study฀(49)฀was฀excluded฀due฀to฀lack฀of฀long-term฀follow-up฀(1฀ month),฀ and฀ injection฀ was฀ periarticular.฀฀ Consequently฀ only฀ one฀ randomized฀ trial฀ (50)฀ was฀ available฀ for฀ review.฀ ฀Among฀ the฀3฀prospective฀evaluations฀(51-53),฀one฀ evaluation฀(51)฀was฀excluded฀as฀it฀failed฀to฀ meet฀inclusion฀criteria฀with฀evaluation฀of฀ short-term฀relief.฀฀The฀second฀evaluation฀ was฀in฀the฀German฀language฀(52).฀฀Consequently,฀only฀one฀study฀(53)฀was฀included฀ in฀ the฀ evidence฀ synthesis.฀ ฀ However,฀ both฀prospective฀studies฀(50,฀53)฀evaluated฀spondyloarthropathy.฀฀Since฀there฀were฀ no฀other฀studies฀[except฀one฀฀retrospective฀฀ study฀(54)]฀evaluating฀non-inflammatory฀ sacroiliac฀joint฀pain,฀it฀was฀decided฀to฀include฀these฀two฀studies.฀฀Further,฀the฀only฀ study฀ evaluating฀ non-inflammatory฀ sacroiliac฀joint฀pain฀(54)฀was฀included,฀even฀ though฀ they฀ studied฀ some฀ patients฀ with฀ pain฀of฀6฀weeks฀duration. One฀ retrospective฀ evaluation฀ (54)฀ was฀included.฀฀These฀studies฀are฀listed฀in฀ Table฀8. Study Characteristics The฀characteristics฀of฀reported฀studies฀are฀listed฀in฀Table฀8. Maugars฀et฀al฀(50)฀performed฀a฀double-blind฀ study฀ in฀ 10฀ patients;฀ 13฀ articulations,฀suffering฀with฀painful฀sacroiliitis.฀ Six฀sacroiliac฀joints฀were฀injected฀with฀steroid฀and฀7฀were฀placebo฀injections.฀฀At฀1฀ month,฀ 5/6฀ sacroiliac฀ joints฀ were฀ inject- McKenzie-Brown et al • Systematic Review of Sacroiliac Joint Interventions 121 Table 8. Study characteristics of included reports of therapeutic intraarticular sacroiliac joint injections ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Results Short-term฀relief฀<฀6฀weeks฀ Study Participants Objective(s) Intervention(s) Outcome(s)฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Long-term฀relief฀>฀6฀weeks Maugars฀et฀al฀(50) Randomized,฀ controlled฀trial AHRQ฀Score 6/10 Cochrane฀Score 6/10 10฀ patients/13฀ articulations฀ with฀ painful฀ sacroiliitis. To฀ assess฀ the฀ effectiveness฀ of฀ sacroiliac฀ corticosteroid฀ injections฀ in฀ spondyloarthropathy. Sacroiliac฀ joint฀ injection฀ with฀ steroids฀ or฀ placebo. 86%฀of฀patients฀had฀a฀good฀result฀ at฀1฀month,฀62%฀at฀3฀months,฀and฀ 58%฀at฀6฀months. Positive฀ short-term฀ and฀longterm Hanly฀et฀al฀(53) 19฀ patients฀ with฀ symptoms฀ of฀ LBP฀ were฀ studied.฀ 13฀ had฀ radiographic฀ evidence฀ of฀ sacroiliitis.฀ The฀ remaining฀ 6฀ patients฀ had฀ normal฀ imaging฀ studies฀ and฀ thus฀ were฀ considered฀ to฀ have฀ mechanical฀ low฀ back฀ pain. To฀ evaluate฀ changes฀ in฀ articular฀ symptoms,฀spinal฀mobility,฀ and฀ global฀ function฀ over฀ 6฀ months฀ after฀ intraarticular฀ injections฀ of฀ long฀ acting฀ corticosteroid฀ into฀ the฀ sacroiliac฀ (SI)฀ joints฀ of฀ patients฀ with฀ inl฀ammatory฀ low฀back฀pain. All฀ patients฀ received฀ bilateral฀ SI฀ joint฀ injections฀ of฀ triamcinolone฀ h ex a ce ton i de฀ (40฀ mg/joint)฀ under฀ computer฀ tomographic฀ guidance. Both฀ groups฀ of฀ patients฀ showed฀ a฀ transient฀ improvement฀ in฀ stiffness฀ and฀ pain,฀ spinal฀ mobility,฀ and฀general฀health฀status฀that฀was฀ most฀ pronounced฀ at฀ 1-3฀ months฀ after฀ intraarticular฀ therapy.฀ This฀ did฀ not฀ reach฀ statistical฀ signii฀cance฀(p฀>฀0.05)฀and฀by฀6฀months฀ followup฀ all฀ outcome฀ variables฀ had฀ reverted฀ to฀ pretherapy฀ levels฀ in฀both฀groups. Positive฀short฀term฀ 31฀ patients฀ were฀ included;฀ each฀ patient฀ met฀ specii฀c฀ physical฀ examination฀ criteria฀ and฀ failed฀ to฀ improve฀ clinically฀ after฀ at฀ least฀ 4฀ wk฀ of฀ physical฀ therapy.฀ Each฀ patient฀ demonstrated฀ a฀ positive฀response฀to฀a฀l฀uoroscopically฀ guided฀ diagnostic฀ sacroiliac฀ joint฀injection. To฀ investigate฀ the฀ outcomes฀ resulting฀ from฀the฀use฀of฀l฀uoroscopically฀ guided฀ therapeutic฀ sacroiliac฀ joint฀injections฀in฀patients฀ with฀ sacroiliac฀ joint฀syndrome. T h e r a p e u t i c฀ sacroiliac฀ joint฀ injections฀ were฀ a d m i n i s tere d฀ in฀ conjunction฀ with฀ physical฀ therapy. Patients’฀symptom฀duration฀before฀ diagnostic฀injection฀averaged฀20.6฀ mo.฀An฀average฀of฀2.1฀therapeutic฀ injections฀ was฀ administered.฀ Follow-up฀ data฀ collection฀ was฀ obtained฀ at฀ an฀ average฀ of฀ 94.4฀ wk.฀ A฀ signii฀cant฀ reduction฀ (P฀ =฀ 0.0014)฀ in฀ Oswestry฀ disability฀ score฀was฀observed฀at฀the฀time฀of฀ follow-up.฀ VAS฀ pain฀ scores฀ were฀ reduced฀ (P฀ <฀ 0.0001)฀ at฀ the฀ time฀ of฀ discharge฀ and฀ at฀ follow-up.฀ Work฀status฀was฀also฀signii฀cantly฀ improved฀at฀the฀time฀of฀discharge฀ (P฀=฀0.0313)฀and฀at฀follow-up฀(P฀ =฀ 0.0010).฀ A฀ trend฀ (P฀ =฀ 0.0645)฀ toward฀ less฀ drug฀ usage฀ was฀ observed. Prospective฀ evaluation฀ AHRQ฀Score 5/8 Slipman฀et฀al฀(54) Retrospective฀ evaluation AHRQ฀Score 6/8 ed฀ with฀ corticosteroid,฀ (in฀ comparison฀ to฀ 0/7฀ of฀ the฀ placebo฀ group),฀ described฀ a฀relief฀of฀>฀70%,฀(P฀<฀0.05).฀฀Six฀out฀of฀ the฀ seven฀ sacroiliac฀ joints฀ of฀ the฀ placebo฀ group฀and฀2฀patients฀from฀the฀corticosteroid฀ group฀ who฀ either฀ failed฀ the฀ first฀ injection฀or฀whose฀pain฀returned,฀were฀reinjected฀with฀corticosteroid.฀At฀1฀month,฀12/ 14฀(85.7%)฀had฀good฀results฀and฀patients฀ were฀still฀significantly฀better฀at฀3฀months฀ (62%)฀and฀6฀months฀(58%). Hanly฀ et฀ al฀ (53)฀ studied฀ changes฀ in฀ articular฀ symptoms,฀ spinal฀ mobility,฀and฀global฀function฀over฀6฀months฀after฀intraarticular฀injections฀of฀long฀acting฀ corticosteroid฀into฀the฀sacroiliac฀joints฀of฀ 19฀patients฀with฀low฀back฀pain.฀฀Thirteen฀ (68%)฀had฀radiographic฀evidence฀of฀sacroiliitis฀ and฀ were฀ considered฀ to฀ have฀ in- flammatory฀ low฀ back฀ pain,฀ 6฀ patients฀ (32%)฀ had฀ normal฀ imaging฀ studies฀ and฀ thus฀were฀considered฀to฀have฀mechanical฀ low฀back฀pain.฀All฀patients฀received฀bilateral฀ SI฀ joint฀ injections฀ of฀ triamcinolone฀ hexacetonide฀ (40฀ mg/joint)฀ under฀ computer฀ tomographic฀ guidance.฀ Outcome฀ variables฀ included฀ the฀ duration฀ of฀ low฀ back฀ morning฀ stiffness฀ back฀ pain฀ (by฀ visual฀ analog฀ scale,฀ McGill฀ Pain฀ Questionnaire),฀ spinal฀ mobility฀ (chest฀ expansion,฀ Schober฀test,฀10฀cm฀segments฀test,฀fingerfibula฀ distance),฀ and฀ self-report฀ health฀ status฀ (SF-36).฀ ฀ The฀ resulting฀ improvement฀in฀stiffness฀and฀pain฀as฀well฀as฀improved฀spinal฀mobility฀were฀transient฀and฀ were฀most฀pronounced฀at฀1-3฀months฀after฀the฀injections.฀฀This฀did฀not฀reach฀statistical฀ significance฀ (p฀ >฀ 0.05)฀ and฀ by฀ 6฀ Negative฀฀-฀ long฀term฀ Positive฀ short-term฀ and฀longterm months฀ follow-up฀ all฀ outcome฀ variables฀ had฀reverted฀to฀pretherapy฀levels฀in฀both฀ groups.฀ ฀ Based฀ on฀ these฀ preliminary฀ observations,฀ SI฀ corticosteroid฀ injections฀ were฀ considered฀ to฀ be฀ ineffective฀ in฀ the฀ management฀ of฀ patients฀ with฀ inflammatory฀spondyloarthropathy. Slipman฀ et฀ al฀ (54),฀ in฀ a฀ retrospective฀ evaluation฀ with฀ independent฀ clinic฀ review,฀ evaluated฀ the฀ use฀ of฀ fluoroscopically฀ guided฀ therapeutic฀ sacroiliac฀ joint฀ injections฀ in฀ patients฀ with฀ sacroiliac฀ joint฀ syndrome.฀ ฀ The฀ symptom฀ duration฀of฀this฀patient฀population฀was฀as฀early฀as฀1.5฀months฀prior฀to฀inclusion฀in฀the฀ study฀with฀an฀average฀symptom฀duration฀ of฀ 20.6฀ months.฀ ฀ They฀ reported฀ a฀ significant฀ reduction฀ (P฀ =฀ 0.0014)฀ in฀ Oswestry฀disability฀scores฀at฀the฀time฀of฀follow- Pain Physician Vol. 8, No. 1, 2005 McKenzie-Brown et al • Systematic Review of Sacroiliac Joint Interventions 122 up.฀Visual฀Analog฀ Scale฀ pain฀ scores฀ were฀ reduced฀ (P฀ <฀ 0.0001)฀ at฀ the฀ time฀ of฀ discharge฀and฀at฀follow-up.฀Work฀status฀was฀ also฀significantly฀improved฀at฀the฀time฀of฀ discharge฀ (P฀ =฀ 0.0313)฀ and฀ at฀ follow-up฀ (P฀=฀0.0010).฀A฀trend฀(P฀=฀0.0645)฀toward฀ less฀ drug฀ usage฀ was฀ observed.฀ They฀ concluded฀that฀fluoroscopically฀guided฀therapeutic฀sacroiliac฀joint฀injections฀are฀a฀clinically฀ effective฀ intervention฀ in฀ the฀ treatment฀of฀patients฀with฀sacroiliac฀joint฀syndrome. and฀negative฀long-term฀results฀in฀spondyloarthropathy.฀ ฀ The฀ retrospective฀ evaluation฀showed฀positive฀results.฀฀Thus฀it฀was฀ concluded฀that฀evidence฀for฀intraarticular฀ sacroiliac฀ joint฀ injections฀ was฀ moderate฀ for฀short-term฀relief฀and฀limited฀for฀longterm฀relief. Radiofrequency Neurotomy Percutaneous฀ radiofrequency฀ neurotomy฀of฀sacroiliac฀joint฀innervation฀has฀ been฀ described฀ to฀ provide฀ long-term฀ relief.฀ ฀ Our฀ literature฀ search฀ yielded฀ 46฀ reEvidence Synthesis ports.฀฀There฀were฀4฀relevant฀reports฀availThe฀ present฀ systematic฀ review฀ in- able฀for฀review฀(55-58).฀฀Of฀these,฀one฀(55)฀ cluded฀ one฀ randomized฀ trial฀ (50),฀ one฀ was฀prospective,฀and฀3฀were฀retrospective฀ prospective฀trial฀(53),฀and฀one฀retrospec- (56-58). tive฀evaluation฀(54).฀฀The฀randomized฀trial฀ (50)฀ showed฀ positive฀ results฀ both฀ for฀ Methodological Quality short-term฀and฀long-term.฀฀The฀prospecThe฀one฀and฀only฀available฀prospective฀trial฀(53)฀showed฀positive฀short-term฀ tive฀ evaluation฀ (55)฀ was฀ of฀ 3-month฀ fol- low-up.฀ ฀ Consequently,฀ it฀ failed฀ to฀ meet฀ inclusion฀criteria.฀฀All฀of฀the฀three฀retrospective฀reports฀(56-58)฀met฀inclusion฀criteria฀(Table฀9). Study Characteristics Ferrante฀et฀al฀(56),฀in฀a฀retrospective฀ report,฀published฀the฀results฀of฀a฀consecutive฀ series฀ of฀ 50฀ sacroiliac฀ joint฀ radiofrequency฀ denervations฀ performed฀ in฀ 33฀ patients฀ with฀ sacroiliac฀ joint฀ syndrome.฀฀ All฀ patients฀ underwent฀ diagnostic฀ sacroiliac฀ joint฀ injections฀ with฀ local฀ anesthetic฀ before฀ denervation.฀ ฀ Outcome฀ parameters฀ included฀ changes฀ in฀ visual฀ analog฀ pain฀scores,฀pain฀diagrams,฀physician฀examination฀including฀tenderness฀overlying฀ the฀ joint,฀ SI฀ joint฀ pain฀ provocation฀ test,฀ and฀range฀of฀motion฀of฀the฀lumbar฀spine,฀ and฀opioid฀use฀pre-฀and฀post฀denervation.฀฀ The฀ defined฀ criteria฀ for฀ successful฀ radio- Table 9. Description of studies evaluating radiofrequency neurotomy of sacroiliac joint ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Result(s) Outcome(s)฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Short-term฀relief฀<฀3฀months ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Long-term฀relief฀>฀3฀months Study Participants Objective(s) Intervention(s) Ferrante฀et฀al฀(56) 33฀ patients฀ with฀sacroiliac฀ syndrome. Radiofrequency฀(RF)฀ denervation฀ of฀ the฀ sacroiliac฀ (SI)฀ joint฀ has฀ been฀ advocated฀ for฀ the฀ treatment฀ of฀ sacroiliac฀ syndrome,฀ yet฀ no฀ clinical฀ studies฀ or฀ case฀ series฀ support฀its฀use. All฀ patients฀ underwent฀ diagnostic฀ SI฀ joint฀injections฀with฀ local฀ anesthetic฀ before฀denervation. The฀criteria฀for฀successful฀RF฀denervation฀were฀at฀least฀a฀50%฀decrease฀in฀VAS฀ for฀a฀period฀of฀at฀least฀6฀months;฀36.4%฀ of฀patients฀(12฀of฀33)฀met฀these฀criteria.฀ Failure฀ of฀ denervation฀ correlated฀ with฀ the฀ presence฀ of฀ disability฀ determination฀ and฀ pain฀ on฀ lateral฀ l฀exion฀ to฀ the฀ affected฀ side.฀ The฀ average฀ duration฀ of฀ pain฀ relief฀ was฀ 12.0฀ +/-฀ 1.2฀ months฀ in฀ responders฀versus฀0.9฀+/-฀0.2฀months฀in฀ nonresponders฀(P฀<฀or฀=฀0.0001). Negative฀ short-term฀ and฀longterm 14฀ patients฀ met฀ inclusion฀ criteria฀ for฀ this฀retrospective฀study. To฀examine฀the฀ effectiveness฀of฀ sensory฀stimulationguided฀radiofrequency฀neurotomy฀ for฀the฀treatment฀of฀ recalcitrant฀sacroiliac฀joint฀pain. Sensory฀ stimulation-guided฀ sacral฀ lateral฀ branch฀ radiofrequency฀ neurotomy฀ after฀ dual฀ analgesic฀ sacroiliac฀ joint฀ deep฀ interosseous฀ ligament฀ analgesic฀testing. Sixty-four฀ percent฀ of฀ patients฀ experienced฀ a฀ successful฀ outcome,฀ with฀ 36%฀ experiencing฀ complete฀ relief.฀ Fourteen฀ percent฀of฀patients฀did฀not฀achieve฀any฀ improvement. Positive฀ short-term฀ and฀longterm 9฀patients฀who฀ ex p e r i e n ce d฀ >50%฀pain฀relief฀underwent฀ RF฀ lesioning฀ of฀the฀nerves. The฀ purpose฀ of฀ this฀ study฀ was฀ to฀ determine฀ the฀ efi฀cacy฀ of฀ reducing฀ SI฀ joint฀ pain฀ by฀ percutaneous฀ RF฀ lesioning฀ of฀ the฀ nerves฀ innervating฀the฀SI฀joint Nerve฀ blocks฀ of฀ the฀ L4-5฀ primary฀ dorsal฀ rami฀ and฀ S1-3฀ lateral฀ branches฀ innervating฀ the฀ affected฀joint. 13฀of฀18฀patients฀who฀underwent฀L4-5฀ dorsal฀ rami฀ and฀ S1-3฀ lateral฀ branch฀ blocks฀ (LBB)฀ obtained฀ signii฀cant฀ pain฀ relief,฀ with฀ 2฀ patients฀ reporting฀ prolonged฀ benei฀t.฀ At฀ their฀ next฀ visit,฀ 9฀patients฀who฀experienced฀>50%฀pain฀ relief฀ underwent฀ RF฀ lesioning฀ of฀ the฀ nerves.฀ Eight฀ of฀ 9฀ patients฀ (89%)฀ obtained฀ >/=50%฀ pain฀ relief฀ from฀ this฀ procedure฀ that฀ persisted฀ at฀ their฀ 9month฀follow-up. Positive฀ short-term฀ and฀longterm AHRQ฀Score 4/8 Yin฀et฀al฀(57) AHRQ฀Score 4/8 Cohen฀and฀Abdi฀ (58) AHRQ฀Score 4/8 Pain Physician Vol. 8, No. 1, 2005 RF฀ lesioning฀ of฀ the฀ nerves. McKenzie-Brown et al • Systematic Review of Sacroiliac Joint Interventions frequency฀denervation฀was฀at฀least฀a฀50%฀ decrease฀in฀VAS฀for฀a฀period฀of฀at฀least฀6฀ months.฀฀The฀results฀showed฀that฀12฀of฀33฀ patients฀ or฀ 36%฀ of฀ the฀ patients฀ met฀ the฀ criteria฀ for฀ successful฀ denervation.฀ ฀ The฀ average฀duration฀of฀pain฀relief฀was฀12.0฀+ 1.2฀months฀in฀responders฀versus฀0.9฀+฀0.2฀ months฀ in฀ non-responders฀ (P฀ <฀ .0001).฀฀ They฀ also฀ noted฀ that฀ a฀ positive฀ response฀ was฀associated฀with฀an฀atraumatic฀inciting฀ event.฀฀They฀concluded฀that฀radiofrequency฀denervation฀of฀the฀sacroiliac฀joint฀can฀ significantly฀ reduce฀ pain฀ in฀ selected฀ patients฀ with฀ sacroiliac฀ joint฀ syndrome฀ for฀ a฀ protracted฀ time.฀ ฀ With฀ a฀ 6-month฀ response฀ of฀ only฀ 36%฀ of฀ the฀ patients฀ this฀ study฀is฀judged฀as฀negative฀by฀the฀authors฀ of฀this฀review.฀฀ Yin฀et฀al฀(57),฀in฀a฀retrospective฀audit฀ and฀examination฀of฀anatomic฀findings฀as฀ well฀as฀the฀effectiveness฀of฀sensory฀stimulation-guided฀ radiofrequency฀ neurotomy฀ for฀ the฀ treatment฀ of฀ recalcitrant฀ sacroiliac฀ joint฀ pain,฀ studied฀ 14฀ patients.฀ ฀ They฀ defined฀success฀as฀greater฀than฀60%฀consistent฀ subjective฀ relief฀ and฀ greater฀ than฀ a฀ 50%฀ consistent฀ decrease฀ in฀ pain฀ score฀ maintained฀for฀at฀least฀6฀months฀after฀the฀ procedure.฀ ฀ They฀ reported฀ that฀ 64%฀ of฀ the฀patients฀experienced฀a฀successful฀outcome฀with฀36%฀experiencing฀complete฀relief.฀฀The฀authors฀concluded฀that฀a฀sensory฀ stimulation-guided฀ approach฀ toward฀ the฀ identification฀ and฀ subsequent฀ radiofrequency฀ thermocoagulation฀ of฀ symptomatic฀ sacral฀ lateral฀ branch฀ nerves฀ appears฀ to฀offer฀significant฀therapeutic฀advantages฀ over฀ existing฀ therapies฀ for฀ the฀ treatment฀ of฀ chronic฀ sacroiliac฀ joint฀ complex฀ pain.฀฀ Even฀ though฀ this฀ study฀ included฀ only฀ 14฀ patients฀ that฀ met฀ the฀ inclusion฀ criteria,฀ the฀authors฀of฀the฀study฀as฀well฀as฀authors฀ of฀ this฀ systematic฀ review฀ considered฀ this฀ study฀positive. Cohen฀and฀Abdi฀(58)฀performed฀radiofrequency฀lesioning฀on฀9฀patients฀who฀ experienced฀ greater฀ than฀ 50%฀ pain฀ relief฀ following฀nerve฀blocks฀of฀the฀L4-5฀primary฀ dorsal฀ rami฀ and฀ S1-3฀ lateral฀ branches฀ innervating฀the฀affected฀joint.฀฀Eight฀of฀9฀ patients฀ (89%)฀ obtained฀ 50%฀ or฀ greater฀ pain฀ relief฀ from฀ this฀ procedure฀ that฀ persisted฀ at฀ their฀ 9-month฀ follow-up.฀ ฀ The฀ authors฀ concluded฀ that฀ in฀ patients฀ with฀ sacroiliac฀ joint฀ pain฀ who฀ respond฀ to฀ L4L5฀ dorsal฀ rami฀ and฀ S1-3฀ lateral฀ branch฀ blocks,฀ radiofrequency฀ denervation฀ of฀ these฀ nerves฀ appears฀ to฀ be฀ an฀ effective฀ treatment.฀฀The฀authors฀of฀this฀study฀and฀ the฀authors฀of฀this฀systematic฀review฀con- 123 sidered฀ this฀ retrospective฀ evaluation฀ as฀ known.฀ ฀ Consequently,฀ it฀ is฀ imperative฀ positive. that฀ previous฀ studies฀ are฀ replicated฀ and฀ high฀quality฀evidence฀produced. Evidence Synthesis There฀ is฀ no฀ doubt฀ that฀ sacroiliac฀ Based฀ on฀ the฀ available฀ literature,฀ joints฀ are฀ innervated฀ and฀ are฀ capable฀ of฀ which฀consisted฀of฀3฀retrospective฀evalu- producing฀low฀back฀and฀referred฀pain฀in฀ ations฀with฀small฀numbers฀of฀patients,฀the฀ the฀ lower฀ extremity฀ (8-17).฀ ฀ Diagnostic฀ evidence฀ for฀ radiofrequency฀ neurotomy฀ criteria฀ for฀ sacroiliac฀ joint฀ syndrome฀ as฀ in฀managing฀chronic฀sacroiliac฀joint฀pain฀ defined฀ by฀ the฀ International฀ Association฀ was฀limited. for฀the฀Study฀of฀Pain฀(IASP)฀(21)฀included฀pain฀in฀the฀region฀of฀the฀sacroiliac฀joint฀ Safety and Complications with฀possible฀radiation฀to฀the฀groin,฀meNo฀complications฀have฀been฀report- dial฀ buttocks฀ and฀ posterior฀ thigh;฀ reproed฀ in฀ any฀ of฀ the฀ studies฀ included฀ in฀ this฀ duction฀ of฀ pain฀ by฀ physical฀ examination฀ review.฀ ฀ However,฀ potential฀ complica- techniques฀ that฀ stress฀ the฀ joint;฀ eliminations฀ include฀ infection,฀ hematoma฀ for- tion฀ of฀ pain฀ with฀ intraarticular฀ injection฀ mation,฀ neural฀ damage,฀ trauma฀ to฀ the฀ of฀local฀anesthetic;฀and฀a฀morphologicalsciatic฀ nerve,฀ gas฀ and฀ vascular฀ particu- ly฀normal฀joint฀with฀demonstrable฀patholate฀ embolism,฀ leakage฀ of฀ the฀ drug฀ from฀ gnomic฀ radiographic฀ abnormalities.฀ ฀ Of฀ the฀ joint,฀ and฀ other฀ complications฀ relat- this฀ criterion,฀ pain฀ referral฀ patterns฀ have฀ ed฀ to฀ drug฀ administration.฀ ฀Without฀ flu- been฀ well฀ described฀ (14-17).฀ ฀ However,฀ oroscopy,฀successful฀joint฀injection฀is฀doc- with฀ regards฀ to฀ the฀ second฀ criterion,฀ the฀ umented฀in฀only฀12%฀to฀22%฀of฀the฀cas- reproduction฀ of฀ pain฀ by฀ physical฀ exames฀(59).฀฀Rosenberg,฀et฀al฀(59)฀also฀showed฀ ination฀ techniques฀ that฀ stress฀ the฀ joint,฀ that฀there฀was฀epidural฀spread฀in฀24%฀of฀ positive฀ correlations฀ have฀ been฀ reported฀ the฀ patients฀ and฀ contrast฀ was฀ noted฀ in฀ by฀some฀(18,฀24,฀25),฀while฀others฀have฀rethe฀sacral฀foramen฀in฀44%฀of฀the฀patients.฀฀ futed฀ these฀ criterion฀ (17,฀ 19,฀ 20,฀ 26-28).฀฀ Others฀ (60)฀ also฀ have฀ shown฀ low฀ rate฀ of฀ The฀third฀criterion,฀described฀by฀IASP฀as฀ accurate฀placement฀of฀the฀needle฀into฀the฀ elimination฀of฀pain฀with฀intraarticular฀injoint฀without฀fluoroscopy. jection฀ of฀ local฀ anesthetic,฀ was฀ demonstrated฀ in฀ multiple฀ evaluations฀ (17,฀ 18,฀ DISCUSSION 28,฀45,฀46).฀฀Finally,฀the฀last฀criterion฀deThis฀ systematic฀ evaluation฀ of฀ diag- scribing฀ a฀ morphologically฀ normal฀ joint฀ nostic฀ and฀ therapeutic฀ interventions฀ of฀ without฀ demonstrable฀ radiographic฀ abthe฀ sacroiliac฀ joint฀ showed฀ moderate฀ ev- normalities฀ or฀ lack฀ of฀ correlation฀ of฀ raidence฀of฀accuracy฀of฀diagnostic฀sacroili- diographic฀abnormalities฀also฀has฀been฀ilac฀joint฀blocks฀with฀a฀prevalence฀of฀10%฀ lustrated฀(3-5,฀22,฀23,฀29-37,฀40).฀฀Historto฀ 19%฀ and฀ a฀ false฀ positive฀ rate฀ of฀ 20฀ to฀ ically,฀in฀the฀early฀1900’s,฀Goldthwait฀first฀ 22%.฀฀This฀evaluation฀also฀showed฀limited฀ proposed฀the฀sacroiliac฀joint฀(2)฀and฀facevidence฀for฀the฀therapeutic฀effectiveness฀ et฀joints฀(61)฀to฀be฀potential฀pain฀generaof฀ intraarticular฀ injections฀ and฀ radiofre- tors.฀฀After฀100฀years,฀these฀early฀proposiquency฀ neurotomy฀ in฀ managing฀ sacroil- tions฀have฀been฀proven. iac฀joint฀pain.฀฀ The฀ strength฀ of฀ our฀ systematic฀ reThe฀results฀of฀this฀systematic฀evalu- view฀is฀based฀on฀its฀compliance฀with฀strict฀ ation฀ are฀ similar฀ to฀ previous฀ reports฀ as- criteria฀ for฀ evaluation฀ of฀ diagnostic฀ tests฀ sessing฀the฀value฀and฀validity฀of฀sacroiliac฀ as฀ established฀ by฀AHRQ฀ (39),฀ and฀ QUAjoint฀injections฀(43).฀฀However,฀there฀were฀ DAS฀ (40).฀ ฀ The฀ criteria฀ for฀ therapeutic฀ no฀reports฀of฀systematic฀reviews฀of฀sacro- management฀ also฀ included฀ AHRQ฀ criiliac฀joint฀injections.฀฀As฀expected,฀the฀lit- teria฀ for฀ observational฀ studies.฀ ฀ We฀ also฀ erature฀on฀diagnostic฀and฀therapeutic฀in- applied฀ Cochrane฀ review฀ criteria฀ for฀ one฀ terventions฀of฀the฀sacroiliac฀joint฀is฀scarce.฀฀ randomized฀trial.฀฀The฀inability฀of฀a฀phyHowever฀the฀literature฀on฀diagnostic฀sac- sician฀to฀provide฀appropriate฀and฀accurate฀ roiliac฀ joint฀ injections฀ is฀ superior฀ to฀ the฀ diagnosis฀ for฀ a฀ patient฀ with฀ chronic฀ spiliterature฀ on฀ therapeutic฀ interventions.฀฀ nal฀pain฀including฀that฀of฀sacroiliac฀joint฀ Due฀ to฀ the฀ lack฀ of฀ significant฀ literature,฀ pain฀ continues฀ to฀ be฀ frustrating.฀ ฀ Even฀ the฀ level฀ of฀ evidence฀ was฀ low,฀ even฀ with฀ though,฀some฀of฀the฀recent฀literature฀suginclusion฀ of฀ studies฀ of฀ spondyloarthrop- gests฀that฀sacroiliac฀joint฀pain฀can฀be฀diathies.฀The฀relationship฀of฀sacroiliac฀joint฀ agnosed฀based฀on฀provocative฀maneuvers฀ pain฀and฀its฀management฀with฀and฀with- (18,฀25,฀26),฀the฀authors฀of฀this฀systematout฀ inflammatory฀ arthropathy฀ is฀ not฀ ic฀review฀find฀this฀to฀be฀far฀from฀a฀reali- Pain Physician Vol. 8, No. 1, 2005 McKenzie-Brown et al • Systematic Review of Sacroiliac Joint Interventions 124 ty.฀฀Further฀studies฀are฀required฀to฀prove฀ REFERENCES this฀assertion. 1. Mixter WJ, Barr JS. Rupture of the interver- CONCLUSION This฀systematic฀review฀showed฀mod- 2. erate฀ evidence฀ for฀ the฀ accuracy฀ of฀ diagnostic฀sacroiliac฀joint฀injections฀in฀the฀diagnosis฀of฀sacroiliac฀joint฀pain.฀฀This฀systematic฀review฀also฀showed฀moderate฀evi- 3. dence฀for฀therapeutic฀intraarticular฀sacroiliac฀joint฀injections฀and฀limited฀evidence฀ for฀radiofrequency฀neurotomy฀in฀manag- 4. ing฀chronic฀sacroiliac฀joint฀pain. AUTHOR AFFILIATION Ann฀Marie฀McKenzie-Brown,฀MD Assistant฀Professor฀of฀Anesthesiology Division฀Director,฀Division฀of฀Pain฀ Medicine Emory฀Department฀of฀Anesthesiology Emory฀Center฀for฀Pain฀Medicine 550฀Peachtree฀Street,฀NE Atlanta฀GA฀30308 [email protected] Rinoo฀V.฀Shah,฀MD Assistant฀Professor Pain฀Fellowship฀Director Interventional฀Pain฀Institute฀ Texas฀Tech฀University฀Health฀Sciences฀ Center 4430฀South฀Loop฀289 Lubbock,฀TX฀79414 [email protected] Nalini฀Sehgal,฀MD Assistant฀Professor฀of฀Rehabilitation฀ Medicine Medical฀Director฀of฀Interventional฀Pain฀ Program University฀of฀Wisconsin฀Hospital฀&฀ Clinics E3/268฀Clinical฀Science฀Center 600฀Highland฀Avenue Madison,฀WI฀53792-3228 [email protected] Clifford฀R.฀Everett,฀MD Assistant฀Professor,฀ Department฀of฀Orthopaedics฀ and฀Physical฀Medicine฀and฀ Rehabilitation University฀of฀Rochester฀Medical฀Center 601฀Elmwood฀Avenue,฀Box฀65 Rochester,฀NY฀฀14642 [email protected] 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 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