Paper of the month December 2023
A Review and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain.
J Pain Res. 2020 Dec 8;13:3337-3348.
Falowski S, Sayed D, Pope J, Patterson D, Fishman M, Gupta M, Mehta P.
I was informed of this paper by Dr. Volker Fuchs, written by interventional pain physicians. It presents an algorithm for diagnosis and treatment leading to implant insertion via the posterior approach (the method discussed in the “Paper of the month, November 2023”), which they are now actively practicing.
Although the paper is considered to be an “expert opinion” paper, their thoughts are expressed in Figure 1. The main part of the paper is a collection of literatures on diagnostic criteria, physical exam findings, common etiologies and risk factors, non-surgical treatment, etc., and not their own opinions as experts. Finally, the paper details the surgical procedures they are recommending with a posterior or posterior oblique approach. So, the article does not indicate how many interventional pain experts agree or recommend each item (physical findings, diagnostic procedures, treatment) as their opinion, which is what I would have expected.
During the course of the patient's follow-up, two opportunities for sacroiliac joint injections are provided. The first is for diagnosis and the second is for treatment. Some insurance carries require two injections prior to surgical fixation. Their algorithm covers this requirement. Even if it is not related to insurance carry, I agree that it is important to confirm the diagnosis and condition of the patient by using sacroiliac joint injections at least twice.
There are well-known European guidelines, “Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008 Jun;17(6):794-819“- Of course, Dr. Bengt Sturesson is involved, so the opinion of surgeon is included, but mainly from the perspective of physical therapists and anatomists. They do not recommend sacroiliac intraarticular injections for the definitive diagnosis, because it is not reliable. If so, the sensitivity and specificity of provocation tests that they have studied in a large number of cases with a confirmed diagnosis of sacroiliac joint injections for a long time cannot be relied on as well. In reality, however, we need to be able to diagnose and treat sacroiliac joint dysfunction in clinical practice. In addition, the main topic of discussion is not the sacroiliac joint itself, but rather pelvic girdle pain in pregnant and postpartum women, which obscures the target of treatment. Sacroiliac joint fusion surgery is not recommended in this European guidelines. In actuality, we do see some severe patients with sacroiliac joint dysfunction who really do need a surgical treatment, and it is important not to overlook them.
Let me return once again to the topic of the paper presented here. This time, the paper was written by interventional pain physicians. We, the surgeons of SIMEG, would have different expert opinions than that of the pain physician or the physical therapist. I believe that we may be able to create a diagnostic and therapeutic algorithm that will be useful in clinical practice, especially for sacroiliac joint surgeons.
First, I would like to ask the board members who actually perform sacroiliac joint fusion surgery to answer the following questions. Of course, there are many surgeons who are members of SIMEG, so we would like to get comments from them as well. Through these activities, we would like to create our own algorithm under the direction of Dr. Volker Fuchs. We will continue to consider additional questions and will need literatures to support our opinions.
Questions for experts
Q1: Do you focus on the following items in your physical examination for diagnosis?
- One finger test (Fortin finger test) Yes/No/Unknown
- SIJ shear test Yes/No/Unknown
- Thigh thrust test Yes/No/Unknown
- Gaenslen’s test Yes/No/Unknown
- Fabere test Yes/No/Unknown
- Distraction test Yes/No/Unknown
- Compression test Yes/No/Unknown
- Sacral thrust Yes/No/Unknown
- Gillet test Yes/No/Unknown
- Standing flexion test Yes/No/Unknown
- sitting posterior-superior iliac spine palpation Yes/No/Unknown
- supine long-sitting test Yes/No/Unknown
- Prone knee flexion test. Yes/No/Unknown
- Tenderness of the posterior superior iliac spine (PSIS) Yes/No/Unknown
- Tenderness of the long posterior sacroiliac ligament (LPSL) Yes/No/Unknown
- Tenderness of the sacrotuberous ligament (STL) Yes/No/Unknown
- Active SLR test Yes/No/Unknown
- Sitting tolerance time Yes/No/Unknown
- Roll over time Yes/No/Unknown
- Others （ ）
Q2. Diagnosis using an sacroiliac joint injection
What percentage of pain relief should be considered
- 50% or more Yes/No
- 70% or more Yes/No
- Do you perform sacroiliac joint injection yourself? Yes/No
- Is a diagnosis using periarticular (posterior ligament) sacroiliac joint injection acceptable? Yes/No
- Only intra-articular sacroiliac joint injection has diagnostic value? Yes/No
- Both peri-and intra-articular injections are performed simultaneously to predict preoperative efficacy? Yes/No
Q3. What type of conservative therapy do you recommend?
- Pelvic belt
- Abdominal core muscle training
- Motion guidance
- Manual therapy specific for sacroiliac joint dysfunction
- Radiofrequency neurotomy
- Spinal cord stimulation
- Others （ ）
Q4. What information is decisive for surgery?
- Poor response to conservative therapy for more than 3 months
- Poor response to conservative therapy for more than 6 months
- Inability to apply sufficient load with the affected lower limb
- Short sitting tolerance for less than 15 minutes
- Uses a cane to walk
- Requires a wheelchair for mobility
- Others （ ）
Q5. How do you differentiate between sacroiliac joint dysfunction and other diseases?
- Diagnosis and exclusion of complicated lumbar spine disease
- Do yourself Yes/ No ➡Refer to spine surgeon? Yes/No
- Diagnosis and exclusion of patients with hip joint disease
- Do yourself Yes/ No ➡Refer to a hip surgeon? Yes/No
Q6: What is your first choice of surgical procedure?
- Lateral Yes/No
- Posterior Yes/No
- Anterior Yes/No
Q7: What are the most important procedure of the surgery?
- Strong fixation
- Bone grafting for bone fusion in the intraarticular area
- Bone grafting for bone fusion in the extra-articular area
- Compression procedures
- Disarticulation procedures
- Others ( )
Q8. Do you restrict postoperative weight bearing?
- 1/2 partial weight bearing up to 6 weeks
- 1/2 partial weight bearing up to 8 weeks
Q9. Length of hospital stay after surgery
- One day
- One week
- Less than one month
- More than one month
Q10. Sacroiliac joint fusion surgery for women
After surgery, would you recommend a cesarean section at delivery? Yes/No/Unknown
Q11. About revision surgery
How do you determine when revision surgery is necessary?
- The effect of sacroiliac joint injection to patients who undergo primary sacroiliac joint
- Implant loosening on imaging findings
3．Both of them
Q12. Can you do revision surgery yourself?
Q13. Is a surgeon without a revision strategy allowed to perform the surgery?