Paper of the month January 2024

Sacroiliac Joint Pain
^{Pain Pract. 2023 Dec 28. doi: 10.1111/papr.13338.}
Szadek K, Cohen SP, de Andrès Ares J, Steegers M, Van Zundert J, Kallewaard JW.This is a review of SIJ pain from a pain physician's perspective, published by Dr. Szadek Karolina. It contains current information and must have been a difficult task to summarize.

Here are my questions and the author's answers:

1. What physical findings do pain physicians typically pay attention to, which of the provocation tests do they use most often, and which do they rely on most in clinical practice?
   

   Physical examination is always a point of discussion. I relay on my own regime. I do the neurological screening to exclude the neurological problem. Then, I divide the back in quadrants, whereby I draw the line through the L5. So, you have the above L5 left and right and lower left and right. In the case of SI joint pain, I let to point the painful area twice (the Fortin finger test), and then I put some pressure on this area. If I think SI joint may be the problem, then I do the provocation tests. I always do the TTT as the last one, otherwise if the test is positive, I usually am biased by the result. I case of instability I do the Stork test, but I am not very good in that one.

2. The Gillet test is not a test I usually use. But is this test standard among pain physicians?
   

   I don't think it is standard. We are focused on pain and therefore we have the provocation tests.

3. How many pain physicians routinely perform SIJ injections? Do you organize workshops on SIJ injections to standardize the technique?
   

   From the WIP we have the hands-on training. There is a book published by A. Stogicza about the procedures. Regarding the denervation, the treatment is not reimbursed in The Netherlands. If I perform it I use the bipolar palisade technique.

4. Periarticular SIJ injection using ultrasound to localize only the SIJ interosseous ligamentous region, with just 0.3-0.5 ml of 1% Lidocaine injected into each of the four sections, dramatically improves symptoms and contributes to the diagnosis. If the volume is too large, the local anesthetic will leak into the S1 or S2 foramen, which may obscure the diagnosis. What does the pain physician's workshop think about the periarticular SIJ injection method?
   

   In my center we use periarticular injection for > 20 years now. Only in case of proved inflammation I inject intraarticularly. Why?, well if it doesn't work for a prolonged period of time then I have done the prognostic block to do the RF.

5. Regarding the reference number 130 that you cite, it is interesting to note that in cases of chronic pain, if there is a 30-50% relief of pain on the NRS, the patient feels very much improved. I use a "Pain Relief Scale" of at least 70% pain relief as a definitive diagnostic criterion for SIJ dysfunction/pain by using SIJ injections, and 50% means that the other half is a mixture of things that are not from SIJ, which seems a bit weak as a definitive diagnosis. What percentage do you typically use as a criterion?
   

   Difficult question, as we usually use the NRS. The patients sometimes do not understand the difference between the NRS and percentage of pain relief. I use minimum of 50% pain relief. I do not see the patients with “simple” SI joint pain in Amsterdam. This kind of patients I see coming from the general practitioner on Bonaire.

   Evaluating sacroiliac joint pain as part of a chronic pain syndrome can be difficult because the degree of pain relief is subjective to the individual. How much load can be placed on the affected lower extremity after the SIJ injection? How much has sitting time increased? How much has the time to turn over twice in a row been reduced? I have recently been working with PTs to estimate the effect of the SIJ injection using these quantifiable indicators.

My practice is based on orthopaedic and spine surgery, so I always keep in mind the differentiation and complications of lumbar spine disease and SIJ dysfunction/pain. Hip disorders, especially hip labral injuries and femoral acetabular impingement cases, can present with severe sacroiliac pain as an initial symptom, and I pay attention to that as well.

In Dr. Szadek's review article, a clinical practice algorithm is presented in Figure 2.

The algorithm that SIMEG will create will add a clinical perspective from orthopaedic and spine surgeons and will express the elements to identify cases that require surgical treatment.

I also try to treat young women with attention to SIJ pain as part of pelvic ring instability or laxity, not just in the postpartum period. We use functional pelvic bracing and prolotherapy in the posterior ligament of the SIJ.

• 6. Do you use prolotherapy in your usual clinical practice, although it is not mentioned in this review?
  

  No, we don't use it as a standard care.

• 7. Finally, how do pain physicians deal with patients who have both sacroiliac problems and coccygeal pain?
  We deal with a lot of mixed problems. I think the majority of our patients have the combination of facet, discogenic and SI joint pain. I see the combination of coccygeal pain and SI joint pain rarely.

It must have been very difficult to collect and summarize the huge number of reference papers. I would like to thank you for publishing a very valuable paper and I am convinced that you, pain physicians, are also absolutely necessary for the scientific development of SIMEG. And of course, patients will expect to be treated by the techniques of pain physicians, as no one would want surgical treatment in the first place. I sincerely hope that you will make great progress in improving your advance intervention management.

Daisuke Kurosawa/Karolina Szadek