Sacroiliac Joint Block and Neuroablation

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Chapter 11 Sacroiliac Joint Block and Neuroablation

Kyung-Hoon Kim, MD, PhD, Sang-Wook Shin, MD, PhD

The sacroiliac joint (SIJ) is the largest axial joint in the body with an average surface area of 17.5 cm2 [1]. It is a large, auricular-shaped, diarthrodial synovial joint. However, only the anterior third of the interface between the sacrum and ilium is a true synovial joint; the rest of the junction is comprised of an intricate set of ligamentous connections. If the joints become painful, they may cause pain in the low back, buttocks, abdomen, groin or legs (Figs. 11-1 and 11-2).

image

Figure 11–1 Density of referral zones for sacroiliac joint pain. 0.5+ is the least common referral zone, 4+ the most common.

image

Figure 11–2 Common referral zones for sacroiliac joint pain. The sacroiliac joint can become inflamed from an acute injury or from chronic postural abnormalities. Undue stress on the joint following low back fusion surgery can also cause inflammation and pain here. Pain from sacroiliac joint abnormalities occurs in the low back, buttock/hip, abdomen, groin, or legs.

The primary function of the sacroiliac joint is to lend stability, which it accomplishes through the following mechanisms:

image The transmission and dissipation of truncal loads to the lower extremities
image Limiting of x-axis rotation
image Facilitation of parturition

The biomechanics of the SIJ withstand a medially directed force six times greater than the lumbar spine, but only half of the torsion and 1/20 of the axial compression load.

Sacroiliac joint dysfunction

Typically, SIJ dysfunction is initially symptomatic after a minor traumatic event, such as a fall onto the buttocks or a slip while pushing a heavy object. It is then aggravated by transitional activities, such as climbing stairs, getting up from a chair, and getting out of a car. Pain in the SIJ can also be provoked by activities requiring asymmetrical loading through the lower extremities or pelvis, such as skating, gymnastics, golfing, and step aerobics.

Dreyfuss and colleagues [2] have shown that the pain referral pattern in asymptomatic volunteers consists of the following areas:

image The buttock, the groin, and the entire lower limb, but not the back above the L5 level
image An area extending 10 cm caudally and 3 cm laterally from the posterior superior iliac spine

The diagnostic criteria for sacroiliac joint syndrome, as defined by the International Association for the Study of Pain (IASP), are as follows:

image Pain in the region of the SIJ with possible radiation to the groin, medial buttocks, and posterior thigh
image Reproduction of pain by physical examination techniques that stress the joint
image Elimination of pain with intra-articular injection of a local anesthetic
image An ostensibly morphologically normal joint without demonstrable pathognomonic radiographic abnormalities

One of the most consistent physical findings in patients with SIJ dysfunction is point-specific tenderness over the sacral sulcus as well as the posterior sacroiliac spine.

The prevalence of SIJ pain in carefully screened patients with low back pain (LBP) is in the range of 15% to 25%. 39% of patients with SIJ dysfunction were also diagnosed [3] with an associated spinal disorder. Of these spinal disorders complicated by SIJ dysfunction, the most common are as follows:

image Facet joint syndrome (41%)
image Spondylolisthesis (29%)

SIJ dysfunction can stem from both intra-articular and extra-articular sources, although extra-articular sources such as enthesopathy and fractures are more common. Nociception in the SIJ can also be caused by pathologic changes affecting many different SIJ structures, such as the following:

image Capsular or synovial disruption
image Capsular and ligamentous tension
image Hypomobility or hypermobility
image Extraneous compression or shearing forces
image Abnormal joint mechanics
image Microfractures or macrofractures
image Chondromalacia
image Soft tissue injury
image Inflammation

The following factors predispose an individual to SIJ dysfunction:

image Degenerative joint disease
image Joint (ligamentous) laxity and pregnancy
image A history of minor direct trauma, such as a fall onto the buttocks

The average mechanical threshold of the SIJ nociceptive unit is shown in Table 11.1.

Table 11.1 Average Mechanical Threshold of Sacroiliac Joint and Other Nociceptive Units

Nociceptive Unit Average Mechanical Threshold (g)
Sacroiliac joint 70
Lumbar facet joint 6
Anterior lumbar disc 241

SIJ treatment options are injections, nerve blocks, and denervation. A sacroiliac joint injection serves the following two purposes:

image Injecting anesthetic medication into the joint confirms whether or not pain comes from the joint.
image The local anesthetic and cortisone can help break a pain cycle, possibly facilitating a rehabilitative exercise program.

The evidence for the effectiveness of SIJ block and denervation as diagnostic and therapeutic methods for SIJ dysfunction is shown in Table 11.2.

Table 11.2 Level of Evidence for Intra-articular Injection and Neurotomy

Intra-articular injection:  
Diagnostic method Moderate evidence for diagnosis of pain from the sacroiliac joint (SIJ)
Therapeutic method Moderate evidence for short-term relief (<3 months)
Limited evidence for long-term relief
Radiofrequency neurotomy Indeterminate evidence for managing SIJ pain

Indications

The primary indication for treatment with SIJ block and neuroablation is intra-articular sacroiliac joint pain. The diagnostic criteria for identifying idiopathic intra-articular sacroiliac joint pain are as follows:

image Absence of neurologic deficits
image Absence of dural tension signs
image Absence of laboratory, imaging, or clinical evidence of medical causes of sacroiliac joint pain
image Maximal pain below L5
image No evidence of lumbar pain generators (if indicated, this can be confirmed through negative results of zygapophys-eal joint block and discography)
image At least 75% relief with controlled, dual, fluoroscopically guided, contrast-enhanced intra-articular SIJ injections

Several major diagnostic tests are used to confirm a diagnosis of intra-articular SIJ pain; they are described in Table 11.3 and Box 11.1, and shown in Figures 11-3 through 11-5.

Table 11.3 Sensitivity and Specificity of Major Diagnostic Tests Used to Identify Patients with Intra-articular Sacroiliac Joint Pain

Test Sensitivity Specificity
Sacroiliac joint pain ++++ +
Groin pain + +++
Buttock pain ++++ +
Indication of posterior superior iliac spine as pain source ++++ ++
Abnormal sitting posture + ++++
Pain lessens with:
Nonsteroidal anti-inflammatory drugs
Exercise
Manipulation		 ++
++
+++		 ++
++++
++++
Gillet test ++ +++
Patrick test +++ +
Gaenslen test +++ ++
Sacral sulcus tenderness ++++ +
Midline sacral thrust +++ ++
Bone scan ++ ++++
Computed tomography +++ +++

+, 0-25%; ++, 26%-50%; +++, 51%-75%; ++++, 76%-100%.

BOX 11.1 Common Tests Utilized in Evaluation of Sacroiliac Joint Dysfunction

Laguerre Test

To differentiate hip pain from sacroiliac pain, the patient is supine. The examiner passively flexes the patient’s hip and knee 90°. Then the hip is passively abducted and placed in extreme external rotation. This maneuver moves the femoral head into the anterior part of the joint capsule of the hip. Pain within the hip suggested degenerative disease, hip dysplasia, or contracture of the iliopsoas muscle. Pain felt posteriorly in the sacroiliac joint suggests a disease process at that site.

Gillet Test

Also called sacral fixation test, ipsilateral posterior rotation test.

The Gillet test has been described as the one leg standing test, sacral fixation test, ipsilateral posterior rotation test, marching test, and the ipsilateral flexion kinetic test. To perform this test, the patient stands while the examiner palpates the posterior superior iliac spine (PSIS) with one thumb and palpates the sacrum with the other thumb staying parallel to the first thumb. The patient is then instructed to stand on one leg while pulling the opposite knee up toward the chest. The test is then repeated on the other side and compared bilaterally. A positive test is noted when the PSIS on the ipsilateral side of the knee flexion does not move or moves minimally in the inferior direction. The PSIS on the side of hip flexion should move slightly anterior.

Patrick Test (see Fig. 11-4)

The knee is flexed to 90° on the affected side and the foot is rested on the unaffected knee. Holding the HYPERLINK http://en.wikipedia.org/wiki/Pelvis \o “Pelvis”pelvis firm against the examination table, the affected-side knee is pushed towards the examination table, a maneuver which provides external rotation of the leg at the hip HYPERLINK http://en.wikipedia.org/wiki/Joint \o “Joint”joint. If pain results, this is considered a positive Patrick’s test and sacroiliitis is more likely.

Gaenslen Test (see Fig. 11-3)

Also called the pelvis torsion test.

The hip joint is flexed maximally on one side and the opposite hip joint is extended, stressing both sacroiliac joints simultaneously. This is often done by having the patient lying on his or her back, lifting the knee to push towards the patient’s chest while the other leg is allowed to fall over the side of an examination table, and is pushed toward the floor, flexing both sacroiliac joints. The test can also be performed with the patient in the supine position. The examiner passively flexes the hip while stabilizing the other limb to keep the contralateral limb in a neutral position. The test is considered positive if the patient experiences pain while this test is performed, and may indicate a need for further testing, such as an HYPERLINK http://en.wikipedia.org/wiki/X-ray \o “X-ray”x-ray or lumbar HYPERLINK http://en.wikipedia.org/wiki/Computer_tomography \o “Computer tomography”CT scan.

Yeoman Test (see Fig. 11-5)

Yeoman’s test stresses the sacroiliac joint by extending the leg and rotating the ilium. A positive test produces pain over the back of the sacroiliac joint.

image

Figure 11–3 Gaenslen test is often done by having the patient lying on his or her back, lifting the knee to push towards the patient’s chest while the other leg is allowed to fall over the side of an examination table, and is pushed toward the floor, flexing both sacroiliac joints (See the detail in BOX 11.1).

image

Figure 11–4 Patrick test stresses the hip and sacroiliac joints. In a positive result, the test produces back, buttocks, or groin pain.

image

Figure 11–5 Yeoman’s test stresses the sacroiliac joint by extending the leg and rotating the ilium. A positive test produces pain over the back of the sacroiliac joint.

Complications

Sacroiliac Joint Injection

Complications of SIJ injection are as follows:

No pain relief: If the cause of the pain was not the SIJ itself, injecting it will not relieve the pain. Attempting an SIJ injection without fluoroscopic guidance is very difficult and increases the chance that pain relief will not be achieved.
Temporary leg weakness: The sciatic nerve runs just in front of the SIJ. In some patients, the local anesthetic mixture spreads from the joint onto the nerve, causing temporary weakness and inability to stand. The magnitude and duration of the complication depend on the type and strength of the local anesthetic used.
Infection: The procedure must be performed under aseptic conditions to reduce the risk of infection.
Increased pain: As in any pain procedure, the pain can appear to be worse afterwards. The cause of this complication cannot always be explained.
Cortisone-related side effects: Fluid retention, weight gain, increased blood sugar (mainly in diabetic patients), elevated blood pressure, mood swings, irritability, insomnia, and suppression of the body’s own natural production of cortisone. Fortunately, the serious side effects and complications relating to cortisone are uncommon.

There is also a risk of tissue injury and bleeding. Injections near the spine carry the risk of dural puncture and spinal headache.

Neuroablation

Complications of SIJ neuroablation are as follows:

image Pain or discomfort around the injection site
image Numbness of skin covering the injection site
image Worsened pain due to muscle spasm in the area of the injection
image Permanent nerve pain
image Allergies or reactions to medications used
image Infection

Preoperative preparation

Physical Examination

The physical examination performed before SIJ block or neuroablation consists of the following tests:

Fortin finger test: The patient points to the area of pain with one finger. The result is positive if the site is within 1 cm of and generally inferomedial to the posterior superior iliac spine (PSIS).
Gaenslen test: The patient is supine. The hip and knee of one leg are maximally flexed toward the trunk, and the other leg is extended. Some examiners perform this test with the patient’s extended leg off the examining table to force the SIJ through the maximal range of motion. The result is positive if pain is felt across the SIJ. This maneuver also stresses the hip joint, producing trochanteric pain (see Fig. 11-3).
FABER maneuver (flexion, abduction, external rotation, and extension of hip; also called Patrick test): The patient is supine. One heel is placed on the other knee and the elevated leg is guided toward the examining table. The result is positive if pain is elicited along the SIJ. This also stresses the hip joint and may result in trochanteric pain (see Fig. 11-4).
Compression test: The patient lies on one side. The examiner applies pressure to one pelvic brim in the direction of the other. A positive result is pain across the SIJ.
Compression test at the SIJ: The patient is prone. The examiner places a palm along the SIJ or on the sacrum and makes a vertical downward thrust. Discomfort along the joint line is considered a positive result.
Pubic symphysis test: The patient is supine. Pressure is applied with the examining finger at the left or right public bone adjacent to the symphysis. The result is positive if pain is felt at the site. Most patients are not aware of this tenderness before it is elicited. The examiner should ask permission before applying pressure and might consider having a witness in the room to avoid the misconception of inappropriate sexual contact.
Distraction test: The patient is supine. The examiner alternately presses each anterior superior iliac spine (ASIS) in a posterolateral direction. The result is positive if the pressure produces pain or if movement is asymmetrical.
FADE test (flexion, adduction, extention): The patient is supine. The hip is flexed and adducted to the midline. The examiner applies pressure to the long axis of the femur to push the ilium posterior. Pain is considered a positive result of this test.
Passive straight-leg raising: The patient is supine. The examiner grasps the heel and lifts the leg vertically from the examining table with the knee extended. The patient is asked to hold the leg elevated and then to slowly lower it. A positive result is ipsilateral pain, which suggests anterior rotation.
One-legged stork test: The patient stands in front of the examiner. The examiner’s thumbs are placed on one PSIS and on the sacrum at S2. The patient then flexes the palpated hip to 90 degrees. If the examiner’s thumb moves upward instead of inferolaterally, as would be expected, the result is positive.
Van Durson standing flexion test: The patient stands in front of the examiner. The examiner’s thumbs are placed just below each PSIS. The patient flexes the trunk forward without bending the knees. A positive sign is asymmetrical motion (i.e., upward motion on the involved side).
Piedallu test or the seated flexion test: The patient is seated in front of the examiner. The examiner’s thumbs are placed just below each PSIS. The patient flexes the trunk forward. A positive result is asymmetry of motion (i.e., upward motion on the involved side).
Rectal examination: Although it is not specific for SIJ involvement, a thorough rectal examination is necessary to search for referred pain from the prostate, uterus, or spasm in muscles of the pelvic floor. Piriformis muscle spasm can be localized at the end of the examiner’s finger at the 2 o’clock or 10 o’clock position. Because piriformis muscle spasms are associated with sciatic nerve entrapment, compression of this muscle reproduces painful symptoms.
Yeoman test: With the subject prone, the test is performed by rotating the ilium with one hand and extending the hip while the knee is extended. Pain over the ipsilateral posterior sacroiliac joint area is indicative of sacroiliitis.

ANATOMY[1]

The anatomy of the pelvis is shown in (Figures 11-6 and 11-7):

image The pelvis consists of the two ilia and the sacrum
image The anterior side of the joint is lined with thick hyaline cartilage
image The posterior iliac side of the joint is lined with fibrocartilage
image

Figure 11–6 Posterior view of the articulations and associated ligaments of the sacroiliac joint and surrounding structures.

image

Figure 11–7 Anterior view of the articulations and associated ligaments of the sacroiliac joint and surrounding structures.

Important aspects of the anatomy of the SIJ (Fig. 11-8) are as follows:

image The innervation of the SIJ is extremely complex, and while there is no clear consensus concerning the exact innervation, the most accepted view is described in Box 11.2.
image The sacroiliac joint connects the sacrum (the triangular bone at the bottom of the spine) with the pelvis (iliac crest).
image The joint transmits all the forces of the upper body to the pelvis and legs.
image It acts as a shock-absorbing structure.
image It does not have much motion.
image

Figure 11–8 1, Articular surface of sacroiliac joint. 2, Nutation of the sacroiliac joint

BOX 11.2 Innervation of the Sacroiliac Joint

Posterior innervation: The lateral branches of the L4-S3 (L3-S4) dorsal rami.

Anterior innervation: The L2-S2 (L4-S2 or L5-S2) ventral rami.

Procedures

Sacroiliac Joint Injection

The procedure for sacroiliac joint injection is as follows:

1. The patient’s written informed consent is obtained.
2. With the use of local anesthesia and sometimes light intravenous sedation, a small-diameter needle is placed into the joint in question under fluoroscopic guidance (Fig. 11-9).
3. Radiographic contrast medium is injected to confirm correct needle placement. A mixture of local anesthetic and steroid is injected (usually 5-10 mL of 0.4% lidocaine plus triamcinolone 20-40 mg).
4. After the injection, some patients may obtain further relief by wearing a specifically designed SIJ support belt.
image

Figure 11–9 The block needle is placed on the right sacroiliac joint.

Denervation of the Sacroiliac Joint

1. The patient’s written informed consent is obtained.
2. The patient is placed in the prone position on the fluoroscopy table.
3. The fluoroscopy unit is angled inward so that the lines of the posterior aspects of the joint are seen.
4. The tube is angled caudad and obliquely from the side opposite the joint to be lesioned—that is, an oblique view at 15 to 20 degrees from the opposite side of the body is used to correctly visualize the posterior joint lines, approximately 5 mm lateral to the foramen, just before the nerves enter the surrounding ligaments (Fig. 11-10).
5. The procedure of denervation is done as usual manner.
image

Figure 11–10 Schematic drawing showing the S1-S3 lateral branches innervating the sacroiliac joint and overlying ligaments. The needles depict the approximate location for the diagnostic lumbar branch block.[4]

From Dreyfuss P, Dreyer SJ, Cole A, Mayo K. Sacroiliac joint pain. J Am Acad Orthop Surg 2004;12:255-265.

CASE STUDY 11.1

A 76-year-old woman had suffered from low back and left posterior buttock pain without radiating pain below the knee for 3 months. Physical examination elicited positive stress test results and severe tenderness on the left posterior superior iliac spine. The patient underwent sacroiliac joint block. During the procedure the pain source was verified by pain provocation upon application of contrast medium and appropriate anesthetic agents were applied for pain relief (Fig. 11-11).

image

Figure 11–11 A, A K-wire indicates the left posterior sacroiliac joint (SIJ) within 0.5 cm distance of the lowest point of the SIJ. B, A 10-cm, 22-gauge block needle is placed in the left SIJ. C, The block needle is placed in the left SIJ on lateral view. The contrast medium is injected into the joint. D and E, The fluoroscope is rotated slowly from the lateral to anteroposterior view to monitor the configuration of the spread of contrast medium. F, Finally, the left SIJ becomes dark with the contrast medium in the shape of a gourd or flask. After confirmation of of contrast medium spread and pain provocation, a mixture of 2 to 3 mL of 0.4% lidocaine and 20 mg of triamcinolone is injected.

Postprocedural management

Immediate postprocedure management consists of the following:

image The patient should be encouraged to walk and to try to perform a motion that would normally bring about pain.
image The patient is asked to report the percentage of pain relief and to record the relief experienced during the next week on a post-injection evaluation sheet (“pain diary”).

The patient’s leg(s) may feel numb for a few hours; the patient should be reassured that this is fairly uncommon but does occasionally happen. On occasion, the back or neck may feel odd or slightly weak for several weeks after the neuroablation procedure.

Success rates of neuroablation vary, but typically, about 30% to 50% of patients undergoing this procedure experience significant pain relief for as long as 2 years. Of the remaining patients, about 50% get some pain relief for a shorter period. Some patients do not experience any relief from pain with this procedure.

In some cases (<5%), pain is increased rather than relieved by the procedure. This result is believed to occur from increased irritation of a nerve that was only partially damaged, not completely destroyed, during the procedure. It can be treated with medication and usually goes away in several months.

Full pain relief from neuroablation will typically not be experienced until about 2 to 3 weeks after the procedure, when the nerves have completely died. The nerves will eventually grow back (regenerate), but the patient’s pain may or may not recur. If the pain does recur, a second neurotomy can be performed.

References

1. Cohen S.P. Sacroiliac joint pain: A comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg. 2005;101:1440-1453.

2. Dreyfuss P., Dryer S., Griffin J., et al. Positive sacroiliac screening tests in asymptomatic adults. Spine. 1994;19:1138-1143.

3. Schwarzer A.C., Aprill C.N., Bogduk N. The sacroiliac joint in chronic low back pain. Spine. 1995;20:31-37.

4. Dreyfuss P., Dreyer S.J., Cole A., Mayo K. Sacroiliac joint pain. J Am Acad Orthop Surg. 2004;12:255-265.

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