Sacroiliac Joint
J. Scott Bainbridge, MD
www.DenverBackPainSpecialists.com
SIJ Background
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Proposed as potential source of pain by
Goldthwaite in 1905
Incidence of SIJ pain in LBP population: 1840% (Schwarzer, Maigne, DePalma, Liliang,
Schofferman)
SIJ Anatomy
SIJ Anatomy
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Diarthrodial joint
Hyalin cartilage, fibrocartilage also on ilial side
Interlocking contours
Ligaments: anterior and posterior SIL, interosseous
SIL, sacrospinous and sacrotuberous
Muscles: paraspinous, gluteal, psoas, iliacus, abdominal,
sartorius, rectus femoris, hamstrings, latissimus dorsi
(lumbodorsal fascia)
Nutation
SIJ Innervation
SIJ Innervation
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Early: Cunningham’s…, Bernard and Cassidy,
Ikeda, Nagakawa, etc. included anterior
innervation (ventral rami)
Fortin et al, Grob et al: macroscopic and fetal
microscopic fetal studies: innervation entirely
dorsal rami (S1-3[4])
Yin, Willard, Carreiro, Dreyfuss: defined (fluoro)
course of sacral dorsal rami; reported SIJRF
pilot technique and results
S-1 Dorsal Rami
Yin, et al. Spine 2003
S-2 Dorsal Rami
S-3 Dorsal Rami
Diagnosis
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X-ray, MRI, CT, bone scan generally not helpful except
to rule in/out fracture, stress response, infection,
tumor, sacroiliitis
Arthrogram may show capsular disruption
Need double intraarticular SIJ blocks to diagnose,
although single IA, posterior ligament, or dorsal rami
blocks have been used by various authors/practitioners
Blockade of the L5 Dorsal Rami and Sacral 1-3 lateral
branches, using the multi-site, multi-depth technique of
Dreyfuss, et al. (Pain Medicine 2009) is necessary for
radiofrequency neurotomy (RFN) screening.
Diagnosis - History
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Unilateral pain at or below PSIS, PSIS pointing
(Fortin, Maigne)
, no pain above L5, pain over SIJ and Buttock
(Dreyfuss, et al)
Diagnosis – Physical Exam
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Maigne: Patrick’s – trend – p=0.9
Broadhurst and Bond: double blind, lido v saline
FABER (Flexion, ABduction, External Rotation)
 POSH (POsterior SHear)
 REAB (REsisted ABduction)
 100% specificity, 77-80% specificity @ 70% < pain
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Diagnosis – Physical Exam
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Dreyfuss, et al (multidisciplinary expert panel)
12 key pain, Hx, and PE parameters
 Single block, 90% relief
 PSIS pointing, no pain above L5, sacral sulcus
tenderness, pain over SIJ/buttock
 Gillet’s test best of provocative maneuvers
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Diagnosis – Physical Exam
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Van der Wurff, et al, 2006
Double blocks, >50% relief
3 of 5 positive tests (distraction, compression,
thigh thrust, Patrick, Gaenslen)
Sensitivity .85, specificity .79
PPV .77, NPV .87
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Discogenic: Centralization w McKenzie method
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Pain w rising from sitting
Sacroiliac: Unilateral pain; No lumbar pain
Pain rising from sitting
 3/5 provocation tests: distraction, compression,
sacral thrust, thigh thrust, Gaenslen’s
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LZJ: no pain rising from sitting
SIJ - Treatment
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Manual therapy
Exercise (m. balance, stabilization)
Medication
IA injection (corticosteroids)
Prolotherapy
PRP – Platelet Rich Plasma
Neuromodulation
Dennervation (RF neurotomy)