I see many patients who come into my office with an MRI that shows something wrong or off in their sacroiliac joint or joints and a compliant that they have low back pain. Some will tell me that based on their MRI, their doctors are confirming that the primary source of their low back pain is their sacroiliac joint. Further, the patient has been told to strongly consider a surgical recommendation to spinal fusion.
For many of these people, the MRI was the confirmation that their surgeon needed to go ahead with the surgery. For many patients, this may have been the same doctor who had taken them through a course of conservative treatments. These treatments may have included anti-inflammatory medications, back braces, physical therapy, and cortisone and epidural injections.
Sacroiliac joint dysfunction is the improper movement of the joints at the bottom of the spine that connect the sacrum to the pelvis. It can result in pain in the low back and legs, or inflammation of the joints known as sacroiliitis.
The challenges of diagnosis and management of Sacroiliac joint dysfunction: “Although Sacroiliac joint dysfunction accounts for a large portion of chronic low back pain prevalence, it is often overlooked or under diagnosed and subsequently under treated. “
The challenges of diagnosis and management of Sacroiliac joint dysfunction was the topic of an October 2021 paper. (1) Here the study authors wrote:
“Sacroiliac joint (SIJ) pain is one of the most common causes of low back pain, accounting for 15 to 30% of all cases. Although Sacroiliac joint dysfunction accounts for a large portion of chronic low back pain prevalence, it is often overlooked or under diagnosed and subsequently under treated.”
Next the authors offered guidelines to their fellow practitioners:
“The practitioner must focus on the history, location of pain, observed gait pattern, and perform key points of the physical exam including sacroiliac provocative maneuvers. If the patient exhibits at least three provocative maneuvers (movements that cause pain in the SI joint) then the Sacroiliac joint may be considered as a possible source of pain. Additionally, a thorough review of the imaging should be performed to rule out other etiologies of low back pain. In the absence of any pathognomonic tests or examination findings, diagnostic Sacroiliac joint blocks have evolved as the diagnostic standard.
“The diagnosis of SIJ pain is a multifaceted process that involves a careful assessment including differentiating other pain generators in the region. This involves careful history taking, appropriate physical examination including provocative maneuvers and diagnostic injections. Once the diagnosis is confirmed, long-term solutions may be considered, including recent advances in sacral lateral branch denervation and sacroiliac joint fusion.”
Here the conclusion ended with the possibility of surgical recommendation.
A recent study suggests that sacroiliac joint dysfunction patients do not get treatment relief because they did not have sacroiliac joint dysfunction
How does a patient subsequently get to sacral lateral branch denervation and sacroiliac joint fusion? Typically this occurs because all other treatments have not worked. Why? A recent 2019 study in the Clinical Spine Journal (2) offers the suggestion that sacroiliac joint dysfunction patients do not get treatment relief because they did not have sacroiliac joint dysfunction. This may be somewhat difficult for you to believe because all along you have been told you have sacroiliac joint pain.
Look at what the doctors of this study reported: Confusion and a lot of it. The sacroiliac joint was found to be a rare pain generator (3%-6%) in patients complaining of more than 50% sacroiliac joint region related pain.
As in our office, many doctors see patients that have pain all over the hip, pelvic, low back, groin regions. The above study reports that incidence of primary sacroiliac joint ranges from 15% to 30%. (In other words 15% to 30% of these people will get a diagnosis of sacroiliac joint dysfunction.) When they do not get a diagnosis of sacroiliac joint dysfunction, they may get a diagnosis of:
- pain generated from the lumbar spine, (degenerative disc disease),
- secondary sacroiliac joint dysfunction, (not the primary cause of their pain and therefore not the primary target)
- and the hip joint.
When these researchers re-examined these patients, with the goal of proving or disproving sacroiliac joint as the primary cause, what they found after a complete diagnostic workup was:
- 112 (90%) had lumbar spine pain,
- 5 (4%) had hip pain,
- 4 (3%) had primary sacroiliac joint dysfunction pain, and
- 3 (3%) had an undetermined source of pain upon initial diagnosis.
Patients did not have sacroiliac joint dysfunction as the primary source of their pain. In fact the sacroiliac joint was found to be a rare pain generator (3%-6%) in patients complaining of more than 50% sacroiliac joint region related pain. Pain in the sacroiliac joint area is commonly a referral pain from the lumbar spine (88%-90%).
This is why treatments including the use of cortisone will not work in patients with sacroiliac joint dysfunction. The wrong area is getting treated OR the right areas are not getting treated. The right areas may include:
- The axial low back,
- buttock/leg region
- groin/anterior thigh region
Platelet Rich Plasma injections vs cortisone for Sacroiliac Joint Injection
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the low back area to stimulate healing and regeneration.
Blood platelets contain healing agents or “growth factors.” This is what the growth factors do:
- Platelet-derived growth factor (PDGF) is a protein that helps control cell growth and division, especially blood vessels. When more blood (and the oxygen it carries) is delivered to the site of a wound, there is more healing.
- Transforming growth factor beta (or TGF-β) is a polypeptide and is important in tissue regeneration.
- Insulin-like growth factors are signaling agents. They help change the environment of the damaged joint from diseased to healing by “signaling” the immune system to start rebuilding tissue.
- Vascular endothelial growth factor (VEGF) is an important protein that brings healing oxygen to damaged tissue where blood circulation might be damaged or inadequate.
- Epidermal growth factor plays a key role in tissue repair mechanisms.
A study published in Pain practice : the official journal of World Institute of Pain (3) compared the effectiveness of these two injection treatments. These are the paper’s main points:
- “Despite widespread use of steroids to treat sacroiliac joint (SIJ) pain, their duration of pain reduction is short. Platelet-rich plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain.
- Forty patients with chronic low back pain diagnosed with SIJ pathology were randomly allocated into 2 groups.
- Group S received methylprednisolone
- Group P received PRP
- After treatment:
- Intensity of pain was significantly lower in the PRP group at 6 weeks and 3 months as compared to the steroid group.
- The efficacy of steroid injection was reduced to only 25% at 3 months while it was 90% in the PRP group.
- A strong association was observed in patients receiving PRP and showing a reduction of pain of more than 50% from baseline. Pain and function scores favored the PRP treatment as well. In the steroid group pain reduction and function improvements were seen up until 4 weeks after treatment and then the effectiveness declined. While the PRP group saw pain and function scores steadily increase at the three month marker.
Conclusion: “The intra-articular PRP injection is an effective treatment modality in low back pain involving SIJ.”
In our office, we do not consider PRP a one shot treatment.
Giving another opinion is a November 2021 (4) paper. Here doctors compared outcomes with a fluoroscopically-guided intra-articular injection of steroid or platelet rich plasma injection. Follow-up was at 1-month, 3 months, and 6-months.
Results: “At one, three, and six months, both groups improved, however subjects who received steroid injections reported lower pain scores than subjects who received platelet rich plasma. Using categorical data, we observed significantly more responders (defined as pain scores which improved by 50% or more from baseline) at one and three months in the group that received steroids compared to the group that received platelet rich plasma. Conclusion: While both groups showed improvements in pain and function, the steroid group had significantly greater response and significantly more responders than the PRP group. “
In our office, we do not consider PRP a one shot treatment. Often the treatment requires a peppering of numerous PRP injections into the back and more than one treatment occasion. Our process is described below.
PRP treatment for a soldier’s sacroiliac joint pain who was taking high-dose opioids
A case history was given in August 2020 in the journal Military medicine (5) of a soldier with sacroiliac joint pain. Here is a summary of this case:
“Back pain and its associated complications are of increasing importance among military members. The sacroiliac joint is a common source of chronic low back pain and functional disability. Many patients suffering from chronic low back pain utilize opioids to help control their symptoms. Platelet-rich plasma (PRP) has been used extensively to treat pain emanating from many different musculoskeletal origins; however, its use in the sacroiliac joint has been studied only on a limited basis.
The patient in this case report presented with chronic low back pain localized to the sacroiliac joint and subsequent functional disability managed with high-dose opioids. After failure of traditional treatments, she was given an ultrasound-guided PRP injection of the sacroiliac joint which drastically decreased her pain and disability and eventually allowed for complete opioid cessation. Her symptom relief continued one year after the injection. This case demonstrates the potential of ultrasound-guided PRP injections as a long-term treatment for chronic low back pain caused by SIJ dysfunction in military service members, which can also aid in the weaning of chronic opioid use.”
Study: “Ultrasound-guided platelet-rich plasma injections in the sacroiliac joint are effective at reducing disability and pain with most improvement seen within 4 weeks after injection and with sustained reduction at 6 months.”
An August 2020 study (6) investigated the efficacy of ultrasound-guided platelet-rich plasma in reducing sacroiliac joint disability and pain. in 50 patients diagnosed with low back pain secondary to sacroiliac joint dysfunction.
“Platelet-rich plasma was injected into the sacroiliac joint under ultrasound guidance. Oswestry Disability Index and Numeric Rating Scale were measured at baseline, 2 weeks, 4 weeks, 3 months, and 6 months after injection.
- Results: The mean reduction in Oswestry Disability Index and Numeric Rating Scale scores were significantly reduced at 6 months after injection compared with baseline values. All timeframes showed significant mean reduction compared with baseline, but overall improvement tapers off after 4 weeks with no statistically significant reduction from 4 weeks to 3 months or three to six months.
- Conclusions: Ultrasound-guided platelet-rich plasma injections in the sacroiliac joint are effective at reducing disability and pain with most improvement seen within 4 weeks after injection and with sustained reduction at 6 months.”
We usually ask the patients to return for more treatment if initial results were good and then being to taper off. In our years of experience and as documented in our medical research, we usually find multiple PRP treatments to be more effective than a single treatment. But, people do vary, some may derive benefit from one treatment.
Medical literature references
1 Buchanan P, Vodapally S, Lee DW, Hagedorn JM, Bovinet C, Strand N, Sayed D, Deer T. Successful Diagnosis of Sacroiliac Joint Dysfunction. Journal of Pain Research. 2021;14:3135.
2 DePhillipo NN, Corenman DS, Strauch EL, Zalepa LK. Sacroiliac Pain: Structural Causes of Pain Referring to the SI Joint Region. Clinical spine surgery. 2018 Oct.
3 Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid vs. platelet‐rich plasma in ultrasound‐guided sacroiliac joint injection for chronic low back pain. Pain Practice. 2017 Jul;17(6):782-91.
4 Chen AS, Solberg J, Smith C, Chi M, Lowder R, Christolias G, Singh JR. Intraarticular Platelet Rich Plasma vs Corticosteroid Injections for Sacroiliac Joint Pain—a Double Blinded, Randomized Clinical Trial. Pain Medicine. 2021 Nov 24.
5 Broadhead DY, Douglas HE, Bezjian Wallace LM, Wallace PJ, Tamura S, Morgan KC, Hemler DE. Use of Ultrasound-Guided Platelet-Rich Plasma Injection of the Sacroiliac Joint as a Treatment for Chronic Low Back Pain. Military medicine. 2020 Jul;185(7-8):e1312-7.
6 Wallace P, Wallace LB, Tamura S, Prochnio K, Morgan K, Hemler D. Effectiveness of ultrasound-guided platelet-rich plasma injections in relieving sacroiliac joint dysfunction. American journal of physical medicine & rehabilitation. 2020 Aug 1;99(8):689-93.