Marc Darrow, MD, JD.
Patients will often come into our office with a lumbar spine MRI, low back pain and a diagnosis of sacroiliac joint dysfunction. They are in our office because they may have been told that they should consider a surgical recommendation to spinal surgery. For many of these people, the MRI was the confirmation that their surgeon needed to go ahead with the surgical recommendation. For many patients, this may have been the same doctor who had taken them through a course of conservative treatments including long bouts with anti-inflammatory medications, back braces, physical therapy, and cortisone injections.
The question then to ask is, if these people do not respond to treatment, do they even have sacroiliac joint dysfunction?
Sacroiliac joint dysfunction patients do not get treatment relief because they do not have sacroiliac joint dysfunction
A recent 2019 study in the Clinical Spine Journal (1) offers the suggestion that sacroiliac joint dysfunction patients do not get treatment relief because they do 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.
A person goes to the doctor for pain in the pelvic / hip / groin lower back region.
The currently reported 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),
- sacroiliac joint dysfunction, (but not as the primary cause of their pain and therefore not the primary target),
- and pain coming from the 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.
The challenges of diagnosis and management of Sacroiliac joint dysfunction
A October 2021 paper (2) discusses the problem of Sacroiliac joint dysfunction being “often overlooked or under diagnosed and subsequently under treated.”
“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.
Conclusion:
“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.
Why did researchers find so many poor sacroiliac joint pain treatment results? The chances are the patient did not have sacroiliac joint dysfunction.
We will often receive an email that will describe cortisone injections or nerve blocks that did not help the e-mailer with their low back pain. As we have seen in many patients, the hip-spine-sacroiliac joint complex is a challenging one to differentiate where the pain is coming from. Injections into the hip may not provide relief if the pain is in the sacroiliac joint region. Injections into the sacroiliac joint region may not work if the pain is from the hip or groin.
A study in the medical journal Pain Physician (3) looked at various treatment recommendations for patients suffering from sacroiliac joint pain. These treatments included burning the nerves, freezing the nerves, applying cortisone and Botox.
The researchers found the following:
- “The evidence for cooled radiofrequency neurotomy (freezing the nerve) in managing sacroiliac joint pain is fair.
- The evidence for effectiveness of intraarticular steroid injections is poor.
- The evidence for periarticular injections of local anesthetic and steroid or botulinum (Botox) toxin is poor.
- The evidence for effectiveness of conventional radiofrequency neurotomy (burning the nerves) is poor.
- The evidence for pulsed radiofrequency is poor.”
Why did they find so many poor results? The chances are the patient did not have sacroiliac joint dysfunction.
Let’s look at another study. This time from June 2017 in the journal Medicine.(4) In this research, doctors investigated the degree of pain reduction following intra-articular pulsed radiofrequency stimulation of the sacroiliac joint in patients with chronic sacroiliac joint pain that had not responded to corticosteroid injection.
These research too found disappointing results:
- Intra-articular pulsed radiofrequency stimulation of the sacroiliac joint was not successful in most patients (80% of all patients). Based on our results, we cannot recommend this procedure to patients with chronic sacroiliac joint pain that was unresponsive to corticosteroid injection.
Here is where treatments that are not helping the sacroiliac joint can become dangerous. How so? Because they will lead to a surgery that will not work either.
This was also suggested by a late 2019 study.(5)
- “The rationale for SI joint fusion is to relieve pain created by the movement of a joint through the removal of movement by arthrodesis (fusion) of the joint space. Only few comparative studies of percutaneous SI joint fusion and denervation have been reported, and they had limited clinical evidence.”
Many do not respond to corticosteroid injections for sacroiliac joint pain
A November 2022 study (7) “Intra-articular or peri-articular corticosteroid injections are often used for treatment of sacroiliac joint pain. However, response to these injections is variable and many patients require multiple injections for sustained benefit.” In this study, the researchers aimed to see if they could predict who would respond and who would not respond to sacroiliac joint injections. Who was at risk for not responding as well?
- Patients with a history of depression and anxiety
- Older patients
Of note is that the researchers speculated that the patients who did not have clinically significant pain relief scores did not accurately record perception of success after sacroiliac joint injection (on patient outcome self-reporting surveys). The researchers suggest their pain relief should have been greater.
But let’s point out that steroid injections can provide short-term relief. The injections can be more effective when combined with nerve blocks as shown in a March 2022 (8) study which evaluated the effectiveness of intraarticular steroid injections with lateral branch radiofrequency neurotomy for sacroiliac joint pain. The researchers found both sacroiliac joint intraarticular steroid injections and sacroiliac joint lateral branch radiofrequency neurotomy demonstrated significant pain relief for patients with sacroiliac joint pain. Sacroiliac joint lateral branch radiofrequency neurotomy provided a longer duration of pain relief (82 days) versus sacroiliac joint intraarticular steroid injection (38 days).
In the studies we just examined, the surgeons wrote there are many factors that would effect the outcome including finding the patient’s true source of pain. Let’s look at a relatively unexplored source of pain. The spinal ligaments.
Doctors at the Mayo Clinic (9) have published a paper entitled: Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. In this paper the Mayo Clinic researchers wanted to make a clear definition between two problems affecting low back pain patients.
- First, that pain could be coming from the discs.
- Second that pain could be coming from the spinal ligaments.
The Mayo researchers suggest that recognizing how the spine moves is essential for distinguishing between the many different types of spinal disorders, and a diagnosis which may ultimately, and erroneously lead to back surgery.
- If a patient has instability, excessive movement, and decreased stiffness, doctors should examine for ligament damage.
- If the opposite, less movement, more stiffness, the doctor should look for disc disease.
This information can help determine the true cause of a patient’s sacroiliac joint dysfunction. When nothing is working, look at the ligaments. How do you look at the ligaments? Through physical examination.
Sacroiliac joint denervation
A June 2024 study (27) assessed the long-term efficacy, safety, clinical outcomes, and outcome predictors of uniportal full-endoscopic sacroiliac joint denervation. (In simpler terms, burning or heating the nerves though minimally invasive incision).
- 47 patients with pain secondary to sacroiliac joint dysfunction underwent uniportal full-endoscopic sacroiliac joint denervation.
- The patient group was on avergae, about 60 years old, with 63.8% females.
- Symptom duration averaged 62 months
- All patients were discharged on the same day of surgery following a surgery that took about one hour.
- Significant improvement was noted in pain and disability scores at 3, 6, 12 months, and 2 years.
- Thirty-four patients (72.3%) returned to normal functioning with an average of 82% pain relief and a satisfaction rate of 78.7% at a mean follow-up of 18 months. A significant factor that influences outcomes is the presence of concomitant lumbar pathology. (Success may not be achived because of other lumbar problems concomitant with SI Joint problems).
A diagnosis which may ultimately, and erroneously lead to back surgery.
In our own published peer-review research appearing in the July 2018 in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018, (10) we examined treating spinal ligaments with low back pain. Below is an explanatory adaption of the introductory paragraph of that study. It gives a good understanding of the importance of understanding that we should be looking at the ligament problems in back pain.
The challenge of sacroiliac joint dysfunction may be a ligament problem.
- An Orthopaedic Knowledge Update from the American Academy of Orthopedic Surgeons tells its surgeon members that muscle strains, ligament sprains, and muscle contusions account for up to 97% of low back pain in the adult population (11)
- Additionally, researchers wrote in the Spine Journal that spinal ligaments are often neglected compared to other pathology that account for low back pain (12). This could be due to the over-reliance of MRIs to guide physicians to correct diagnoses. They write: The influence of the posterior pelvic ring ligaments on pelvic stability is poorly understood. Low back pain and sacroiliac joint pain are described being related to these ligaments. When these ligaments are damaged or weakened, they serve as generators of low back pain.
Sacroiliac joint dysfunction following lumbar surgery
A January 2024 study (13) addressed the incidence of Sacroiliac joint dysfunction following lumbar surgery. Sacroiliac joint dysfunction (SIJD) after lumbar/lumbosacral fusion has become increasingly recognized as a problem following lumbar fusion. Despite the significant pain and dysfunction associated with Sacroiliac joint dysfunction, uncertainty regarding its diagnosis and treatment remains. To help answer the question of Sacroiliac joint dysfunction following lumbar fusion. The researchers assessed data from seventeen previously published studies and found after lumbar fusion “the incidence of new onset Sacroiliac joint dysfunction was 7.0%.” The average age of the patients were 56 years old, and the follow-up length was 30 months. Intra-articular injection for pain decreased the Visual Analogue Scale (VAS 0 – 10 pain score) score by 75%, while radiofrequency ablation (RFA) reduced the score by 90%.
Conclusions: “Lumbar fusion predisposes patients to SIJD, likely through manipulation of the SIJ’s biomechanics” (the surgical disruption of the sacroiliac joint.)
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