Sacroiliac Joint Precision Treatment
A variety of radiofrequency procedures have been developed for the treatment of proven sacroiliac joint pain. The term "precision treatment" refers to treatment of a proven pain generator unlike treating "non-specific low back pain." In research either an intraarticular block or lateral branch blocks are performed for precision diagnosis, and two blocks are preferred to reduce the false positive rate. Lateral branch blocks do not necessarily block sensory information from the ventral surface of the joint. A 2015 systematic review by Simopopoulos et al of radiofrequency procedures found high heterogeneity, and a meta-analysis was not feasible.[1] In general cooled radiofrequency is the only procedure with positive RCT evidence [Level 2]. The author is not aware of any Musculoskeletal Medicine specialists in New Zealand using cooled radiofrequency neurotomy for any use case. Traditional radiofrequency neurotomy for sacroiliac joint pain does not have good evidence. Repeated intraarticular prolotherapy injections is another treatment option with some evidence. [Level 2]
Intraarticular Injections
There are two RCTs based on controlled blocks. An anteroposterior approach is faster and equal in efficacy to the traditional oblique approach.[2]
Study | N | Arms | Selection Criteria | Results | Comments |
---|---|---|---|---|---|
Kim et al 2010 (RCT)[3] | 50 |
|
1 x positive intraarticular block (>50% pain relief) | โ
Positive study
|
|
Jee et al 2014 (RCT)[4] | 120 |
|
1 x positive intraarticular block (>80% pain relief) | Focused more on accuracy of ultrasound rather than outcomes
Ultrasound group: 87% accuracy, Fluoroscopic group: 98.2% accuracy No difference in pain scores and ODI at 2 and 12 weeks. |
Looking at the utility of using ultrasound versus fluoroscopy |
Periarticular Injections
No RCTs used controlled blocks for diagnosis. 2 x non-precision RCTs (Luukkainen et al 1999 and 2002) both positive results for steroid over saline.
Radiofrequency Procedures
Sacroiliac Joint Innervation
This topic is controversial.
- Ventral surface: Ventral root of L4/L5 โ S2, or branches from sacral plexus
- Dorsal surface: Dorsal root of L4/L5, and S1-3 lateral branches.
- Ligaments: S1-3 lateral branches
Location is variable person to person, side to side, and level to level.
Cooled Radiofrequency Neurotomy
Cooled radiofrequency neurotomy techniques are the only intervention with positive RCT evidence.
Study | N | Arms | Selection Criteria | Results | Comments |
---|---|---|---|---|---|
Cohen et al 2008 (RCT)[5] | 28 |
|
Single block (>75% pain relief) | โ
Positive study
Success defined as pain <50%
|
|
Patel et al 2012 + 2015 (RCT) (RCT)[6] | 120 |
|
Two positive blocks lateral branches (>75% pain relief) | โ
Positive study
Success defined as pain <50% plus improvement in another measure
|
|
Other Radiofrequency Techniques
There is no positive RCT evidence for other techniques such as conventional, pulsed, strip, or bipolar radiofrequency neurotomy. Cohen in 2009 published a study which found that the only predictor of success was whether cooled RF was used. [7]
There is one negative RCT looking at the Simplicity III probe which allows a single point of entry to ablate the sacroiliac joint innervation in a strip lesion, plus a secondary entry point for the L5 dorsal root.[8]
A non placebo controlled trial used heterogenous techniques (cooled, bipolar or simplicity III) and had negative results. This study, one part of a set of three RCTs on spinal RF treatments, has received a large amount of critisism.[9]
Surgery
There are two positive non-placebo controlled RCTs evaluating minimally invasive sacroiliac joint fusion with the iFUSE implant system for confirmed sacroiliac joint pain based on a positive diagnostic block with greater than 50% pain relief. [10][11] There were large improvements in pain and disability over the control group of conventional medical management. Polly et al allowed radiofrequency procedures, while Dengler et al didn't. These studies were industry funded, partially industry authored and had no sham group and so should be interpreted with caution.
The iFUSE system involves the fluoroscopic insertion of 2-4 triangular implants through the ilium across the sacroiliac joint into the centre of the sacrum lateral to the neural foramina. The implant is coated with a porous material allowing fixation of bone. The triangular shape allows immediate stabilisation and minimises micromotion and rotation of the joint.
Quiz
Bottom Line
- Intraarticular prolotherapy injections: [Level 2]
- Intraarticular steroid injections: [Level 4]
- Periarticular injections: [Level 4]
- Conventional or heterogenous RF neurotomy: [Level 5]
- Cooled RF: [Level 2]
- Minimally invasive fusion: [Level 2]
See Also
References
- โ Simopoulos et al.. Systematic Review of the Diagnostic Accuracy and Therapeutic Effectiveness of Sacroiliac Joint Interventions. Pain physician 2015. 18:E713-56. PMID: 26431129.
- โ Chauhan et al.. A Randomized Controlled Trial of Fluoroscopically-Guided Sacroiliac Joint Injections: A Comparison of the Posteroanterior and Classical Oblique Techniques. Neurospine 2019. 16:317-324. PMID: 30531656. DOI. Full Text.
- โ Kim et al.. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. Journal of alternative and complementary medicine (New York, N.Y.) 2010. 16:1285-90. PMID: 21138388. DOI.
- โ Jee H, Lee JH, Park KD, Ahn J, Park Y. Ultrasound-guided versus fluoroscopy-guided sacroiliac joint intra-articular injections in the noninflammatory sacroiliac joint dysfunction: a prospective, randomized, single-blinded study. Arch Phys Med Rehabil. 2014;95(2):330-337. doi:10.1016/j.apmr.2013.09.021
- โ Cohen et al.. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology 2008. 109:279-88. PMID: 18648237. DOI. Full Text.
- โ Patel. Twelve-Month Follow-Up of a Randomized Trial Assessing Cooled Radiofrequency Denervation as a Treatment for Sacroiliac Region Pain. Pain practice : the official journal of World Institute of Pain 2016. 16:154-67. PMID: 25565322. DOI.
- โ Cohen et al.. Outcome predictors for sacroiliac joint (lateral branch) radiofrequency denervation. Regional anesthesia and pain medicine 2009. 34:206-14. PMID: 19587617. DOI.
- โ van Tilburg et al.. Randomized Sham-controlled Double-Blind Multicenter Clinical Trial to Ascertain the Effect of Percutaneous Radiofrequency Treatment for Sacroiliac Joint Pain: Three-month Results. The Clinical journal of pain 2016. 32:921-926. PMID: 26889616. DOI. Full Text.
- โ Juch et al.. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials. JAMA 2017. 318:68-81. PMID: 28672319. DOI. Full Text.
- โ Polly et al.. Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. International journal of spine surgery 2016. 10:28. PMID: 27652199. DOI. Full Text.
- โ Dengler et al.. Randomized Trial of Sacroiliac Joint Arthrodesis Compared with Conservative Management for Chronic Low Back Pain Attributed to the Sacroiliac Joint. The Journal of bone and joint surgery. American volume 2019. 101:400-411. PMID: 30845034. DOI. Full Text.
Literature Review
- Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf
- Articles from all years: PubMed search, Google Scholar search.
- TRIP Database: clinical publications about evidence-based medicine.
- Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,