Sacroiliac Joint Precision Treatment

From WikiMSK

Revision as of 14:25, 10 July 2020 by Jeremy (talk | contribs) (→‎Surgery)

Introduction

A 2015 Review of interventional procedures found high heterogeneity, with a meta-analysis not feasible.[1] In general cooled radiofrequency is the only procedure with RCT 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]

SIJ Intraarticular Injections RCTs
Study N Arms Selection Criteria Results Comments
Kim et al 2010 (RCT)[3] 50
  1. Fluoroscopic injections of 25% dextrose prolotherapy, up to 3 times, until >90% relief
  2. Fluoroscopic injections of 40mg triamcinolone, up to 3 times, until >90% relief
 1 x positive intraarticular block (>50% pain relief) ✅Positive study

Success defined as >50% relief 2 weeks: 100% vs 100% 6 months: 63.6% vs 27.2% 15 months: 58.7% vs 10.2% Prolotherapy group needed more injections to reach initial 90% pain reduction (2.7 vs 1.5)

  • No placebo control
  • Difference in number of injections, single block
Jee et al 2014 (RCT)[4] 120
  1. Ultrasound guided with colour doppler (1 dominant colour to confirm IA) injection of lidocaine, omnipaque, plus 10mg dexamethasone. Accuracy assessed by fluoroscopy.
  2. Fluoroscopically guided injection of same
 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 – 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.

Cooled Radiofrequency Neurotomy
Study N Arms Selection Criteria Results Comments
Cohen et al 2008 (RCT)[5] 28
  1. Cooled radiofrequency ablation of S1 to S3 lateral branches, and L5 dorsal ramus
  2. Placebo RF
 Single block (>75% pain relief) ✅Positive study

Success defined as pain <50%

  • 1 month: 79% vs 14%
  • 3 months: 64% vs 0%
  • 6 months: 47% vs not analysed
  • Local anaesthetic is considered an active control by some,
  • Single block
Patel et al 2012 + 2015 (RCT) (RCT)[6] 120
  1. Cooled radiofrequency ablation of S1 to S3 lateral branches, and L5 dorsal ramus
  2. Placebo RF
 Two positive blocks lateral branches (>75% pain relief) ✅Positive study

Success defined as pain <50% plus improvement in another measure

  • 3 month: 47% vs 12%
  • 6 months: 38% vs not analysed
  • 9 months: 59%. vs NA
  • 12 months: 40% success vs NA
  • Local anaesthetic is considered an active control by some, unblinded at 3 months.
  • How to explain wavy success curves

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.

Bottom Line

References

  1. ↑ Simopoulos TT, Manchikanti L, Gupta S, et al. Systematic Review of the Diagnostic Accuracy and Therapeutic Effectiveness of Sacroiliac Joint Interventions. Pain Physician. 2015;18(5):E713-E756.
  2. ↑ Pictures from: Chauhan G, Hehar P, Loomba V, Upadhyay A. A Randomized Controlled Trial of Fluoroscopically-Guided Sacroiliac Joint Injections: A Comparison of the Posteroanterior and Classical Oblique Techniques. Neurospine. 2019;16(2):317-324. doi:10.14245/ns.1836122.061
  3. ↑ Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010;16(12):1285-1290. doi:10.1089/acm.2010.0031
  4. ↑ 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
  5. ↑ Cohen SP, Hurley RW, Buckenmaier CC 3rd, Kurihara C, Morlando B, Dragovich A. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008;109(2):279-288. doi:10.1097/ALN.0b013e31817f4c7c
  6. ↑ Patel N. Twelve-Month Follow-Up of a Randomized Trial Assessing Cooled Radiofrequency Denervation as a Treatment for Sacroiliac Region Pain. Pain Pract. 2016;16(2):154-167. doi:10.1111/papr.12269
  7. ↑ Cohen SP, Strassels SA, Kurihara C, et al. Outcome predictors for sacroiliac joint (lateral branch) radiofrequency denervation. Reg Anesth Pain Med. 2009;34(3):206-214. doi:10.1097/AAP.0b013e3181958f4b
  8. ↑ van Tilburg CW, Schuurmans FA, Stronks DL, Groeneweg JG, Huygen FJ. Randomized Sham-controlled Double-Blind Multicenter Clinical Trial to Ascertain the Effect of Percutaneous Radiofrequency Treatment for Sacroiliac Joint Pain: Three-month Results. Clin J Pain. 2016;32(11):921-926. doi:10.1097/AJP.0000000000000351
  9. ↑ Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials [published correction appears in JAMA. 2017 Sep 26;318(12 ):1188]. JAMA. 2017;318(1):68-81. doi:10.1001/jama.2017.7918
  10. ↑ Polly DW, Swofford J, Whang PG, et al. Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. Int J Spine Surg. 2016;10:28. Published 2016 Aug 23. doi:10.14444/3028
  11. ↑ Dengler J, Kools D, Pflugmacher R, et al. Randomized Trial of Sacroiliac Joint Arthrodesis Compared with Conservative Management for Chronic Low Back Pain Attributed to the Sacroiliac Joint. J Bone Joint Surg Am. 2019;101(5):400-411. doi:10.2106/JBJS.18.00022
Retrieved from ‘https://wikimsk.org/w/index.php?title=Sacroiliac_Joint_Precision_Treatment&oldid=2223’