Presentation1.pptx, radiological imaging of sacroiliac joint diseases.
Sacroiliac Joint
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Transcript of Sacroiliac Joint
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Sacroiliac JointSacroiliac JointJ. Scott Bainbridge, MDJ. Scott Bainbridge, MD
www.DenverBackPainSpecialiwww.DenverBackPainSpecialists.comsts.com
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SIJ BackgroundSIJ Background Proposed as potential source of pain Proposed as potential source of pain
by Goldthwaite in 1905by Goldthwaite in 1905 Incidence of SIJ pain in LBP Incidence of SIJ pain in LBP
population: 18-40% (Schwarzer, population: 18-40% (Schwarzer, Maigne, DePalma, Liliang, Maigne, DePalma, Liliang, Schofferman)Schofferman)
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SIJ AnatomySIJ Anatomy
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SIJ AnatomySIJ Anatomy Diarthrodial jointDiarthrodial joint Hyalin cartilage, fibrocartilage also on ilial sideHyalin cartilage, fibrocartilage also on ilial side Interlocking contoursInterlocking contours Ligaments: anterior and posterior SIL, Ligaments: anterior and posterior SIL,
interosseous SIL, sacrospinous and interosseous SIL, sacrospinous and sacrotuberoussacrotuberous
Muscles: paraspinous, gluteal, psoas, iliacus, Muscles: paraspinous, gluteal, psoas, iliacus, abdominal, sartorius, rectus femoris, hamstrings, abdominal, sartorius, rectus femoris, hamstrings, latissimus dorsi (lumbodorsal fascia) latissimus dorsi (lumbodorsal fascia)
NutationNutation
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SIJ InnervationSIJ Innervation
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SIJ InnervationSIJ Innervation Early: Cunningham’s…, Bernard and Early: Cunningham’s…, Bernard and
Cassidy, Ikeda, Nagakawa, etc. included Cassidy, Ikeda, Nagakawa, etc. included anterior innervation (ventral rami)anterior innervation (ventral rami)
Fortin et al, Grob et al: macroscopic and Fortin et al, Grob et al: macroscopic and fetal microscopic fetal studies: fetal microscopic fetal studies: innervation entirely dorsal rami (S1-3[4])innervation entirely dorsal rami (S1-3[4])
Yin, Willard, Carreiro, Dreyfuss: defined Yin, Willard, Carreiro, Dreyfuss: defined (fluoro) course of sacral dorsal rami; (fluoro) course of sacral dorsal rami; reported SIJRF pilot technique and reported SIJRF pilot technique and resultsresults
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S-1 Dorsal RamiS-1 Dorsal Rami
Yin, et al. Spine 2003
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S-2 Dorsal RamiS-2 Dorsal Rami
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S-3 Dorsal RamiS-3 Dorsal Rami
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DiagnosisDiagnosis X-ray, MRI, CT, bone scan generally not helpful X-ray, MRI, CT, bone scan generally not helpful
except to rule in/out fracture, stress response, except to rule in/out fracture, stress response, infection, tumor, sacroiliitisinfection, tumor, sacroiliitis
Arthrogram may show capsular disruptionArthrogram may show capsular disruption Need double intraarticular SIJ blocks to diagnose, Need double intraarticular SIJ blocks to diagnose,
although single IA, posterior ligament, or dorsal rami although single IA, posterior ligament, or dorsal rami blocks have been used by various blocks have been used by various authors/practitionersauthors/practitioners
Blockade of the L5 Dorsal Rami and Sacral 1-3 lateral Blockade of the L5 Dorsal Rami and Sacral 1-3 lateral branches, using the multi-site, multi-depth technique branches, using the multi-site, multi-depth technique of Dreyfuss, et al. (Pain Medicine 2009) is necessary of Dreyfuss, et al. (Pain Medicine 2009) is necessary for radiofrequency neurotomy (RFN) screeningfor radiofrequency neurotomy (RFN) screening..
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Diagnosis - HistoryDiagnosis - History Unilateral pain at or below PSIS, Unilateral pain at or below PSIS,
PSIS pointing (Fortin, Maigne)PSIS pointing (Fortin, Maigne) , no pain above L5, pain over SIJ and , no pain above L5, pain over SIJ and
Buttock (Dreyfuss, et al)Buttock (Dreyfuss, et al)
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Diagnosis – Physical Diagnosis – Physical ExamExam
Maigne: Patrick’s – trend – p=0.9Maigne: Patrick’s – trend – p=0.9 Broadhurst and Bond: double blind, Broadhurst and Bond: double blind,
lido v salinelido v saline FABER (Flexion, ABduction, External FABER (Flexion, ABduction, External
Rotation)Rotation) POSH (POsterior SHear)POSH (POsterior SHear) REAB (REsisted ABduction)REAB (REsisted ABduction) 100% specificity, 77-80% specificity @ 100% specificity, 77-80% specificity @
70% < pain70% < pain
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Diagnosis – Physical Diagnosis – Physical ExamExam
Dreyfuss, et al (multidisciplinary Dreyfuss, et al (multidisciplinary expert panel)expert panel) 12 key pain, Hx, and PE parameters12 key pain, Hx, and PE parameters Single block, 90% reliefSingle block, 90% relief PSIS pointing, no pain above L5, sacral PSIS pointing, no pain above L5, sacral
sulcus tenderness, pain over SIJ/buttocksulcus tenderness, pain over SIJ/buttock Gillet’s test best of provocative Gillet’s test best of provocative
maneuversmaneuvers
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Diagnosis – Physical Diagnosis – Physical ExamExam
Van der Wurff, et al, 2006Van der Wurff, et al, 2006 Double blocks, >50% reliefDouble blocks, >50% relief 3 of 5 positive tests (distraction, 3 of 5 positive tests (distraction,
compression, thigh thrust, Patrick, compression, thigh thrust, Patrick, Gaenslen)Gaenslen)
Sensitivity .85, specificity .79Sensitivity .85, specificity .79 PPV .77, NPV .87PPV .77, NPV .87
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Discogenic: Centralization w McKenzie Discogenic: Centralization w McKenzie methodmethod Pain w rising from sittingPain w rising from sitting
Sacroiliac: Unilateral pain; No lumbar Sacroiliac: Unilateral pain; No lumbar painpain Pain rising from sittingPain rising from sitting 3/5 provocation tests: distraction, 3/5 provocation tests: distraction,
compression, sacral thrust, thigh thrust, compression, sacral thrust, thigh thrust, Gaenslen’sGaenslen’s
LZJ: no pain rising from sittingLZJ: no pain rising from sitting
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SIJ - TreatmentSIJ - Treatment Manual therapyManual therapy Exercise (m. balance, stabilization)Exercise (m. balance, stabilization) MedicationMedication IA injection (corticosteroids)IA injection (corticosteroids) ProlotherapyProlotherapy PRP – Platelet Rich PlasmaPRP – Platelet Rich Plasma NeuromodulationNeuromodulation Dennervation (RF neurotomy)Dennervation (RF neurotomy)