Background: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. Objective: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. Design: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. Methods: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). Results: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is moderate. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis.

Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain

Sacroiliac (SI) joint pain is a challenging condition affecting 15% to 25% of patients with axial low back pain, for which there is no standard long-term treatment. Recent studies have demonstrated that historical and physical examination findings and radiological imaging are insufficient to diagnose SI joint pain. The most commonly used method to diagnose the SI joint as a pain generator is with small-volume local anesthetic blocks, although the validity of this practice remains unproven. In the present review I provide a comprehensive review of the anatomy, function, and mechanisms of injury of the SI joint, along with a systematic assessment of its diagnosis and treatment.

http://ossano.com/Bibliotek/iFuse/Cohen%202005%20-%20Sacroiliac%20Joint%20Pain%20A%20Comprehensive%20Review%20of%20Anatomy.pdf

Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment.

Study design Consecutive case series cohort. Objective To determine the relative frequencies of the spine, the sacroiliac (SI) joint, and the hip joint being the primary pain generator among patients presenting at a spine surgery clinic for low back pain (LBP). Summary of background data Identification of the primary pain generator in a patient with LBP is difficult. Possible pain sources include the lumbar spine, the SI joint, and the hip joint. Their relative frequencies among patients presenting at a spine surgeon's clinic have not been well established. Methods Three hundred sixty-eight new patients were seen at a single spine surgeon's clinic during a 10-month period. Of these, 289 (78.5%) complained primarily of LBP with or without leg pain. Seventy-seven had previous surgery. The remaining 200 cases were reviewed for all diagnostic tests performed, as well as the final diagnosis. Results One hundred sixty-four (82%) had spine pathology, but only 130 (65%) had spine-only pathology, whereas 35 (17.5%) had a combination of spine plus hip and/or SI joint pathology. An additional 16 (8%) had hip and/or SI joint pathology without spine pathology. Twenty (10%) had an undefined pain source. Overall, 25 (12.5%) had hip pathology, and 29 (14.5%) had SI joint pathology. Conclusion For patients presenting to a spine surgeon's clinic for LBP, up to 25% of patients may have significant pain contribution from the hip or SI joints, and an additional 10% will still have an undefined pain source even after diagnostic workup. This underscores the need for clinicians to be aware of nonspinal pain generators and to appropriately pursue alternative diagnoses.

http://www.ossano.se/Bibliotek/iFuse/Sembrano%202008%20-%20How%20Often%20Is%20Low%20Back%20Pain%20Not%20Coming%20From%20the%20Back.pdf

How often is low back pain not coming from the back

The sacroiliac joint is an accepted source of pain in those with ankylosis spondylitis, those with metabolic disorders with involvement of the sacroiliac joint, and in those with osteoarthritis, infection, or tumors of the sacroiliac joint. The occurrence of isolated sacroiliac joint pain in the absence of these types of diseases is controversial. Mixter and Barr’s 1934 study shifted the focus of attention from the sacroiliac joint to the disk. More recent fluoroscopically guided, contrastenhanced injection techniques demonstrate that the sacroiliac joint is a source of primary low back pain and/or lower extremity pain in approximately 15% of patients with low back pain. 1,2 Understanding the anatomy, biomechanics, innervation, and pathophysiology of the sacroiliac joint can help in differentiating sacroiliac joint pain from muscular, discogenic, or degenerative lumbar spine symptoms. This is important because treatment modalities for the patient with sacroiliac joint symptoms differ from those for other causes of low back pain. Anatomy The sacroiliac joint becomes C-shaped by adulthood. The sacrum is wedged between the ilia. It is the largest axial joint in the human body, with a surface area of approximately 17.5 cm 2 . It is considered to be a synovial joint even though 75% of its superior joint surface is not synovial. A fibrous capsule surrounds the sacroiliac joint. The anterior capsule and overlying ligament are relatively thin, and the anterior joint ligament blends into the iliolumbar ligament. A posterior sacroiliac joint capsule is often rudimentary or absent. The posterior border of the sacroiliac joint often is formed by the tough interosseous ligament. Accessory ligaments and the posterior sacroiliac, long posterior sacroiliac, sacrotuberous, and sacrospinous ligaments further support the sacroiliac joint (Fig. 1). The L5 ventral ramus and the lumbosacral trunk course anterior to the sacroiliac joint 2 cm below the pelvic brim; the S1 ventral ramus courses over the inferior anterior aspect of the sacroiliac joint. 3 The morphology of the sacroiliac joint not only changes with age but it also varies greatly in size, shape, and contour from side to side as well as between individuals. The surface of the joint is flat until after puberty. By age 30, bony ridges are present on the articular surface of the ilium. In the third and fourth decades, elevations and depressions develop and enhance stability of the joint. The synovial articular surfaces erode; the synovial cleft narrows to 1 to 2 mm in individuals aged 50 to 70 years and to 0 to 1 mm in those aged more than 70 years. Ankylosis has been reported in individuals aged more than 50

Sacroiliac Joint Pain

Sacroiliac joint (SIJ) pain is an underappreciated source of mechanical low back pain, affecting between 15 and 30% of individuals with chronic, nonradicular pain. Predisposing factors for SIJ pain include true and apparent leg length discrepancy, older age, inflammatory arthritis, previous spine surgery, pregnancy and trauma. Compared with facet-mediated and discogenic low back pain, individuals with SIJ pain are more likely to report a specific inciting event, and experience unilateral pain below L5. Owing in part to its size and heterogeneity, the pain referral patterns of the SIJ are extremely variable. Although no single physical examination or historical feature can reliably identify a painful SIJ, studies suggest that a battery of three or more provocation tests can predict response to diagnostic blocks. Evidence supports both intra- and extra-articular causes for SIJ pain, with clinical studies demonstrating intermediate-term benefit for both intra- and extra-articular steroid injections. In those who fail to experience sustained relief from SIJ injections, radiofrequency denervation may provide significant relief lasting up to 1 year. This review covers all aspects of SIJ pain, with the treatment section being primarily focused on procedural interventions.

Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment

https://www.archives-pmr.org/article/S0003-9993(00)90080-7/pdf

Kwai T. Chan

Papers

Sacroiliac joint pain referral zones