Pain in the sacroiliac joint

The sacroiliac joint (SIJ) often poses issues for patients with lower back pain, affecting 15% to 30% of individuals. The quality of life for those with SIJ-related pain is notably worse than, for example, patients with chronic obstructive pulmonary disease or mild heart failure, equivalent to patients with osteoarthritis of the hip or knee joints. Economic costs for providing conservative care to this patient category are estimated at $1.6 billion USD per 100,000 population over the course of 3 years. Interestingly, among spinal surgeons, there has been a significant rise in minimally invasive surgical procedures starting from 2009. Simultaneously, the focus has been shifting towards procedural solutions for treating pain specifically in the SIJ. Specialists continue to explore and discuss the anatomical and biomechanical aspects of the SIJ structure, in addition to clinical perspectives on the pathology of this joint.

It is often challenging to accurately diagnose pain associated with the sacroiliac joint (SIJ) solely through clinical examination and standard X-rays. The standard for diagnosing SIJ dysfunction involves the use of injections into the SIJ under X-ray guidance. Intra-articular blockade serves both diagnostic and therapeutic purposes. In its turn, a subjective positive effect of more than 75% improvement from acute pain is a diagnostic sign that the SIJ is the source of the problem. These findings are supported by numerous publications in specialized literature, emphasizing that intra-articular SIJ blockade is a standard and most frequently used procedure for pain in this location. Initial treatment stages include conservative methods such as:

•  Modifying the patient’s physical activity;
•  Using sacroiliac belts/braces/corsets;
•  Applying NSAIDs (nonsteroidal anti-inflammatory drugs);
•  Physiotherapy.

Initial treatment for suspected SIJ dysfunction should begin with the use of conservative methods (as indicated below) for 4 weeks before considering intra-articular injections. In cases of pain that significantly restrict standard workloads, performing the blockade may be considered earlier.

Radiofrequency ablation and prolotherapy can potentially be suggested as treatment measures, although only limited research confirms their use as a primary method of SIJ pain therapy. Surgical treatment is suggested for patients with a positive response to intra-articular injections, experiencing over 75% improvement, failures of nonsurgical treatments, and ongoing or recurrent SIJ pain. Percutaneous SIJ arthrodesis may be recommended as first-line surgical treatment due to its improved safety profile compared to open arthrodesis. However, in cases of revision surgery, non-union, and altered anatomy, open arthrodesis should still be considered.

Conservative Treatment

The goal of non-surgical treatment is to eliminate pain generators, correct the biomechanics of the lumbar-sacral spine and sacroiliac region, and restore the patient’s functional activity.

Early stages of the SIJ dysfunction treatment can be divided into three phases:

1.  Acute phase (1 to 3 days), involving rest, immobilization, cold (ice) or heat application, depending on individual indications;
2.  Recovery phase (3 days to 8 weeks), during which joint mobilization and physiotherapy are employed;
3.  Maintenance phase, ensuring proper postural dynamics.

Using multiple types of therapy concurrently is recommended for active patient care.

The arsenal of applied conservative treatment methods should be comprehensive and broad before considering the necessity of surgical intervention. The use of NSAIDs can help alleviate inflammation in the SIJ and may be recommended to enhance the effects of physical treatment methods. Opioid medications and antidepressants should be used with caution, though their prolonged use is not recommended. Topical menthol or lidocaine patches, as well as percutaneous nerve stimulation, can be utilized as non-invasive methods with minimal risk of side effects, serving as supplementary pain management techniques for SIJ pain.

Bracing Therapy (belts, corsets, supports)

A brace that stabilizes the pelvis and lumbar spine can limit movement in the sacroiliac joints and provide relief from acute SIJ-related pain. The use of a compression belt can also reduce the SIJ mobility in addition to decreasing muscle tension in the area. Prolonged use of a compression belt is not recommended to prevent dependency and muscle weakness resulting from excessive habituation and muscle atrophy in the pelvic region. Wearing a pelvic stabilizing corset is particularly significance for the SIJ pain resulting from pregnancy. This is an important treatment method because therapy with drugs, X-rays, and injections may be significantly limited or even contraindicated in this condition.

Rehabilitation Therapy

Physiotherapy, manual therapy, and therapeutic exercise are often used for musculoskeletal pain treatment and can also be employed to reduce the intensity of the SIJ pain. Manual therapy is most effective during acute pain for addressing muscle spasms, proprioception, and mobility in the pelvic-lumbar region. Strengthening the core musculature in the pelvic area through physical exercises is quite beneficial due to training the tension and stretching of most muscle-fascial anatomical structures that attach to the SIJ complex. The following methods are often used  with manual therapy methods – direct ways to affect the muscle-ligament apparatus, direct joint mobilization, or post-isometric relaxation methods, which in several cases yield good therapeutic results.

Prolotherapy

Prolotherapy is based on the use of agents (such as phenol or glucose solution) injected into the ligament complex in order to induce an inflammatory reaction which causes fibroblastic migration and ligament inflammation. This subsequently leads to the formation of dense scar tissue in the SIJ area. Prolotherapy is considered most effective under conditions of increased ligament weakness. Numerous randomized controlled studies have been conducted comparing the treatment outcomes of patients with the SIJ pain who received intra-articular corticosteroid injections and those who underwent prolotherapy (up to three injections). Significant pain relief over a longer period was observed in the prolotherapy group. The average duration of pain relief was more than 9 months compared to 3 months in the group of patients receiving intra-articular steroid injections. However, further research and additional data are needed for objective confirmation of prolotherapy’s effectiveness as a method for treating the SIJ pain.

Intra-Articular Injections

Of all non-surgical therapy methods, intra-articular SIJ injections with local anesthetics and corticosteroids have the strongest evidence base, confirming their high effectiveness. However, it has been demonstrated that intra-articular SIJ injections without visualization occurred in only 22% of patients. Accordingly, radioscopic visualization is crucial for accurate needle insertion into the joint. It should be noted that the use of corticosteroid injections should be limited to three injections within a 6-month period and four injections within a year. A series of randomized blind studies have proven that corticosteroid injections for the SIJ pain are more effective compared to placebo (i.e., isotonic physiological saline solution equivalent in volume) with noticeable results at 3 months (over 60% of patients) and 6 months (50% of patients). In the placebo group, no improvement occurred in any of the patients within 1 month. It was also demonstrated that the effectiveness of injections was lower for patients with pain localized in the lumbar or lumbosacral region. Almost two-thirds of the studied patients reported > 50% reduction in pain within 6 weeks, with an average duration of subsequent pain relief lasting approximately 8 months. Furthermore, in patients with symptoms of pain persisting for an average of 20 months before treatment initiation, substantial improvements were observed in Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores after just two intra-articular blocks. These patients returned to work, and a significant trend towards reduced use of narcotic analgesics was noted.

Radiofrequency Ablation

Radiofrequency ablation involves applying radiofrequency to joint surfaces to disrupt sensory innervation of the SIJ and provide longer-lasting pain reduction in patients. The effectiveness of this treatment is limited due to the complex innervation of the SIJ. Prior to 2022, controlled studies were limited by the amount of evidence available to assess positive effects. Overall, positive results of radiofrequency ablation are limited by the inability to denervate nerve structures of the anterior parts of the SIJ and the ability of nerve fibers to regenerate over several months.

Sacropelvic Arthrodesis

The use of arthrodesis for the SIJ stabilization as a method of pain relief was described as early as 1920. The rationale for the SIJ arthrodesis is similar to indications for fusing other joints. Pain resulting from joint movement can be reduced by eliminating motion through reducing the space between joint surfaces. Traditionally, this type of arthrodesis is performed through open access to the SIJ.

Open Arthrodesis

Open SIJ arthrodesis can be performed using anterior or posterior approaches. The anterior approach provides direct access to the abdominal and upper parts of the SIJ without significant ligament damage. Additionally, the exposed iliac crest can be used for autotransplantation. The anterior approach carries significant risks of potential damage to vital vascular and neural structures, including ventral roots of the sacral nerve (particularly L5 and SI) and pelvic vessels, in addition to structures passing through the sciatic foramen. The posterior approach to the SIJ is also well-known. Despite the more superficial location of the joint, the bony ridge of the posterior iliac process limits the view of the joint. The incision is usually positioned in the dependent position, which plays a role in complications after surgery. In both anterior and posterior approaches, after opening the joint, removal of the articular cartilage and implantation of a bone graft into the prepared joint space is performed. The joint can then be stabilized using various screw fixation constructs. Plates with screws, iliosacral screws, or cages are most commonly used. After open SIJ arthrodesis, axial load is limited for 8–12 weeks until early radiographic signs of bone fusion are detected. Open SIJ arthrodesis is particularly relevant for patients with altered SIJ anatomy, sacral dysmorphism, or those who had failed previous arthrodesis and require revision surgery.

Minimally Invasive (Percutaneous) Arthrodesis

In recent years, there has been a trend towards less invasive methods of SIJ arthrodesis, specifically percutaneous techniques. Advantages of the minimally invasive approach include shorter hospital stays, reduced postoperative load restrictions, significantly decreased blood loss, and smaller incisions with lower rates of surgical infections. The minimally invasive approach to SIJ arthrodesis utilizes radiographic visualization for screw or implant insertion through the SIJ. Through a lateral buttock incision, access to the lateral edge of the ilium is gained after blunt dissection of soft tissues. Kirschner wires are then passed through the SIJ, and the SIJ is drilled and prepared for implant placement. After this surgical procedure, patients are initially prescribed limited load-bearing, followed by gradual return to full weight-bearing with progressive physical therapy. Generally, these patients progress to full weight-bearing recovery much faster than those who undergo traditional open arthrodesis. Short-term observation results, as far as one can judge, are generally satisfactory, but extended follow-up is necessary to assess patient treatment outcomes and radiographic consolidation evidence to determine if true arthrodesis without SIJ decortication can be achieved. However, it is already evident that percutaneous SIJ arthrodesis demonstrates an advantage over open arthrodesis in terms of reduced blood loss, shorter hospital stays, and average surgical procedure time with a similar complication profile and improved quality of life indicators. Furthermore, it is clear that percutaneous SIJ arthrodesis improves short-term quality of life compared to surgical treatment.

Conclusion:

The treatment of sacroiliac joint arthralgia/arthropathy is a complex and individualized process that requires consideration of each patient’s unique characteristics. Despite its complexities, the following recommendations can be highlighted based on the available data and evidence:

1.  The initial approach should include non-steroidal anti-inflammatory drugs, short-term use of a sacroiliac belt, and rehabilitation therapy. This allows for an assessment of the effectiveness of conservative treatment before moving on to more invasive methods.
2.  Intra-articular injections to the sacroiliac joint with anesthetics and corticosteroids can be considered for diagnosis and treatment. Relief of pain by more than 75% after injection can confirm the diagnostic value of the procedure.
3.  Non-surgical methods, such as radiofrequency ablation and prolotherapy, may be considered for patients who have not achieved desired results with conservative treatment.
4.  In cases when conservative and non-surgical treatment is ineffective, percutaneous sacroiliac joint arthrodesis can be considered, especially for patients with abnormal anatomy or dysplasia.
5.  Open sacroiliac joint arthrodesis remains an option, particularly in cases of nonunion.

Effective treatment of sacroiliac joint arthralgia/arthropathy requires a careful individual assessment and discussion of the most optimal treatment plan. Further research and observation are necessary to assess the long-term results of different treatment methods for sacroiliac joint pain and identify the most effective therapeutic approaches.