Chronic Sacroiliac Pain

Sacroiliac joint dysfunction is improper movement of the joints at the bottom of the spine that connect the sacrum to the pelvis. It can result in pain in the low back and legs, or inflammation of the joints known as sacroiliitis. Sacroiliac joint (SIJ) pain is an underappreciated source of mechanical low back pain, affecting between 15 and 30% of individuals with chronic, nonradicular pain. The literature reports that the SIJ is the pain origin in as many as 30% of patients presenting with low back pain. 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. The most common cause of sacroiliac joint pain is osteoarthritis. Sacroiliac joint pain is also common in pregnancy. During pregnancy, hormones, such as relaxin, are increased leading to ligamentous laxity and joint hypermobility. Risk factors include leg length discrepancy, abnormal gait pattern, trauma, scoliosis, lumbar fusion surgery with fixation of the sacrum, heavy physical exertion, and pregnancy.Clinically, the SIJ can be challenging to evaluate; however, assessing pain location, patient posture/movement, and provocative manual testing are useful in making the presumptive diagnosis of SIJ disruption. 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. The most definitive evaluation is image-guided injection of anesthetic solutions into the joint which is diagnostic if there is at least 75% symptom relief acutely. Treatment begins with nonoperative intervention including use of NSAIDs and ice, physical therapy and injection. If these fail, the next option is generally radiofrequency denervation (rhizotomy) of the joint. If this does not provide adequate relief, surgical intervention, in the form of minimally invasive SIJ fusion may be considered.