Sacroiliac dysfunction

Disfunção sacroilíaca

ARTIGO DE REVISÃO

Sacroiliac dysfunction

Disfunção sacroilíaca

Sady RibeiroI, ^*; Andre Prato Schmidt^II; Peter van der Wurff^III

^IPain Specialist (American Pain Board of Medicine). Department of Neurobiology. University of Texas - Houston

^IIResident of anesthesia of Faculdade de Medicina da Universidade de São Paulo FMUSP - SP

^IIIMilitary Rehabilitation Centre Doorn. Lecturer Polytechnic of Utrecht The Netherlands

SUMMARY

The sacroiliac joint, due to its anatomic aspect, is a very particular joint. It can be affected by several pathologies. Seronegative spondyloarthropaties are classical examples of these disorders.

Sacroiliac Dysfunction seems to be a biomechanical dysfunction of this joint and could be a cause of chronic back pain. History and physical exam, due to poor specificity, might not be enough to make this diagnosis. Imaging studies are not very helpful either Anesthetics block, guided by fluoroscopy, CT, or MRI is considered the "gold standard" test, which proves that pain originates from the joint.

When conservative treatment fails, invasive therapeutic modalities can be used, but their efficacy has not yet been proven. Arthrodesis should be reserved for the very disabling cases that did not respond to the less aggressive approaches. Opioids may be the last hope for some patients

Disorders of the sacroiliac joint sometimes can be a challenge regarding diagnosis and treatment⁽⁸⁾. Since the joint is deeply located, proper assessment is difficult⁽⁴⁾. Its anatomy is complex and unique with a syndesmotic superior compartment and synovial inferior one⁽⁴⁾. The iliac bone presents a thin fibrocartilagionous cartilage and the sacral bone is covered by a thicker hyaline cartilage, which makes the iliac side more vulnerable to any pathology that might affect the joint^(6,9).

The joint surfaces remain flat until the twenties, but with time there is an increase in the number and size of elevations and depressions of the articular surfaces^(5,21); enhancing friction and stability of the joint⁽¹⁵⁾. Ligamentous structures, which are the strongest of the body, localize anteriorly and posteriorly, contributing to the stability of the joint⁽⁷⁾.

Capsulated and uncapsulated nerve endings are present in the joint and surrounding ligaments, making the sacroiliac joint a possible source of pain⁽⁵⁴⁾. Posteriorly the joint receives branches of the posterior rami from L4 to S3 and anteriorly from L2 to S2^(2,7).

This innervation results in a complex and often confusing pain referral pattern^(19,26,27).

The joint is surrounded by powerful muscles that have no direct influence on its motion, but can interfere in its mobility⁽⁴⁾.

The debate about joint mobility goes back to Hippocratic time. It is now an almost general consensus that despite being small mobility takes place⁽⁶⁸⁾. Speaking in favor of mobility, we have the synovial nature of the inferior compartment coupled with degenerative changes occurring in the joint^(5,15). This movement is more significant in women during pregnancy and menstruation due to the effects of relaxin on the strength and rigidity of the collagen⁽³⁰⁾. Age–related changes, as periarticular ankylosis and alterations in the articular surfaces, make joint mobility decrease with time⁽⁶⁷⁾.

Sacroiliac joints can be involved in multiple pathologies^(53,59). The diagnosis can be made by the clinical picture of the disease in question^(37,51,74), the presence of pain⁽⁷³⁾, and the findings of laboratory⁽³³⁾ and imaging studies^(10,12,31).

Seronegative spondyarthropaties, more specifically ankylosing spondylitis, are typical examples of pathologies that involve the sacroiliac joints. In this group of diseases the sacroiliac may be affected longer before changes are noted in the spine⁽⁵¹⁾. Rarely, the spondylitis precedes the sacro-ileiteis⁽⁷⁴⁾. X-Ray can be normal in the early phase of these diseases⁽¹⁷⁾, while CT enhances the possibility to detect early changes⁽¹²⁾. Further improvements can be made with MRI that could still be more sensitive when done with contrast⁽²⁰⁾. Bone scanning is of questionable value in this situation^(31,34).

Degenerative changes that usually start around the forties are more common in men, but as in other joints these changes can be asymptomatic^(59,73). In the early stage, the differences between degenerative changes and inflammatory sacroiliitis are difficult when done by X- ray^(10,41). Later on, the formation of periarticular osteophytes can also be confused with intrarticular ankylosis of the spondyloarthopaties, but CT will help to clarify this doubt^(12,17).

Rheumatoid arthritis may involve the sacroiliac joint in the advanced stage of the disease⁽⁵³⁾. Gouty sacroiliitis is more common in the severe thophaceous gout and can be bilateral⁽³⁶⁾.

Calcium pyrophosphate crystal deposition disease, sarcodosis,ochronosis, hyperparathyroidism, paget disease, osteomalacia, acromegaly are other pathologies that can affect the sacroiliac joints^{(1,9,18,39,40,73)}.

Primary tumors are rare. Pigmented villonodular synovitis, which is more common in children, can be accompanied by significant bone destruction⁽³⁵⁾. Metastatic lesions more frequently are associated to lung, breast, kidney and prostate cancer^(9,73).

Infection is uncommon in the sacroiliac joint⁽²³⁾.

Staphylococcus is the most common germ⁽⁴²⁾, however Pseudomonas should be remembered in an infected sacroiliac of a drug addict⁽⁶⁵⁾. Bilateral tuberculosis has been reported⁽³⁸⁾. Bone scanning can be useful in the diagnosis of infectious sacroiliitis⁽⁷²⁾.

Stress fractures of sacrum, ilium or both can occur in runners and military recruits⁽⁴⁸⁾, and insufficiency fractures are a complication of osteoporotic pelvis⁽¹⁶⁾. Again, bone scanning can be helpful in the diagnosis of these two conditions^(31,43).

Finally, osteitis condensans ilii is a benign condition occurring in young multiparous⁽⁵⁶⁾, although this condition has also been described in men⁽⁵⁶⁾. It is characterized by asymptomatic bilateral involvement along the inferior iliac side of the joint, which on X-Ray may be confused with sacroileitis of spondyarthropaties. However, the clinical picture and CT help to clarify any doubt in the differential diagnosis^(56,73,74).

Nevertheless, that which may still be controversial and even unaccepted by some authors is the condition called Sacroiliac dysfunction, Syndrome of the sacroiliac joint, or Mechanical sacroiliac joint^{(4,5,8,56,73,74)}.

These terminologies are used to characterize an abnormality of the sacroiliac joint where a biomechanical disorder would exist, with no apparent lesion^(9,21). Although sometimes a positive bone scan has been found, raising the possibility that inflammatory changes might be present^(46,64,72).

The prevalence of this condition varies with the literature consulted, being higher in the chiropractic and osteopathic sources^(4,8,9,22).

The pattern of pain from the sacroiliac joint has been determined by injections of contrast intrarticularly in healthy volunteers^(26,27). It is, more frequently, located below the territory of L5 (the most specific area is 10 cm caudally and 3 cm laterally to the posterior-superior iliac spine - the so-called, Fortin area)^(28,62), radiating to buttock, thigh, and groin and eventually extending to leg, and sometimes imitating sciatic^(28,62). Patients with Sacroiliac dysfunction described pain that is aggravated by bending, sitting, or riding in an automobile⁽⁵³⁾. Standing or walking can alleviate the pain⁽⁵³⁾. The condition can be bilateral, but when unilateral, it more frequently favors the right side^(29,73). Pathologies as discopathy, lumbar facet syndrome, hip disease, and myofascial syndrome can refer pain to the sacroiliac joint area, being subject of a differential diagnosis^(29,53). In the presence of a clinical picture of Sacroiliac dysfunction, a true limb discrepancy will reinforce this diagnosis⁽¹⁴⁾.

Some authors believe that spine arthrodesis might result in Sacroiliac dysfunction due to a change in the biomechanical of the pelvic-lumbar complex, which would cause a high stress in this joint^(24,32). Pelvic instability would also be a potential complication of bone graft harvesting from the posterior aspect of the iliac crest⁽⁶¹⁾. Subluxation and dislocation of the sacroiliac joint have been reported after removal of full thickness grafts from the posterior ilium⁽¹³⁾. Dysfunction of the sacroiliac joint can also occur during pregnancy and usually settles spontaneously with the passage of time⁽⁷³⁾.

Several tests have been advocated to assess sacroiliac joint clinically⁽⁷¹⁾. Unfortunately, none of the individual test seems to be reliable⁽⁷⁰⁾. They can be divided into two groups: provocative and mobility tests⁽⁷¹⁾.

Provocative tests are maneuvers that cause stress in the sacroiliac joint and consequently provoke pain. Unfortunately, they are not specific. A positive test could be obtained with pathologies of hip and lumbar spine⁽⁷¹⁾. Patrick and Ganeslen tests are well known examples, whose descriptions can be found in almost any physical exam textbook.

Mobility tests are based on changes in landmarks that may occur in standardized movements. Gilllet test, Hip rotation test and Supine to sitting test are examples of this category.

Gillet Test: The patient is standing. The examiner, behind the patient, places one of his/her thumbs on the posterior superior iliac spine (on the side being tested). The other thumb is rested in the midline of the sacrum at the level of S2 foramen. The patient is asked to flex knee and hip, bringing the knee towards the body. Normally, the thumb in the posterior superior iliac spine has to dislocate inferiorly when compared to the opposite thumb⁽⁷¹⁾.

Hip rotation test: Patient lies supine with the medial malleolli touching each other. The position of the medial malleoli of the side to be tested is determined in relation to the opposite medial malleoli. The leg of the side tested is abducted and externally rotated to its maximum. The leg is then returned to neutral position. Normally, what is expected is an apparent lenghting of the leg of the side tested⁽⁷¹⁾. This phenomenon is explained by a movement of the superior anterior iliac spine that moves down as the hip is externally rotated. When a joint dysfunction exists in the sacroiliac joint, the protective guarding of the musculature over the sacroiliac joint prevents the caudal shift of the ilium and no apparent lengthening will occur⁽⁷³⁾.

Supine to sitting test: Patient is supine and the leg lengths are determined. Patient is asked to sit up. If an apparent lengthening of a leg occurs, this would be highly suggestive of Sacroiliac dysfunction⁽⁷¹⁾.

Clinical history and physical tests have showed limited validation in Sacroiliac dysfunction⁽⁵³⁾. The tests are also subject to a high interobserver error⁽⁴⁵⁾. They might depend on the skill and experience of the examiner. Provocative tests can stress other structures apart from the sacroiliac joints. Obesity can make the determination of the proper landmarks difficult. The presence of structural disorders as scoliosis and true limb length discrepancy make the interpretation of the mobility test harder.

Diagnostic block has been presented as the standard gold test to prove if pain comes from the sacroiliac joint⁽⁴⁷⁾. The principle is simple. If a local anesthetic is correctly placed inside the joint and the pain goes away, for a time compatible with the action time of the medication, the joint is most likely the source of pain (A pain relief of at least 50% on a visual analogue scale is desirable). As in every diagnostic block, the false positive response is a challenge. To avoid this question some authors have proposed a block in two different times using local anesthetics with different action time^(45,59). Initially the patient receives a block with lidocaine and if relief of the pain is obtained, a second injection with bupivacaine is performed, which causes a relief that should last longer than the first block. In the past, the blocks were executed blindly, which made their reliability poor. Currently, these blocks are performed under fluoroscopy or CT^(60,63). In pregnant women MRI has been used⁽⁵⁷⁾. The use of contrast is also important to confirm the needle position inside the joint and to show no vascular up take of the anesthetic (a phenomenon that would result in a false negative response)⁽⁶⁹⁾. Ideally, the block should be performed by someone that is not treating the patient to avoid any bias. The amount of contract injected is 1cc and of local anesthetic is 2cc. Bleeding disorders and infections are contra–indications for the blocks⁽⁶³⁾.

However, as the block is performed in the synovial aspect of the joint, one should not exclude the possibility of pain originating from ligaments, muscles, and the non-synovial compartment^(53,58).

The treatment of Sacroiliac dysfunction is also a debatable subject. Correction of true limb discrepancy (when present), nonsteroidal anti-inflammatory drugs, and physiotherapy are the first choices for almost every physician^(9,52,53,73). Ostheopaths, chiropractors, and manual therapists defend the use of manipulation and mobilization, which can be associated with medication and physiotherapy^(50,55). Physiotherapy is focused on an exercise program to correct muscle imbalance. Gluteus maximus, medius, and hip external rotators are strengthened. Illiopsoas, rectus femoris, and hamstrings are stretched. Manipulation and mobilization are used as an attempt to restore joint mechanics. Some of its defenders claim that these two modalities reduce subluxation. Belts have been used, mainly in pregnant women, to reduce instability.

The intra-articular injection of steroids is a questionable treatment for Sacroiliac dysfunction, although it has been used to treat sacroiliitis of the seronegatives spondyloar-thropaties^(49,74). Certainly, steroid injections do not change the biomechanical disorder of the joint. However, the steroid might address an inflammatory component of the dysfunction, which could enhance the ability of a patient to participate in a physiotherapy program. The same recommendations made with the diagnostic blocks are also applicable in steroid injections. Some practitioners, apart from the injection in the synovial compartment of the joint, also inject the medication into the periarticular structures of the joint⁽⁴⁴⁾.

Prolotheraphy is another type of therapy that has been used in Sacroiliac dysfunction. It involves the injection of screrosant substances (such as dextrose and phenol) into the ligamentous portion of the joint⁽⁵⁵⁾. This would encourage the production of stiffer and more abundant ligamentous tissue, resulting in more stability. However, some authors believe that the therapeutic response to prolotherapy is caused by a chemical neurolysis of branches of the posterior rami that innervate the posterior aspect of the joint.

Radiofrequency thermocoagulation of the medial branches of the posterior rami is a therapeutic modality that has been used in the treatment of cervical and lumbar facet syndrome. This procedure has also been utililized by some doctors in treating the Sacroiliac dysfunction⁽²⁵⁾. In this situation, the ablation is performed in branches to the posterior rami of L5 to S2. However, this method does not address the innervation of the anterior aspect of the joint.

Neuroaugmentation is part of the therapeutic arsenal in the treatment of chronic back pain. It can be used as TENS unit or through the implantation of epidural electrodes. In sacroiliac pain, the TENS unit can be associated to other conservative modalities. Some anecdotal reports exist referring to the use of electrodes placed in the sacral epidural space for the treatment of Sacroiliac dysfunction, which have not responded to a more conservative approach⁽¹¹⁾.

Viscosuplementation with hyaluronic acid-like products is a new treatment for osteoarthitis. Encouraging results have been reported in the treatment of knee osteoarthitis⁽³⁾. Few cases exist in the literature of patients with possible Sacroiliac dysfunction that apparently responded well to this kind of treatment⁽⁶⁶⁾.

Arthodesis in the treatment of the Sacroiliac dysfunction should be reserved for intractable and disabling cases⁽³²⁾.

Finally, as in other chronic pain syndromes, some patients could be managed with opioid analgesics. Concerns about tolerance and addiction must be considered.

Key words: Sacroiliac joint; Spondylarthropathies; Artrodesis; Narcotics.

CONCLUSION

Sacroiliac joint is a potential source of pain. How often Sacroiliac dysfunction causes back pain is another question. This condition can be confused and co-exist at the same time with other disorders. In the absence of other pathologies such discopathy, lumbar facet syndrome, and hip disease, the history and physical exam could be enough to make the diagnosis. However, in cases of doubt, intra-articular injection of local anesthetics, under imaging guidance, might be necessary. When conservative treatment fails, the physician should look for other available options, yet keep in mind the lack of controlled and prospective studies in these invasive modalities.

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Trabalho recebido em 06/11/2002

Aprovado em 05/03/2003

Publication Dates

• Publication in this collection
  13 June 2003
• Date of issue
  Apr 2003