Up to 30% of Low Back Pain May Be From the Sacroiliac (SI) Joint1
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A symptomatic sacroiliac (SI) joint may refer pain to the low back, buttock, groin and lower extremity. Pain complaints may be related to prolonged sitting or standing, stair climbing, sexual intercourse, or even rolling over in bed.
Spine Physician’s Clinical Experience
Amish Patel, DO is an Interventional Pain Physician in Columbus, OH. Dr. Patel is a paid consultant of SI-BONE, Inc.
“In my practice, the prevalence of sacroiliac joint pain is quite high. In patients presenting with a chief complaint of low back pain, I've seen as high as 30% have pain arising from the sacroiliac joint. Painful SI joints are identified by taking a thorough history and performing a physical exam. The diagnosis is confirmed with a diagnostic sacroiliac joint injection performed under fluoroscopic or CT guidance. The sacroiliac joint may present with a pain referral pattern similar to the pain referral pattern of other spine-related pathology such as conditions of the spinal nerve, the intervertebral disk, the lumbar facets, or the piriformis muscle.”—Amish Patel, DO
SI joint pain has several typical presenting symptoms, including:
- Lower back pain
- Sensation of lower extremity: pain, numbness, tingling, weakness
- Pelvis / buttock pain
- Hip / groin pain
- Feeling of leg instability (buckling, giving wayI)
- Disturbed sitting patterns (unable to sit for long periods, sitting on one side)
- Pain going from sitting to standing
Essential First-Step: An Accurate Diagnosis
The patient history includes questions about the onset of pain, mechanism of pain, duration of pain, exacerbating factors, relieving factors, and prior history. Other things the spine physician checks for are whether or not the patient is suffering from fever, chills, night sweats, or bowel and/or bladder incontinence.
The patient’s prior history includes description of any treatments the patient may have received for their SI joint condition. This would include recent physical rehabilitation or physical therapy, recent history of NSAIDs (nonsteroidal anti-inflammatory drugs) or other medications, history of recent SI joint or other spine injections, or any other lumbar spine treatments.
Location, Location, Location
Location of pain is extremely important in the diagnosis of SI joint pain. Patients presenting with SI joint pain typically have midline spine pain below the level of L5 (lowest lumbar vertebra) or in the buttock region.
Key tests and observations during the physical exam:
- The patient points to the site of pain while standing
- The patient is evaluated while they are in a seated position to see if they will sit with weight on the painful side
- Does the patient report tenderness over the sacroiliac joint?
- Does the patient report tenderness over the sacrum?
Physical examination and the Five Provocative Maneuvers
Spine physicians use five provocative maneuvers to help diagnose SI joint pain. These tests are: Distraction (Figure 1), Thigh Thrust (Figure 2), FABER (Figure 3), Compression (Figure 4), and Gaenslen (Figure 5). One or more of these tests may reproduce the patient’s pain. If three out of these five provocative maneuvers are positive—meaning the patient’s typical symptom(s) were provoked during testing—then there is a high likelihood that the patient has SI joint pathology.
Figure 1: Distraction
Figure 2: Thigh Thrust
Figure 3: FABER
Figure 4: Compression
Figure 5: Gaenslen
Diagnostic SI Joint Injection
A diagnostic sacroiliac joint injection is used to confirm the diagnosis. In this particular type of injection, a local anesthetic such as lidocaine or bupivacaine is used to numb the joint. The medication is injected into the SI joint under fluoroscopic guidance (eg, real time x-ray).
Could your low back pain be SI joint related?
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