Sacroiliac Joint Disorder (eBook)

Dr. Eiichi Murakami, JCHO Sendai Hospital

Preface 5
Acknowledgements 7
Contents 8
About the Author 12
1: The Sacroiliac Joint (SIJ) Has Been Forgotten from History 13
1.1 Causes of Low Back Pain 13
1.1.1 Classification 13
1.1.2 Pain from Ligaments or Fascias Should Be Much More Common than that from Lumbar Nerve Roots 14
1.2 The Forgotten Joint: The Sacroiliac Joint 16
References 18
2: Basic Understanding of the Sacroiliac Joint 19
2.1 Anatomy 19
2.1.1 Changes of the Pelvis in the Transition from Quadrupedal to Bipedal Walking (Fig. 2.1a, b) 19
2.1.2 Morphological Anatomy 22
2.2 Innervation (Fig. 2.5) [10] 24
2.3 Biomechanics 26
2.3.1 Structure 26
2.3.2 Movement 26
2.3.3 Proof of Movement in the SIJ on X-Ray 27
2.3.3.1 Vacuum Phenomenon 27
2.3.3.2 Change of Pelvic Incidence 29
2.4 Function 30
2.4.1 Essential Functions to the Human Body 30
2.4.1.1 Two Types of Synovial Joints 30
2.4.1.2 The SIJ, Parallel to the Gravity Line, Plays a Leading Role in Absorbing Vertical Loads 31
2.4.1.3 The Main Functions of the SIJ: Supporting the Upper Body and Absorbing the Impact from the Ground 32
2.4.2 Specific Movements of the SIJ for Absorbing Impact 33
2.4.2.1 Ligamento-Muscular Reflexes 33
2.4.2.2 Arthrostatic Reflex and Arthrokinetic Reflex 33
2.4.2.3 The SIJ Functions Characteristically Like a Damper 37
2.4.2.4 The SIJ Easily Causes Joint Dysfunction (Fig. 2.21) 40
2.4.3 A Mechanism for Providing the Stability of the Pelvis 40
2.4.3.1 Form Closure and Force Closure (Fig. 2.22) 40
2.4.3.2 The Transversus Abdominis Muscle and the Gluteus Maximus Muscle Are Important in Stabilizing the SIJ 41
2.4.3.3 The Inner Unit and the Outer Unit 41
References 43
3: Pathophysiology of Sacroiliac Joint Disorder 45
3.1 Pathophysiology and Etiology 45
3.1.1 Pathophysiology 45
3.1.2 Classification of SIJ Disorder (Fig. 3.4) 48
3.1.3 The Prevalence of SIJ Disorder 50
3.1.4 Age Distribution 51
3.1.5 Bilateral SIJ Pain 52
3.1.6 Combination of SIJ Disorder and Lumbar Spinal Lesions 52
3.2 Clinical Features 52
3.2.1 Pain Areas of SIJ Disorder 52
3.2.2 Differentiation Between Leg Symptoms from SIJ Disorder and Those from Damaged Lumbar Roots 53
3.2.3 Characteristic Motions and Postures Which Induce SIJ Pain 56
3.2.4 Discrimination of Pain Area in Sitting Between Lumbar Lesions and SIJ Disorder 57
3.3 Physical Findings 58
3.3.1 Neurological Findings 58
3.3.2 Tenderness Points 59
3.3.3 Difference Between the Straight Leg Raising (SLR) Test and the BowString Sign 60
3.4 Findings from Image and Blood Examinations 60
3.4.1 Image Findings 60
3.4.1.1 X-ray Findings 61
3.4.1.2 CT Findings 62
3.4.1.3 MRI Findings 62
3.4.1.4 Bone Scintigraphic Findings 62
3.4.2 Recent Topics Surrounding Image Findings 62
3.4.2.1 SPECT/CT Findings 62
3.4.2.2 Ultrasound Findings 62
3.4.3 Findings from Blood Investigation 63
References 65
4: Diagnosis of Sacroiliac Joint Disorder 66
4.1 Characteristic Pain Areas of SIJ Disorder 66
4.2 Examination 67
4.2.1 Pain Provocation Test 67
4.2.1.1 Why Are Provocation Tests and SIJ Injections Unreliable? 68
4.2.1.2 Commonly Used Pain Provocation Tests for the Assessment of SIJ Disorder 69
Gaenslen’s Test (Fig. 4.4) 69
Patrick’s Test (Fig. 4.4) 69
Sacroiliac Joint Shear Test (Fig. 4.5) 70
Thigh Thrust Test (Fig. 4.5) 70
Pelvic Distraction Test (Fig. 4.6) 70
Pelvic Compression Test (Fig. 4.6) 70
4.2.2 The One-Finger Test (Fig. 4.7) 71
4.2.3 Tenderness Points Which Are Useful for Diagnosis 74
4.3 Diagnosis 76
4.3.1 The Criteria for Diagnosing SIJ Disorder 76
4.3.2 Diagnostic Procedure for SIJ Disorder 77
4.3.3 Evaluation of Injection Effectiveness 77
4.4 SIJ Injection 79
4.4.1 Two Types of SIJ Injection (Intra-articular and Peri-articular) (Fig. 4.15) 79
4.4.2 Intra-articular Injection (Fig. 4.16a) 80
4.4.2.1 The Diagnostic Rate by Intra-articular Injection Is Low 80
4.4.2.2 The Reason for the Low Diagnostic Rate by Intra-articular Injection 80
4.4.2.3 Intra-articular Injections Are Technically Not Easy to Perform 81
4.4.3 Peri-articular Injection (Fig. 4.17) 81
4.4.3.1 A Peri-articular Injection Is Much Easier to Perform than an Intra-articular Injection 81
4.4.3.2 Most SIJ Disorders Can Be Diagnosed by Using a Peri-articular Injection 81
4.4.4 A Diagnostic Algorithm for SIJ Disorder 83
4.5 Differential Diagnosis 84
4.5.1 Differentiation Between SIJ Disorder and Lumbar Spinal Diseases 84
4.5.1.1 Degenerative Lumbar Spine Diseases Differentiated by Pain Area (Fig. 4.21) [20] 84
4.5.1.2 Spinal Metastasis Caused by Cancer 85
4.5.1.3 Pyogenic Spondylitis 85
4.5.1.4 Osteoporotic Vertebral Compression Fracture 85
4.5.2 Noteworthy Pain Which Originates from Around the SIJ (Fig. 4.22a) 86
4.5.2.1 Entrapment Neuropathy of the Superior Cluneal Nerve [21] 86
4.5.2.2 Iliolumbar Ligament Syndrome [22] 86
4.5.2.3 Sacrotuberous Ligament Syndrome [23] 86
4.5.2.4 Piriformis Syndrome [24] 86
4.5.2.5 Entrapment Neuropathy of the Superior Gluteal Nerve [25] 86
4.5.3 Relationship Between the Hip Joint and SIJ 88
4.5.4 Organ Diseases Which Should Be Differentiated from SIJ Disorder [27] 89
4.5.4.1 Obstetrics and Gynecological Diseases 89
Endometriosis 89
Ovarian Cyst, Ovarian Cancer 89
Uterine Myoma, Uterine Retroflexion 89
4.5.4.2 Urological Diseases 89
Urinary Tract Stone 89
Pyelonephritis 89
Kidney Cancer 89
4.5.4.3 Lung Cancer 89
4.5.4.4 Digestive Diseases 90
4.5.4.5 Disorders of the Blood System 90
Multiple Myeloma 90
Spinal Metastasis of Malignant Lymphoma 90
4.5.4.6 Vascular Diseases 90
4.5.4.7 Psychogenic Low Back Pain 90
References 90
5: Treatment of Sacroiliac Joint Disorder 92
5.1 Treatment Strategy for SIJ Disorder 92
5.2 Conservative Treatments 92
5.2.1 SIJ Injection 92
5.2.1.1 The Origin of Most SIJ Disorder Is Probably Located in the Peri-articular Region 93
5.2.1.2 Mechanism of Pain Relief by an Injection (Fig. 5.3) 94
How Can an Injection of Local Anesthetic Relieve Pain for a Long Period of Time? 94
5.2.1.3 Which Is More Effective, Injection into the Posterior Ligamentous Region or the Posterior Nerve Branch? 95
5.2.1.4 Pre-injection Test 95
MRI 95
Blood Test 95
5.2.1.5 Complications Resulting from Injections 95
5.2.2 Medications (Fig. 5.5) 97
5.2.3 Wearing a Rubber Pelvic Belt (Fig. 5.6) 98
5.2.4 Arthrokinematic Approach (AKA)-Hakata Method (A Manual Therapy) 98
5.3 Surgical Treatments 100
5.3.1 The Lateral Approach: iFuse Implant System (Fig. 5.8) 100
5.3.1.1 Surgical Technique 101
5.3.1.2 Clinical Outcomes 101
5.3.1.3 Complications 101
5.3.2 The Posterior Approach: DIANA Method (Fig. 5.9) 102
5.3.2.1 Surgical Technique 102
5.3.2.2 Clinical Outcomes 102
5.3.2.3 Complications 103
5.3.3 The Anterior Approach: Our Anterior SIJ Fusion [22] 103
5.3.3.1 The Transition of Our Surgical Technique 103
5.3.3.2 Former Approach (Fig. 5.10) 103
5.3.3.3 Current Approach (Fig. 5.11) 103
5.3.3.4 Clinical Outcomes 105
5.3.3.5 Complications 105
5.3.3.6 The Advantage of Our Anterior Approach 107
References 107
6: Manual for Sacroiliac Joint Injections 109
6.1 The Peri-Articular Injection Under Fluoroscopic Guidance [1] 109
6.1.1 Sections Designated for an Injection 110
6.1.2 Supplies/Necessary Items for an Injection (Fig. 6.6) 112
6.1.2.1 Insertion Needle 112
6.1.2.2 A Syringe 113
6.1.2.3 The Local Anesthetic 113
6.1.3 Procedure 113
6.1.4 Volume of Local Anesthetic to Be Injected 115
6.1.5 Check the Depth of the Injection Needle 115
6.1.6 Actual Injection Procedure 116
6.1.6.1 Injection into Area 0 116
6.1.6.2 Injection into Area 1 117
6.1.6.3 Injection into Area 2 119
6.1.6.4 Injection into Area 3 120
6.1.7 Referred Pain Area of Each Section 120
6.1.8 Evaluation of Injection Effect 124
6.1.9 Progress After Injections 124
6.2 The Peri-Articular Bedside Injection (Fig. 6.22) 125
6.2.1 Comparison of the Positions for an Injection 125
6.2.1.1 The Prone Position 125
6.2.1.2 The Slightly Bent Forward Standing Position 126
6.2.1.3 The Slightly Bent Forward Sitting Position 126
6.2.2 Items Used for the Bedside Injection (Fig. 6.26) 128
6.2.2.1 Local Anesthetic Drugs 128
6.2.2.2 An Insertion Needle 128
6.2.2.3 An Injection Syringe 128
6.2.3 Identification of the PSIS 128
6.2.3.1 Identification Method I: Palpating Along the Iliac Crest (Fig. 6.27) 129
6.2.3.2 Identification Method II: Measuring the PSIS on an X-ray Image (Fig. 6.28) 129
6.2.3.3 Identification Method III: Speculation on CT Measurements (Fig. 6.29) 129
6.2.4 The Direction for Needle Insertion 130
6.2.4.1 The Direction for a Safe Insertion of the Needle: Inserting the Needle from the Cranial Side of the PSIS 132
6.2.4.2 A Safe and Effective Needle Insertion 132
6.2.5 Actual Procedure of a Needle Insertion 133
6.2.5.1 The Slightly Bent Forward Standing Position 133
6.2.5.2 Needle Insertion 133
6.2.6 Important Points for Bedside Injections 134
6.2.6.1 Hunting for the Area Where the Familiar Pain Is Induced by a Needle Insertion Is Very Important 134
6.2.6.2 When Inserting for Area 0 136
6.2.6.3 Limits and Risks of an Injection from the Caudal Side of the PSIS 137
6.2.7 When a Needle Becomes Obstructed 137
6.2.7.1 The Cause for the Needle Not Advancing 137
6.2.7.2 Techniques for Advancing the Needle 137
6.2.8 The Depth of the Needle, Injection Dose of Local Anesthetic Used, Infusion Speed, and Evaluation After an Injection 138
6.2.8.1 The Depth of the Needle 138
6.2.8.2 Injection Dose of Local Anesthetic 139
6.2.8.3 Infusion Speed for Local Anesthetic: A Forceful Injection is Dangerous 140
6.2.8.4 Evaluation of Injection Effectiveness 140
6.2.9 Summary of the Procedure for Bedside Injections (Fig. 6.43) 141
6.2.9.1 Positioning of the Patient 141
6.2.9.2 Identification of the PSIS 141
6.2.9.3 Insertion of the Needle 141
6.2.9.4 Injection of Local Anesthetic 141
6.2.9.5 Evaluation After the Injection 141
6.3 The Intra-Articular Injection 143
6.3.1 Supplies/Necessary Items for an Injection (Fig. 6.45a) 143
6.3.2 Procedure 144
References 147
7: Improvements and Prevention of Sacroiliac Joint Disorder 149
7.1 Differences in the Pelvis of Males and Females [1] 149
7.2 Useful Items to Improve SIJ Disorder 150
7.2.1 A Rubber Pelvic Belt (see Fig. 5.6) 150
7.2.2 An Exercise Ball (Fig. 7.2) 150
7.3 Prevention of SIJ Disorder 151
7.3.1 Points for Preventing SIJ Disorder (Fig. 7.3) 151
7.3.1.1 Avoid Working in the Same Posture for a Long Time 151
7.3.1.2 Do Not Be Relaxed While in Semi-flexion Posture or During Action 151
7.3.1.3 Do Not Get Tired, Do Not Let Your Body Cool Down 153
7.3.1.4 Do Squats Up and Down After Bathing or in the Morning 153
7.3.1.5 Active Walking 153
7.3.2 Physical Therapy for Stabilizing the SIJ 153
7.3.2.1 Exercise for the Transversus Abdominis Muscle 154
Draw-In: Inward Movement of the Lower Abdominal Wall (Fig. 7.4) 154
7.3.2.2 Exercise for the Gluteus Maximus Muscle 154
7.3.2.3 Preventing Contracture of the Rectus Femoris Muscle or Hamstring Muscle 155
7.3.3 Squatting Exercise for Maintaining the Function of the SIJ 155
7.3.3.1 Exercises: The Patient Squats While Keeping Your Legs Open 155
References 156
8: The Tragedy of Low Back Pain that Cannot Be Diagnosed from Images 158
8.1 Case 1: SIJ Disorder that Was Almost Performed Posterior Lumbar Interbody Fusion (PLIF) 158
8.2 Case 2: SIJ Disorder with a Chief Complaint of Groin Pain 159
8.3 Case 3: Hip Osteoarthrosis: Pain Was Relieved After SIJ Injection 160
8.4 Case 4: SIJ Disorder Developed After Total Hip Arthroplasty (THA) 163
8.5 Case 5: SIJ Disorder Complicated with Lumbar Disc Herniation 163
8.6 Case 6: SIJ Disorder Developed After Surgery for Lumbar Spinal Stenosis 166
8.7 Case 7: SIJ Disorder in Which Symptoms Disappeared After Removal of Lumbar Disc Herniation 167
8.8 Case 8: SIJ Disorder Developed After Lumbar Spinal Fusion 169
8.9 Case 9: SIJ Disorder: Pain Was Relieved After Removing the Instruments Used for Lumbar Spinal Fusion 169
8.10 Case 10: SIJ Disorder: Occurring After Thoracolumbar-Compressed Fracture 172
8.11 Case 11: SIJ Disorder: Weakness of Lower Limb, Which Developed Due to SIJ Disorder, Made Walking Difficult 173
8.12 Case 12: SIJ Disorder Diagnosed as Psychogenic Pain 174
8.13 Case 13: SIJ Disorder in a Patient Who Was Suspected of Faking His Disease 175
Reference 178
9: Overview of Our Activities 179
9.1 Sacroiliac Joint Seminar 179
9.2 Low Back Pain and Sacroiliac Joint Center (Fig. 9.2) 180
9.3 Japanese Sacroiliac Joint Research Society (Fig. 9.3) 180
Glossary 182
Index 183