Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature.
BACKGROUND
The sacroiliac joint has been implicated as a source of low back and lower extremity pain. There are no definite historical, physical, or radiological features that can definitively establish a diagnosis of sacroiliac joint pain. Based on the present knowledge, an accurate diagnosis is made only by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected patients with chronic low back pain utilizing controlled comparative local anesthetic blocks.


METHODS
A systematic review of diagnostic and therapeutic sacroiliac joint interventions.


OBJECTIVE
To evaluate the accuracy of diagnostic sacroiliac joint interventions and the utility of therapeutic sacroiliac joint interventions.


METHODS
The literature search was carried out by searching the databases of PubMed, EMBASE, and Cochrane reviews. Methodologic quality assessment of included studies was performed using the Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria for diagnostic accuracy and observational studies, whereas randomized trials were evaluated utilizing the Cochrane review criteria. Only studies with scores of 50 or higher were included for assessment. Level of evidence was based on the U.S. Preventive Services Task Force (USPSTF) criteria.


METHODS
For diagnostic interventions, the outcome criteria included at least 50% pain relief coupled with a patient's ability to perform previously painful maneuvers with sustained relief using placebo-controlled or comparative local anesthetic blocks. For therapeutic purposes, outcomes included significant pain relief and improvement in function and other parameters. Short-term relief for therapeutic interventions was defined as 6 months or less, whereas long-term effectiveness was defined as greater than 6 months.


RESULTS
The indicated level of evidence is II-2 for the diagnosis of sacroiliac joint pain utilizing comparative, controlled local anesthetic blocks. The prevalence of sacroiliac joint pain is estimated to range between 10% and 38% using a double block paradigm in the study population. The false-positive rate of single, uncontrolled, sacroiliac joint injections is 20% to 54%. The evidence for provocative testing to diagnose sacroiliac joint pain is Level II-3 or limited. For radiofrequency neurotomy the indicated evidence is limited (Level II-3) for short- and long-term relief.


CONCLUSIONS
The limitations of this systematic review include the paucity of literature evaluating the role of both diagnostic and therapeutic interventions and widespread methodological flaws.


CONCLUSIONS
The indicated evidence for the validity of diagnostic sacroiliac joint injections is Level II-2. The evidence for the accuracy of provocative maneuvers in the diagnosing of sacroiliac joint pain is limited (Level II-3). The evidence for radiofrequency neurotomy is also limited (Level II-3).
Rupert
Matthew P
MP
Vanderbilt Interventional Pain Center, Cool Springs, Cool Springs Surgery Center, Franklin, TN 37067, USA. mattrupert@comcast.net
Lee
Marion
M
Manchikanti
Laxmaiah
L
Datta
Sukdeb
S
Cohen
Steven P
SP
D000772:Anesthesia, Local / Q000379:methods; D000779:Anesthetics, Local / Q000627:therapeutic use*; D019317:Evidence-Based Medicine; D006801:Humans; D007270:Injections, Intra-Articular / Q000379:methods; D017116:Low Back Pain / Q000188:drug therapy* / Q000503:physiopathology; D009407:Nerve Block / Q000379:methods; D010147:Pain Measurement; D012446:Sacroiliac Joint / Q000473:pathology / Q000503:physiopathology*; D016896:Treatment Outcome
D000779:Anesthetics, Local