BRP Spine

1. SI Joint Dysfunction
Pengampu:
dr. Tjuk Risantoso, Sp. B, Sp. OT (K)
Resident:
dr. Rizqi Daniar Rosandi (ROD)
dr. Ganang Dwi Cahyono (GIN)
dr. Adytia Andreyta Refa (DIF)
Dr. Muammar HB (MAM)
Serial BRP Spine
Malang, Februari 2021

2. Introduction
• A degenerative condition of the sacroiliac joint resulting in lower back pain
• 15% to 30% of cases of lower back pain in the outpatient setting
• Treatment is generally conservative
• SI joint arthrodesis reserved for patients who fail physical therapy, SI joint
injections, and radio frequency nerve ablation

3. Risk factors
• previous lumbar spine fusion
• pregnancy and vaginal delivery
• previous trauma to the pelvis
• prior iliac crest bone graft harvesting

4. Intraarticular mechanism
Extraarticular mechanism
Idiopathic mechanism
Pathophysiology
Genetic
Associated condition

5. Idiopathic Mechanism
• The most common
• Result of repetitive trauma to the SI joint (insidiously or acutely)
Ligamentous/
capsule tension
Extraneous compression/
shear forces
Hypomobility or
hypermobility
Abberant joint
mechanics
Myofascial or kinetic chain
imbalance
inflamation
SI joint pain
generators

6. Intraarticular mechanism
arthritis
infection
metabolic
tumors
• Inflamation &
degeneration of SI joint
• Usually with
spondyloarthropathies
subchondral sclerosis, subchondral cyts,
osteopytes, joint space narrowing, and
ankylosis
• Result of hematogenous
spread
• Typically unilateral
involvement
Organisms: staph aureus,
pseudomonas,
Cryptococcus organism,
mycobacterium tb
Predisposing factors:
immunosuppression,
endocarditis, iv drugs
abuse
Leads to early degeneration
of the joint
Disease: gout, renal
osteodystrophy, acromegaly
Primary : very rare
Secondary (metastatic): most
common

7. Extraarticular mechanisms
Ethesopathy Post-traumatic
Insufficency
fractures
• Inflamation of the
ligamentous
attachements to the SI
joint
• frequently occurs with
spondyloarthropathies
• more frequently the
posterior ligaments
• Osteoporotic fracture
in elderly patients
• Repetitive trauma in
athletes & military
recruitment
• More common after
lateral compression
pelvic ring injuries

8. Genetics
Associated
conditions
HLA-B27, associated with ankylosing spondylitis
Orthopaedic condition:
• Lumbar spinal fusion
• Post-traumatic arthritis
• Metastatic tumors
Medical condition & comorbidities:
• Ankylosing spondylitis
• Gout
• Pseudogout
• infections

9. Anatomy
- articulation of the ilium and the sacrum  largest axial joint in the body (Joint surface
area 17.5 cm^2)
- Consist of 2 part:
Anterior part  true synovial joint
Posterior part  syndesmosis (sacroilliaca ligament)
 Ampiarthrodial joint: stable, rigid, relatively immobile & allowing effective load
transfer
- Articular surface change with age: flat until puberty  ridge by age 30  erode the
synovial surface by age 50  ankyloses is common in men by age 50

11. Biomechanic
• SI joint function as a triplanar shock absorber
- Dissipates load of the upper trunks and faciliates parturition
- Withstand a medial directed load six times greater than the lumbar spine
- Fails in 1/20 the axial load of the lumbar spine

12. • complex motion at the SI joint:
- Gliding
- Rotation
- Tilting
- Nodding (nutation)
- Translation
• joint motion is limited to <4° of rotation and 1.6 mm of translation
• motion of the joint progressively decreased with age: age 40-50 for men, greater
than 50 for women

14. Presentation
Symptoms
Physical exam
Pain  pain usually present just inferior to the posterior
superior iliac spine
Look  may have antalgic gait
Motion  evaluate hip & knee for underlying pathologies
Feel  identify focal areas of tenderness
• Sacral sulcus (most tender location)
• PSIS (2nd most tender location)

16. Provocative Test
• based on a battery of tests, no single test has 100% diagnostic accuracy
• >3 positive tests is highly suggestive of the diagnosis

19. Imaging
• Imaging modalities have not proven to be much more beneficial than the physical examination
Radiographs
Recommended view :
- Pelvis AP
- SI joint view
- Lumbosacral AP/lateral  to identify other spinal pain generators
Findings:
• joint space narrowing
• subchondral sclerosis
• subchondral cysts
• osteophytes
• ankylosis

20. Imaging
• CT
- Has poor diagnostic power compared to SI joint injections
- Deformity correction or surgical intervention is planned
• MRI
- Done to exclude other diagnoses
- Identification of tumors, infectious procces, or soft tissue components

21. Diagnosis is based on four major criteria:
• Positive patient history
• Evaluation of lumbar spine and hip joints
• Positive SIJ pain provocative tests
• Positive SIJ infiltration

22. Differential diagnosis
Top 5:
• lumbar spinal stenosis
• degenerative disc disease
• hip osteoarthritis
• hip labral tear
• lumbar disc herniation

23. Management
Nonoperative
First line : oral medication, physical therapy, pelvic belt & prolotherapy
Second line: SI joint corticosteroid injection
Third line : Radiofrequency ablation
Operative : SI joint arthrodesis

24. Nonoperative management-First Line
• Oral medication
- NSAID to reduce inflammatory procces associated with pain
- Opiod medication should be used sparingly
• Physical therapy
- treatment focuses on addressing core muscle strengthening, proprioception, and
flexibility to correct lumbopelvic and hip biomechanics
• Pelvic belt
- applies medial directed force on greater trochanters
- limits the motion and shear forces across the SI joint by providing compression

25. Nonoperative management-First Line
• Prolotherapy (controversy)
- phenol or glucose-based solutions injected at the base of ligamentous complexes to
induce scarring
- generates inflammatory response resulting in fibroblastic migration and resultant
scar that stabilizes joint
• Outcome :
- most effective in the acute phase of pain
- pelvic belt more effective for SI joint pain following pregnancy
- prolotherapy more effective in the setting of ligamentous laxity
4 week of non-operative modalities trial before proceeding with SI joint injection

26. SI Joint Corticosteroid Injection- 2nd Line
Diagnostic
Theraupetic
• Single diagnostic vs dual diagnostic blocks
• Single diagnostic  injected lidocaine, (+) if 70% pain relieved
• Dual diagnostic  first injected lidocaine, 2nd injected bupivacaine,
(+) if 75% pain relieved
• With local anesthetic & steroid
• Corticosteroid offer anti-inflammatory mechanism to reduce pain
• Fluoroscopy or USG guidance
• No more than 3 injections in a 6 month or 4 injection in 1 year

27. Radiofrequency ablation- 3rd line
• Applying an electrical current generated by radio waves to heat nerve fibers
• Targets lateral branches of the sacral nerve roots
• Succesful criteria : 50% or > pain relief & significant functional
improvement in 3 and 6 months after procedure
• Outcomes  efficacy is limited due to the inability to denervate the anterior
neural structues of the SI joint

28. Operative: SI joint arthrodesis
Confirmed diagnosis
Aberrant SI anatomy,
sacral dysmorphism,
revision surgery
Normal SI joint
Poor respone to
nonoperative
Percutaneus SI joint
arthrodesis
Open SI joint arthrodesis

29. References