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WHAT IS THE SACROILIAC JOINT?
The SIJ is a complex structure, that connects the spine to the legs. Located in the lower back, the SIJ is composed of 2 different structures: the sacroiliac joint (SIJ) and the posterior sacroiliac joint ligaments. These structures have different innervation (Burnham et al, 2020).
WHAT ARE THE SYMPTOMS OF SACROILIAC JOINT PAIN?
SIJ pain can be acute or a chronic process. Sacroiliac joint pain can cause radiating pain into the back, buttock, groin and lower extremities. The majority of the time (94%) of patients will have pain in the low back.
Up to 60% of patients will also have leg pain (Murakami et al 2007). Leg pain typically occurs in the upper part of the leg (buttock, thigh and groin). Some patients will have numbness or a tingling sensation as well, making it sometimes challenging to distinguish SIJ pain from other causes of low back pain.
HOW IS SIJ PAIN DIAGNOSED?
SIJ pain cannot be diagnosed by imaging studies (Schwarzer et al 1995; Cohen 2005). SIJ pain can be identified by assessing the location of the pain, movement and posture of the patient and by physical examination.
HOW IS SIJ PAIN TREATED?
In many cases, conservative management can be helpful. Typical treatments include NSAIDs, physical therapy and corticosteroid injections. Physical therapy can address any asymmetry of the pelvis that may stress the SIJ and nonsteroidal anti-inflammatory drugs (NSAIDs) used for pain relief.
In some cases, the treatment of SIJ pain remains a challenge. In cases that fail therapy, steroid injections are commonly used. These injections have been found to be effective to treat SIJ pain in some patients. Studies have shown that periarticular SIJ injections are more effective than an intraarticular injection (Murakami et al 2007), which indicates that SIJ pain originating from the ligaments may cause the majority of SIJ pain.
Sometimes the effects of cortisone are short-lived, and repeated steroid injections can decrease bone density and suppress hormones (Bouvard et al 2010; Younes et al 2007). In some cases, radiofrequency neurotomy or surgical fusion are used to manage pain.
WHAT ARE THE AVAILABLE ORTHOBIOLOGIC THERAPIES FOR SIJ PAIN?
PRP (platelet rich plasma) injections are rich in growth factors that enhance the body’s natural healing response. While insurance companies still consider this procedure experimental, the studies available show promising results. Given the underwhelming evidence for other therapeutic procedures (i.e. physical therapy, steroid injections and radiofrequency neurotomy) the novel approach using PRP is welcomed (Urits et al 2019).
In 2 case series of patients with SIJ laxity and pain, injecting PRP into the SIJ ligaments led to significant improvement in pain scores (Ko 2010; Singla et al 2017). In a prospective randomized controlled study of 40 patients that got either a steroid injection or PRP injection patients were followed for 3-months. In this study, PRP injections were more effective than steroid injections for SIJ pain with 90% of patients after PRP experiencing significant pain relief compared to only 25% of patients after the steroid injection (Singla et al 2017). Unlike the short-term benefits from a steroid injection, another study found that patients can still have pain relief even at 4-years out from the PRP injection (Ko 2010).
HOW DOES PRP COMPARE TO STEROID INJECTIONS?
In summary, in Singla's small study PRP injections improved pain more than steroid injections. While steroid injections for SI joint pain are covered by insurance and the conventional mainstay treatment, steroids may not be a great long-term treatment when compared to PRP which increased the body’s natural ability to heal and may provide long-term relief.
References:
Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment, Anesth. Analg. 2005;101:1440–1453.
Ko GD. Platelet-rich plasma injections for sacroiliac joint pain: case series with preliminary screening tool and literature review. Pract Pain Manage. 2010;10:55–67. (Newsletter).
Murakami E, Tanaka Y, Aizawa T, et al. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. J. Orthop. Sci. 2007;12:274–280.
Schwarzer AC, Aprill CN, Bogduk N, The sacroiliac joint in chronic low back pain. Spine. 1995;20:31–37.
Simopoulos TT, Manchikanti L, Singh V, et al. A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician. 2012;15:E305–E344.
Singla V, Batra YK, Bharti N, et al. Steroid vs. platelet-rich plasma in ultrasound-guided sacroiliac joint injection for chronic low back pain. Pain Pract. 2017;17:782–91.
Urits I, Viswanath O, Galasso AC, et al. Platelet-Rich Plasma for the Treatment of Low Back Pain: a Comprehensive Review. Curr Pain Headache Rep. 2019;23(7):52.
Younes M, Neffati F, Touzi M, et al. Systemic effects of epidural and intra-articular glucocorticoid injections in diabetic and nondiabetic patients. Jt Bone Spine 2007;74(5):472–6.
Bouvard B, Legrand E, Audran M, Chappard D. Glucocorticoid induced osteoporosis: A review. Clin Rev Bone Miner Metab. 2010;8(1):15–26.
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