Sacroiliac Joint (SI) Disease

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Sacroiliac Joint Disease

The sacrum is the triangle area below the lumbar spine. The Iliac bone connects to where the hip is.

The sacroiliac joint (SI joint) is a large and weight bearing joint. All the weight of the body and upper extremities comes down the spine down the SI joint through the iliac joints and down the legs, so it’s a very important joint.

As people age, that joint starts to fuse and some people get arthritis in that joint. SI pain usually feels like low back and buttock type pain. Usually the pain doesn’t radiate below the knee, but in rare occasions it can.

Something that is very common is pain on the side of the legs, which is called a bursitis. Whenever a person has pain the body moves just a little bit different than if they didn’t have pain; which is usually the cause of bursitis. This pain can be very severe and radiate from the front or back of the hips and legs.

The most common joint pain treatment is a diagnostic block, which we call an SI Joint injection.

We put a needle directly into the joint and watch the medicine spread into that area and check after a short time to see if the pain feels better.

For many people, this will give significant relief.

Other treatments are physical therapy and active release techniques.

There are many strong ligaments and muscles that come into this area and all those need to be relaxed to ultimately getting you moving the proper way again.

As joint pain doctors, we try to get patients out of pain whether it be through injection or some other treatment and into some therapy.

If we do an injection, and a patient keeps moving the same way that they were before, the SI joint pain will come back and a lot of times the bursitis will come back as well.

Many times we will treat both bursitis and SI Joint pain at the same time.

The other thing joint pain specialists will do for stubborn SI pain, is Radiofrequency

At Florida Spine Institute, we do a treatment called Medial Branch Blocks and Lateral Branch Blocks; where we numb the small joints in the lumbar spine and down to the SI Joint.

Sometimes we do this a few times (called a double diagnostic block) and see if a patient feels relief. If they get significant relief then we can cauterize the nerves, which we test before cauterizing to make sure we are in the right area. If we cauterize the nerves the average pain relief is about a year.

SI pain can be difficult to treat sometimes because 2/3 of the nerves come from the back of the joint and 1/3 comes from the front. Pain doctors can only inject nerves in the back section, which is most common for pain.

If a patient’s pain is from the front nerves then there are other options such as a Spinal Cord Stimulator, exercise and stretching, or surgeons can actually fuse the joint in rare cases that don’t respond to any other join pain treatment.

Joint pain treatments can greatly improve your comfort level and give you significant relief.

Emerging Science

Rheumatol Int. 2014 Sep;34(9):1195-202. doi: 10.1007/s00296-014-2959-5. Epub 2014 Feb 12.

Tomography-guided palisade sacroiliac joint radiofrequency neurotomy versus celecoxib for ankylosing spondylitis: a open-label, randomized, and controlled trial.

Zheng Y1Gu MShi DLi MYe LWang X.


Sacroiliac joint (SIJ) pain is a common symptom in ankylosing spondylitis (AS). Palisade sacroiliac jointradiofrequency neurotomy (PSRN) is a novel treatment for the SIJ pain. In the current clinical trial, we treated AS patients with significant SIJ pain using PSRN under computed tomography guidance and compared the results with the celecoxib treatment. The current study included 155 AS patients. Patients were randomly assigned to receive PSRN or celecoxib treatment (400 mg/day for 24 weeks). The primary endpoint was global pain intensity in visual analog scale, at week 12. Secondary endpoints included pain intensity at week 24,disease activity, functional and mobility capacities, and adverse events at week 24. In comparison with the baseline collected immediately prior to the interventions, global pain intensity was significantly lower at both 12 and 24 weeks after the treatment in both arms. Pain reduction was more robust in the PSRN arm (by more than 1.9 and 2.2 cm at 12 and 24 weeks in comparison with the celecoxib arm, P < 0.0001 for both). The PSRN was also more effective in improving physical function and spinal mobility (P < 0.05 vs. celecoxib for both). Gastrointestional irritation was more frequent in the celecoxib arm than in the PSRN arm (P < 0.05). No severe complications were noted in either arm. PSRN is both efficacious and safe in managing SIJ pain in patients with AS.

PMID: 24518967


Pain Med. 2012 Mar;13(3):383-98. doi: 10.1111/j.1526-4637.2012.01328.x. Epub 2012 Feb 2.

A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain.

Patel N1Gross ABrown LGekht G.



The objective of this study was to compare the efficacy of lateral branch neurotomy using cooledradiofrequency to a sham intervention for sacroiliac joint pain.


Fifty-one subjects were randomized on a 2:1 basis to lateral branch neurotomy and sham groups, respectively. Follow-ups were conducted at 1, 3, 6, and 9 months. Subjects and coordinators were blinded to randomization until 3 months. Sham subjects were allowed to crossover to lateral branch neurotomy after 3 months.


Subjects 18-88 years of age had chronic (>6 months) axial back pain and positive response to dual lateral branch blocks.


Lateral branch neurotomy involved the use of cooled radiofrequency electrodes to ablate the S1-S3 lateral branches and the L5 dorsal ramus. The sham procedure was identical to the active treatment, except that radiofrequency energy was not delivered.


The principal outcome measures were pain (numerical rating scale, SF-36BP), physical function (SF-36PF), disability (Oswestry disability index), quality of life (assessment of quality of life), and treatment success.


Statistically significant changes in pain, physical function, disability, and quality of life were found at 3-month follow-up, with all changes favoring the lateral branch neurotomy group. At 3-month follow-up, 47% of treated patients and 12% of sham subjects achieved treatment success. At 6 and 9 months, respectively, 38% and 59% of treated subjects achieved treatment success.


The treatment group showed significant improvements in pain, disability, physical function, and quality of life as compared with the sham group. The duration and magnitude of relief was consistent with previous studies, with current results showing benefits extending beyond 9 months.

PMID: 22299761


Pain Physician. 2011 May-Jun;14(3):301-4.

Pulsed radiofrequency of the sural nerve for the treatment of chronic ankle pain.

Todorov L1.



The application of radiofrequency (RF) has been successfully used in the treatment of chronic pain conditions, including facet arthropathy, sacroiliac joint pain, groin pain, radicular pain, cervicogenic headaches, and phantom limb pain. Due to the neurodestructive effect of continuous RF ablationand possible deafferentation sequelae, only pulsed radiofrequency (PRF) has been applied to peripheral sensory nerves. There are no previous reports of successful PRF application to the sural nerve.


To report on the successful use of PRF to the sural nerve for the treatment of ankle pain. To discuss current theories on the mechanism by which PRF produces pain relief.


The report presented here describes the case of a 39-year old patient who sustained injury to her ankle. The patient was complaining of pain in the distribution of the sural nerve, which was confirmed by electrodiagnostic studies. The pain did not respond to oral and topical analgesics. The patient had short-term relief with a sural block with bupivacaine and triamcinolone. The patient then underwent PRF application to the right sural nerve for 240 seconds at 45 volts.


The patient reported complete relief. There was no pain recurrence 5 months after the procedure.


This report describes a single case report.


It is conceivable that PRF may provide long-term pain relief in cases of sural nerve injury. The exact mechanism of the antinociceptive effect is still unknown. Possible mechanisms include changes in molecular structure by the electric field, early gene expression, stimulation of descending inhibitory pathways, and transient inhibition of excitatory transmission.

PMID: 21587334


Pain Pract. 2008 Sep-Oct;8(5):348-54. doi: 10.1111/j.1533-2500.2008.00231.x.

Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis: the first case-series.

Kapural L1Nageeb FKapural MCata JPNarouze SMekhail N.


Sacroiliitis and sacroiliac (SI) joint dysfunction are frequent causes of the chronic lower back pain. Therapeutic solutions include intra-atricular injections with short-term pain relief and surgical fusion, which appears ineffective. Radiofrequency (RF) of the joint capsule or lateral branches has been previously reported with variable successes. Cooling tissue adjacent to the electrode (cooled RF) increases the radius of lesion. We present here the first retrospective data on pain relief and changes in function after such RF denervation. We reviewed electronic records of 27 patients with chronic low back pain (median 5 years) who underwent cooled RF of S1, S2, and S3 lateral branches and of dorsal ramus (DR) L5 following two diagnostic SI joint blocks (>50% of pain relief). Patient sample consisted of 20 women and 7 men, 38 to 92 years old. Pain disability index (PDI), visual analog scale (VAS) pain scores, global patient satisfaction (GPE) and opioid use before and 3-4 months after the procedure were analyzed. One patient had an incomplete chart. Observed were improvements in function (PDI) from 32.7 +/- 9.9 to 20.3 +/- 12.1 (P < 0.001) and VAS pain scores 7.1 +/- 1.6 to 4.2 +/- 2.5 (P < 0.001) at 3-4 months after the procedure. Opioid use decreased from median 30 to 20 mg morphine equivalent. Eighteen patients rated their improvement in pain scores using GPE as improved or much improved, while eight claimed minimal or no improvement. The majority of patients with chronic SI jointpain experienced a clinically relevant degree of pain relief and improved function following cooled RF of sacral lateral branches and DR of L5 at 3-4 months follow-up.


Pain Pract. 2008 Sep-Oct;8(5):385-93. doi: 10.1111/j.1533-2500.2008.00227.x. Epub 2008 Aug 19.

Radiofrequency and pulsed radiofrequency treatment of chronic pain syndromes: the available evidence.

van Boxem K1van Eerd MBrinkhuizen TPatijn Jvan Kleef Mvan Zundert J.


There are currently 6 reviews on (pulsed) radiofrequency (RF) for the management of spinal pain. Two reviews on interventional pain management techniques in general also discuss RF. The outcomes of those reviews depend on the type of studies included and the opinion of the reviewers, which may result in different evidence levels. Radiofrequency denervation at the cervical and lumbar level has produced the most solid evidence. The differences in treatment outcome registered in the 5 randomized controlled trials (RCTs) regarding lumbar facet denervation can be attributed to differences in patient selection and/or inappropriate technique. There is not sufficient evidence supporting the use of RF facet denervation for the management of cervicogenic headache. The studies examining the management of cervical radicular pain suggest a comparable efficacy for RF and pulsed RF (PRF). The PRF treatment is supposed to be safer and therefore should be preferred. The superiority of RF treatment adjacent to the lumbar dorsal root ganglion for the management of lumbar radicular pain has not been demonstrated in an RCT. Information regarding RF treatment of sacroiliac jointpain is accumulating. No randomized sham-controlled trials on the value of RF treatment of the Gasserian ganglion for the management of idiopathic trigeminal neuralgia have been published. One RCT indicates superiority of RF over PRF for the management of idiopathic trigeminal neuralgia. Future research to confirm or deny the efficacy of (P)RF should be conducted in carefully selected patient populations. The tests used for patient inclusion in such a trial could potentially help the clinician in selecting patients for this type of treatment. The value of PRF treatment of the peripheral nerves also needs to be confirmed in well-designed trials.


Dig Surg. 2008;25(3):188-90. doi: 10.1159/000140687. Epub 2008 Jun 23.

Management of advanced abdominopelvic tumors with combined radiofrequencyablation and surgical debulking.

Spiliotis J1Hadjicostas PRogdakis AVaxevanidou AMalakounides NDatsis ATsiveriotis KKarkavitsa ZKekelos S.



Advanced abdominopelvic tumors due to rectal cancer, gynecological cancer or sarcomas are often unresectable using surgery alone. This study presents the combination of radiofrequency ablation (RFA) and surgical debulking for such tumors.


Between November 2005 and June 2007 we treated 4 patients with tumor fixation to the pelvic side wall and to the sacroiliac joint. Two of these patients had recurrent gynecological cancer while the other 2 had rectal cancer. All 4 of them had received prior treatment. The radiofrequency probe was placed in the center of the tumor. A 5- to 8-cm tissue core was ablated and aspirated or curetted out. This was repeated centrifugally out to the tumor capsule.


Control of the tumor for more than 12 months was achieved in 3 patients. One patient died 14 months after the procedure due to tumor progression. Two patients are still alive 12 and 14 months after the operation without symptoms. The other patient is alive 6 months after the operation in a disease-free condition.


Combined RFA and surgical debulking is beneficial as an alternative palliative method in patients with inoperable abdominopelvic tumors.


Reg Anesth Pain Med. 2001 Mar-Apr;26(2):137-42.

Radiofrequency sacroiliac joint denervation for sacroiliac syndrome.

Ferrante FM1King LFRoche EAKim PSAranda MDelaney LRMardini IAMannes AJ.



Radiofrequency (RF) denervation of the sacroiliac (SI) joint has been advocated for the treatment of sacroiliac syndrome, yet no clinical studies or case series support its use.


We report the results of a consecutive series of 50 SI joint RF denervations performed in 33 patients with sacroiliac syndrome. All patients underwent diagnostic SI joint injections with local anesthetic before denervation. Changes in visual analog pain scores (VAS), pain diagrams, physical examination (palpation tenderness over the joint, myofascial trigger points overlying the joint, SI joint pain provocation tests, and range of motion of the lumbar spine), and opioid use were assessed pre- and postdenervation.


The criteria for successful RF denervation were at least a 50% decrease in VAS for a period of at least 6 months; 36.4% of patients (12 of 33) met these criteria. Failure of denervation correlated with the presence of disability determination and pain on lateral flexion to the affected side. The average duration of pain relief was 12.0 +/- 1.2 months in responders versus 0.9 +/- 0.2 months in nonresponders (P < or = 0.0001). A positive response was associated with an atraumatic inciting event. Successful denervation was associated with a change in the pain diagram and a reduction in the pattern of referred pain, a normalization of SI joint pain provocation tests, and a reduction in the use of opioids.


This study suggests that RF denervation of the SI joint can significantly reduce pain in selected patients with sacroiliac syndrome for a protracted time period. Moreover, certain abnormal physical findings (i.e., SI joint pain provocation tests) revert to normal for the duration of the analgesia.