Sacroiliac Joint Pain
Similar to other structures in the spine, it is assumed the sacroiliac joint (SIJ) may be a source of low back pain. In fact, before 1928, the SIJ was thought to be the most common cause of sciatica. In 1928, the role of the intervertebral disc was elucidated, and from that point forward, the SIJ received less research attention.
Research into SIJ pain has been plagued by lack of a criterion standard to measure its prevalence and against which various clinical examinations can be validated. For example, SIJ pain is typically without any consistent, demonstrable radiographic or laboratory features and most commonly exists in the setting of morphologically normal joints. Clinical tests for SIJ pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the individual. Further confounding study of the SIJ is that multiple structures, (e.g., posterior facet joints, lumbar discs) may refer pain to the area surrounding the SIJ.
Because of inconsistent information obtained from history and physical examination, some have proposed the use of image-guided anesthetic injection into the SIJ for the diagnosis of SIJ pain. Treatments being investigated for SIJ pain include prolotherapy, corticosteroid injection, radiofrequency ablation, stabilization, and arthrodesis. Some procedures have been referred to as SIJ fusion but may be more appropriately called fixation (this is because there is little to no bridging bone on radiographs). Devices for SIJ fixation/fusion that promote bone ingrowth to fixate the implants include a triangular implant (iFuse Implant System) and cylindrical threaded devices (Rialto, SImmetry, Silex, SambaScrew, SI-LOK). Some devices also have a slot in the middle where autologous or allogeneic bone can be inserted. This added bone is intended to promote fusion of the SIJ.
Arthrography of the sacroiliac joint is considered investigational.
Injection of anesthetic for diagnosing sacroiliac joint pain may be considered medically necessary when the following criteria have been met:
Injection of corticosteroid may be considered medically necessary for the treatment of sacroiliac joint pain when the following criteria have been met:
Minimally invasive fixation/fusion of the sacroiliac joint using a titanium triangular implant may be considered medically necessary when ALL of the following criteria have been met:
Fixation/fusion of the sacroiliac joint for the treatment of back pain presumed to originate from the sacroiliac joint is considered investigational under all other conditions and with any other devices not listed above.
Radiofrequency denervation of the sacroiliac joint is considered investigational.
North American Spine Society
The North American Spine Society (NASS; 2015) published coverage recommendations for percutaneous sacroiliac joint (SIJ) fusion. NASS indicated that there was relatively moderate evidence. In the absence of high-level data, NASS policies reflect the multidisciplinary experience and expertise of the committee members in order to present reasonable standard practice indications in the United States. NASS recommended coverage when ALL of the following criteria are met:
American Society of Interventional Pain Physicians
The American Society of Interventional Pain Physicians (2013) guidelines have been updated. The updated guidelines recommend the use of controlled SIJ blocks with placebo or controlled comparative local anesthetic block when indications are satisfied with suspicion of SIJ pain. A positive response to a joint block is considered to be at least a 75% improvement in pain or in the ability to perform previously painful movements. For therapeutic interventions, the only effective modality with fair evidence was cooled radiofrequency neurotomy, when used after the appropriate diagnosis was confirmed by diagnostic SIJ injections.
American Society of Anesthesiologists et al
The American Society of Anesthesiologists and the American Society of Regional Anesthesia and Pain Medicine (2010) updated their joint guidelines for chronic pain management. The guidelines recommended that “Diagnostic sacroiliac joint injections or lateral branch blocks may be considered for the evaluation of individuals with suspected sacroiliac joint pain.” Based on opinions of consultants and society members, the guidelines recommend that “Water-cooled radiofrequency ablation may be used for chronic sacroiliac joint pain.”
American Pain Society
The practice guidelines from the American Pain Society (2009) were based on a systematic review commissioned by the Society.NA The guidelines stated that there was insufficient evidence to evaluate validity or utility of diagnostic SIJ block as a diagnostic procedure for low back pain with or without radiculopathy; the guidelines further stated that there was insufficient evidence to adequately evaluate benefits of SIJ steroid injection for nonradicular low back pain.
International Society for the Advancement of Spine Surgery
The International Society for the Advancement of Spine Surgery (2014) updated its policy statement on minimally invasive SIJ fusion in 2016. Society recommendations indicated that individuals who met all of the following criteria may be eligible for minimally invasive SIJ fusion:
National Institute for Health and Care Excellence
The National Institute for Health and Care Excellence (2017) guidance on minimally invasive SIJ fusion surgery for chronic sacroiliac pain included the following recommendations:
1.1 “Current evidence on the safety and efficacy of minimally invasive sacroiliac (SI) joint fusion surgery for chronic SI pain is adequate to support the use of this procedure….
1.2 Individuals having this procedure should have a confirmed diagnosis of unilateral or bilateral SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption.
1.3 This technically challenging procedure should only be done by surgeons who regularly use image-guided surgery for implant placement. The surgeons should also have had specific training and expertise in minimally invasive SI joint fusion surgery for chronic SI pain.”