Medical studies have determined that the sacral iliac joint (SIJ) is the primary cause of 20% of all patients who suffer with chronic low back pain. The SIJ connects the sacrum, which is the lowest segment of the spinal column, to the pelvis. Injuries to the SIJ occur by several different mechanisms including falls, motor vehicle accidents, and motorcycle accidents. It must be understood that SIJ pain maybe a concomitant injury with lumbar herniated disc or fractures of the lumbar spine in the injured patient. It is not uncommon for patients to have incomplete improvement following a lumbar discectomy or lumbar fusion and be left to live with pain from an untreated SIJ.

The SIJ has two primary functions: first to stabilize the posterior rim of the pelvis, second to transmit and dissipate upper body force to the lower extremity during functional activities such as walking and jumping. Only the lower 1/3 of the SIJ has the characteristics of a true joint with joint fluid and cartilage, while the upper 2/3 has significant ligamentous connections that accounts for much of the stability to the posterior pelvis. There are a multitude of muscles and ligaments that both cross the SIJ and assist with stability of the SIJ. Most of the function of the SIJ serves to stabilize the pelvis and dissipate force and unlike most other joints in the body there is only a small amount of movement afforded in any direction.

Injuries to the intra articular surface (inside the joint) and extra articular surface (outside the joint) are thought to be the potential pain generators of the SIJ.
The extra articular surface includes ligaments and the capsule that provides stability to the SIJ. Most common symptom for SIJ pain is buttock pain that is exacerbated by weight bearing on the symptomatic side that does not radiate to the thigh. There are no findings on physical exam or on MRI that are specific for SIJ related pain. Therefore, it is imperative that physicians take a careful clinical history, understand the mechanism of injury, provide a thorough physical exam, and interpret findings on MRI as it relates to the other potential sources of low back pain. By using fluoroscopically targeted diagnostic and therapeutic injections physicians can rationally treat SIJ related pain and other pain generators of the lumbar spine.

Severity of pain and disability varies among individuals with chronic low back pain related to the SIJ. Patients with previous lumbar fusions are particularly prone to SIJ mediate chronic pain. Treatment for acute SIJ related pain consists of anti-inflammatories, narcotic medications, and physical therapy. It must be understood that acute and chronic SIJ mediated pain may have sources of pain inside the joint by way of structural damage to the cartilage and/or pain by way of structural damage to the ligamentous complex outside the SIJ. It is important for clinicians to understand that intra articular and extra articular injections to the SIJ are necessary to fully investigate SIJ mediated pain.

Most medical insurances and government payer sources will provide for intra and extra articular anesthetic and steroid injections that are used both for diagnostic and therapeutic purposes. For the patients who receive some short term pain relief with these injections they may be candidates for radiofrequency denervation (destroying the nerves) that provide sensation to the SIJ which may provide significant relief between twelve and twenty-four months.

Prolotherapy is a proven but not widely recognized treatment of SIJ related pain. Prolotherapy uses the body’s own healing ability to assist with aberrant or incomplete healing of strained and torn ligaments. For example, in the situation of a motor vehicle accident or fall the ligaments may be strained or torn and may heal incorrectly or incompletely. This may lead to instability of the joint that may cause pain that is exacerbated by activity.

A trained physician in prolotherapy may inject phenol or dextrose (sugar water) along the ligamentous capsule of the SIJ that will induce a significant inflammatory response along the sites of injection. Inflammation contains numerous cells that breakdown and remove unhealthy tissue and lays down new ligamentous tissue with the hope that the new ligamentous tissue will provide superior stability to the unstable joint and painful joint. Prolotherapy with dextrose has been proven 40 percent more effective than steroid injections to the extra articular SIJ. Phenol may prove to be superior to dextrose since it not only causes the inflammatory response but also is a neurolytic agent that destroys the nerves that provide sensation of pain from the SIJ.

Surgical fusions of a painful SIJ and intra articular injections of phenol have shown promise in studies but are at this time investigational so they are not available with most insurance but are available for fee for service patients.

Life Care Planners must understand that the natural history of SIJ related pain is unclear at this time. Studies indicate that SIJ pain becomes more prevalent as one age, but this will not assist with predicting the necessary care of an injured person into the future. An Academic Physician Life Care Planner is in the best position to build a rational road map for future care with the goal of maintaining function and preventing complications by analyzing the treatments provided to date and the clinical response to targeted injections.

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