A Systematic Evaluation of Prevalence and Diagnostic Accuracy of Sacroiliac Joint Interventions

Pain Physician 2012; 15:E305-E344 • ISSN 2150-1149
Systematic Review
A Systematic Evaluation of Prevalence and

Diagnostic Accuracy of Sacroiliac Joint
Interventions
Thomas T. Simopoulos, MD1, Laxmaiah Manchikanti, MD2, Vijay Singh, MD3,
Sanjeeva Gupta, MD4, Haroon Hameed, MD5, Sudhir Diwan, MD6, and
Steven P. Cohen, MD7
Background: The contributions of the sacroiliac joint to low back and lower extremity pain have
been a subject of considerable debate and research. It is generally accepted that 10% to 25% of
From: 1Beth Israel Deaconess
patients with persistent mechanical low back pain below L5 have pain secondary to sacroiliac joint
Medical Center, and Harvard pathology. However, no single historical, physical exam, or radiological feature can definitively
Medical School, Boston, MA; establish a diagnosis of sacroiliac joint pain. Based on present knowledge, a proper diagnosis can
2
Pain Management Center of only be made using controlled diagnostic blocks. The diagnosis and treatment of sacroiliac joint
Paducah, Paducah, KY, and
pain continue to be characterized by wide variability and a paucity of the literature.
University of Louisville,Louisville,
KY; 3Pain Diagnostics Associates,
Niagara, WI; 4Bradford Teaching Objective: To evaluate the accuracy of diagnostic sacroiliac joint interventions.
Hospitals NHS Foundation Trust,
Bradford, United Kingdom; Study Design: A systematic review of diagnostic sacroiliac joint interventions.
5
Johns Hopkins University School
of Medicine, Baltimore, MD;
6
The Spine And Pain Institute of Methods: Methodological quality assessment of included studies was performed using Quality
New York, New York, New York; Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy studies meeting at least 50%
and 7Johns Hopkins School of of the designated inclusion criteria were utilized for analysis. Studies scoring less than 50% are
Medicine, Baltimore, MD, and
Uniformed Services University of
presented descriptively and analyzed critically.
the Health Sciences, Bethseda, The level of evidence was classified as good, fair, or limited (or poor) based on the quality of
MD
evidence developed by the United States Preventive Services Task Force (USPSTF).
See Additional Author Afffiliations
on page E335. Data sources included relevant literature identified through searches of PubMed and EMBASE
from 1966 to December 2011, and manual searches of the bibliographies of known primary and
Address correspondence: review articles.
Thomas T. Simopoulos, MD
Beth Israel Deaconess
One Brookline Place, Ste. 105 Outcome Measures: In this evaluation we utilized controlled local anesthetic blocks using at
Boston, MA 02445 least 50% pain relief as the reference standard.
E-mail: tsimopou@bidmc.
harvard.edu Results: The evidence is good for the diagnosis of sacroiliac joint pain utilizing controlled
Disclaimer: There was no external comparative local anesthetic blocks. The prevalence of sacroiliac joint pain is estimated to
funding in the preparation of this range between 10% and 62% based on the setting; however, the majority of analyzed studies
manuscript. suggest a point prevalence of around 25%, with a false-positive rate for uncontrolled blocks of
Conflict of interest: None. approximately 20%. The evidence for provocative testing to diagnose sacroiliac joint pain was fair.
Manuscript received: 02/12/2012
The evidence for the diagnostic accuracy of imaging is limited.
Revised manuscript received:
03/12/2012 Limitations: The limitations of this systematic review include a paucity of literature, variations in
Accepted for publication: technique, and variable criterion standards for the diagnosis of sacroiliac joint pain.
04/09/2012
Free full manuscript: Conclusions: Based on this systematic review, the evidence for the diagnostic accuracy of
www.painphysicianjournal.com sacroiliac joint injections is good, the evidence for provocation maneuvers is fair, and evidence for
imaging is limited.
Key words: Chronic low back pain, sacroiliac joint pain, sacroiliitis, sacroiliac joint injection,
sacroiliac joint dysfunction, provocation manuevers, controlled diagnostic blocks, intraarticular
injection, extraarticular injection.
Pain Physician 2012; 15:E305-E344

www.painphysicianjournal.com
Pain Physician: May/June 2012; 15:E305-E344
C hronic low back pain, with or without lower

extremity pain, that arises from various
structures of the spine constitutes a majority of
pain complaints (1-11). The high prevalence of chronic
low back pain, the numerous modalities of treatments
The sacroiliac joint is a true diarthrodial joint;
matching articular surfaces separated by a joint space
containing synovial fluid and enveloped by a fibrous
capsule, but, with unique characteristics not typically
found in other diarthrodial joints (90-96). The sacro-
for managing the problem, and the growing social iliac joint contains fibrocartilage in addition to hyaline
and economic costs continue to influence medical cartilage (97), and is characterized by discontinuity of
decision-making (1,2,5,12-35). Even though low back the posterior capsule, with ridges and depressions that
pain is a common complaint in primary care and minimize movement and enhance stability (51). Conse-
tertiary care, it is often difficult to reach a definitive quently, the sacroiliac joint has been described as a true
diagnosis (2,35-45). Controlled studies have established synovial joint only in the anterior portion. In contrast,
intervertebral discs, facet joints, and sacroiliac joints the posterior connection is a syndesmosis consisting of
as potential sources of low back and lower extremity the ligamenta sacroiliaca, the musculus gluteus medius
pain (2,35-49). Thus, the sacroiliac joint is accepted as and minimus, and the musculus pyriformis (57).
a potential source of low back and/or buttock pain The sacroiliac joint is well imbued with nocicep-
with or without lower extremity pain (2,36,39,41-44,46- tor and proprioceptors. Information on the innerva-
53). The sacroiliac joint has been implicated as the tion pattern is the subject of considerable controver-
primary source of pain (2,36,39,44,47-49,53) in 10% to sy. Solonen (98) examined data from earlier studies
27% (41,54,55) of patients with mechanical low back (1857-1944) that collectively identified branches from
pain below L5 utilizing controlled, comparative local the lumbosacral plexus, superior gluteal nerve, dorsal
anesthetic blocks. rami of S1 and S2, and the obturator nerve, as provid-
A major source of the exponential growth in treating innervation. But despite multiple studies (99-105),
ment modalities is the inherent difficulty in obtaining the exact innervation continues to be unclear. The an-
an accurate diagnosis (1-5,14-36,56-71). An inaccurate terior portion may be innervated by the sacral plexus,
or incorrect diagnosis may lead not only to treatment whereas the posterior portion may have innervation
failure, but also results in wasted health care dollars, from the spinal nerves. It has been proposed that the
diverting essential health care resources. Fundamen- predominant innervation is via the L4 to S1 nerve roots,
tal to an accurate diagnosis is the reliability of the test with some contribution from the superior gluteal nerve
used to make the diagnosis (2,39,40,44,47,48,49,53,72- (106). Even though there may be input from ventral
77). Attempts have been made to improve the ac- rami, several authors have argued that the joint is in-
curacy of diagnosing sacroiliac joint pain by multi- nervated only by the sacral dorsal rami (104,107). Ber-
ple means, including physical examination, imaging nard (108) proposed that the posterior innervation is
techniques, and controlled local anesthetic blocks from the lateral branches of the posterior rami of L4 to
(2,36,39,41,42,44,47,49,53-55,78-84). S3, whereas the anterior innervation stems from the L2
However, there is no universally accepted gold to S2 segments.
standard for the diagnosis of low back pain, regard- Nakagawa (109) reported that the nerve filaments
less of whether the suspected source is the sacroiliac to the joint are derived from the ventral rami of L4 and
joint(s), intervertebral disc(s), or facet joint(s) (2,35- L5, the superior gluteal nerve, and the dorsal rami of
49,53-55,79-86). The recommended reference stan- the L5, S1, and S2. In contrast, Grob et al (104) found
dards typically involve anesthetic or provocative injec- that the innervation of the sacroiliac joint is almost ex-
tions (2,35-49,53). Multiple arguments have been made clusively derived from the sacral dorsal rami. Dissections
in favor of and against the diagnostic accuracy of con- of fetal pelvises confirmed that innervation of the sac-
trolled local anesthetic blocks (2,27,39-49,53,74,75,85- roiliac joint originates in the dorsal rami because neural
89), but controlled local anesthetic blocks continue to filaments are noted solely in the dorsal mesenchyme
be the best available tool to identify intervertebral (107,109).
discs, facet, or sacroiliac joint(s) as the source of low Murata et al (101) evaluated the sensory innerva-
back pain. Yet, these reference standards are invasive, tion of the sacroiliac joint in rats and concluded that
expensive, and often difficult to interpret, and there- the sacroiliac joint was innervated by sensory neurons
fore may not be suitable for routine clinical use as a in dorsal root ganglia ipsilateral to the joint from the
primary diagnostic modality. L1 to S2. They also concluded that sensory fibers from
E306 www.painphysicianjournal.com
Prevalence and Diagnostic Accuracy of Sacroiliac Joint Interventions
the L1 and L2 dorsal root ganglia passed through the idiopathic onset of sacroiliac joint pain. Among the
paravertebral sympathetic trunk. various inciting events, motor vehicle accidents and
Histologic analyses of chronically painful sacroiliac falls comprise a majority (82,115,116). Other described
joints has verified the presence of nerve fibers within causes include fusion surgery (83,117-119), anterior dis-
the joint capsule and adjoining ligaments (107,110,111). location (120), inflammatory and degenerative sacro-
A recent cadaveric study by McGrath and Zhang (112) iliac joint disease (121), and multiple other etiologies
found that the long posterior sacroiliac ligament re- (36,46,47,50,78,79,122,123). In a study by Ha et al (124),
ceived afferent input from S2 (96%) and S3 (100%) in the authors found that sacroiliac joint degeneration is
almost all specimens, from S4 in 59% of cases, and only nearly universal 5 years following fusion to the sacrum,
occasionally from S1 (4%). The nerve fascicles contain and considerably more common than in non-operated
both myelinated and unmyelinated nerve fibers, 2 mor- controls after floating fusions.
photypes of paciniform-encapsulated mechanorecep- In a systematic review evaluating a battery of tests
tors, and a single nonpaciniform mechanoreceptor, to identify the disc, sacroiliac joint, or facet joint as the
suggesting that both pain and proprioception are trans- source of low back pain, Hancock et al (49) suggested
mitted from the sacroiliac joint (99,103,110,111,113). that a combination of sacroiliac joint pain provocative
Szadek et al (105) concluded that the presence of cal- maneuvers appears to be useful in pinpointing the
citonin gene-related peptide and substance P immuno- sacroiliac joint as the principal source of symptoms in
reactive fibers in the anterior capsular and interosseous patients with pain below the 5th lumbar vertebra. A
ligaments provide a morphological and physiological systematic review by Szadek et al (80) showed that the
base for pain signals originating from these structures. thigh thrust test, the compression test, and 3 or more
They further hypothesized that infiltration techniques positive stressing tests contain sufficient discriminative
used to diagnose sacroiliac joint pain should consider power for diagnosing sacroiliac joint pain. A systematic
extraarticular as well as intraarticular approaches. Saka- literature review performed by Song et al (81) conclud-
moto et al (103) showed that most mechanoreceptor ed that scintigraphy is of limited value at best in estab-
units in the sacroiliac joint are high-threshold group 3 lishing sacroiliitis in patients with ankylosing spondyli-
units that likely serve a nociceptive function. However, tis. In a best-evidence review of diagnostic procedures
they contend that the sacroiliac joint has little proprio- for neck and low back pain, Rubinstein and van Tul-
ceptive function. der (44) concluded that there was moderate evidence
Forst et al (51) described extensive communication for the validity and accuracy of injections identified
between the sacroiliac joint and nearby neural struc- 3 systematic reviews (49,125,126). An evidence-based
tures. Patterns of extracapsular extravasation from the review by Laslett (53) determined that among chronic
sacroiliac joint have been observed on postarthrogra- back pain patients, the presence of 3 or more positive
phy computed tomography (CT) (114). These patterns provocation sacroiliac joint tests in conjunction with
include posterior extension into the dorsal sacral foram- the absence of “centralization” are associated with a
ina, extravasation into the L5 epiradicular sheath via 77% probability of sacroiliac joint pain, 89% in preg-
the superior recess, and ventral leakage into the lum- nant women. In contrast, in an evidence-based medi-
bosacral plexus (111,114). Thus, it is plausible that in the cine series, Vanelderen et al (57) concluded that it was
setting of capsular disruption, inflammatory mediators difficult to distinguish sacroiliac joint pain from other
could leak out from the sacroiliac joint into nearby neu- forms of low back pain based on history and physical
ral structures, causing radicular pain in certain patients exam alone. They also reported that provocative ma-
(111,114). neuvers have weak predictive value, though combined
Several mechanisms of injury have been linked batteries of tests can help ascertain a diagnosis.
to the development of sacroiliac joint pain, including The primary purpose of this review is to system-
a direct fall on the buttocks, a rear-end or broad-side atically assess the literature on diagnostic sacroiliac
type motor vehicle accident, and an unanticipated step joint interventions. The secondary objectives are to
into a hole or from a miscalculated height (90,91). In analyze studies for quality, and factors that can affect
a study performed in 54 patients with suspected sacro- generalizability.
iliac joint syndrome, Chou et al (115) found that 44% of
patients cited a specific traumatic event, 21% reported
1.0 Methods
a cumulative injury, and 35% had had spontaneous or The methodology utilized in this systematic review
www.painphysicianjournal.com E307
followed the review process derived from evidence- clinicaltrials.gov/

based systematic reviews and meta-analysis of diagnos- The search period was from 1966 through Decem-
tic accuracy studies (22,44,49,72-77,127,128). ber 2011.
1.1 Criteria for Considering Studies for This 1.3 Search Strategy
Review The search strategy emphasized chronic low back
pain, sacroiliac joint pain/arthritis, and diagnostic sac-
1.1.1 Types of Studies roiliac joint interventions and techniques.
Diagnostic accuracy studies evaluating sacroiliac This systematic review focused only on diagnostic
joint pain studies, including invasive and noninvasive techniques
and reports of complications. Only sacroiliac joint in-
1.1.2 Types of Participants jections performed under fluoroscopy or CT imaging
Participants of interest were adults aged at least 18 techniques were evaluated. Interventional techniques
years with chronic low back and lower extremity pain performed blindly or using other identification modali-
of at least 3 months duration. ties were excluded. All studies describing appropriate
Participants must have failed previous pharmaco- outcome evaluations with proper statistical evaluations
therapy, exercise therapy, etc., prior to starting diag- were reviewed. Reports without appropriate diagnosis,
nostic interventional pain management techniques. nonsystematic reviews, book chapters, and case reports
were excluded.
1.1.3 Types of Interventions At least 2 of the review authors independently, in
The interventions were diagnostic sacroiliac joint an unblinded standardized manner, performed each
interventions appropriately performed with proper search. Accuracy was confirmed by a statistician. All
technique under fluoroscopic or CT guidance. searches were combined to obtain a unified search
strategy. Any disagreements between reviewers were
1.1.4 Types of Outcome Measures resolved by a third author and consensus.
• The primary outcome parameter was pain relief
concordant with the type of controlled diagnostic 1.4 Data Collection and Analysis
blocks performed. The quality of each individual article used in this as-
• The secondary outcome measures were the ability sessment was based on Quality Appraisal of Reliability
to perform previously painful movements without Studies (QAREL) checklist (Table 1) (73). This checklist
significant pain or complications. has been validated and utilized in multiple systematic
• At least 2 of the review authors independently, in reviews (73). Each study in the final sample of eligible
an unblinded standardized manner, assessed the manuscripts was assessed using a 12-item appraisal
outcomes measures. Any disagreements between checklist designed to assess the quality and applicabil-
reviewers were resolved by a third author and ity of studies. The face validity of these checklists was
consensus. established by consultation with methodology experts
(73) and comparison with quality appraisal checklists
1.2 Literature Search used in other systematic reviews examining diagnostic
Searches were performed from the following reliability (129-134). This checklist was also developed
sources without language restrictions: in accordance to the Standards for Reporting Studies
1. PubMed from 1966 of Diagnostic Accuracy (STARD) (76), and the Quality
www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed Assessment of Diagnostic Accuracy Studies (QUADAS)
2. EMBASE from 1980 (76,77) appraisal tool. Studies were not given an overall
www.embase.com/ numeric quality score; instead, each item was consid-
3. Cochrane Library ered separately and graded as “yes,” “no,” “unclear,”
www.thecochranelibrary.com/view/0/index.html or “not applicable.”
4. U.S. National Guideline Clearinghouse (NGC)
www.guideline.gov/ 1.4.1 Selection of Studies
5. Previous systematic reviews and cross references • In an unblinded standardized manner, 2 review au-
6. Clinical Trials thors screened the abstracts of all identified studies
Table 1. Quality Appraisal of Diagnostic Reliability (QAREL) checklist.
Item Yes No Unclear N/A

1. Was the test evaluated in a spectrum of subjects representative of patients who
would normally receive the test in clinical practice?
2. Was the test performed by examiners representative of those who would normally
perform the test in practice?
3. Were raters blinded to the reference standard for the target disorder being evaluated?
4. Were raters blinded to the findings of other raters during the study?
5. Were raters blinded to their own prior outcomes of the test under evaluation?
6. Were raters blinded to clinical information that may have influenced the test
outcome?
7. Were raters blinded to additional cues, not intended to form part of the diagnostic
test procedure?
8. Was the order in which raters examined subjects varied?
9. Were appropriate statistical measures of agreement used?

10. Was the application and interpretation of the test appropriate?
11. Was the time interval between measurements suitable in relation to the stability of
the variable being measured?
12. If there were dropouts from the study, was this less than 20% of the sample?
TOTAL
Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of physical examination for diagnosis of myofascial trigger points. Clin J Pain 2009;
25:80-89 (72).
against the inclusion criteria. 2. Is the intervention described in sufficient detail to

• All articles with possible relevance were then re- enable one to apply its use to patients in interven-
trieved in full text for comprehensive assessment tional pain management settings?
of internal validity, quality, and adherence to inclu- A. Nature of intervention.
sion criteria. B. Frequency of intervention.
C. Duration of intervention.
1.4.2 Inclusion and Exclusion Criteria 3. Were clinically relevant outcomes measured?
The following are the inclusion and exclusion A. Proportion of pain relief.
criteria. B. Disorder/specific disability.
1. Are the patients described in sufficient detail to al- C. Functional improvement.
low one to decide whether they are comparable to D. Allocation of eligible and noneligible patients
those who are treated in interventional pain man- to return to work.
agement clinical practices? E. Ability to work.
A. Setting – office, hospital, outpatient, inpatient.
B. Physician – interventional pain physician, gen- 1.4.3 Clinical Relevance
eral physician, anesthesiologist, physiatrist, The clinical relevance of the included studies was
neurologist, rheumatologist, orthopedic sur- evaluated according to 5 questions recommended by
geon, neurosurgeon, etc. the Cochrane Back Review Group (Table 2) (135,136).
C. Patient characteristics - duration of pain. Each question was scored as positive (+) if the clinical
D. Noninterventional techniques or surgical in- relevance item was met, negative (–) if the item was
tervention in the past. not met, and unclear (?) if data were not available to
answer the question.
Table 2. Clinical relevance questions.
P (+) N (-) U (unclear)

A) Are the patients described in detail so that one can decide whether they are comparable to those
who are treated in clinical practice?
B) Are the interventions and treatment settings described in sufficient detail to apply its use in clinical
practice?
C) Were clinically relevant outcomes measured and reported?
D) Is the size of the effect clinically meaningful?
E) Do the likely treatment benefits outweigh the potential harms?
Scoring adapted and modified from Staal JB, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev 2008;
3:CD001824 (136).
1.4.4 Methodological Quality or Validity 1.4.7 Measurement of Treatment Effect in Data

Assessment Synthesis (Meta-Analysis)
Each study was evaluated by at least 2 authors for Data were separately summarized using meta-anal-
stated criteria and any disagreements discussed with a ysis when at least 5 studies per type of diagnostic crite-
third reviewer. Authors with a perceived conflict of in- ria were available that met the inclusion criteria (e.g.,
terest for any manuscript were recused from reviewing single block, double blocks, and 50% to 80% relief. )
the manuscript. The minimum acceptable relief was considered to
Only diagnostic accuracy studies meeting at least be 50%; however, data were sub-analyzed for ≥ 80%
50% of applicable inclusion criteria were included for and 50% to 80% relief as the cutoff threshold for a
analysis. Studies scoring less than 50% are reported de- positive block during the performance of previously
scriptively with critical analysis. painful movements. Four separate diagnostic catego-
ries were evaluated (i.e., 50% to 80% relief as the cut-
1.4.5 Data Extraction and Management off threshold with single and dual blocks; and 80% to
Two review authors independently, in an unblind- 100% relief as the cutoff threshold with single or dual
ed standardized manner, extracted the data from the blocks). For dual blocks, there had to have been concor-
included studies. Disagreements were resolved by dis- dant response with short-acting and long-acting local
cussion between the 2 reviewers; if no consensus could anesthetics, or placebo.
be reached, a third author was called in to break the
impasse. 1.4.8 Integration of Heterogeneity
A meta-analysis was performed only if there were
1.4.6 Assessment of Heterogeneity at least 5 studies meeting inclusion criteria for each
Whenever meta-analyses were conducted, the I- variable.
squared (I2) index was used to identify heterogeneity Statistical heterogeneity was explored using uni-
(137). Combined results with I2 > 50% were considered variate meta-regression (137).
substantially heterogenous.
Analysis of the evidence was based on diagnos- 1.5 Summary Measures
tic criteria as follows: 1) blocks in which the reference Summary measures included 50% to 80% or 80%
standard for diagnosis was between 50% to 80% pain to 100% pain relief with the capability of performing
relief with a single block; 2) blocks in which the refer- previously painful movements concordant with the du-
ence standard for diagnosis was between 50% to 80% ration of local anesthetic.
pain relief with dual blocks; 3) blocks in which the refer-
ence standard for diagnosis was between 80% to 100% 1.6 Analysis of Evidence
pain relief with a single block; and 4) blocks in which The analysis of the evidence was performed based
the reference standard for diagnosis was between 80% on United States Preventive Services Task Force (USP-
to 100% pain relief with dual blocks, to reduce clinical STF) criteria (138) as illustrated in Table 3, which has
heterogeneity. been utilized by multiple authors (22,23,27,28,139-147).
Table 3. Method for grading the overall strength of the evidence for an intervention.
Grade Definition
Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess
Good
effects on health outcomes (at least 2 consistent, higher-quality RCTs or studies of diagnostic test accuracy).
Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality,
size, or consistency of included studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes
Fair (at least one higher-quality trial or study of diagnostic test accuracy of sufficient sample size; 2 or more higher-quality trials or
studies of diagnostic test accuracy with some inconsistency; at least 2 consistent, lower-quality trials or studies of diagnostic test
accuracy, or multiple consistent observational studies with no significant methodological flaws).
Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained
Limited
inconsistency between higher-quality trials, important flaws in trial design or conduct, gaps in the chain of evidence, or lack of
or Poor
information on important health outcomes.
Adapted and modified from methods developed by U.S. Preventive Services Task Force (22,138).
Computerized and manual search of

literature
n = 2,736
Articles excluded by title and/ Potential articles

or abstract n = 450
n = 2,286
Abstracts reviewed
n = 450
Abstracts excluded
n = 372
Full manuscripts reviewed = 129
Diagnostic accuracy studies = 18

Other studies = 85
Manuscripts considered for diagnostic

accuracy = 18
Fig. 1. Flow diagram illustrating published literature evaluating the diagnosis of sacroiliac joint pain by sacroiliac joint
injections.
The analysis was conducted using 3 levels of evi- ers were recused from assessment and analysis.
dence ranging from good to fair to limited (or poor)
(22,23,138). 1.7 Outcome of the Studies
At least 2 of the review authors independently, in Outcomes included the prevalence of sacroiliac
an unblinded standardized manner, analyzed the evi- joint pain and false-positive rate. Based on the above
dence. Any disagreements between reviewers were re- parameters, the reliability of the data derived from
solved by a third author and consensus. If there were each study was assessed.
any conflicts of interest (e.g., authorship), those review-
2.0 Results
Figure 1 shows a flow diagram of study selec- (54,82,148,154,155,157,159,160,175,189,199-201),

tion. There were 103 studies considered for inclu- 43 evaluated diagnostic imaging (83,152,156,166-
sion (41,42,54,55,71,78,79,82,83,89,119,123,148-237) 168,171,176,202-205,207-237), 4 evaluated the accu-
Among these, 18 evaluated diagnostic sacroiliac racy of sacroiliac joint injections with fluoroscopy, CT
joint injections (41,42,54,55,78,79,82,83,119,148, or magnetic resonance imaging (MRI) (191-193,198),
152,154,155,157,159,160,175,194,195), 13 evalu- and 8 evaluated pain patterns (82,148,153,161-165).
ated provocative testing and clinical evaluation Table 4 shows the list of the 23 excluded studies
Table 4. List of excluded studies.
Manuscript Author(s) Reason for Exclusion

Berthelot et al (89) This was a review article rather than a diagnostic accuracy study.
DePalma et al (123) This was a study of patients with or without surgical discectomy with only 11 patients being included who
had surgical discectomy with 0% prevalence of sacroiliac joint pain in patients with surgical discectomy and
18.1% in patients without surgery.
Maigne et al (156) Inclusion criteria was of patients suffering with 7 weeks of pain pattern compatible with sacroiliac joint pain
– acute pain.
Klauser et al (169) This study evaluated the feasibility of ultrasound-guided sacroiliac joint injection with landmarks at 2
different levels.
Harmon & Alexiev (170) Sonoanatomy and injection technique of iliolumbar ligament was evaluated.
Gupta (172) An alternative method with a double needle technique for performing difficult sacroiliac joint injections
was evaluated.
Hart et al (173) Intraarticular injections of the sacroiliac joint were evaluated after lumbar stabilization as a therapeutic
modality.
Morimoto et al (174) This was a case description of abdominal pain associated with sacroiliac joint dysfunction.
Hamauchi et al (177) This was a case report presenting acute low back pain secondary to sacroiliac joint arthritis arthropathy.
Migliore et al (178) A technical contribution for ultrasound-guided injection of sacroiliac joints was evaluated.
Streitparth et al (179) Evaluation included image-guided spinal injection procedures in open high field MRI with vertical field
orientation studying its feasibility and technical features.
Khurana et al (180) Therapeutic intervention with percutaneous fusion was evaluated.
Dreyfuss et al (181) An evaluation of the ability of single site, single depth sacral lateral branch blocks to anesthetize the
sacroiliac joint complex showed significant anatomic limitations with single site, single depth lateral branch
injections rendering them physiologically ineffective on a consistent basis.
Dreyfuss et al (182) The evaluation of the ability of multi-site, multi-depth sacral lateral branch blocks to anesthetize the
sacroiliac joint complex showed that there is physiologic evidence that the intraarticular portion of the
sacroiliac joint is innervated from both ventral and dorsal sources.
Sadreddini et al (183) An evaluation of unguided sacroiliac joint injections showing effectiveness.
Borowksy & Fagen (184) This study evaluated the sources of sacroiliac region pain to gain insight into intraarticular injection
compared to a combination of intraarticular and periarticular injection rather than determining prevalence.
The prevalence estimates were not available. Only outcomes were available.
Harmon & O’Sullivan (185) Injection technique with ultrasound guidance was evaluated.
Günaydin et al (186) This study was an evaluation of the therapeutic effectiveness of repeat injections under magnetic resonance
imaging.
Murakami et al (187) This study was a comparative evaluation of periarticular and intraarticular lidocaine injections for sacroiliac
joint pain.
Haufe & Mork (188) This is a description of a technique for the treatment of sacroiliac joint pain with sacroiliac joint debridement.
Pekkafahli et al (190) Sacroiliac joint injections were performed with sonographic guidance.
Bokov et al (196) An evaluation of the reasons for failed back surgery syndrome and partial results after different types of
surgical lumbar nerve root compression; however, there was no evaluation for sacroiliac joint.
(89,123,156,169,170,172-174,177-188,190,196). off threshold (82,83,157), 7 studies utilizing dual

blocks with 50% to 80% relief as the cutoff thresh-
2.1 Diagnostic Accuracy Studies old (54,55,78,79,119,160,194,195), and one duplicate
Table 5 illustrates the characteristics of studies study (78,195). There were 6 studies utilizing 80% to
considered for inclusion. There were 3 studies utiliz- 100% relief as the cutoff threshold with a single block
ing a single block with 50% to 80% relief as the cut- (42,148,152,154,155,175), and 2 studies utilizing dual
Table 5. Characteristics of reported diagnostic accuracy studies.
Participants Objective(s) Interventions(s) Result(s)
50% TO 79% RELIEF WITH SINGLE BLOCK

Schwarzer et al (82) 43 consecutive patients with To establish the prevalence Intraarticular injection of 1 Prevalence =
chronic low back pain maximal of sacroiliac joint pain, the mL of 2% lignocaine. 30%
Utilized 75% relief below L5/S1 were investigated. validity of pain provocation,
whether any arthrographic
abnormalities predict a
response to joint block, and
whether certain pain patterns
discriminate patients with this
diagnosis.
Maigne & Planchon (83) This was a prospective series To determine if the sacroiliac Intraarticular injection with Prevalence =
of 40 patients with persistent joint could be a possible 2 mL of 2% lidocaine. 35%
Utilized 75% relief low back pain after technically source of pain and to search
successful fusion who received predictive factors for a positive
a sacroiliac anesthetic block block.
under fluoroscopic control.
Broadhurst & Bond (157) Double-blind trial of 40 patients To determine the sensitivity Intraarticular injection of Prevalence = not
to determine the sensitivity and specificity of 3 commonly 4 mL of 1% lignocaine or 4 available
Utilized 70% relief and specificity of 3 commonly used pain provocation tests for mL of normal saline into the
used pain provocation tests sacroiliac joint dysfunction. painful joint in 20 patients
for sacroiliac joint dysfunction in each group.
if suppression of pain by 70%
with injection of either normal
saline or lidocaine.
50% TO 79% RELIEF WITH DUAL BLOCKS
Maigne et al (54) 54 patients aged 18-75 with To determine the prevalence Successful blockade of Prevalence =
chronic unilateral low back pain of sacroiliac joint pain in a the sacroiliac joint in 54 18.5%
Utilized 75% relief with or without radiation to the selected population of patients patients. A screening block
posterior thigh for > 50 days with low back pain and assess was done with 2% lidocaine False-positive
(median 4.2 months). Patients certain pain provocation tests. and a confirmatory block rate = 20%
had failed epidural or lumbar was performed with
facet injections. bupivacaine 0.5%. Greater
than 75% relief was
considered a positive block.
Irwin et al (55) 158 patients underwent To evaluate the prevalence The fluoroscopically guided Prevalence =
sacroiliac joint injections with and correlation among age, contrast medium-enhanced 26.6%
Utilized 70% relief average duration of symptoms sex, and body mass index sacroiliac joint injections
being 34 months. Patients failed with dual, comparative local were performed initially with False-positive
conservative modalities prior to anesthetic blocks. 2 mL of 2% lidocaine for the rate = Not
injection therapy. first injection, followed by available
2 mL of 0.25% bupivacaine,
a local anesthetic, for the
confirmatory injection. A
patient was required to have
at least 70% reduction of
familiar painful symptoms
after the initial injection for
3 or 4 hours for a positive
response.
Table 5 (cont.). Characteristics of reported diagnostic accuracy studies.
DePalma et al (78,195) 156 patients underwent To estimate the prevalence, Intraarticular sacroiliac Prevalence =
diagnostic procedures mean age, and association of joint injections with 2 mL 18.2%
Utilized 75% relief including discography, dual prevalence and age of lumbar of 1% lidocaine and 0.5%
diagnostic facet joint blocks, internal disc disruption, bupivacaine. False-Positive
and intraarticular sacroiliac facet joint pain, sacroiliac Rate = Not
joint injections to evaluate the joint pain, spinal and pelvic available
source of chronic low back insufficiency fractures,
pain based on age. A screening interspinous ligament injury/
block was performed with 1% Baastrup Disease, and soft
lidocaine and a confirmatory tissue irritation by fusion
block was performed with 0.5% hardware.
bupivacaine.
DePalma et al (79) Retrospective evaluation of 27 To estimate prevalence rates Intraarticular sacroiliac Prevalence =
motor vehicle collision-induced of discogenic, facet, and joint injections with 2 mL 18.2%
Utilized 75% relief chronic low back pain patients sacroiliac joint pain, and of 1% lidocaine and 0.5%
undergoing multiple types of describe clinical features of bupivacaine. False-Positive
diagnostic interventions. chronic low back pain patients Rate = Not
whose symptoms were available
initiated by motor vehicle
collision.
DePalma et al (119) The diagnoses of 28 fusion To estimate the prevalence Intraarticular sacroiliac Prevalence =
cases identified from 170 low of lumbar internal disc joint injections with 2 mL 18.2%
Utilized 75% relief back pain patients undergoing disruption, zygapophysial of 1% lidocaine and 0.5%
diagnostic procedures included joint pain, sacroiliac bupivacaine. False-Positive
12 with sacroiliac joint pain. joint pain, and soft tissue Rate = Not
irritation by fusion hardware available
in postfusion low back
pain patients compared to
nonfused patients utilizing
diagnostic spinal procedures.
van der Wurff et al (160) Total number of 140 patients To compare the diagnostic The fluoroscopically guided Prevalence =
with chronic low back pain accuracy of a multi-test contrast medium-enhanced 38%
Utilized 50% relief visiting a pain clinic in the regimen of 5 sacroiliac joint sacroiliac joint injections
Netherlands; 60 patients pain provocation tests with were performed initially False-positive
entered the study. fluoroscopically controlled with 2 mL of 2% lidocaine rate = 21%
double sacroiliac joint blocks and then with 0.25%
using a short- and long-acting bupivacaine.
local anesthetic.
A reduction in the patient’s
characteristic pain of 50%
or more on the visual
analog scale (VAS) lasting
for at least one hour for
lidocaine or 4 hours for
bupivacaine was considered
as positive. When a patient
showed a VAS reduction
after both intraarticular
sacroiliac joint blocks, this
was considered a positive
response. Any other
outcome was considered a
negative response.
Liliang et al (194) 130 patients who underwent To ascertain whether Intraarticular injections Prevalence =
lumbar or lumbosacral fusion sacroiliac joint pain represents of either lidocaine or 40%
were evaluated for sacroiliac a potential source of pain in bupivacaine, 1 mL, with
joint pain. Of these, 52 patients patients who have undergone 40 mg of triamcinolone False-positive
obtained positive findings lumbar or lumbosacral acetonide. rate = 26%
with 3 of the provocative tests fusions.
for sacroiliac joint pain. They
were selected to receive dual
diagnostic blocks. Among the
52 patients, 20 were considered
to have sacroiliac joint pain on
the basis of 2 positive responses
to diagnostic blocks with 75%
as the criterion standard.
80% TO 100% RELIEF
WITH SINGLE BLOCK
Pang et al (42) 104 consecutive adult patients To evaluate the usefulness of Intraarticular injection with Prevalence =
who underwent spinal pain this modality in diagnosing 2 mL of 2% lidocaine. 10% of total
Utilized 90% relief mapping were examined and low back pain of uncertain sample
analyzed. They found in this etiology.
group a total of 87% of the
patients with a diagnosed
pain source and 13% without
a source. In this evaluation,
sacroiliac joint pain was
identified in 10% of the patients
from the total sample.
Dreyfuss et al (148) This prospective study included To identify a single sacroiliac Intraarticular injection of Prevalence =
85 patients based on historical joint test or ensemble of tests 1.5 mL of 2% lignocaine 53%
Utilized 90% relief data with 12 tests performed that are sufficiently useful in and 0.5 mL of Celestone®
by 2 examiners. 90% or more diagnosing sacroiliac joint Soluspan® (betamethasone)
relief was considered a positive disorders to be clinically unless a firm endpoint was
response, and less than 90% valuable. reached before this volume.
relief was considered a negative
response.
Slipman et al (152) 50 consecutive patients meeting To determine the sensitivity Intraarticular injection of Prevalence =
a pre-established criteria from a and specificity of radionuclide 1 mL of betamethasone 62%
Utilized 80% relief chronic spine practice. imaging in establishing a sodium phosphate and
diagnosis of sacroiliac joint acetate suspension, 60
syndrome in patients with low mg per mL, 3 mL of 1%
back pain. lidocaine hydrochloride,
or 3 mL of 2% lidocaine
hydrochloride. Among
the patients with positive
response, there were 27
patients with negative scans
and 4 patients with positive
scans.
Laslett et al (154) Prospective evaluation of 48 To examine the diagnostic Intraarticular injection Prevalence =
patients satisfying inclusion power of pain provocation of 1 mL of 2% lignocaine. 33%
Utilized 80% relief criteria from a total of 62 sacroiliac joint tests singly All patients underwent
patients agreeing to participate and in various combinations provocation testing.
and were evaluated. Patients in relation to an accepted
with buttock pain, with or criterion standard.
without lumbar or lower
extremity symptoms were
included.
Young et al (155) A prospective evaluation To identify significant Intraarticular injection with Prevalence =
of 81 patients with chronic components of a clinical 1.5 mL of lidocaine. 39%
Utilized 80% relief lumbopelvic pain to evaluate examination that are
the correlation of the clinical associated with symptomatic
examination characteristics lumbar discs, zygapophysial
with 3 sources of chronic low joints, and sacroiliac joints.
back pain with diagnostic
injections as criterion standard.
57 patients were suspected to
have sacroiliac joint pain.
Stanford & Burnham Evaluation of 34 patients with To evaluate the diagnostic Intraarticular injection of Prevalence =
(175) suspected unilateral mechanical usefulness of repeating 1.5 mL of 2% lidocaine and 32%
sacroiliac joint pain. sacroiliac joint provocative 1 mL of corticosteroid.
Utilized 80% relief tests postblock.
80% TO 100% RELIEF

WITH DUAL BLOCKS
Manchikanti et al (41) 120 patients (age 18-90) To determine the frequency of All patients had facet Prevalence =
presenting to the clinic with > various structures responsible blocks. 10%
Utilized 80% relief 6 months of low back pain and for low back pain.
no structural basis for the pain Those not responding who False-positive
by radiographic imaging. 20 fit the criteria had double rate = 22%
patients were evaluated for SI injection sacroiliac joint
joint pain. blocks. The screening block
was done with 2% lidocaine
and the confirmatory block
was performed using 0.5%
bupivacaine.
Laslett et al (159) 48 patients received an initial To assess the diagnostic 16 patients had a positive Prevalence =
sacroiliac joint diagnostic accuracy of clinical response to sacroiliac joint 25.6%
Utilized 80% relief injection, derived from 62 examination in identifying injections and 5 of them did
patients with buttock pain with symptomatic and not receive a confirmatory False-positive
or without lumbar or lower asymptomatic sacroiliac joints diagnostic injection rate = NA
extremity symptoms. using double-diagnostic because they derived such
injections as the reference symptomatic relief from
standard. the initial procedure that
a confirmatory injection
could not be justified.
11 patients received a
confirmatory injection and
all of them tested positive.
Overall 32 patients had
negative sacroiliac joint
injections and did not
require a confirmatory
injection.
blocks with a > 80% cutoff threshold (41,159). ies scoring less than 50% were considered to be of poor
quality and excluded.
2.1.1 Clinical Relevance There were 3 studies utilizing a single block with
Among the 18 studies assessed for clinical rel- 50% to 80% relief as the cutoff threshold (82,83,157),
evance (41,42,54,55,78,79,82,83,119,148,152,154,155 7 studies utilizing 50% to 80% relief following dual
,157,159,160,175,194,195) with one duplicate publica- blocks (54,55,78,79,119,160,194,195), with one dupli-
tion (78,195), 17 studies met criteria, scoring 5 out of 5 cate study (78,195). There were 6 studies utilizing > 80%
(41,42,54,55, 78,79,82,83,119,148,152,154,155,159,160, relief following a single block as the reference standard
175,194,195). Table 6 illustrates the assessment of clini- (42,148,152,154,155,175), and 2 studies in which > 80%
cal relevance. relief following dual blocks was used as the diagnostic
criterion (41,159).
2.1.2 Methodological Quality Assessment There were 18 studies evaluating diagnostic
A methodological quality assessment of diagnostic accuracy (41,42,54,55,78,79,82,83,119,148,152,154,
accuracy studies meeting inclusion criteria was carried 155,157,159,160,175,194,195), with one study being
out utilizing QAREL criteria as shown in Table 7. Studies published in duplicate (78,195). Seventeen studies
achieving 50% or higher scores were included. Scores were considered to be high quality (41,42,54,55,78,
of 67% or higher were considered to be high quality, 79,82,83,119,148,152,154,155,157,159,160,194,195)
50% were considered to be moderate quality, and stud-
Table 6. Clinical relevance of included studies.
Manuscript Author(s) A) Patient B) Description C) Clinically D) Clinical E) Benefits Total

description of interventions relevant importance versus Criteria
and treatment outcomes potential Met
settings harms
Manchikanti et al (41) + + + + + 5/5
Pang et al (42) + + + + + 5/5
Maigne et al (54) + + + + + 5/5
Irwin et al (55) + + + + + 5/5
DePalma et al (78,195) + + + + + 5/5
DePalma et al (79) + + + + + 5/5
Schwarzer et al (82) + + + + + 5/5
Maigne & Planchon (83) + + + + + 5/5
DePalma et al (119) + + + + + 5/5
Dreyfuss et al (148) + + + + + 5/5
Slipman et al (152) + + + + + 5/5
Laslett et al (154) + + + + + 5/5
Young et al (155) + + + + + 5/5
Broadhurst & Bond (157) + - - - + 2/5
Laslett et al (159) + + + + + 5/5
van der Wurff et al (160) + + + + + 5/5
Stanford & Burnham (175) + + + + + 5/5
Liliang et al (194) + + + + + 5/5
+ = positive; - = negative
Scoring adapted from Staal JB, et al. Injection therapy for subacute and chronic low back pain. Cochrane Database Syst Rev 2008; 3:CD001824
(136).
Table 7. Quality Appraisal of Diagnostic Reliability checklist.

Manchikanti Pang et Maigne Irwin DePalma DePalma DePalma van der Schwarzer Maigne Dreyfuss
et al (41) al (42) et al et al et al et al (79) et al Wurff et al (81) & et al
(54) (55) (78,195) (119) et al Planchon (148)
(160) (83)
1. Was the test evaluated Y Y Y Y Y Y Y Y Y Y Y
in a spectrum of
subjects representative
of patients who would
normally receive the test
in clinical practice?
2. Was the test Y Y Y Y Y Y Y Y Y Y Y
performed by examiners
representative of those
who would normally
perform the test in
practice?
3. Were raters blinded to NA NA NA NA NA NA NA NA NA NA NA
the reference standard
for the target disorder
being evaluated?
4. Were raters blinded Y Y Y Y Y Y Y Y Y Y Y
to the findings of other
raters during the study?
5. Were raters blinded Y Y Y Y Y Y Y Y Y Y Y
to their own prior
outcomes of the test
under evaluation?
6. Were raters blinded to N N N N N N N N U U N
clinical information that
may have influenced the
test outcome?
7. Were raters blinded N N N N N N N N N N N
to additional cues, not
intended to form part
of the diagnostic test
procedure?
8. Was the order in Y N U N N N N Y Y U U
which raters examined
subjects varied?
9. Were appropriate Y Y Y Y Y Y Y Y Y Y Y
statistical measures of
agreement used?
10. Was the application Y Y Y Y Y Y Y Y Y Y Y
and interpretation of
the test appropriate?
11. Was the time interval Y Y Y Y Y Y Y Y Y Y Y
between measurements
suitable in relation to the
stability of the variable
being measured?
12. If there were Y Y Y Y Y Y Y Y Y Y Y
dropouts from the
study, was this less than
20% of the sample.
TOTAL 9/11 8/11 8/11 8/11 8/11 8/11 8/11 9/11 9/11 8/11 8/11
Y=yes; N=no; U=unclear; N/A=not applicable

25:80-89 (72).
Table 7 (cont.). Quality Appraisal of Diagnostic Reliability checklist.

Broadhurst Stanford & Liliang
Slipman et Laslett et al Young et al Laslett et
& Bond Burnham et al
al (152) (154) (155) al (159)
(157) (175) (194)
1. Was the test evaluated in a spectrum of subjects Y Y Y Y Y Y Y
representative of patients who would normally
receive the test in clinical practice?
2. Was the test performed by examiners Y Y Y Y Y Y Y
representative of those who would normally perform
the test in practice?
3. Were raters blinded to the reference standard for NA NA NA NA NA NA NA
the target disorder being evaluated?
4. Were raters blinded to the findings of other raters Y Y Y Y U Y Y
during the study?
5. Were raters blinded to their own prior outcomes of Y Y Y Y NA Y Y
the test under evaluation?
6.Were raters blinded to clinical information that may N N N Y N N N
have influenced the test outcome?
7. Were raters blinded to additional cues, not N N N Y N N N
intended to form part of the diagnostic test
procedure?
8. Was the order in which raters examined subjects U N N Y N N N
varied?
9. Were appropriate statistical measures of agreement Y Y Y Y Y Y Y
used?
10. Was the application and interpretation of the test Y Y Y Y Y Y Y
appropriate?
11. Was the time interval between measurements Y Y Y Y Y Y Y
suitable in relation to the stability of the variable
being measured?
12. If there were dropouts from the study, was this Y Y Y Y Y Y Y
less than 20% of the sample.
TOTAL 8/11 8/11 8/11 11/11 6/11 8/11 8/11
Y=yes; N=no; U=unclear; N/A=not applicable
25:80-89 (72).
and one study was rated as being of moderate qual-

ity (175). ies with a cutoff threshold between 50% and 80%, 2
studies utilized 75% pain relief as the criterion standard
2.1.3 Meta-Analysis (82,83) and one study utilized 70% relief (157). In the
All diagnostic accuracy studies were evaluated studies with a cutoff between 50% and 80% pain relief
for homogeneity for inclusion in the meta-analysis that employed dual blocks as the criterion standard, 3
(Table 8). There was only one placebo-controlled studies utilized 75% pain relief as the criterion thresh-
study (157). There were 7 studies in the dual block old (54,78,79,119,195,195); with 4 of these publications
group using 50% to 80% relief as the cutoff thresh- (78,79,119,195) from one retrospective study (78). An-
old (54,55,78,79,119,160,194,195), with one duplicate other retrospective evaluation utilized 70% pain re-
study (78,195). Six studies met inclusion that utilized lief as the criterion standard (55), and one prospective
a single block with a cutoff threshold > 80% pain re- study used 50% relief following double comparative
lief (42,148,152,154,155,175). In the single block stud- blocks as the criterion standard (160). Thus, the studies
were not homogenous. 2.1.4 Study Characteristics

A second category was comprised of 6 studies us- Table 9 illustrates the characteristics of the includ-
ing a single block with a criterion standard ranging be- ed studies utilizing cutoff thresholds between 50% and
tween 80% and 100% relief. In this evaluation, 2 stud- 80% pain relief, and > 80% relief, following single and
ies utilized 90% pain relief (42,148), whereas 4 studies dual blocks.
utilized 80% or greater relief as criterion standard
(152,154,155,175). Inclusion criteria were different. 2.1.5 Analysis of Evidence
Thus, there was no homogeneity among the studies. The evidence was synthesized based on the relief
In the double block group using a cutoff threshold be- criteria when sacroiliac joint injections were performed.
tween 80% and 100% pain relief, only 2 studies were Table 9 illustrates the results of diagnostic studies.
identified (41,159).
Consequently, there was no meta-analysis 2.1.5.1 Single Block with 50% to 80% Pain Relief
performed. Two of the studies evaluating the prevalence
Table 8. Data of prevalence of sacroiliac joint pain by controlled diagnostic blocks.
% Relief Methodological Number of Prevalence False-Positive

Study
Used Criteria Score Subjects Estimates Rate
50%-79% RELIEF WITH A SINGLE BLOCK
Schwarzer et al (82) 75% 9/11 43 30% ---
Maigne & Planchon (83) 75% 8/11 40 35% ---
Broadhurst & Bond (157) 70% 11/11 40 NA ---
50%-79% RELIEF WITH A DUAL BLOCK

Maigne et al (54) 75% 8/11 54 18.5% 20%
Irwin et al (55) 70% 8/11 158 26.6% NA
DePalma et al (78,195) 75% 8/11 156 18.2% NA
DePalma et al (79) 75% 8/11 27 18.2% NA
DePalma et al (119) 75% 8/11 170 18.2% NA
van der Wurff et al (160) 50% 9/11 60 38% 21%
Liliang et al (194) 75% 8/11 52 40.4% 26%

80%-100% RELIEF WITH A SINGLE BLOCK
Pang et al (42) 90% 8/11 104 10% ---
Dreyfuss et al (148) 90% 8/11 85 53% ---
Slipman et al (152) 80% 8/11 50 62% ---
Laslett et al (154) 80% 8/11 48 33% ---
Young et al (155) 80% 8/11 81 39% ---
Stanford & Burnham (175) 80% 6/11 34 32% ---
80%-100% RELIEF WITH DUAL BLOCKS
Manchikanti et al (41) 80% 9/11 20 10% 22%

Laslett et al (159) 80% 8/11 43/48 25.6% NA
NA = Not available
Table 9. Summary characteristics of studies utilizing 50% and 70% relief for single and dual blocks.
Number of Methodological
Reference,
Patients Outcome Strengths Quality
Year Intervention Results Comments
Selection Measures Weaknesses Assessment
Criteria Score
50%-79% RELIEF WITH SINGLE BLOCK
Schwarzer 43 consecutive Intraarticular A positive Prevalence = Strengths: This study 9/11 Well performed
et al (82) patients with injection of response 30% from 1995 is the study, but with
chronic low 1 mL of 2% was classed earliest performed, a single block
back pain lignocaine. as definite if with strict selection which may
maximal below there was a criteria and performed result in lesser
L5/S1 were 75% or greater by experts in the field. prevalence with
investigated. reduction of Weakness: A single a certain false-
pain over the block. positive rate with
sacroiliac joint dual blocks.
and buttock.
Maigne & This was a Intraarticular The study was Prevalence = Strengths: The study 8/11 The study was
Planchon prospective injection with performed 35% was performed a single block
(83) series of 40 2 mL of 2% appropriately appropriately in study with a
patients with lidocaine. in patients patients after lumbar 35% prevalence.
persistent low after lumbar fusion. Further, this
back pain after fusion. Weaknesses: There study showed
technically were 5 unsuccessful that a past
successful blocks out of 45 history of
fusion who patients indicating a posterior iliac
received a high number. Further, bone graft
sacroiliac the study evaluated harvesting had
anesthetic only the patients with no significant
block under postfusion pain with a value in contrast
fluoroscopic single block with 75% to Carragee et al’s
control. pain relief. (243) proposition
that the site of
the bone graft
is painful in
asymptomatic
patients.
Broadhurst Double-blind Intraarticular 70% pain Prevalence Strength: The 11/11 The authors
& Bond trial of 40 injection of suppression. = Not study evaluated the had an excellent
(157) patients to 4 mL of 1% available immediate suppression concept of
determine the lignocaine or 4 of pain with proving that
sensitivity and mL of normal 100% provocative testing placebo is not
specificity of saline into the suppression with injection of local effective yielding
3 commonly painful joint in of pain anesthetic or sodium 100% results
used pain 20 patients in provocation chloride solution. with lidocaine
provocation each group. in patients Local anesthetic injection, which
tests for receiving injection showed 100% was rather
sacroiliac joint lignocaine suppression of pain high volumes,
dysfunction in 3 provocation tests with questioning the
with provocation a specificity of 100% accuracy and
suppression of pain tests for each test and a validity of the
pain by 70% sensitivity range of study.
with injection 77% to 87%. Weakness:
of either The study was
normal saline performed with high
or lidocaine. volumes of solution
which have a tendency
to leak out. Injection of
intraarticular sodium
chloride solution is not
an appropriate model
for placebo testing
(216-223).
Table 9 (cont.). Summary characteristics of studies utilizing 50% and 70% relief for single and dual blocks.
Reference,
Criteria Score
50%-79% RELIEF WITH DUAL BLOCKS
Maigne et 54 patients A screening Greater than Prevalence = Strengths: The study 8/11 The study
al (54) aged 18-75 block was 75% relief was 18.5% was performed in a questions the
with chronic done with 2% considered a prospective manner accuracy of some
unilateral LBP lidocaine and positive block. False- with dual blocks and of the presumed
with or without a confirmatory positive rate a thorough clinical sacroiliac pain
radiation to block was = 20% examination including provocation tests.
the posterior performed pain provocation
thigh for > 50 with tests. Weaknesses:
days (median bupivacaine The selection criteria
4.2 months). 0.5%. is somewhat rigid
Patients had with pain provocation
failed epidural testing.
or lumbar facet
injections.
Irwin et al 158 patients A screening At least 70% Estimated Strengths: The 8/11 The largest
(55) underwent block with reduction false- study included a study to date
sacroiliac joint 2 mL of 2% of familiar positive rate large proportion of utilizing dual
injections lidocaine painful = 53.8% patients with sacroiliac blocks yielding
with average for the first symptoms joint pain inducing prevalence of
symptoms injection, after the initial minimal bias due to a 26.6% with an
duration of followed by 2 injection for Prevalence = retrospective nature. estimated false-
34 months. mL of 0.25% 3 or 4 hours 26.6% Weaknesses: positive rate of
Patients failed bupivacaine, for positive A retrospective nature 53.8%.
conservative a local response. False- of the study.
modalities prior anesthetic, Positive Rate
to injection for the = NA
therapy. confirmatory
injection.
DePalma et 156 patients Intraarticular At least 75% Prevalence = Strengths: The study 8/11
al (78,195) underwent injection of pain relief for 18.2% was performed in
diagnostic 0.5 mL of 2 hours for a heterogenous
procedures anesthetic, lidocaine and False- population in a
to evaluate 1% lidocaine 8 hours for Positive practical setting in a
the source of for first block bupivacaine. Rate = Not retrospective manner
chronic low with 0.5% available overall in a large
back pain based bupivacaine proportion of patients.
on the age. for the second. Weaknesses:
Retrospective
evaluation without
identification of
number of patients
undergoing sacroiliac
joint blocks, thus
not providing actual
prevalence in only
sacroiliac joint
patients.
Reference,
Criteria Score
DePalma Retrospective Intraarticular Diagnostic Prevalence = Strengths: The study 8/11
et al (79) evaluation of 27 injection of blockade of 18.2% performed only in
motor vehicle 0.5 mL of sacroiliac patients with motor
collision- anesthetic, joints was False- vehicle collision with a
induced 1% lidocaine deemed Positive retrospective analysis.
chronic low for first block positive if Rate = Not Weaknesses:
back pain with 0.5% the patient’s available Retrospective analysis
patients bupivacaine index pain was in a small proportion
undergoing for the second. relieved by of patients involving
multiple types 75% or greater multiple etiologies and
of diagnostic after injection with 7 of 27 patients or
interventions. of each 25.9% positive response
anesthetic. rate to dual blocks.
Further, no data is
provided with regards to
the number of patients
undergoing sacroiliac
joint injections.
DePalma The diagnosis Intraarticular Diagnostic Prevalence = The study included 8/11 A small
et al (119) of 28 fusion injection of blockade of 42.9% 28 fusion cases which retrospective
cases identified 0.5 mL of sacroiliac joints were separated from study yielding a
from 170 anesthetic, was deemed False- others. Weaknesses: high percentage
low back 1% lidocaine positive if positive = Retrospective of sacroiliac joint
pain patients for first block the patient’s NA evaluation with rather pain.
undergoing with 0.5% index pain was small proportion of
diagnostic bupivacaine relieved by 75% patients yielding very
procedures for the second. or greater after high sacroiliac joint
included 12 injection of pain prevalence of
with sacroiliac each anesthetic. 42.9% with 12 out of
joint pain. 28 patients.
van der Total number The A reduction Prevalence = Strengths: The study is 9/11 Well performed
Wurff et al of 140 patients fluoroscopically in the patient’s 38% performed in a group study in a large
(160) with chronic guided contrast characteristic of patients drawn from proportion of
low back pain enhanced pain of 50% or False- a large proportion with patients with a
visiting the pain sacroiliac joint more on the positive rate a large proportion of weakness of 50%
clinic in the injections were VAS remaining = 21% patients in sacroiliac pain relief, thus
Netherlands, 60 performed for at least joint pain group itself. maybe resulting
patients entered initially with one hour for Weaknesses: There was in higher
the study. 2 mL of 2% lidocaine or leakage of the fluids in prevalence rate
lidocaine and 4 hours for 5 of 60 patients with of 38%.
next time bupivacaine sciatic nerve palsy. 60
with 0.25% was considered patients of 140 with
bupivacaine. as positive. suspected sacroiliac
When a patient joint pain appears
showed a VAS to be the Center is
reduction more geared towards
after both sacroiliac joint pain.
intraarticular The second weakness
sacroiliac joint is of the 50% or greater
blocks, this pain relief rather than
was considered a criterion standard of
a positive 80% or greater.
response. Any
other outcome
was considered
a negative
response.
Reference,
Criteria Score
Liliang et 52 patients Intraarticular 75% pain Prevalence = Strengths The study 8/11 With 75%
al (194) were selected injection relief for 1 40% is one of the more pain relief, the
from 130 with either to 4 hours recent and well results appear
patients after lidocaine (2%) following the False- performed large to be highly
undergoing or bupivacaine sacroiliac joint positive rate studies, specifically in appropriate with
lumbar or (0.5%), 1 mL, blocks. = 26% sacroiliac joint fusion. highly selected
lumbosacral mixed with Weaknesses: population.
fusions who 40 mg of Only 52 patients and
met the criteria triamcinolone. utilized 75% pain
for at least 3 of relief.
the provocative
tests for
sacroiliac joint
pain.
80% TO 100% RELIEF WITH A SINGLE BLOCK
Pang et al In this Intraarticular 90% pain relief Prevalence = Strengths: This study 8/11 Even though
(42) prospective injection with 10% of total was performed in a this is a well
evaluation, 104 2 mL of 2% sample. large proportion of performed
consecutive adult lidocaine patients for spinal study in a large
patients who mapping purposes proportion
underwent spinal identifying various of patients, it
pain mapping causes. Weaknesses: is not known
were examined The study does not the number of
and analyzed. provide detailed data patients included
They found in on sacroiliac joint pain. for sacroiliac
this group a total joint pain,
of 87% of the thus we do not
patients with know the true
diagnosed pain prevalence of
source and 13% sacroiliac joint
without a source. pain even with a
In this evaluation, single block.
sacroiliac
joint pain was
identified in 10%
of the patients
from the total
sample.
Dreyfuss et The prospective Intraarticular 90% or more Prevalence = Strengths: The study 8/11 The results
al (148) study included injection of relief was 45 out of 85 was performed showed fairly
85 patients 1.5 mL of 2% considered (53%) collaboratively with high proportion
based on lignocaine a positive extremely careful of patients with
historical data and 0.5 mL response, and patient selection sacroiliac joint
with 12 tests of Celestone less than 90% undergoing 12 clinical pain due to
performed by 2 Soluspan relief was tests, which included strict selection
examiners. unless a firm considered multiple provocative criteria. However,
endpoint was a negative maneuvers. there were
reached before response. Weaknesses: 5 patients no historical
this volume. were excluded from features, with
the analysis. Single none of the 12
block with a specific sacroiliac joint
selection criteria. tests and any
combination of
these 12 tests
demonstrating
worthwhile
diagnostic value.
Reference,
Criteria Score
Slipman et 50 consecutive Intraarticular A reduction Prevalence = Strengths: The study 8/11 This study shows
al (152) patients injection of the VAS 62% was performed to low sensitivity
meeting a of 1 mL of rating by at evaluate the value of and high
pre-established betamethasone least 80% was radionuclide imaging specificity of
criteria from a sodium considered in the diagnosis nuclear imaging
chronic spine phosphate a positive of sacroiliac joint in the evaluation
practice. and acetate response to syndrome in patients of sacroiliac joint
suspension, sacroiliac joint who were positive syndrome.
60 mg per block. for at least 3 positive
mL, 3 mL of responses to include
1% lidocaine 2 specific stress
hydrochloride, maneuvers. All the
or 3 mL of patients underwent
2% lidocaine radionuclide imaging.
hydrochloride. Weaknesses:
Among the Stringent selection
patients criteria yielding high
with positive prevalence of sacroiliac
response, joint pain with a single
there were 27 block.
patients with
negative scans
and 4 patients
with positive
scans.
Laslett et al Prospective Intraarticular At least 80% Prevalence Strengths: All patients 8/11 The authors
(154) evaluation of injection of pain relief = 16 of 48 underwent provocation concluded that
48 patients 1 mL of 2% (33%) testing. Authors composites of
satisfying lignocaine. essentially were provocation
inclusion All patients comparing validity of sacroiliac joint
criteria from underwent individual provocation tests are of
a total of 62 provocation tests and composites value in clinical
patients agreed testing. of tests. They reported diagnosis of
to participate sensitivity and symptomatic
and were specificity for 3 or sacroiliac joint
evaluated. more of 6 positive pain when 3
Patients with sacroiliac tests or more of the
buttock pain, were 94% and 78% 6 tests were
with or without respectively. Well positive, with
lumbar or performed study the greatest
lower extremity with evaluation of applicability
symptoms were validity of individual when 4 tests
included. provocation tests and were positive.
composites of tests. When none of
Weaknesses: Strict the provocation
selection criteria tests provoked
probably yielding familiar pain, the
higher prevalence. sacroiliac joint
can be ruled out
as a source of
current low back
pain.
Reference,
Criteria Score
Young et al A prospective Intraarticular At least 80% Prevalence = Strengths: The authors 8/11 The authors
(155) evaluation of injection with pain relief 39% evaluated correlation illustrate
81 patients 1.5 mL of of clinical examination the positive
with chronic lidocaine characteristics with 3 correlation
lumbopelvic sources of chronic low with strongest
pain to evaluate back pain including relationships
correlation sacroiliac joint pain between
of clinical simulating practical sacroiliac joint
examination setting. They found pain and 3 or
characteristics strongest relationships more positive
with 3 sources were seen between pain provocation
of chronic low sacroiliac joint pain tests.
back pain with and 3 or more pain
diagnostic provocation tests.
injections Weaknesses: Highly
as criterion selective group of
standard. 57 patients with positive
patients were provocation tests
suspected with
sacroiliac joint
pain.
Stanford & Evaluation of Intraarticular A positive Prevalence = Strengths: The study 6/11 The study
Burnham 34 patients injection of block was 32% was performed in a illustrates utility
(175) with suspected 1.5 mL of defined as practical setting to of pre-block
unilateral 2% lidocaine greater than evaluate usefulness to sacroiliac joint
mechanical and 1 mL of 79% index repeat sacroiliac joint provocative tests.
sacroiliac joint corticosteroid. pain relief provocative testing post
pain. within the block. Weaknesses: The
first 2 hours small number of patients
post-injection. with a single block and
strict selection criteria.
80% TO 100% RELIEF WITH DUAL BLOCKS
Manchikanti 120 patients The screening At least 80% Prevalence Strengths: The study was 9/11 The study
et al (41) (age 18-90) block was pain relief 10% performed to evaluate illustrates a low
presenting to done with with ability relative contributions proportion of
the clinic with 2% lidocaine to perform False- of various structures sacroiliac joint
> 6 months and the previously Positive Rate in chronic low back pain in 10%
of low back confirmatory painful 22% pain in 120 patients, of the patients
pain and no block was movements even though only 20 with suspected
structural basis performed with patients were evaluated sacroiliac joint
for the pain by using 0.5% concordant for sacroiliac joint pain. pain.
radiographic bupivacaine. relief based Dual blocks were utilized
imaging. 20 on the local with 80% pain relief as
patients were anesthetic the criterion standard.
evaluated for SI injected. Weaknesses: Of the
joint pain. 120 patients, only 20
patients were suspected
of sacroiliac joint pain
or underwent sacroiliac
joint blocks.
Reference,
Criteria Score
Laslett et al 48 patients Intraarticular At least 80% Prevalence Strengths: Provocation 8/11 The authors show
(159) received initial injection of reduction in = 25.6% sacroiliac tests were used the prevalence
sacroiliac joint less than 1.5 pain for the to identify sacroiliac joint of 45.6% in a
diagnostic mL of local duration of pain as part of the clinical select group of
injection, anesthetic anesthetic reasoning process. The patients with
derived from lidocaine for effect. study also illustrated the clinical reasoning
62 patients with initial block diagnostic accuracy of in addition to
buttock pain followed by the clinical examination provocation
with or without bupivacaine and clinical reasoning testing being
lumbar or for the process was superior to superior to
lower extremity confirmatory the sacroiliac joint pain provocation
symptoms. block. provocation tests alone. testing alone.
Weaknesses: This is a
validity study of sacroiliac
provocation tests.
showed a prevalence rate of between 30% and 35% (152), respectively, were found in highly selected popu-
(82,83). lations. Dreyfuss et al (148) employed a reference stan-
dard of greater than 90% pain relief during the blocks,
2.1.5.2 Dual Blocks with 50% to 80% Pain Relief and enrolled study patients who had pain predomi-
There were 7 studies evaluating 50% to 80% re- nantly below L5. Slipman et al (152) used 80% pain re-
lief with dual blocks (54,55,78,79,119,160,194,195) with lief as the criterion standard, and studied a population
one duplicate study (78,195). who had a positive response to 3 sacroiliac joint pain
As one might expect, the prevalence rate was provocation tests. Overall, a single block using 80% to
lower in the 50% to 80% dual block category, espe- 100% pain relief as the reference standard appears to
cially when 75% pain relief was utilized as the crite- yield prevalence of around 35%.
rion standard with approximate prevalence of 18%
(54,78,79,119,195). It was higher (40.4%) in one study in 2.1.5.4 Dual Blocks with 80% to 100% Relief
highly selected population (194). However, when 50% There were a total of 2 studies meeting the inclu-
relief with dual blocks was utilized as the criterion stan- sion criteria (41,159).
dard, the prevalence rate was shown to be 38% with a Using between 80% and 100% pain relief with
false-positive rate of 21% (160). Increasing the thresh- dual blocks as the criterion standard has been advo-
old to 75% does not appear to reduce the accuracy. Ir- cated by some as the most rigorous means for diag-
win et al (55), in a large retrospective evaluation, found nosing sacroiliac joint pain (2,35,38,39,88). In a small
a prevalence rate of 26.6% using 70% pain relief. These study that included only 20 patients, Manchikanti et al
findings suggest that increasing the cutoff threshold re- (41) found a low prevalence rate of 10%. In contrast,
sults in lower estimated prevalence rates. Laslett et al (159) showed a prevalence rate of 25.6%
in a study involving 48 subjects. False-positive rate was
2.1.5.3 Single Block with 80% to 100% Relief 22% (41). Laslett et al have not estimated the false-
There were a total of 6 studies meeting the inclu- positive rate, but looking at the data, it appears to be
sion criteria evaluating sacroiliac joint pain using a cut- 0% (159).
off threshold between 80% and 100% relief following
a single block (42,148,152,154,155,175). 2.2 Level of Evidence
The prevalence in this group ranged from a low of Based on the USPSTF criteria, the evidence was clas-
10% to a high of 62%. The 53% and 62% prevalence sified to be either good, fair, or limited (or poor).
rates reported by Dreyfuss et al (148) and Slipman et al
2.2.1 Single Block with 50% to 80% Relief that sought to identify sacroiliac joint referral patterns
Based on 3 high quality studies (82,83,157), the evi- in 50 patients who obtained > 80% pain relief after a
dence is fair. single intraarticular injection. The most frequent refer-
ral zones were the buttocks (94%) and lower lumbar
2.2.2 Dual Blocks with 50% to 80% Relief region. Fifty percent of patients experienced extension
Based on 7 high quality studies (54,55,78, into the lower extremity, 28% reported pain in the low-
79,119,160,194,195) containing over 500 patients, the er leg, and 14% described groin pain. A study by van
evidence in this group was good, especially when great- der Wurff et al (161) compared pain referral patterns in
er than 70% pain relief was utilized as the criterion patients with sacroiliac joint pain and those with other
standard (n = 5). sources of back pain, based on response to dual compar-
ative local anesthetic blocks. They concluded that pain
2.2.3 Single Block with 80% to 100% Relief diagrams could not reliably distinguish between low
The evidence is good based on the results of 6 stud- back pain patients suffering from sacroiliac joint pain
ies (42,148,152,154,155,175), with 5 of them rated as and those with other primary pain generators. Finally,
high quality (42,148,152,154,155). Jung et al (164) evaluated the usefulness of pain dis-
tribution pattern assessment in decision-making in 419
2.2.4 Dual Blocks with 80% to 100% Relief patients with either lumbar facet joint pain or sacroiliac
The evidence is good based on 2 high-quality stud- joint pain. The authors found several different patterns
ies (41,159) using dual blocks. for sacroiliac joint pain, such as buttock pain, buttock
pain extending into the posterolateral thigh, and but-
2.2.5 Summary of Evidence tock pain radiating into the groin. They concluded that
Overall, there was no significant difference when pain diagrams could be useful in predicting outcomes
70% or greater relief is utilized as the criterion stan- from injections and radiofrequency neurotomy.
dard with dual blocks, with good evidence based on In summary, although pain patterns may be helpful
multiple high quality studies. in identifying patients who might benefit from diag-
nostic injections, they are not pathognomonic.
2.3 Pain Patterns
Sacroiliac joint pain patterns, referral zones, 2.4 Necessity for Fluoroscopically Guided
and intensity mapping have all been evaluated Injections
(148,153,158,161-165). In 1994, Fortin et al (162) gener- Sacroiliac joint injections have been performed by
ated pain referral maps based on provocative injections many means including without imaging guidance based
performed in asymptomatic volunteers, and pain dia- on clinical examination and tenderness (183). However,
grams drawn by patients with low back pain second- the present gold standard is to perform them under
ary to sacroiliac joint pathology or other sources (i.e., fluoroscopy using controlled diagnostic blocks for diag-
facetogenic and discogenic pain). The authors found nostic purposes. In an observational study performed
that individuals whose point of maximum discomfort in 60 patients, Hansen (191) found that blind injections
fell within an area that extended 10 cm caudal and 3 cm done by a single practitioner with 2 ml of contrast re-
lateral to the posterior superior iliac spine were more sulted in intraarticular spread in only 12% of patients.
likely have sacroiliac joint pain (162,163). This finding In a double-blind study, Rosenberg et al (192) evalu-
is supported by the work of Murakami et al (187), who ated the accuracy of clinically guided sacroiliac joint injec-
found that patients who responded to low-volume tions using computerized tomography. Among the 39 in-
periarticular sacroiliac joint injections could pinpoint jections performed in 33 patients, intraarticular injection
their pain to within 2 cm of the posterior superior iliac was accomplished in only 22% of the patients, though the
spine. In a cross-sectional study by Schwarzer et al (82), injected contrast was noted to be within one cm of the
the authors found groin pain to be the best means to joint in 68% of individuals. Furthermore, injected material
distinguish sacroiliac joint pain from other causes of was found to be within the sacral foramina in 44% of cas-
back pain. In contrast, Dreyfuss et al (148) found that es- usually at S1- and in the epidural space following 24%
groin pain was not a discriminating feature of sacroiliac of injections. The authors concluded that the low rate of
joint pain. intraarticular injection observed with landmark-guided
Slipman et al (153) performed an analytical study techniques warranted the use of image guidance in those
at high risk for failure and complications. curacy of multiple tests for back pain utilizing QUADAS
Although expensive and not feasible in routine criteria, Simpson and Gemmell (200) identified 5 stud-
practice, MRI-guided corticosteroid injections of the ies that focused on sacroiliac joint pain. They found no
sacroiliac joints have been reported to be effective single test to be consistently valid.
(171,179,186). Among the multiple studies utilized to evaluate
Multiple authors have described the feasi- provocative testing and clinical evaluation (54,82,148,
bility of ultrasound-guided sacroiliac joint injec- 154,155,157,159,160,175,189,200,201), different con-
tions with consideration of anatomic landmarks clusions were reached. All studies were performed uti-
(166,169,176,178,183,185,190), but no systematic evalu- lizing fluoroscopically guided intraarticular injections
ation has been performed. Further, Hartung et al (166) as the reference standard (54,82,148,154,155,157,159,
performed a small study in which ultrasound was used 160,175,189). Schwarzer et al (82) found that none of
to guide 20 sacroiliac joint injections in 14 patients with the conventional sacroiliac joint examination proce-
sacroiliitis. MRI verification revealed that only 40% of dures tested could reliably discriminate patients with
injections were intraarticular, with the rest being out- sacroiliac joint pain from those with other sources of
side the joint cavity. No differences in outcomes were back pain. Dreyfuss et al (148) evaluated the value of
noted between the intra- and extraarticular groups. medical history and physical examination in diagnosing
Unguided sacroiliac joint injections also have been sacroiliac joint pain by assessing 12 overall tests, along
shown to be effective in some studies (183). with pain diagrams. These provocation tests included
In summary, there is no evidence to support the use the Gillet test, thigh thrust, Patrick test, Gaenslen test,
of ultrasound or landmark-guided injections for sacro- and midline sacral thrust. The results refuted the notion
iliac joint pain. These injections must be performed un- that any single historical or exam finding could reliably
der fluoroscopic or radiologic guidance. identify a painful sacroiliac joint.
Laslett et al and colleagues (154,155,159,189) pub-
2.5 Accuracy of Testing of Provocation lished multiple studies on the validity of pain provo-
Maneuvers cation testing in the identification of sacroiliac joint
Provocation testing has been extensively employed dysfunction. In one study, Laslett et al (154) evaluated
in an attempt for diagnosing sacroiliac joint pain. Mul- the validity of provocation tests individually and collec-
tiple studies have also been performed to evaluate the tively to predict response to a single diagnostic sacro-
validity of clinical examination, which incorporates iliac joint injection. All patients with a positive response
provocation testing. The recommended reference to a diagnostic injection reported pain during at least
standard involves either anesthetic or provocative in- one sacroiliac joint test. The sensitivity and specificity
jections; however, doubts have even been cast on the for 3 or more of the 6 tests were 94% and 78% respec-
validity of a sacroiliac joint block as a diagnostic gold tively. The greatest area under the curve of any of the
standard. A review by Berthelot et al (89) concluded 2 best 4 tests was 0.842. The authors concluded that
clinical signs and maneuvers to be unreliable for diag- composites of provocation sacroiliac joint tests were
nosing pain originating within the sacroiliac joint; they of value in the clinical diagnosis of symptomatic sac-
are fraught with both low sensitivity and specificity. But roiliac joint pain and 3 or more out of 6 tests or have
the authors also concluded that sacroiliac joint blocks the best predictive power in relation to the results of
were similarly unreliable, since pain patterns formerly intraarticular anesthetic blocks. The most valid battery
attributed to the sacroiliac joint can be related to ex- of maneuvers were the distraction, compression, and
traarticular structures, most notably the numerous liga- thigh and sacral thrust tests.Young et al (155) sought to
ments surrounding the joint. However, multiple studies determine whether clinical examination characteristics
evaluated in the same studies have reached different could be associated with 3 sources of chronic low back
conclusions. pain, including 57 patients with sacroiliac joint pain.
In 2 separate systematic reviews, Szadek et al (80) The 5 pain provocation maneuvers utilized were shown
and Hancock et al (49) showed a positive correlation above. The authors demonstrated a significant associa-
between a battery of provocation testing and diagnos- tion between a positive sacroiliac joint injection and
tic blocks. Hancock et al (49) included 6 studies in their 4 of the 9 characteristics evaluated. They also found a
analysis, while Szadek et al (80) included 15 studies. In negative relationship between injection response and
a systematic appraisal of the literature assessing the ac- the presence of midline lumbar pain and pain above L5.
The presence of 3 or more positive sacroiliac joint pain tistically significant association was found between the
provocation tests was found to be significantly corre- response to the blocks and any single clinical param-
lated with a positive block (phi coefficient of 0.6), re- eter. They concluded that no pain provocation test was
sulting in an effect size of 36%. They also found that all a useful predictor of sacroiliac joint pain.
patients with a positive block experienced pain when van der Wurff et al (160) evaluated the diagnostic
rising from sitting, as well as a strong correlation with accuracy of a multi-test regimen of 5 sacroiliac joint pain
the non-centralization of pain. provocation tests by comparing it to the results of fluo-
Laslett et al (159) concluded that the diagnostic ac- roscopically guided double local anesthetic blocks. The
curacy of the clinical examination in conjunction with 5 provocation tests included the distraction test, com-
reasoning processes was superior to sacroiliac joint pain pression test, thigh thrust, Patrick sign, and Gaenslen
provocation maneuvers as stand-alone tests. Excluding test. Among the 60 patients studied, 45% obtained a
patients whose pain peripheralized increased the posi- positive response to both blocks. Whereas none of the
tive likelihood ratio for identifying a symptomatic sacro- provocation tools were specific as a stand-alone test,
iliac joint(s) in patients with 3 or more provocative tests. a combination of 3 or more positive tests was deemed
Laslett et al (189) also evaluated the agreement to be a reliable indicator. Six of the 29 patients who
between a diagnoses reached by clinical examination responded to the initial block failed to experience relief
and the available reference standards in a prospective after the confirmatory block and were thus categorized
study of 216 patients with lumbopelvic pain. They com- as false-positive blocks. The prevalence rate for this
pared blinded clinical diagnoses by physiotherapists study was 38%, with a false-positive rate estimated to
with diagnoses based on available reference standards be around 21%. The sensitivity and specificity of the 3
for known causes of low back pain, such as discogra- or more positive provocation tests were 85% and 80%,
phy, facet joint nerve blocks, sacroiliac joint injections, respectively. The authors’ conclusion that a correlation
epidural injections, advanced imaging studies, or any exists between the finding of 3 or more positive pain
combination of these tests. The authors found that provocation tests and an analgesic response to double
66% and 76% of patients received a single diagnosis intraarticular sacroiliac joint blocks corroborates the re-
based on reference standards and physical examina- sults of Laslett et al (159).
tion, respectively. Overall, exact agreement between Stanford and Burnham (175) evaluated provoca-
the clinical and reference standard diagnosis was 33%, tive testing in 34 patients with suspected sacroiliac joint
and clinical agreement was 51%. For sacroiliac joint pain who underwent double comparative local anes-
pain, the agreement between the clinical diagnosis and thetic blocks. They found the sensitivity, specificity, and
the diagnosis by reference standards was 57%. How- likelihood ratios for patients with 3 or more out of 6
ever, only 6 sacroiliac joint diagnoses were conferred by positive tests were 0.82, 0.57, and 1.9 respectively. The
each method. provocative test utilized in this test were Patrick test,
Broadhurst and Bond (157) also evaluated pain thigh thrust, ipsilateral Gaenslen test, contralateral
provocation tests for the assessment of sacroiliac joint Gaenslen test, lateral compression, and sacral thrust.
dysfunction in a double-blind, controlled fashion. They The review of provocative testing and clinical ex-
found that local anesthetic injection suppressed ap- amination findings illustrates that 6 commonly per-
proximately 70% of the pain that was elicited with pro- formed provocative tests may be useful to select pa-
vocative measures, while saline provided no meaning- tients for further study provided 3 or more of them are
ful relief. One flaw in this study was the large volume positive. These include the distraction, compression,
of local anesthetic (4 mL) utilized. thigh thrust, Gaenslen’s , and sacral thrust tests (154).
Maigne et al (54) determined the prevalence of
sacroiliac joint pain in a selected population of pa- 2.6 Accuracy of Imaging
tients suffering from low back pain and assessed the The value of radiological imaging has been ques-
validity of various pain provocation tests. The patients tioned in the diagnosis of sacroiliac joint pain. Multiple
underwent 7 sacroiliac pain provocation tests, which investigations have been performed, including evalu-
included the distraction test, compression test, sacral ations using plain x-rays, plain CT, MRI (166-168,171,
pressure test, Gaenslen test, Patrick test, resisted exter- 176,194,202,206,208-210,213-237), single-photon emis-
nal rotation of the hip, and direct pressure on the pubic sion computed tomography (SPECT) (83,152-156,207)
symphysis, before and after a screening block. No sta- and positron emission tomography (PET) scanning
(211,212). should be the imaging modality of choice for diagnos-

Among the multiple systematic reviews, Vanelderen ing sacroiliitis.
et al (57) concluded that radiologic imaging is important Puhakka et al (202,203) performed 2 evaluations of
to exclude “red flags” but contributes too little to aid in MRI: one evaluated the modality in normal sacroiliac
diagnosis. Hancock et al (49) concluded that although joints in asymptomatic volunteers with correlation to
a positive bone scan has high specificity, it is associated microscopic histology in cadavers; the second study as-
with a very low sensitivity, which means the majority of sessed MRI abnormalities of the sacroiliac joints in early
patients with sacroiliac joint pain will not be accurately spondyloarthropathy with a one-year follow-up period.
identified. Gupta (238) concluded that medical history, The authors concluded that coronal MRI is not condu-
clinical examination including sacroiliac joint provocative cive to the assessment of normal anatomy. But when
tests, plain radiography, and laboratory investigations there are variants or abnormalities of the ventral and
were helpful in diagnosing sacroiliac joint pathology in dorsal margins of the cartilaginous sacroiliac joint and
only 39% of cases, with 46% needing a CT or MRI. In a in early spondyloarthropathy, MRI can detect signifi-
narrative review, Tuite (239) noted that the sacroiliac joint cant inflammatory and destructive changes over a one-
has several unique anatomical features that make it one year follow-up not observable on CT or plain x-rays, de-
of the more challenging joints to image, and that the ra- spite minimal changes in the clinical parameters. Thus,
diologic findings of sacroiliitis are often equivocal. The MRI may be a sensitive method, with minimal risk, for
author stated that MRI performed with proper sequenc- the early diagnosis and evaluation for disease progres-
ing (i.e., gadolinium enhancement or short tau inversion sion in spondyloarthropathy. Radiologic studies can
recovery (STIR) was the imaging modality of choice for also assist in determining anatomical integrity (204).
patients with suspected sacroiliitis but negative or equivo- A retrospective study (205) showed that CT scans were
cal radiographs; however, it was unlikely to be helpful in negative in 42% of patients with symptomatic sacroiliac
individuals with extraarticular pathology. joint pain.
The majority of the systematic reviews and individ- In a review of imaging for spondyloarthropathy,
ual studies conducted were related to spondyloarthri- Braun et al (230) noted that because inflammatory
tis. Thus, these results may not be applicable to chronic back pain is not a specific indicator of sacroiliitis, there
pain settings for evaluating sacroiliac joint pain. Several is a need for imaging techniques. They concluded that
studies have also evaluated sacroiliac joint pain using scintography lacks specificity, CT is a good method to
various imaging techniques. demonstrate already established bony changes, and
Lawson et al (235) evaluated sacroiliac joints for that MRI possesses the advantage of combining good
their anatomy with plain x-rays and CT analysis. They visualization of the complicated anatomy of the sacro-
found the accuracy of CT to be superior to conventional iliac joint with the ability to localize different degrees
radiography in the detection of early erosive sacroili- of inflammation and edema.
itis and joint space narrowing. In all patients with a Song et al (81) evaluated the diagnostic value of
discrepancy between the 2 radiologic techniques, the scintography in detecting sacroiliitis in ankylosing spon-
changes were either only or better demonstrated by CT dylitis and those with probable sacroiliitis without x-ray
rather than conventional radiography. changes. Following an extensive literature search, they
Blum et al (229) assessed plain radiographs, quan- concluded that scintography of the sacroiliac joints is of
titative sacroiliac scintigraphy, and MRI. The results limited diagnostic value.
showed that MRI was more sensitive (85%) than quan- Slipman et al (152) evaluated the value of radio-
titative sacroiliac scintigraphy (48%) or conventional ra- nuclide imaging in the diagnosis of sacroiliac joint syn-
diography (19%) for the detection of active sacroiliitis. drome and concluded nuclear imaging had high speci-
For all modalities, specificity was significantly higher ficity but very low sensitivity. Consequently, they did
than sensitivity. not recommend radionuclide imaging in the evaluation
Jurik (240) noted that the sensitivity and specificity of sacroiliac joint pain syndrome.
of conventional x-rays were relatively low, which can In an evaluation of quantitative radionuclide bone
delay the diagnosis of sacroiliitis. CT was found to be scanning in the diagnosis of sacroiliac joint syndrome,
superior to conventional x-rays for the diagnosis of sac- Maigne et al (156) found the sensitivity, specificity, and
roiliitis, but this has to be weighed against the higher positive and negative predictive values of the quanti-
radiation doses utilized. The author concluded that MRI tative bone scanning to be 46%, 90%, 86%, and 72%
respectively. community, especially when the efficacy of a procedure

In summary, MRI appears to be a useful test in de- has already been established.
tecting early sacroiliitis, and in following disease pro- There is a paucity of literature on the effective-
gression in individuals with spondyloarthropathy. Im- ness of multiple therapeutic sacroiliac joint interven-
aging may also be helpful in identifying patients who tional techniques including intraarticular injections or
might benefit from further evaluation, especially in radiofrequency neurotomy of the nerve supply. Barriers
combination with provocative maneuvers. to effective treatment include the fact that sacroiliac
joint pain is a heterogeneous condition (i.e. patients
3.0 Discussion may exhibit either intra- or extra-articular sacroiliac
This systematic review reveals that there continues joint pathology) and the complex and variable nerve
to be relatively few high-quality studies which have in- supply, which can make radiofrequency denervation
vestigated the diagnostic accuracy of tests to identify challenging.
the sacroiliac joint(s) as the source of low back and In a retrospective study, Borowsky and Fagen (184)
lower extremity pain. The majority of studies investi- evaluated the sources of sacroiliac region pain to deter-
gated the role of diagnostic sacroiliac joint injections mine the contributions of intraarticular and periarticu-
or provocation maneuvers. The results of diagnostic lar components. One hundred and twenty patients were
accuracy studies evaluating controlled local anesthetic evaluated with either intraarticular (1.5 mL of bupiva-
blocks illustrate good overall evidence based on mul- caine and 80 mg steroid) or a combination of intra- (2
tiple high quality studies. This review indicates the mL of bupivacaine and 40 mg steroid) and periarticular
approximate prevalence rate based on dual blocks to (2 mL of bupivacaine and 40 mg steroid) injections. The
be around 25%, with a false-positive rate of 20%. Al- periarticular injections were performed in the posterior
though provocation maneuvers have been evaluated ligaments and around the lateral branches. The authors
by multiple investigators, an evaluation of these studies reported a success rate of 12.5% in the intraarticular
suggests there is limited evidence that they are helpful group versus 31.25% for the combined injection. Fur-
in determining the likelihood of sacroiliac joint pain in ther, anesthetic response rates were also higher in the
patients with pain located primarily below the 5th lum- combined injection group (62.5% versus 42.5%). They
bar vertebrae. Plain x-rays or advanced imaging appear concluded that extraarticular sources comprise of sig-
to be of no significant value in chronic sacroiliac joint nificant proportion of sacroiliac joint pain, and that
pain without inflammatory arthritis. performing only intraarticular diagnostic blocks may
This systematic review included 18 diagnostic ac- underestimate the true prevalence.
curacy studies using controlled diagnostic blocks and 12 Murakami et al (187) performed a prospective
studies evaluating provocation maneuvers. The threshold study comparing intraarticular to periarticular injec-
was strict in that each study had to meet at least 50% of tions, which were performed in response to pain provo-
the methodological quality assessment criteria. In con- cation tests. The authors found that the periarticular
trast to our previous review (36), in this evaluation we injections effectively relieved pain in all 25 patients, but
broadened our criteria to incorporate those studies that intraarticular injection was effective in only 9 of 25 pa-
utilized a single block and various levels of pain relief as tients. All 16 patients in the intraarticular group who
the reference standards. We found that studies that em- failed to respond to the initial injection experienced
ployed single blocks, and those that used cutoff thresh- significant relief after they received an injection using
olds < 80%, demonstrated a moderate correlation with the periarticular approach. Overall, the 96% improve-
those that utilized more stringent criteria, albeit with ment rate after the periarticular injection was signifi-
somewhat higher prevalence rates. There was only one cantly higher than the 62% success rate noted after the
placebo block available that did not provide prevalence intraarticular injection.
or false-positive rates. The rationale behind using double Dreyfuss et al (181,182) evaluated the ability of sin-
comparative blocks is to eliminate false-positive respond- gle-site, single-depth, and multi-site, multi-depth sacral
ers, which is important to establish efficacy. The evidence lateral branch blocks to anesthetize the sacroiliac joint
for controlled dual blocks generally accepted for the di- complex. They concluded that single-site, single-depth
agnosis of facet joint pain (2,35,38-40,44,87,88,241-246). sacral lateral branch blocks were ineffective in anesthe-
Yet as can be seen from this review, dual blocks are not tizing the lateral branches. In contrast, multi-site, multi-
universally accepted in the interventional pain medicine depth sacral lateral branch blocks were 91% effective
in anesthetizing the lateral branches, and blocked the reference standard employed, opioid use, the ef-
the pain from ligamentous probing in 70% of volun- fects of sedation and local anesthetic use, and the pla-
teers. However, these blocks did not block pain from cebo effect (261-268). Whereas the evidence behind us-
the intraarticular portion of sacroiliac joint, elicited by ing diagnostic blocks to identify the sacroiliac joint(s)
capsular distension. This provides evidence for both a as a pain generator is not robust, one may extrapolate
ventral and dorsal contribution to the innervation of from some of the ample evidence in support of using
the sacroiliac joint, and suggests that multi-side, multi- controlled lumbar facet joint nerve blocks to diagnose
depth lateral branch blocks could be useful to identify lumbar facet joint pain (2,35,38-40,44,49,87,88). The
extraarticular sources of sacroiliac joint pain, and to se- reference standard for surgical situations is clearly es-
lect candidates who might benefit from lateral branch tablished by biopsy or autopsy. However, these stan-
radiofrequency neurotomy. Cohen et al (116) evaluated dards are impossible to apply for pain conditions; hence,
outcome predictors for sacroiliac joint lateral branch the long-term clinical follow-up of subjects appears to
radiofrequency denervation. Fifty-two percent of pa- be the best means of establishing a reference standard
tients obtained a positive outcome, with lower baseline with controlled blocks (87,88). In a retrospective study
pain scores, pain not extending below the knee, age < comparing cutoff values of 50% and 80% following
65 years, no opioid use, and the use of cooled radiofre- dual facet joint nerve blocks, Manchikanti et al (88)
quency being associated with success. Cohen et al (116) reported that 89.5% of patients in the > 80% group
also evaluated radiofrequency neurotomy in a double- continued to have pain relief after 2-years following
blind, randomized controlled trial (68). Significantly therapeutic medial branch blocks or radiofrequency
greater pain relief and functional improvement were denervation, versus 51% of patients in the 50% cutoff
noted in patients who received cooled radiofrequency group. This is in contradistinction to the findings of
denervation. Based on these studies, it appears that sac- Cohen et al, who found no differences in lumbar facet
roiliac joint pain is a heterogeneous condition contain- joint radiofrequency outcomes in a retrospective evalu-
ing both intraarticular and extraarticular components. ation between those subjects who obtained > 80% re-
One question that remains to be answered is how best lief after a single medial branch blocks and those who
to screen patients for denervation (i.e. intra- vs. peri- obtained between 50% and 80% relief (269). The study
articular injections; single vs. double blocks; whether or by Manchikanti et al (88) also found a lower false-pos-
not lateral branch blocks are necessary). itive rate at 2 years in the > 80% pain relief group. The
The previous systematic review by Rupert et al (36) findings by Manchikanti et al are consistent with those
evaluating only dual blocks revealed moderate evidence of other investigators who reported sustained pain re-
for the diagnosis of sacroiliac joint pain. They estimated lief following multiple interventions when stringent di-
that sacroiliac joint pain prevalence rates ranged be- agnostic criteria were employed (88,241-245).
tween 10% and 38% using a double-block paradigm, The use of double blocks is an area of considerable
and that the false-positive rate of single, uncontrolled, controversy. In one study, Manchikanti et al found that
sacroiliac joint injections was around 20%. The authors patients with suspected facet joint pain who tested
also concluded that the evidence for provocation test- negative using the strict criterion of > 80% pain relief
ing to diagnose sacroiliac joint pain was limited. following dual blocks obtained good relief following
There continues to be significant debate sur- epidural steroid injections, which suggests that lower-
rounding the accuracy of diagnostic tests (2,22, ing reference standards may lead to misdiagnosis and
27,28,39,87,88,247,248). Although numerous instru- inappropriate treatment. However, these results are in
ments are available for assessing methodological quality direct contrast to the findings of a randomized, com-
assessment, we utilized the latest available criteria. The parative cost-effectiveness study published by Cohen et
issues pertaining to diagnostic accuracy are somewhat al (262) comparing 0, 1 or 2 diagnostic blocks to select
contentious (35-40,44,45,85-88,138-140,249-255). The patients for lumbar facet joint radiofrequency denerva-
reliability of controlled comparative local anesthetic tion. The authors found that although the double-block
blocks has been criticized, and their validity as precision group had the highest proportion of successful dener-
instruments questioned (2,35,38,39,40,44,87,88,248- vation procedures, the 0-block group had the highest
250,254-262). Issues related to the validity of controlled number of overall positive outcomes, and the lowest
comparative local anesthetic blocks include the quality cost per successful procedure. This underscores the dif-
and quantity of pain relief, the utility of dual blocks, ference between efficacy studies, which by nature must
employ stringent selection criteria to screen out false- ic, the majority rely on pain provocation tests that stress
positive results and placebo responders, and those that the sacroiliac joint structures and provoke pain concor-
seek to evaluate effectiveness, in which more liberal dant with a patient’s typical complaints. The key tests
criteria should be employed. The Cohen study (262)was include distraction, compression, high thrust, Gaenslen,
also conducted in a unique patient population, which and sacral thrust. None of these tests have been de-
may not be generalizable to other patient groups and scribed in sufficient detail to establish a reference
also has been criticized for multiple deficiencies (247). standard (i.e. there is considerably variability in how
A diagnostic test is useful only to the extent that these tests are performed), and many suffer from low
it distinguishes between the reference condition and inter-examiner reliability. Multiple other insufficiently
other disorders that might otherwise be misdiagnosed. defined tests have also been described and advocated
Many tests can differentiate healthy persons from se- (53,154,155,159,189,251-253,272,273). Early studies
verely affected ones, but being able to distinguish be- reported mixed results on the interexaminer reliabil-
tween these 2 groups reveals very little about the clini- ity of pain provocation tests evaluating sacroiliac joint
cal utility of a test. The true pragmatic value of a test pain (53). Subsequently these tests have been shown
is therefore established only in a study that closely re- to possess acceptable levels of reliability provided that
sembles clinical practice. The studies evaluating the ac- they are standardized appropriately (53,272,274-276).
curacy of facet joint nerve blocks have provided us with Multiple studies with replication of results have been
reliability and validity data for controlled diagnostic published (53,154,155,159,189,251,253,272,273). Stud-
blocks. A criterion standard using 80% pain relief dur- ies have shown that sacroiliac joint provocation tests
ing the performance of previously painful movements are frequently positive in patients with other, or co-
as the cutoff threshold following dual blocks has been existing, sources of low back pain, such as discogenic
established as accurate. However, due to the numerous pain, radiculopathy, and facet joint pain (189,277). One
studies that utilized less stringent criteria, we broad- of the most reliable signs of sacroiliac joint pain may
ened the selection criteria for this review. In contrast be the location of pain and tenderness (53,273). The
to facet joint pain, the use of single blocks does not ap- centralization phenomenon is a common clinical sign
pear to result in unacceptably high false-positive rates, observed when patients with low back pain are exam-
which in turn can lead to spurious prevalence estimates. ined using standardized test movements and sustained
The criterion standard of long-term follow-up used for postures first described by McKenzie (278). This phe-
the diagnosis of facet joint pain may also be applied to nomenon has been evaluated for reliability and valid-
sacroiliac joint pain. Despite all the attention focused ity in multiple contexts (279-284). Investigators have
on establishing reference criteria, in the absence of a found that the centralization phenomenon is highly
“gold standard” for diagnosis and treatment, any crite- specific to discogenic pain, and is infrequently observed
ria utilized could be flawed (270). Although the use of in patients with sacroiliac or facet joint pain. One may
multiple blocks and high cutoff thresholds will indubi- therefore assume that positive sacroiliac joint provoca-
tably reduce the false-positive rate, an unintended con- tion tests in the presence of either centralization or a
sequence is that employing stricter diagnostic criteria symptomatic disc herniation are likely to be falsely posi-
may result in more false-negatives, the consequences tive. Consequently, restricting the interpretation of sac-
of which include withholding a safe and effective treat- roiliac joint provocation tests to noncentralization cases
ment from a patient who might benefit – if no alter- was shown to improve the specificity of 3 or more posi-
native treatment is available. Pearl (271) described a tive maneuvers from 78% to 87%, without compromis-
hierarchal outcome approach to test assessments using ing sensitivity, which remained at 91% (159). Satisfying
6 criteria, which included technical aspects, diagnostic these criteria result in a high probability that sacroiliac
accuracy and validity, diagnostic thinking, therapeutic joint pain will be confirmed by diagnostic blocks. This
effectiveness, and the ability to improve patient or soci- reasoning process may be considered a clinical predic-
etal outcomes. We believe that based on long-standing tion rule for the identification of a subset of patients
experience, these criteria can be met through the use of most likely to have pain emanating from the sacroiliac
controlled comparative local anesthetic blocks to diag- joint region (53). Laslett (53) noted that there was a
nose sacroiliac joint pain. 59% probability that 3 or more positive sacroiliac joint
In reference to noninvasive clinical testing for sac- provocation tests would lead to an ultimate diagnosis
roiliac joint pain, since lab and imaging are non-specif- of sacroiliac joint pain, assuming that that 30% of the
population selected will have the reference condition. In summary, sacroiliac joint injections are safe and
If a McKenzie assessment of repeated movements fails reasonable tools when used for diagnosis after properly
to reveal the centralization phenomenon, there is a selecting candidates based on provocative maneuvers.
77% likelihood that the pain is of sacroiliac joint ori-
gin (53). However, in most interventional pain manage-
4.0 Conclusion
ment practices, prevalence rates of 30% are rarely seen. The results of this systematic review demonstrate
Consequently, the overall evidence for provocation ma- fair to good support for diagnostic interventions us-
neuvers is limited to fair. ing dual local anesthetic blocks in patients positive for
The limitations of this systematic review include sacroiliac joint provocation maneuvers who have failed
the paucity of appropriate and high-quality literature conservative management.
available for analysis, the widespread variation in meth-
odology, and the discrepancies in technical applications
Author Affiliations
and reference standards. Only one placebo-controlled Dr. Simopoulos is Assistant Professor, Department
study was identified, which compared the effectiveness of Anesthesia, Critical Care, and Pain Medicine, Beth Is-
of local anesthetic blocks to intraarticular sodium chlo- rael Deaconess Medical Center, Harvard Medical School,
ride on the suppression of pain. However, placebo con- Boston, MA.
trolled injections in interventional pain management is Dr. Manchikanti is Medical Director of the Pain
not only impractical, but also subject to misinterpreta- Management Center of Paducah, Paducah, KY, and
tion (2,27,28,33,34,39,154,246,285). Clinical Professor, Anesthesiology and Perioperative
Some investigators have asserted that any local an- Medicine, University of Louisville, Louisville, KY.
esthetic injection which yields similar results to steroids Dr. Singh is Medical Director, Pain Diagnostics As-
should be considered a placebo response; however, this sociates, Niagara, WI.
interpretations may be inaccurate. The difference be- Dr. Gupta is a Consultant in Pain Medicine and
tween injections of sodium chloride solution and dex- Anaesthesia, Bradford Teaching Hospital NHS Founda-
trose into various structures has yielded varying results tion Trust, Bradford Royal Infirmary, Bradford, United
(246,286-292). In addition, local anesthetics have been Kingdom.
shown to provide long-term relief (293-296) in both Dr. Hameed is with the Department of Physical
clinical and experimental settings. Thus, local compara- Medicine and Rehabilitation, The Johns Hopkins Uni-
tive anesthetic blocks appear may be more practical versity School of Medicine, Baltimore, MD.
than placebo-controlled injections unless the latter are Dr. Diwan is Executive Director of The Spine and
applied and interpreted appropriately. Ghahreman and Pain Institute of New York.
Bogduk (297) illustrated the proper application of a Dr. Cohen is Associate Professor, Department of
placebo in a clinical trial evaluating transforaminal epi- Anesthesiology and Critical Care Medicine, Pain Man-
dural steroid injections, which can be extrapolated in a agement Division, Johns Hopkins School of Medicine,
similar fashion for sacroiliac joint injections. Baltimore, MD, and Associate Professor, Department of
The results of this systematic review may be used in Anesthesiology, Uniformed Services University of the
future research to identify patients more likely to have Health Sciences, Bethesda, MD.
pain originating from the sacroiliac joint, as well as to
evaluate the effectiveness of therapeutic interventions
Acknowledgments
targeting sacroiliac joint pain, but the conclusions are The authors wish to thank Vidyasagar Pampati,
only as robust as the accuracy of the studies analyzed. MSc, for statistical assistance; Sekar Edem for assistance
As noted earlier, there continues to be considerable in the search of the literature; Bert Fellows, MA, and
controversy surrounding the use of diagnostic con- Tom Prigge, MA, for manuscript review; and Tonie M.
trolled local anesthetic blocks. Hatton and Diane E. Neihoff, transcriptionists, for their
assistance in preparation of this manuscript. We would
like to thank the editorial board of Pain Physician for
review and criticism in improving the manuscript.
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A Systematic Evaluation of Prevalence and Diagnostic Accuracy of Sacroiliac Joint Interventions

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Pain Physician 2012; 15:E305-E344 • ISSN 2150-1149

A Systematic Evaluation of Prevalence and

Pain Physician 2012; 15:E305-E344

C hronic low back pain, with or without lower

followed the review process derived from evidence- clinicaltrials.gov/

Table 1. Quality Appraisal of Diagnostic Reliability (QAREL) checklist.

Item Yes No Unclear N/A

9. Were appropriate statistical measures of agreement used?

against the inclusion criteria. 2. Is the intervention described in sufficient detail to

Table 2. Clinical relevance questions.

P (+) N (-) U (unclear)

1.4.4 Methodological Quality or Validity 1.4.7 Measurement of Treatment Effect in Data

Computerized and manual search of

Articles excluded by title and/ Potential articles

Full manuscripts reviewed = 129

Diagnostic accuracy studies = 18

Manuscripts considered for diagnostic

Figure 1 shows a flow diagram of study selec- (54,82,148,154,155,157,159,160,175,189,199-201),

Table 4. List of excluded studies.

Manuscript Author(s) Reason for Exclusion

(89,123,156,169,170,172-174,177-188,190,196). off threshold (82,83,157), 7 studies utilizing dual

Participants Objective(s) Interventions(s) Result(s)

50% TO 79% RELIEF WITH SINGLE BLOCK

Table 5 (cont.). Characteristics of reported diagnostic accuracy studies.

Participants Objective(s) Interventions(s) Result(s)

Table 5 (cont.). Characteristics of reported diagnostic accuracy studies.

Participants Objective(s) Interventions(s) Result(s)

Table 5 (cont.). Characteristics of reported diagnostic accuracy studies.

Participants Objective(s) Interventions(s) Result(s)

80% TO 100% RELIEF

Table 6. Clinical relevance of included studies.

Manuscript Author(s) A) Patient B) Description C) Clinically D) Clinical E) Benefits Total

Table 7. Quality Appraisal of Diagnostic Reliability checklist.

Y=yes; N=no; U=unclear; N/A=not applicable

Table 7 (cont.). Quality Appraisal of Diagnostic Reliability checklist.

Y=yes; N=no; U=unclear; N/A=not applicable

and one study was rated as being of moderate qual-

were not homogenous. 2.1.4 Study Characteristics

Table 8. Data of prevalence of sacroiliac joint pain by controlled diagnostic blocks.

% Relief Methodological Number of Prevalence False-Positive

Broadhurst & Bond (157) 70% 11/11 40 NA ---

50%-79% RELIEF WITH A DUAL BLOCK

Irwin et al (55) 70% 8/11 158 26.6% NA

DePalma et al (78,195) 75% 8/11 156 18.2% NA

DePalma et al (79) 75% 8/11 27 18.2% NA

DePalma et al (119) 75% 8/11 170 18.2% NA

van der Wurff et al (160) 50% 9/11 60 38% 21%

Liliang et al (194) 75% 8/11 52 40.4% 26%

Young et al (155) 80% 8/11 81 39% ---

Stanford & Burnham (175) 80% 6/11 34 32% ---

80%-100% RELIEF WITH DUAL BLOCKS

Manchikanti et al (41) 80% 9/11 20 10% 22%

(211,212). should be the imaging modality of choice for diagnos-

respectively. community, especially when the efficacy of a procedure

iologic study of mechanoreceptors in cohort study over five-year follow-up. 536.

Clin Orthop Relat Res 2001; 382:112-118.

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