Treatment of Sacroiliac Disorders

Publication Date: May 3, 2024
Last Updated: May 6, 2024

Summary of Best Practice Statements

  • It is recommended that clinicians should have a thorough understanding of the anatomy and biomechanics of the SIJ.
  • It is recommended that a relevant history should be taken consistent with complaints in the diagnostic criteria of SID, and that risk factors that put the patient at a higher incidence of SID of the patient should heighten the clinician’s suspicion for it as the source of lower back pain.
  • The clinician should understand the validated physical examination maneuvers that play a role in the diagnosis of SID. The presence of three positive provocative maneuvers increases the specificity of diagnosing SIJ dysfunction, although less than three positive provocation maneuvers does not entirely rule out the SIJ as a source of pain.
  • The clinician should obtain appropriate imaging and rule out other pathologies such as fracture, malignancy, and spinal disease. If planning surgical treatment, advanced imaging such as CT or magnetic resonance imaging (MRI) should be performed within 12 months or with any change in symptomatology.
  • The patient should experience greater than 50% relief when an appropriately performed local anesthetic only injection is completed that is consistent with duration of the local anesthetic utilized. A second confirmatory local anesthetic injection can be considered, but not mandatory, when using diagnostic injections to determine candidacy for surgical treatment.
  • Appropriate conservative care should be considered and when acceptable attempted prior to interventional or surgical treatment of SID.
  • Image-guided, intra-articular corticosteroid injections are recommended for persistent SIJ pain that has persisted despite conservative measures for 4 weeks. Fluoroscopic and CT guided injections are the preferred imaging modality of choice, although ultrasound guidance can be considered in situations where radiation exposure may be problematic.
  • Dual diagnostic blockade of the L5 primary dorsal ramus and sacral lateral branches (S1-3) with 50% improvement in pain and function is the preferred strategy prior to neuroablative procedures of the SIJ.
  • RFA of the SIJ should be performed by an established and researched method and repeated no more than at six-month intervals when an improvement of 50% pain relief and functional improvement is seen.
  • The use of regenerative medicine is an evolving therapy with developing evidence. The current use of these therapies should be used based on current literature, and application of these treatments should be considered on an individualized basis when other more validated treatments fail to provide benefit or are contraindicated.
  • Minimally invasive surgical treatment can be considered when patients have failed 6 months of conservative treatment and the diagnosis has been confirmed via history, physical exam, and greater than 50% pain relief after a diagnostic, image guided, SIJ injection. Currently, there is no comparative evidence to claim superiority of one minimally invasive technique over another. The recommendation is to choose the safest approach with the greatest chance of clinical success. Approach and implants used should have peer reviewed prospective clinical evidence which demonstrate clinical efficacy and safety.

Summary of Recommendations

Minimally invasive posterior SI stabilization with allograft is considered medically necessary when the appropriate clinical criteria have been met.

Inclusions
  • A failure of conservative measures to at least include physical therapy and injections.
  • Pain persisting a minimum of 6 months that interferes with functional activities as documented by both a pain score of VAS/NRS of 5 or greater and an ODI of 30 or more.
  • Failure of at least one therapeutic sacroiliac joint injection (less than 50% pain relief for three months duration).
  • Predominant pain pattern consistent with sacroiliac joint pathology.
  • Positive response from at least three validated maneuvers for sacroiliac joint dysfunction.
  • Positive Fortin finger test.
  • Diagnostic imaging: either CT or MRI that excludes destructive lesions of the sacroiliac joint.
  • Diagnostic confirmation of the SI joint as the pain generator demonstrated by at least one image guided (CTor fluoroscopy) intraarticular injection of the SI joint with 50% or greater pain relief for the expected duration of the local anesthetic.

Exclusions
  • Infection or fracture (unrelated to implant).
  • Tumor.
  • Acute traumatic instability.
(A, I-B)
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Minimally invasive SI fusion with lateral transfixing devices is considered medically necessary when the appropriate clinical criteria have been met.

Inclusions
  • A failure of conservative measures to at least include physical therapy and injections.
  • Pain persisting a minimum of 6 months that interferes with functional activities as documented by both a pain score of VAS/NRS of 5 or greater and an ODI of 30 or more.
  • Failure of at least one therapeutic sacroiliac joint injection (less than 50% pain relief for three months duration).
  • Predominant pain pattern consistent with sacroiliac joint pathology.
  • Positive response from at least three validated maneuvers for sacroiliac joint dysfunction.
  • Positive Fortin finger test.
  • Diagnostic imaging: either CT or MRI that excludes destructive lesions of the sacroiliac joint.
  • Diagnostic confirmation of the SI joint as the pain generator demonstrated by at least one image guided (CTor fluoroscopy) intraarticular injection of the SI joint with 50% or greater pain relief for the expected duration of the local anesthetic.

Exclusions
  • Infection or fracture (unrelated to implant).
  • Tumor.
  • Acute traumatic instability.
(A, I-A)
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Minimally invasive SI fusion implants should be used according to FDA labeling. (A, I-A)
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The use of implants composed of human cell and tissue products for sacroiliac fusion is considered medically necessary only if the guidelines set forth by the FDA Regulation of Human Cells and Tissue is followed and should be registered in the FDA Human Cell and Tissue Establishment Registration. (A, NG)
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ASPN supports the utilization of sacroiliac fusion and stabilization devices with published, peer-reviewed, multi-center, prospective evidence of at least 6 months duration to assess efficacy and safety. (A, I-A)
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The current evidence is insufficient to determine the medical necessity of emerging techniques for minimally invasive sacroiliac fusion such as posterior-transfixing, and hybrid approaches. (I, II)
2296214

Recommendation Grading

Abbreviations

  • ASPN: American Society Of Pain And Neuroscience
  • MRI: Magnetic Resonance Imaging
  • SI: Sacroiliac
  • SID: SI Disorders
  • SIJ: Sacroiliac Joint

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Treatment of Sacroiliac Disorders

Authoring Organization

Publication Month/Year

May 3, 2024

Last Updated Month/Year

May 7, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

Clinical management of sacroiliac disease has proven challenging from both diagnostic and therapeutic perspectives. Although it is widely regarded as a common source of low back pain, little consensus exists on the appropriate clinical management of sacroiliac joint pain and dysfunction. Understanding the biomechanics, innervation, and function of this complex load bearing joint is critical to formulating appropriate treatment algorithms for SI joint disorders. ASPN has developed this comprehensive practice guideline to serve as a foundational reference on the appropriate management of SI joint disorders utilizing the best available evidence and serve as a foundational guide for the treatment of adult patients in the United States and globally.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D012446 - Sacroiliac Joint

Keywords

sacroiliitis, sacroiliac joint fusion, sacroiliac joint, SI joint disorders

Source Citation

Sayed D, Deer TR, Tieppo Francio V, Lam CM, Sochacki K, Hussain N, Weaver TE, Karri J, Orhurhu V, Strand NH, Weisbein JS, Hagedorn JM, D’Souza RS, Budwany RR, Chitneni A, Amirdelfan K, Dorsi MJ, Nguyen DT, Bovinet C, Abd-Elsayed A. American Society of Pain and Neuroscience Best Practice (ASPN) Guideline for the Treatment of Sacroiliac Disorders. J Pain Res. 2024;17:1601-1638 https://doi.org/10.2147/JPR.S464393