Surface and boney landmarks for sacral neuromodulation: a cadaveric study.

INTRODUCTION AND HYPOTHESIS: Standard external landmarks have been suggested as a guide for in-office percutaneous nerve evaluation (PNE), but validity of these landmarks has not been assessed. Our objective was to determine whether the standard 9 cm from the tip of the coccyx indicates the position of the S3 sacral foramen and whether other boney landmarks and measurements improved positioning. METHODS: Measurements and distances between external boney landmarks were obtained in 22 embalmed cadavers. Spinal needles were placed 9 cm superior to the coccyx and 2 cm lateral to midline bilaterally. After dissection, internal measurements relating to sacral length, position of S3, and location of the needle in relation to S3 were recorded. Correlations among measured variables were assessed using descriptive statistics. RESULTS: Mean distance from the tip of coccyx to S3 was 9.26 cm (±0.84), from S3 to midline 2.30 cm (±0.2); from needle to S3 1.25 cm, and needle placement was as likely to be placed above or below S3; and S2-S3 and S3-S4 interforamenal distance 1.48 cm (±0.30) and 1.48 cm (±0.24), respectively. Mean distance from S3 to sacroiliac joint (SIJ) was shorter than S2 to SIJ. All associations between external measurements and length from tip of coccyx to S3 were not significant. CONCLUSION: A distance 9 cm from the tip of the coccyx is a reasonable starting landmark for in-office blind PNE. However, given the variability in coccyx length, caution should be taken; also, sensory-motor response is necessary to confirm proper placement.

Double needle technique: an alternative method for performing difficult sacroiliac joint injections.

The sacroiliac joint (SIJ) is a common source of low back pain. The most appropriate method of confirming SIJ pain is to inject local anesthesia into the joint to find out if the pain decreases. Unfortunately, although the SIJ is a large joint, it can be difficult to enter due to the complex nature of the joint and variations in anatomy. In my experience a double needle technique for sacroiliac joint injection can increase the chances of accurate injection into the SIJ in difficult cases. After obtaining appropriate fluoroscopic images, the tip of the needle is advanced into the SIJ. Once the tip of the needle is correctly placed, its position is checked under continuous fluoroscopy while moving the C-arm in the right and left oblique directions (dynamic fluoroscopy). On dynamic fluoroscopy the tip of the needle should remain within the joint line and not appear to be on the bone. If the tip of the needle appears to be on the bone a new joint line will need to be identified (the most translucent area through the joint) by dynamic fluoroscopy and another needle advanced into the newly identified joint line. Dynamic fluoroscopy is repeated again to confirm that the tip of the second needle remains within the joint line. Once both needles are in place contrast dye is injected through the needle that is most likely to be in the SIJ. If the contrast dye spread is not satisfactory then it is injected through the other needle. I have used this technique in 10 patients and found it very helpful in accurately performing SIJ injection which can at times be challenging.

Dolor de la articulación sacroilíaca. Anatomía, diagnóstico y tratamiento / Sacroiliac joint pain. Anatomy, diagnosis and treatment

El dolor de la articulación sacroilíaca es una causa frecuente de dolor bajo de espalda, sin embargo el diagnóstico de artralgia sacroilíaca no es fácil de confirmar y la exploración física de la articulación es controvertido. Además este diagnóstico a menudo pasa inadvertido para el médico, por lo que la falta de consideración de esta posible causa de lumbalgia da lugar a tratamientos inapropiados e inadecuados. La articulaciones sacroilíacas, sinoviales del tipo anfiartrosico irregular, monoaxiales, en la cual se articulan las carillas articulares del sacro al ilion, Su innervación es cuestión de debate, pero las más recientes investigaciones refieren que deriva de L2-S2, L4-S2, L5-S2. La prevalencia del dolor de la articulación sacroilíaca no esta bien estudiado, hay numerosas etiologías para el dolor de articulación sacroilíaca, estas causas se pueden dividir en intraarticulares y extraarticulares. Para la exploración física se cuenta con una serie de 12 pruebas las cuales fueron emitidas por un comité de expertos y se concluye que encontrar 3 o más pruebas positivas es muy sugestivo de dolor de dicha. El tratamiento se puede dividir en conservador, intervencionista donde se puede utilizar desde la infiltración con anestésico local y esteroide hasta radiofrecuencia y por ultimo quirúrgico para casos seleccionados (AU)

The pain of the sacroiliac joint is a frequent cause of low back pain, however the diagnose of sacroiliac artralgia it is not easy to confirm and the physical exploration of the joint is controversial. Also this I often diagnose it happens inadvertent for the physician, for what the lack of consideration of this possible low back pain cause gives place to inappropriate and inadequate treatments. The sacroiliac joint is synovial of the type irregular anphiarthrosic, monoaxial, in which the sides joint are articulated from the sacrum one to the Ilion, Their innervation is debate question, but those but recent investigations refer that it derives of L2-S2, L4-S2, L5-S2. The prevalence of the pain of the sacroiliac joint not this well studied one, there is numerous etiology for the sacroiliac joint pain, these causes can be divided in intraarticular and extraarticular. For the physical exploration it is had a series of 12 tests which were emitted by a committee of experts and you concludes that to find 3 or but positive tests are very suggestive of pain of happiness. The treatment you can divide in conservative, interventionist where you can use from the infiltration with local anesthetic and steroid until radiofrequency and for finish surgical for selected cases (AU)

Interexaminer reliability of three methods of combining test results to determine side of sacral restriction, sacral base position, and innominate bone position.

CONTEXT: Sacroiliac joint dysfunction is diagnosed based on the combined results of several palpatory examinations. Previous studies have compared the interexaminer reliability of only one of these methods of diagnosis. OBJECTIVE: To compare the interexaminer reliability of three methods of combining palpatory examinations to determine the side of sacroiliac joint dysfunction, sacral base position, and innominate bone position. DESIGN: Blinded single-cohort reliability study. METHODS: Patients with low back pain underwent two identical sets of palpatory examinations given by two physicians, separately, at a university spine center. The results of each set were compiled and interpreted by three methods: using the test result with the highest interexaminer reliability (method 1), requiring at least one test result to be abnormal for the variable to be abnormal (method 2), and requiring all test results to be abnormal for the variable to be abnormal (method 3). The kappa was calculated for each method. RESULTS: There were 24 subjects (mean age, 68.3 years), of which 15 (62%) were women. The kappa was consistently higher with method 1, at 0.47, 0.08, and 0.32 for the sacral position, innominate bone position, and side of sacroiliac joint dysfunction, respectively. Corresponding values for method 2 were 0.09, 0.4, and 0.16, and for method 3 were 0.16, 0.1, and -0.33. CONCLUSION: Using the results of the most reliable examination consistently has the best interexaminer reliability.

The sacroiliac joint: anatomy, physiology and clinical significance.

The sacroiliac joint (SIJ) is a putative source of low back pain. The objective of this article is to provide clinicians with a concise review of SIJ structure and function, diagnostic indicators of SIJ-mediated pain, and therapeutic considerations. The SIJ is a true diarthrodial joint with unique characteristics not typically found in other diarthrodial joints. The joint differs with others in that it has fibrocartilage in addition to hyaline cartilage, there is discontinuity of the posterior capsule, and articular surfaces have many ridges and depressions. The sacroiliac joint is well innervated. Histological analysis of the sacroiliac joint has verified the presence of nerve fibers within the joint capsule and adjoining ligaments. It has been variously described that the sacroiliac joint receives its innervation from the ventral rami of L4 and L5, the superior gluteal nerve, and the dorsal rami of L5, S1, and S2, or that it is almost exclusively derived from the sacral dorsal rami. Even though the sacroiliac joint is a known putative source of low back and lower extremity pain, there are few findings that are pathognomonic of sacroiliac joint pain. The controlled diagnostic blocks utilizing the International Association for the Study of Pain (IASP) criteria demonstrated the prevalence of pain of sacroiliac joint origin in 19% to 30% of the patients suspected to have sacroiliac joint pain. Conservative management includes manual medicine techniques, pelvic stabilization exercises to allow dynamic postural control, and muscle balancing of the trunk and lower extremities. Interventional treatments include sacroiliac joint, intra-articular joint injections, radiofrequency neurotomy, prolotherapy, cryotherapy, and surgical treatment. The evidence for intra-articular injections and radiofrequency neurotomy has been shown to be limited in managing sacroiliac joint pain.

Inter-examiner and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: pilot study.

Despite the paucity of research into the reliability of static palpation, it is still employed extensively as a diagnostic tool by manual medicine practitioners. This study tested the inter- and intra-examiner agreement of ten senior osteopathic students using static palpation on ten asymptomatic subjects. Four assessments of the posterior superior iliac spine (PSIS), sacral sulcus (SS), and the sacral inferior lateral angle (SILA) on every subject by all examiners resulted in 1200 assessments in total. Kappa (Kg) yielded intra-examiner agreement that ranged between less-than-chance to substantial for the SILA (Kg=-0.05 to 0.69; mean Kg=0.21), and slight to moderate for the PSIS (Kg=0.07 to 0.58; mean Kg=0.33) and the SS (Kg=0.02 to Kg=0.60; mean Kg=0.24), with 50% significant beyond the 0.05 level. Inter-examiner agreement was slight (PSIS Kg=0.04; SILA Kg=0.08; SS Kg=0.07) and significant at the 0.01 level. Intra-examiner agreement was greater than inter-examiner agreement, which was consistent with existing palpation reliability studies. The poor reliability of clinical tests involving palpation may be partially explained by error in landmark location.

The sacroiliac joint: a review of anatomy and biomechanics with clinical implications.

OBJECTIVE: To examine the biomedical literature pertaining to the anatomy and biomechanics of the sacroiliac (SI) joint to update current concepts and treatment of SI joint dysfunctions. DATA COLLECTION: The biomedical literature was reviewed for articles containing information on the anatomy, mechanics, dysfunction and treatment of the SI articulation. Emphasis was placed on information published in the past decade. Textbooks and prior reviews were used to compare past and present information. RESULTS: The anatomy and mechanics of the SI joint and surrounding tissues are much more complex than taught in chiropractic colleges and technique systems. The motion of the joint is complex, involving simultaneous rotations of 3 degrees or less and translations of 2 mm or less in three dimensions. The axes of motion for the SI joint are not straightforward and are largely dependent upon the surface topography of the joints. Traditional chiropractic types of dysfunctions and displacements are oversimplified and specific SI joint adjustments have not been demonstrated to correct these displacements. The primary function of the integrated SI system is the transmission and dissipation of mechanical forces. History, physical examination and clinical diagnostic tests have failed to demonstrate predictive validity for true SI dysfunction. CONCLUSION: Treatment of the SI articulation is difficult and all known SI joint tests have questionable validity, with the exception of pain provocation tests. Clinical treatment should be aimed at improving the stability of the surrounding soft tissues and at reducing mechanical stresses and strains from poor posture or using orthotics to level the sacral base. Much more research is needed in the treatment of this area.

The superior intracapsular ligament of the sacroiliac joint: presumptive evidence for confirmation of Illi's ligament.

The existence of a superior intracapsular ligament within the sacroiliac joint has been disputed for years. This study notes that the dissection technique used to open the sacroiliac joint is of critical importance in finding this ligament. A dissection technique that emphasizes an inferior approach to the joint cavity is described. A superior intracapsular ligament of the sacroiliac joint (Illi's ligament) is noted with a 75% frequency in dissected cadavers. Illi's model for motion of the sacrum was based partially on the function of this ligament. The findings of this study suggest that current models of motion at the sacroiliac joint must include the presence of a superior intracapsular ligament.

Function and pathomechanics of the sacroiliac joint. A review.

The purpose of this article is to describe the biomechanics and function of the sacroiliac joint, the dysfunction and pathomechanics of the sacroiliac joint as a common cause of low back pain, a simple assessment procedure, associated pain mechanisms, treatment and prevention of the problem, and a discussion of related literature. The sacroiliac joints are essentially nonweight-bearing joints that function to absorb forces from various directions. The common onset of dysfunction is during trunk flexion when a person is standing without adequate support of the anterior pelvis. The anterior shift of the weight of the upper trunk causes the innominates to rotate anteriorly and downward and become fixed on the sacrum. Movement downward of the acetabula in relationship to the sacroiliac joint not only results in biomechanical changes but causes the legs to appear longer than they actually are. Physical therapists can correct the dysfunction by manually rotating the innominates posteriorly on the sacrum while they observe objective changes in apparent leg length. People can prevent this dysfunction through adequate anterior pelvic support when they lean forward. Some possible consequences of untreated sacroiliac dysfunction are also discussed.

Osseous configurations of the axial skeleton: specific application to spatial relationships of vertebrae.

Traditionally, the chiropractic profession has employed two different methods to describe spatial relationships (i.e., listings) of subluxated vertebrae for corrective orientation purposes. These methods (Palmer- Gonstead - Firth and Diversified), in addition to being somewhat limited in their scope of application, do result in some confusion. This paper, therefore, proposes a new method designating vertebral position and movement based on the "right-handed orthogonal coordinate system" of White, Panjabi and others.