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Sacroiliac Joint Dysfunction 

Sacroiliac Joint Dysfunction
Chapter:
Sacroiliac Joint Dysfunction
Author(s):

Victor Foorsov

, Omar Dyara

, Robert Bolash

, and Bruce Vrooman

DOI:
10.1093/med/9780199350940.003.0019
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Subscriber: null; date: 23 October 2019

Key Points

  • A combined history, physical examination, special tests, and diagnostic interventions best implicates the SIJ as a cause of low back pain.

  • Anatomically, the interosseous ligament binds the sacrum and the ilium joint surfaces closely together to optimize the joint surfaces’ locking mechanism.

  • The source of SIJ pain may be subdivided into both IA and EA sources.

  • The innervation of the SIJ likely arises from L3 to S3, although the principal segments are likely the L5 to S2 dorsal rami.

  • Anterior innervation is less established, though the ventral rami of L5 to S2 are likely to be involved.

  • A combination of the thigh thrust test, the compression test, and three or more positive stressing tests have discriminative power for diagnosing SIJ pain.

  • Advanced imaging techniques are of limited specificity for SIJ pathology.

  • As with many conditions related to the spine, therapeutic exercise is the cornerstone of treatment in SIJ dysfunction.

  • Corticosteroids, due to their anti-inflammatory properties, may be used to alleviate pain from either IA or EA sources.

  • RFA offers advantages over other ablative technologies because of its ease of use, lesion size predictability, low cost, and safety profile.

  • Prolotherapy has been described in the literature; however, without randomized controlled trials, this treatment technique has yet to be validated.

Introduction

Identifying the etiology of low back pain can be a significant challenge because patients with spine pain diagnoses often have overlapping signs and symptoms. Traditionally, sacroiliac joint (SIJ) dysfunction was described as nociceptive pain located discretely in the lower lumbar region and buttock, even though this classical pattern is observed only in approximately 30% of patients.1 At times, pain referral patterns can be associated with SIJ dysfunction extending to the lower extremity, challenging this classical description. Among patients with established SIJ dysfunction, lower extremity pain complaints are present in 50% of patients. Lower leg and foot pain can occur in as many as 28% and 14%, respectively.1

SIJ pain patterns may overlap with other common etiologies of low back pain, including discogenic and radicular pain. Advanced imaging techniques have marginal sensitivity and selectivity. Magnetic resonance imaging (MRI) is typically useful only in detecting early, active, intra-articular SIJ pathology. As a result, the practitioner must combine history, clinical presentation, imaging, and special tests to arrive at an accurate diagnosis of pain arising from the SIJ.

The prevalence of SIJ pain is estimated to range from 13% to 30% in patients with low back pain.2,3,4 The prevalence of lower back pain in the US has been reported to be 5.6% to 36%.5,6,7 Using these figures conservatively, if we estimate that 15% of low back pain is related to the SIJ, then roughly 10 million adults in the US are affected. Interestingly, the burden of SIJ pain appears to be higher than in many common medical conditions that are considered to be disabling, including depression and severe chronic obstructive pulmonary disease.8 With annual direct and indirect costs of chronic low back pain estimated to exceed $100 billion annually in the US,9 SIJ pain represents a sizeable proportion of healthcare expenditures.

In this chapter we will discuss the functional anatomy of the SIJ, its innervation, and the pathophysiology leading to dysfunction and pain. We will describe a strategy for the effective diagnosis of SIJ dysfunction and will describe select treatment options to address both the pain and functional limitations.

Anatomy

The sacrum is an important structure distributing the forces transmitted through the lumbar spine and the lower extremities. The sacrum directly articulates with the lowest lumbar vertebra and the two wedge-shaped iliac bones. The SIJ has been described as a “stress-relieving” joint.10 Its architecture is dissimilar from a typical joint whose motions are regulated by muscular contraction; SIJ movements are small and passive. Twisting forces that occur during locomotion are accommodated by the SIJ to diminish the stress placed upon the pelvic ring.10 The relative stability and the minimal motion of the SIJ allow it to be an effective dampener of weight while efficiently transmitting forces needed for functional activities.

The SIJ is a diarthrodial one, with the two surfaces held together by a fibrous capsule containing synovial fluid, locked and wedged into the ilium.4 The sacral and ilial surfaces of the joint are covered by hyaline cartilage.10 The joint space is characterized by an irregular contour, with various areas of elevation and depression. Ligaments impart further stability upon the joint. The most important ligament of the SIJ is the interosseous sacroiliac ligament. This dense, short, and thick collection of collagen fibers lies dorsally, deep within the narrow recess between the sacrum and ilium.10 The primary function of this ligament is to bind the two joint surfaces closely together and optimize the joint surface’s locking mechanism. Additional joint stability is provided by the anterior sacroiliac ligament, dorsal sacroiliac ligament, sacrospinous ligament, and sacrotuberous ligament.

Innervation of the SIJ

Sensory supply to the SIJ remains a subject of contention, with several opposing sources of innervation being described. The joint is innervated both anteriorly and posteriorly. Posterior innervation likely arises from L3 to S3, with the predominant innervation arising from L5 to S2 dorsal rami.10 Anterior innervation is less clear, with contributions arising from branches of the ventral rami of L5 to S2.11 Communications between the SIJ capsule and other nearby structures have also been described after observations of post-arthrography computed tomography (CT) demonstrated extracapsular extravasation from the joint, including posterior spread into the dorsal sacral foramina and into the L5 epidural sheath by means of the superior recess, and ventral spread into the lumbosacral plexus.12,13 These communications suggest that in the setting of capsular disruption, inflammatory mediators may leak to these structures; this may be why SIJ dysfunction can mimics radicular pain symptoms.14

Pathophysiology

The source of SIJ pain may be subdivided into both intra-articular (IA) and extra-articular (EA) etiologies. Immunohistochemical studies have shown nociceptors to be located intra-articularly within the joint capsule and the superficial layers of the sacral and iliac cartilage.4,15,16 Mechanoreceptors and nerve fibers have been located in the sacroiliac ligament.17

IA sources of pain include arthritis and seronegative spondyloarthropathies such as ankylosing spondylitis and psoriatic arthritis.4,18 EA sources of pain include direct ligamentous and muscular injury.4 Finite element modeling of the SIJ has demonstrated that maximum ligamentous strains occur at the interosseous sacroiliac ligament.19 Direct injury to the ligaments sustained by a torsion, a fall, or a high-impact injury (e.g., automobile accident) may lead to pain and dysfunction.

The presence of calcitonin gene-related peptide (CGRP) and substance P immunoreactive fibers in the normal anterior capsular ligament and interosseous ligaments further suggests a periarticular/ligamentous source of SIJ pain.16,17 Forces resulting from biomechanical structural abnormality, length discrepancy, scoliosis, gait abnormality, persistent strain/low-grade trauma, and spine surgery may lead to ligamentous injury and laxity.4 Prolonged laxity may progress to joint hypermobility.

With the development of ligamentous laxity, destructive forces may progress to involve the joint itself, resulting in an IA source of pain. Hormonal changes, especially those related to pregnancy, may also result in ligamentous laxity by the direct effect of relaxin combined with postural and weight changes, resulting in joint dysfunction and pain.4 A study of pregnancy-related pelvic joint pain demonstrated a total incidence of 20.1%; the incidence of one-sided SIJ pain was 5.5% and that of bilateral SIJ pain was 6.3%.20

Diagnosis

Several pain referral patterns can result from SIJ pathology.4 Symptoms from associated spine pain pathologies such as disc herniation and facet syndrome can overlap, thus clouding the clinical presentation. Diagnosis is made using a combination of physical examination, provocation tests, diagnostic blocks, and imaging (Table 19.1).

Table 19.1. Provocation Tests.

Provocative Test

Description of Test

Patrick tests (FABER)

FABER = Flexion, ABduction, External Rotation. Patient is positioned supine. On the side being tested, the leg is placed in flexion, abduction, and external rotation (heel placed over contralateral knee) and pressure is applied to the tested limb’s knee in the posterior direction. A positive test will reproduce pain in the back or buttocks. Pain within the groin is more indicative of hip pathology.

Compression test

Also known as the midline sacral thrust. With the patient in the lateral position, downward pressure is applied on the upper iliac crest, directed toward the floor. A positive test is indicated by pain in the SIJ. The compression test has ~60% to 70% sensitivity and specificity.23

Thigh thrust test

With the patient in the supine position, the hip is flexed to 90 degrees with the knee bent. A quick motion of a thrust or a steadily increasing pressure is applied. A positive test is indicated by pain at the SI joint. The thigh thrust test has a sensitivity of ~90% and a specificity similar to the compression test of ~60% to 70%.

Gaenslen test

The patient is positioned supine with one leg hanging off the table (side to be tested). The contralateral hip is flexed toward the chest and pressure is placed on the leg hanging off the table. In a positive test, pain is reproduced in the back over the region of the SIJ when pressure is applied to the limb.

Distraction test (iliac gapping test)

With the patient positioned supine, the clinician places his or her palms on the anterior superior iliac spines and applies pressure in a lateral and posterior direction so as to “gap” the anterior sacroiliac ligaments.

Gillet test

The patient is standing and the clinician is behind the patient. One thumb is placed on the sacrum and the other is placed on the inferior portion of the posterior superior iliac spine (PSIS). The patient is asked to flex the ipsilateral hip (the side thumb is placed on the PSIS). Normally, the thumb on the PSIS moves inferiorly relative to the thumb on the sacrum. A positive test is when there is no motion relative to both thumbs.

Fortin finger test

The patient is directed to localize his/her pain with one finger. If the patient is able to localize pain exactly to the location of the SIJ, it is likely that SIJ pathology is involved. The test is considered positive if the patient can point to the exact location twice.

Fortin et al. injected contrast and lidocaine to characterize pain referral patterns arising from the SIJ in asymptomatic subjects. His study determined that a specific region located 10 cm caudal and 3 cm lateral to the posterior superior iliac spine most consistently correlated to SIJ pain provocation.4,21 A variety of researchers have attempted to correlate pain referral patterns with SIJ pathology, though they have been challenged by heterogeneous clinical presentations and variable pain presentations.

Appropriate medical history and a thorough physical exam will help the clinician to make an accurate diagnosis of SIJ dysfunction. A variety of risk factors may help the clinician in further characterizing the diagnosis. Recent falls, a history of lifting and/or twisting of the pelvis, especially during manual labor, previous lumbar fusion surgery, leg-length discrepancy, and pregnancy suggest that the SIJ may be implicated. A systematic review by Szadek et al.22 suggested that a combination of the thigh thrust test, the compression test, and three or more positive stressing tests have discriminative power for diagnosing SIJ pain and may be used as a clinical tool to determine which patients will respond positively to diagnostic SIJ injections. Special tests, used in combination with imaging and diagnostic blocks, can help discern SIJ pain, although consensus upon this topic remains elusive, as no single test is reliable in the diagnosis of SIJ dysfunction.4 If during testing the patient experiences weakness, loss of sensation, loss of reflexes, or numbness, an underlying nerve root pathology may be the etiology.

IA SIJ injection, via fluoroscopy or CT guidance using a local anesthetic solution and a contrast medium, may help determine underlying SIJ dysfunction (Fig. 19.1). Because of the heterogeneous appearance of the joint surface, placing a needle directly into the SIJ frequently presents a challenge. Duplication of the patient’s pain pattern when contrast is injected may be indicative of sacroiliac etiology. A positive diagnosis of SIJ dysfunction may be elucidated if the patient reports at least an 80% reduction of the pre-block visual analog scale rating.24 Although IA injections may be of diagnostic value, the clinician should remember that these data are provided for IA sources of pain, and EA sources of pain such as those arising from the ligaments remain an emerging area of research.4,25

Figure 19.1. Anteroposterior (A) and lateral (B) fluoroscopic view of SIJ injection.

Figure 19.1. Anteroposterior (A) and lateral (B) fluoroscopic view of SIJ injection.

Though radiologic imaging is an important tool for diagnosing many spine pathologies, it is often of limited specificity for SIJ pathology. Several imaging tests, such as radiography, CT, scintigraphy, and magnetic resonance imaging (MRI), are routinely employed for spine pain pathologies outside the SIJ. However, these modalities do not routinely reveal underlying abnormalities of the SIJ and thus cannot reliably be used to include the diagnosis of SIJ pathology. The value of imaging has been investigated in multiple studies. A systematic review conducted by Vanelderen et al.26 concluded that radiologic imaging does little to diagnose SIJ pathology, but it is useful to diagnose life-threatening pathology that may seem to arise from the SIJ.27 However, a prospective study by Blum et al.28 involving 44 patients demonstrated that MRI was 95% sensitive for the detection of active sacroiliitis, compared to 48% for quantitative SIJ scintigraphy and 19% for conventional radiography. The utility of MRI for detection of non-inflammatory SIJ pathology is poor, however.29 While imaging may be used as an aid to help determine underlying pathology, it should not be relied upon as the sole means of diagnosis. A thorough medical history, physical examination, provocation testing, imaging, and injections (both IA and EA) are necessary to adequately diagnose pain arising from SIJ dysfunction.

Treatment

Physical Therapy and Exercise

As with many pain conditions relating to the spine, therapeutic exercise is the cornerstone of treatment. As a result of the difficulty of accurately diagnosing SIJ dysfunction, there have been limited randomized controlled trials exploring the effectiveness of exercise on SIJ dysfunction. However, several studies have validated the rationale for exercise as a treatment modality for this condition.

Therapeutic exercise focuses upon the muscles that are involved with stabilization of the SIJ. Unilateral pulling from the erector spinae/multifidus muscles or the quadratus lumborum or through the hamstrings may act as an asymmetric force through the SIJ.30 Muscles such as the transversus abdominis, internal oblique, and multifidus, the diaphragm, and the pelvic floor muscles play a role in lumbopelvic pain and stability. Hodges and Richardson31 popularized the notion of core stabilization. They described how these deep muscles exhibit anticipatory stabilizing activity prior to initiation of gross movements or bearing of external loads and demonstrated that the onset of lumbosacral pain disrupts these muscles’ anticipatory action, further contributing to dysfunction. Focused core exercise has been shown to improve muscle anticipatory function and alleviate lumbosacral pain.31

Compressive load forces through the SIJ are more effectively increased by muscles that are deeper and closer to the axis of rotation of the spinal elements and SIJ. The erector spinae and multifidus are the fundamental muscle groups that stabilize the SIJ. The sacral connections of the erector spinae/multifidus complex promote nutation (anterior flexion) of the sacrum, tensing the ligaments surrounding the SIJ.32 This action leads to forced closure while increasing joint stiffness. In addition to the deeper muscular elements, large muscles with long lever arms exert an influence upon the SIJ. Dysfunction of muscles such as gluteus maximus, hamstrings, sartorius, rectus femoris, and iliacus may influence proper SIJ mechanics and contribute to SIJ pain. These muscular influences must also be considered when prescribing therapeutic exercise. Other biomechanical influences, such as leg-length discrepancies and gait abnormalities, warrant consideration as well.

External orthotics such as pelvic belts and manual therapy may also have utility in concert with a well-rounded therapeutic exercise program.

Corticosteroid Therapy

Corticosteroids are known to have strong anti-inflammatory properties that may contribute to the analgesia following IA injection. Previous data have shown that they also have a direct neural anti-nociceptive effect.33 The goals of SIJ injections are to help confirm the actual joint as the source of pain and to help alleviate pain derived from it.

This SIJ injection procedure is performed under strict aseptic technique, using fluoroscopic guidance. Ultrasound-guided therapy is also an option, although it may be less effective as a diagnostic measure due to lower accuracy.34 Patients can be given a short-acting intravenous anxiolytic and/or opioid for comfort. Patient perception should be maintained throughout the procedure to monitor the patient’s response to the injection. A mixture of a local anesthetic, usually lidocaine or bupivacaine, and a corticosteroid is normally injected. The corticosteroid has an anti-inflammatory effect aiding in the reduction of pain, which at times lasts several months. Because the source of the pain may be IA or EA, it may be beneficial for the clinician to divide and administer the aliquot into both potential pain sources during the procedure.

Common absolute contraindications to SIJ injection include patient refusal, history of anaphylaxis or allergy to the injectate being considered, local malignancy, and local or systemic infection.35 Relative contraindications to corticosteroid injection include ongoing anticoagulation therapy (considered a “low risk procedure” with updated guidelines from various pain societies in 2015),36 underlying coagulopathy, no or minimal relief after two previous corticosteroid injections, and uncontrolled diabetes mellitus.

IA SIJ Injections

Although the IA corticosteroid injection may be performed without fluoroscopy, image guidance is likely necessary to reliably inject into the SIJ.4 Recent studies have shown that EA or periarticular SIJ injections tend to be more effective than IA joint injections, but IA injections may still have an effect, depending on the etiology. One study demonstrated positive IA joint injection in only 8 of 37 patients using landmark guidance alone.37

A double-blind study performed by Maugars et al.38 to evaluate IA steroid injections versus a placebo effect in patients with painful sacroiliitis demonstrated a significant reduction in pain in those injected with corticosteroid. Patients in the placebo group, and two patients who failed to respond to initial corticosteroid injection, were then re-injected with corticosteroid. At 1-month follow-up, 85.7% of patients in the group had significant reduction in pain. Results remained significant at 3 months (62%) and 6 months (58%).

While select patients obtain significant improvement in pain with IA joint injections, several treatments may be required to achieve efficacy. Overall studies show that the long-term effectiveness of IA steroid injections is poor.39

EA SIJ Injections

There appears to be growing evidence supporting EA steroid injection over IA. Murkami et al.40 demonstrated that those receiving EA injections all had improvement of pain, compared to only 36% of those who received only IA injections. In a retrospective study Borowsky et al.41 compared outcomes of IA injections versus combined IA and EA injections: subjects receiving combined IA and EA injections showed greater pain relief than those who received IA injections alone. Immunohistological evidence of nociceptors originating from the periarticular ligaments may account for the efficacy of EA steroid injections.16

Complications of SIJ Steroid Injections

SIJ injections are considered among the safest interventional spine pain procedures. The most common immediate adverse effect is vasovagal reaction. The most common delayed event is soreness at the injection site. Other infrequent complications include pain exacerbation, facial flushing, or sweating. Patients with bilateral injections were noted to have greater adverse effects than those receiving only a single-site injection.42

Radiofrequency Ablation

There are various interventional techniques for tissue ablation with a range of applications for spine pain procedures. Ablation options include radiofrequency ablation (RFA), percutaneous ethanol injection, microwave, laser, cryotherapy, and focused ultrasound. Understanding the characteristics of the various treatments, namely the specific heat effects upon tissue, enables the clinician to predict volumes of tissue destruction. RFA is currently a leading technology used in minimally invasive spine procedures. It is argued to be superior to other ablative technologies because its ease of use, predictable lesion size, low cost, and safety profile. Image guidance (fluoroscopy, CT, ultrasound) is used to position a needle electrode with an insulated shaft and a non-insulated distal tip near the target for destruction. The energy exposed at the tip leads to ionic agitation and frictional heat, resulting in cell death and coagulation necrosis.43 “Charring” of tissue can occur, ultimately limiting the lesion size as energy transmission within the target tissue is compromised. Cooled RFA limits the temperature at the tip of the electrode, minimizing charring and thus sending optimal lesion energy to a larger tissue volume.

Denervation of the nerve supply to the SIJ with RFA is typically performed following concordant symptom improvement after SIJ injections that require longer duration of efficacy. RFA, however, is not without possible risks: infection, damage to nontargeted nerves, hematoma, and cutaneous nerve damage. RFA may be appropriate after other more conservative measures have failed.44,45

Conventional/Monopolar RFA

Conventional RFA lesions has been used longer than the other RFA techniques to ablate the lateral branches of the sacral nerves. Factors such as needle gauge, temperature, duration, tissue type, and liquid medium used affect the lesion size.

The variability in the targeted location of the nerves, coupled with small lesion sizes, increases the likelihood that the lesions could miss the targeted nerves. One method describes overcoming this technical disadvantage by positioning the electrodes at a shallow angle relative to the surface of the sacrum so as to maximize the surface area of the lesion in contact with bone.4 In this method the clinician creates multiple lesions surrounding the outer perimeter of the sacral foramen while being careful not to enter the sacral foramen. Injecting lidocaine prior to lesioning improves patient tolerance for the procedure and can increase lesion size by approximately 50%.4 Studies comparing conventional RFA to cooled RFA have not clearly indicated that one technique is superior to the other.46,47 Lesion targets may vary given the heterogeneous joint innervation patterns described earlier, but the dorsal ramus of L5 and the lateral branches of S1–2 should be included regardless of the chosen technique.

Bipolar RFA

In contrast to conventional/monopolar RFA, bipolar RFA uses two electrodes to produce “strip lesions” in which the lesion is produced between the two electrodes, one active and the other passive. Cheng et al.48 developed a template (SIJ PalisadeTM, Cosman Company) for performing a bipolar strip lesion of the L5 dorsal ramus to the lateral branches of S2. Pino et al.49 studied lesions produced in egg whites using a 22-gauge electrode with 5-mm active tips at 90°C for 90 seconds. The study determined that electrodes should be placed between 4 and 6 mm apart to maximize the surface area of the lesions, though greater distances can be used, such as up to 10 mm. The bipolar technique may maximize lesion size, minimize procedure time, and improve the likelihood of producing an effective lesion of the variable innervation to the SIJ.

Cooled RFA

Cooled RFA is a technique that has been used with increased frequency recently.46,50,51 Long-term efficacy has been demonstrated for up to 2 years.51,52 The treatment approach is similar to conventional RFA treatment (Tables 19.2 and 19.3).53 With conventional RFA therapy there can be an inconsistent lesion of the targeted lateral branch nerves.45,54 When using the cooled RFA approach, the electrode is cooled with a sterile water system, which decreases tissue charring and produces a larger lesion.4

Table 19.2. Advantages of Cooled RFA over Conventional RFA.

Cooled RFA

Conventional RFA

Lesion diameter

Larger

Smaller (due to more tissue charring)

Depth

Greater depth

Less depth

Area

Greater area ablated

Less area ablated

Data from references 4 and 50.

Table 19.3. Disadvantages of Cooled RFA versus Conventional RFA.

Cooled RFA

Conventional RFA

Cost

Hardware components are more costly.

Less expensive, reusable components

Time of procedure

Longer treatment time

Shortened treatment time

Electrode size

Larger, hence an increased risk of bleeding and pain

Smaller-diameter needles can be used.

During this procedure, the patient is awake and communicating with the physician, with possible addition of moderate sedation. Internal reference points must first be established. 27-gauge 3.5-inch Quincke needles may be placed into the S1, S2, and S3 posterior sacral foramina using fluoroscopy to determine the location of the foramen, but the surgeon must be careful not to advance the needle farther than the posterior aspect of the foramen to avoid iatrogenic injury. After appropriate electrode location and impedance checks have been confirmed, local anesthetic is injected and the RF energy is subsequently delivered for 150 seconds. The target temperature of the electrode is 60°C. Within the sacral foramina, however, the temperature should not exceed 45°C, and this is ensured by placing the electrodes at least 7 mm lateral to the lateral aspect of the foramen.4,50

A number of studies have shown improvement of SIJ pain after cooled RFA. A large-scale European case series by Stelzer et al.55 reviewed the records of 126 patients diagnosed with chronic low back pain who had undergone treatment with cooled RFA. The patients who had received the treatment were selected after experiencing greater than 50% relief from an IA SIJ injection and physical examination. Pain scores, quality of life, and medication usage were among the parameters evaluated in this study. At the time of follow-up at 4 to 6, 6 to 12, and more than 12 months, 86%, 71%, and 48% of the patients had greater than 50% reduction in pain scores, respectively, and 96%, 93%, and 85% reported an increase in their quality of life. Opioid consumption was decreased as well: 100%, 62%, and 67% of the patients had either stopped taking opioids or had a significant decrease in their consumption.

Prolotherapy

Prolotherapy is a technique of strengthening tissue attachments by inducing the proliferation of new cells using irritant solutions. These solutions include phenol, glycerin, or hypertonic glucose combined with an anesthetic agent. The goal of therapy is to induce an inflammatory reaction within the tissue, leading to deposition of new collagen fibers within the ligaments surrounding the SIJ and thus inducing increased stability of the joint itself. A study by Kim et al.56 comparing prolotherapy to steroid injection demonstrated comparable pain and disability scores between the two groups at 2-week follow-up. The cumulative incidence of more than 50% pain relief at 15 months was 58.7% in the prolotherapy group compared to 10.2% in the steroid group. A prospective descriptive study by Cusi et al.57 demonstrated positive clinical outcomes in 76% of patients at 3 months, 76% at 12 months, and 32% at 24 months. There have been no randomized controlled trials performed of this method.

Plasma-Rich Protein

Most recently the use of plasma-rich protein (PRP) in the treatment of SIJ dysfunction has been described.58,59 In a case series, Ko et al.59 described ultrasound-guided injections of the SIJ in four patients, with improvements in pain, function, and joint stability maintained at 4 years following injection. Singla et al.58 reported superior outcomes in pain and function in an prospective, randomized, open-label, blinded endpoint study for those undergoing ultrasound-guided PRP injections as compared to those receiving ultrasound-guided corticosteroid injections at up to 3 months following injection. Although promising, larger, more robustly designed studies are needed.

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