Susan J. Dreyer

Sacroiliac Joint Pain

Abstract The sacroiliac joint is a source of pain in the lower back and buttocks in approximately 15% of the population. Diagnosing sacroiliac joint‐mediated pain is difficult because the presenting complaints are similar to those of other causes of back pain. Patients with sacroiliac joint‐mediated pain rarely report pain above L5; most localize their pain to the area around the posterior superior iliac spine. Radiographic and laboratory tests primarily help exclude other sources of low back pain. Magnetic resonance imaging, computed tomography, and bone scans of the sacroiliac joint cannot reliably determine whether the joint is the source of the pain. Controlled analgesic injections of the sacroiliac joint are the most important tool in the diagnosis. Treatment modalities include medications, physical therapy, bracing, manual therapy, injections, radiofrequency denervation, and arthrodesis; however, no published prospective data compare the efficacy of these modalities.

Positive sacroiliac screening tests in asymptomatic adults.

Study Design In a prospective, single-blinded study, the incidence of false-positive screening tests for sacroiliac joint dysfunction was investigated using the standing flexion, seated flexion, and Gillet tests in 101 asymptomatic subjects. Objectives This study determined if these commonly used sacroiliac screening tests can be abnormal in an asymptomatic population. Summary of Background Data The sacroiliac joint is a potential source of back and leg pain. One condition affecting this joint is termed sacroiliac joint dysfunction. Diagnosis of this is made primerily by physical examination using screening tests as preliminary diagnostic tools. These screening tests evaluate for asymmetry in sacroiliac motion due to a relative, unilateral hypomobility in one the sacroiliac joints. The specificity of these tests, however, has not been thoroughly evaluated in a well-selected asymptomatic population. Methods A single-blinded examiner performed the standing flexion, seated flexion, and Gillet tests on all subjects. An asymptomatic and a symptomatic group were studied. Results Overall, 20% of asymptomatic individuals had positive findings in one or more of these tests. The specific percentage of false positives are reported by test, age, sex, and side. Conclusion This study suggests that asymmetry in sacroiliac motion due to relative hypomobility as determined by these tests can occur in asymptomatic joints. Obviously, one should not rely solely on these tests to diagnose symptomatic sacroiliac dysfunction.

Low back pain and the zygapophysial (facet) joints

A basic science and clinical review of low back pain due to the lumbar zygapophysial (facet) joints was performed based on a literature search of scientific journals and textbooks. Recent studies estimate that 15% to 40% of chronic low back pain is due to the zygapophysial joints. The histological basis for zygapophysial joint pain has been scientifically established, but the precise clinical etiology remains undetermined. There are no unique identifying features in the history, physical examination, and radiological imaging of patients with pain of lumbar zygapophysial joint origin. Spine physicians diagnose zygapophysial joint pain based on analgesic response to anesthetic injections into the zygapophysial joints or at their nerve supply. Studies on treatment of isolated zygapophysial joint pain are limited. This review summarizes current understanding of lumbar zygapophysial joint disorders while highlighting the need for additional research.

Thoracic zygapophyseal joint pain patterns. A study in normal volunteers.

Study Design. Nine asymptomatic volunteers underwent 40 provocative intra-articular injections of the thoracic zygapophyseal joints. Objective. The purpose of the study was to isolate and stimulate the thoracic zygapophyseal joints via fluoroscopically gulded intra-articular injections to determine whether they are potential pain generators. Summary of Background Data. Experimentally, the cervical and lumbar zygapophyseal joints have been shown to produce pain, and tentative referral patterns have been established. Referral patterns based on stimulation of the thoracic zygapophyseal joints have not been previously reported. Methods. Four subjects underwent right-sided T3-T4, T5-T6, T7-T8, and T9-T10 joint injections, and four subjects underwent left-sided T4-T5, T6-T7, T8-T9, and T10-T11 joint injections. One subject underwent both the right - and left-sided joint injections. The zygapophyseal joints were injected with contrast medium only, and the quality, intensity, and distribution of evoked pain was recorded. Results. In this asymptomatic population, 72.5% of joints injected produced a sensation/pain that was different from the sensation of needle advancement through the soft tissues. In 27.5% of joints injected, there was no evoked pain despite adequate capsular distension. Evoked referral patterns were consistent in all subjects. Significant overlap occurred in the referral patterns, with most thoracic regions sharing 3–5 different joint referral zones. Conclusions. This study provides preliminary confirmation that the thoracic zygapophyseal joints can cause both local and referred pain. A referral pain diagram has been constructed.

Lumbar zygapophysial (facet) joint injections.

The lumbar zygapophysial joints are a potential cause of back and lower extremity pain. Absolute diagnosis of lumbar zygapophysial joint-mediated pain is based on selective analgesic injections of these joints or their nerve supply. The therapeutic role of zygapophysial joint injections is controversial. This contemporary concepts paper reviews the anatomy, mechanics, pathology, and diagnosis of this condition. A critical review of previous studies assessing the role of diagnostic and potentially therapeutic zygapophysial joint injection procedures is presented. The need for future studies is addressed, and current recommendations for the role of zygapophysial joint injection procedures based on this critical scientific review are provided.

Natural history of rheumatoid arthritis of the cervical spine.

This article reviews the natural history of rheumatoid arthritis involving the cervical spine with special attention given to predictors of paralysis. Understanding the natural history of rheumatoid arthritis of the cervical spine is necessary to determine the benefit of various interventions. The primary treatment goal for cervical instability is prevention of irreversible neurologic injury. The natural history of rheumatoid arthritis for a period of 10 years or more is one of significant disease progression. The natural history of cervical instability in patients with rheumatoid arthritis is more variable, with only some patients having a neurologic deficit develop. Recent studies support prophylactic stabilization of the rheumatoid cervical spine to prevent paralysis in high risk patients. However, proponents for prophylactic arthrodesis must acknowledge that not all cervical instability in rheumatoid arthritis progresses to neurologic deficit, and surgical intervention in patients with rheumatoid arthritis incurs added morbidity and mortality. Identifying the risk factors for progression of cervical instability is the first step in eliminating morbidity and mortality from spinal cord and brain stem compression. Surgical stabilization is indicated not only for those patients with paralysis, but for the subgroups of patients with cervical rheumatoid disease who are at risk for spinal cord and brain stem compression. The posterior atlantodental interval is the most reliable screening tool and predictor of progressive neurologic deficit.

Nonoperative treatment of neck and arm pain

LEARNING OBJECTIVES— After reading this article, the practitioner should be able to: Identify the genesis of neck pain. Identify patients in whom nonoperative treatment is an option. Recall what medications are required and the proper dosing regimen.

Laboratory evaluation in neck pain

Laboratory investigations for neck pain play a minor role in most cases. When clinical suspicion of infection or tumor arises, however, laboratory testing can provide definitive information to direct the patients care. Specialized laboratory testing including autoantibody titers can be useful in confirming and categorizing inflammatory arthritides. Judicious use of laboratory tests greatly enhances the physicians ability to provide appropriate care.

Zygapophysial (facet) Joint Injections

Fluoroscopically guided analgesic zygapophysial joint (z-joint) injections are a safe and scientific method of documenting z-joint pain. Lumbar z-joint injections provide significant diagnostic data and may facilitate a more focused treatment program. Because of the possibility of placebo response to a single block, however, diagnosis of definitive z-joint-mediated pain requires a physiologic response to two separate injections with different local anesthetics. The therapeutic effects of intra-articular corticosteroids remain more controversial, with only open studies supporting their use. Further research is needed to address whether injections followed by a more aggressive conservative program of exercise and manual therapy during the period of relative analgesia increase long-term benefit.

Management Of Sympathetic Pain Disorders

The sympathetic nervous system is thought to play a role in many painful disorders involving the face and extremities. Successful diagnosis and treatment of these disorders is best accomplished by an aggressive, multimodal approach involving medical, surgical, and percutaneous therapies. Local techniques for sympathetic blockade are the cornerstone of these treatment programs and are discussed in detail. The rehabilitation physician is encouraged to become familiar with the indications, methods, and potential complications of these therapies.