The difficulties identified in terms of sensitivity and specificity, particularly in comparing diagnostic blockade to a known, or reproducible, standard also apply to SI joint blockade. It is generally accepted that the SI joint can be a source of pain owing to posterior ligamentous disruption, secondary to trauma, infection, or tumor. The characteristics of so-called SI joint pain without these obvious anatomical correlates, are, however, controversial. To date, no physical finding has proven to be specific enough to reliably diagnose sacroiliac joint pain.48 Additionally, the sacroiliac joint appears to be relatively immobile and position has not been shown to be altered by manipulation.49 Technically, the SI joint may be more difficult to access than others, although access is possible with strict attention to fluoroscopic technique.50-52 Several studies have noted that the pain provoked by joint distention may be ablated by anesthetic block.50,51 The clinical significance of this finding is unclear. Unfortunately, many of the appropriate afferent pathways are poorly understood. Additionally, in the presence of capsular incompetence, contrast extravasations may anesthetize nearby neural structures, further compounding the diagnostic difficulties with this particular injection.
From a surgical point of view, perhaps the most telling limitation is the lack of any reproducible surgical procedure to treat sacroiliac joint pain. While joint reconstruction or arthrodesis has been demonstrated to restore pelvic stability in traumatic situations, there are no published reports in the peer-reviewed literature of significant pain relief following SI joint fusion for clinical syndromes diagnosed by SI joint blockade. Cavillo et al.53 reported two instances of successful treatment of presumptive SI joint pain by neurostimulation. The precise mechanism is unclear and certainly cannot be extrapolated.
Thus, from a surgeon's point of view, sacroiliac joint injections are therapeutic only because no firm recommendations can be made on surgical treatment for these presumed disorders.
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